Every finding on record at Sunrise Retirement Community

Based on observation, interview and record review the facility failed to implement safe transfer techniques for 1 of 2 residents. In an observation of the use of the mechanical lift, E-Z Stand, it was discovered that Resident #46 was not standing firmly on the platform and she expressed that she was having pain in her knees. Staff failed to ensure that the resident was strong enough to complete a safe transfer with the E-Z Stand. The facility reported a census of 67 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #46 was unable to complete a Brief Interview for Mental Status (BIMS) screening. She had short and long-term memory problems and had impaired decision-making skills. The resident required partial assistance for lower body dressing, sit to stand and toilet transfer, and supervision only for walking 10 feet. The Care Plan updated on 8/4/25 showed that staff were to transfer Resident #46 with a pivot transfer to wheelchair only due to falls related to knee pain/weakness. She had advanced dementia and increased assistance was needed with activities of daily living. On 9/08/2025 at 1:17 PM, Staff E, Certified Medication Aide (CMA) and Staff F, (CNA in training) positioned the mechanical lift, E-Z stand, in front of Resident #46 and instructed her to put her feet on the platform. They attached a lift sling around her back, and to the machine. Staff E connected a second strap to the machine (Fanny Seat). The residents left arm was on the outside of the Fanny strap. While the CNA's moved the machine to the commode, the resident said several times that her knees hurt and she rested her buttocks on the Fanny seat. The Fanny Seat was unhooked while the resident was sitting on the commode. At 1:25 PM, she said she was done and they lifted her to semi-standing position, cleaned her bottom and resident said they should hurry, because she was having trouble standing. The staff failed to attach the Fanny seat strap before transferring back to the recliner. The resident said ouch several times, and was bearing weight in her arm pits with her elbows straight out, parallel to the floor. Once the resident was back in the recliner Staff E said that she had been having more pain in her knees and had recently upgraded from a pivot transfer to E-Z Stand. The following was found in the Nursing Progress Notes:a. On 8/20/25 at 11:22 AM, frequent urination/urgency incontinence, strong odor, increased confusion and frequently getting angry at staff, redirection difficult. b. On 8/25/25 at 9:17 AM, due to bilateral lower extremity weakness, resident would be an E-Z stand for all transfer for safety. c. On 8/31/25 at 2:37 AM, does not tolerate E-Z stand well, she lets go of the handle and yells out.d. On 9/4/25 at 2:49 AM, Resident does not do well with E-Z stand. Lets her arms go loose and bottom drops, does not assist with standing. She vocalizes discomfort and puts most of her weight on the safety strap. e. On 9/4/25 at 10:32 AM, the resident does not tolerate E-Z Stand will, yells out and screams, tells staff they don't know what they are doing and will let go of the handles on the machine.f. On 9/5/25 at 10:36 AM, the CNAs reported resident was having bad transfers with E-Z stand, won't stand up straight and elbows were flared out, this caused resident to slide down. CNAs were able to safely transfer resident at the end. g. On 9/9/25 at 5:40 AM, the resident did poorly with E-Z stand, calls out through transfer and picks up feet at times, sags bottom while in strap. On 9/9/25 at 11:00 AM Staff D CNA said that she had been transferring Resident #46 and noticed that she wasn't tolerating it very well. She said she did tell the nurse but the reason they haven't changed her to a Hoyer transfer is because she used the commode and don't know how they would get her on the toilet with a Hoyer. On 9/10/2025 at 8:16 AM, Staff C, Registered Nurse, (RN) said that he had been noticing that the resident hadn't been tolerating the E-Z stand very well. He said that they used two people and the extra strap under her which helps some but sometimes she doesn't want to hang on or she will lift her feet. There were times when she just doesn't want to get up so she will complain of pain and elbows out like chicken wings. When asked about use of Hoyer he agreed she's about getting there He said that it would be a nursing judgement to upgrade transfer status. On 9/10/2025 7:34 AM Staff A, RN said that the resident had a change in condition so they went from pivot transfer to sit to stand. They had recently discovered that she was not bearing weight, having difficulty determining where to put her hands so they went to two assists with sit to stand. The CNAs this morning, that transferred the resident that morning had her come in and watch the transfer and she said they would have a discussion about going to a Hoyer because her knee pain and difficulty bearing weight and chicken winging they have a toileting sling they can use for her on the commode. She will discuss with Unit Manager. The Care Plan for Resident #46 was updated on 9/10/25 to include the use of the E-Z stand for all transfers with 2 people. On 9/11/2025 at 8:29 AM, the Director of Nursing (DON) said that they have weekly meetings with the therapy department and discuss residents that may be struggling with transfers and brainstorm on what is safe for them. She said that the staff should have used the Fanny Seat after Resident #46 was finished on the commode and it was not acceptable to have the residents arms parallel to the floor while transferring with the E-Z Stand. She said that nursing always had the option to downgrade transfer status when they see a resident was not tolerating what they were using. A facility policy titled: E-Z Stand/Lift Policy, dated 1/3/25, showed that residents must be able to bear some weight. The residents Care Plan would reflect if the resident was able to use the E-Z Stand device. The Fanny seat strap would be used for all transfers. Report any complaints or inability to tolerate the E-Z lift to charge nurse. According to the facility policy: Resident Transfer, reviewed on 2/14/25 all resident transfers would be performed using safe techniques, appropriate equipment and in accordance with the resident's care plan. Assessment prior to transfer, assess the resident's condition, strength, balance, cognition, pain medication equipment in use.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene after resident care for 1 of 2 residents reviewed (Resident #9). The facility reported a census of 67 residents.Findings include: Observation on 9/10/25 at 12:55 PM showed Staff H, Certified Nursing Assistant, (CNA) performed hand hygiene, donned personal protective equipment (PPE) of a gown and gloves then provided catheter care. When finished Staff H removed the soiled gloves, failed to perform hand hygiene, and donned new gloves. Staff H then rearranged the wheelchair, opened the door and exited the room. Staff H doffed PPE, failed to perform hand hygiene then proceeded down the hall. The Hand Hygiene policy last updated January 2025 identified hand hygiene should be performed and consistent with accepted standards of practice. In an interview on 9/11/25 at 1:10 PM, Staff I, Registered Nurse, Unit Manager reported the CNA should have performed hand hygiene in between glove changes and immediately after doffing PPE.

Based on observation, interview and record review the facility failed to properly monitor and store controlled substances for 2 of 3 residents. Staff failed to destroy controlled medications after the physician's order was discontinued for Resident #36 and #5. They failed to accurately document and verify destruction of controlled medication for Resident #36. The facility reported a census of 70 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete the assessment). The resident was admitted to the facility on [DATE] and had severe cognitive impairment. Resident #36 was totally dependent on staff for transfers, she was receiving hospice services and her diagnoses included; diabetes mellitus, dementia, supraventricular and tachycardia. The Care Plan for Resident #36, updated on [DATE], showed that she was on hospice services from [DATE] - [DATE], and then restarted with hospice on [DATE]. On [DATE], the As Needed (PRN) lorazepam (Ativan) was discontinue due to nonuse. In an observation of medication storage on [DATE] at 10:47 AM, Staff A Registered Nurse (RN) displayed an unused bubble package that contained 14 tabs of Ativan. The sticker showed that the order was dated [DATE]. Staff A said that they would destroy the Ativan if/when it was outdated. She was unsure about how long hospice medications were stored in the cart before being destroyed. According to the Individual Resident Controlled Substance Record (IRCSR) for Resident #36, On [DATE], 14 Ativan was delivered for Resident #36 and none had been used. A separate IRCSR showed the on [DATE], 14 Ativan were delivered and it was used three times, and on [DATE], eleven tabs were destroyed. The Orders tab in the electronic chart showed that Ativan 0.5 milligrams (mg) was renewed on [DATE] and discontinued on [DATE]. On [DATE] at 2:35 PM, the pharmacy said that they had delivered 14 tabs of Ativan on [DATE] and 14 tabs on [DATE]. That order had expired on [DATE]. They received a new order on [DATE], and sent 14 tabs. On [DATE] at 6:25 AM, Staff B, RN said that she was not sure about the policy on destruction of discontinued medications was, but she tried to go through the PRN medication every once in a while to make sure there weren't any out of date. On [DATE] at 3:09 PM, The Director of Nursing and Administrator looked at the orders and the IRCSR sheets and the DON said that they have a process for destroying controlled medications with two nurses once it was discontinued. 2) The MDS dated [DATE] for Resident #5 showed she had a BIMS score of 5 (severe cognitive deficits) and she was admitted to the facility on [DATE]. Resident #5 was on high risk medications that included a diuretic, opioid and an antiplatelet. She had occasional pain and diagnoses that included heart failure, hypertension, diabetes mellitus, Alzheimer's Disease, The Care Plan for Resident #5, updated on [DATE], showed that the cardiologist had ordered Lasix and directed staff to obtain daily weights. If there was a gain of ,d+[DATE] pounds overnight or 5 pounds in a week, staff were to notify cardiology. The resident had complaints of pain to left leg, pelvis and left wrist due to fractures and on [DATE], her PRN tramadol was discontinued. In a review of the IRCSR for Resident #5 revealed that on [DATE], 30 Tramadol 50mg tabs, were delivered to the facility and 21 tabs were destroyed on [DATE]. Staff failed to indicate the disposition of the remaining doses and failed to include a second nurse signature. A second IRCSR showed that 30 tabs of Tramadol were delivered on [DATE] and on [DATE] 30 tabs were destroyed. The form included one nurse signature with no disposition. The Medication Administration Record for Resident #5, in the month of March, showed that the Tramadol 50mg PRN had been discontinued on [DATE]. On [DATE] at 10:40 AM The DON acknowledged that the nurse signing off on the destruction of tramadol did not sign the right place on the form and the disposition of the medication was not included on the form. She said that she would prefer to use a different form. The nurses should have been aware of when a medication was discontinued. A facility policy titled; Discontinued Medications, reviewed on [DATE], showed that staff would follow strict protocols for documenting the removal of controlled substances; including having a witness during the removal and disposal process. Both parties must sign off in the controlled substance log, and quantity destroyed.

Based on interview, record and policy review the facility failed to ensure accurate and complete resident records for 1 of 16 Residents reviewed, (Resident #5). Resident #5 had a change in medication with an increased dose. Staff documented the resident did not have adverse reaction to the increased dose, even though the medication hadn't been administered. The facility reported a census of 70 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficits). Resident #5 was on high risk medications that included a diuretic, opioid and an antiplatelet. She had occasional pain and diagnoses that included heart failure, hypertension, diabetes mellitus, Alzheimer's Disease, The Care Plan for Resident #5, updated on 8/28/24, showed that the cardiologist had ordered Lasix and directed staff to obtain daily weights. If there was a gain of 2-3 pounds overnight or 5 pounds in a week, staff were to notify cardiology. The Orders tab showed that Resident #5 had the following medication orders: b. rivastigmine patch 4.6 mg/24hr. Order dated 7/2/24 c. rivastigmine patch 9.5mg/24 hour transdermal. Order dated 8/28/24. According to the Medication Administration Record (MAR) for July, the rivastigmine patch 4.6mg. had not been given on the 3rd, 4th, or the 5th because it was unavailable. The August MAR showed that the rivastigmine patch 9.5 mg. had not been given on the 28th, 29th, 30th, 31st and September 1st, 2nd, and 3rd because it was not available. Staff were directed to monitor resident due to rivastigmine increase on 8/27/24. Assess, monitor for adverse reaction and effectiveness of medication document findings in a Progress Note. The Nursing Progress Notes indicated that the resident had no adverse reactions to increase in medication on the following dates: a. 8/29/24 at 8:48 PM b. 9/1/24 at 3:44 AM c. 9/3/24 at 5:57 AM d. 9/4/24 at 2:54 AM On 9/26/24 at 9:01 AM, Staff D, Licensed Practical Nurse (LPN) said that when a resident was put on a new medication or had an increase, there was an automatic alert in the electronic charting for staff to monitor for side effects or change in condition. She said that there was an option to say that medication hadn't been given. She did not remember what she had documented for response on the patch and thought that the alert hadn't come up until after the patch was delivered to the facility. On 9/26/24 at 10:40 AM the Director of Nursing (DON) acknowledged that there was an automatic assessment that popped up in the electronic chart for new medications. The nurses had an option to indicate that it hadn't been given. According to a facility policy titled: Documentation, last reviewed on 8/9/24, all nurse documentation would be completed, accurately, timely and reflect the care provided to the residents. Documentation was essential for ensuring continuity of care, meeting regulatory requirements and supporting legal, financial and clinical responsibilities.

Based on observation, interview and record review the facility failed to ensure that staff followed through with physicians' orders for 1 of 5 residents reviewed. Resident #5 had an order for furosemide (Lasix) related to congestive heart failure and rivastigmine for dementia. Staff failed to ensure that the medications were delivered and administered in a timely manner. The cardiologist directed staff to call if/when Resident #5 had weight gains and staff failed to follow through. The facility reported a census of 70 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 (severe cognitive deficits). Resident #5 was on high risk medications that included a diuretic, opioid and an antiplatelet. She had occasional pain and diagnoses that included heart failure, hypertension, diabetes mellitus, Alzheimer's Disease, The Care Plan for Resident #5, updated on 8/28/24, showed the cardiologist had ordered Lasix and directed staff to obtain daily weights. If there was a gain of 2-3 pounds overnight or 5 pounds in a week, staff were to notify cardiology. The Orders tab showed Resident #5 had the following medication orders: a. furosemide 20 milligrams (mg) 1 tab daily. Order dated 5/22/24. b. rivastigmine patch 4.6 mg/24hr. Order dated 7/2/24. c. rivastigmine patch 9.5mg/24 hour transdermal. Order dated 8/28/24. According to the Medication Administration Record (MAR) for July, the rivastigmine patch 4.6mg. had not been given on the 3rd, 4th, or the 5th because it was unavailable. The August MAR showed that the rivastigmine patch 9.5 mg. had not been given on the 28th, 29th, 30th, 31st and September 1st, 2nd, and 3rd because it was not available. The MARs for Resident #5 showed that the furosemide had not been given on August 31st, [DATE]nd, and 3rd because it was unavailable. The following was included in the Nursing Progress Notes: On 8/27/24 at 5:29 PM, the resident had an increase in the Exelon patch to 9.5mg On 8/29/24 at 9:41 AM, the Exelon patch order was faxed to the pharmacy. At 9:42 AM, the medication orders sent to the Veterans Administration (VA). On 8/29/24 at 2:16 PM, the Primary Care Physician (PCP) indicated that scripts had been sent to VA on 8/28/24. On 8/31/24 at 6:23 PM, nurse attempted to call VA regarding furosemide order but the pharmacy was closed. On 9/1/24 at 1:41 PM, nurse called pharmacy for patch but they did not have in stock and will order. On 9/3/24 at 10:19 AM, called to local pharmacy for furosemide and patches, they received the order today. On 9/4/21 at 12:21 PM resident started on increased dose of patch. On 9/24/24 at 10:47 AM, Staff A, Registered Nurse (RN) said that getting medications from VA was sometimes challenging. They assumed that it would take at least 10 days to get the medications delivered so they would try to go to the resident's home pharmacy to get a supply until the VA supply was delivered. She said that she had called the pharmacy several times to try to get the medications for Resident #5. On 9/26/24 at 2:04 PM, Staff E, LPN said that she personally had gone to the pharmacy and got some Lasix for Resident #5 when she was out. According to the Orders tab in the electronic chart, Resident #5 had an order dated 1/12/24, for daily weights. If she had a weight gain of 2-3 pounds overnight, or 5 pounds in week staff were to call cardiology. Resident #5's weights included: On 7/24; 208 pounds (lbs.) on 7/25; 211 lbs. (weighed after breakfast) On 7/28; 208 lbs. on 7/29; 219 lbs. On 7/30; 207 lbs. on 7/31; 210 lbs. On 8/16; 204 lbs. on 8/17; 210 lbs. On 9/7; 195 lbs. on 9/9; 199.8 lbs. The Nursing Notes lacked reference to the weight gain, if there was a re-weigh, or if cardiology had been contacted. On 9/25/24 at 1:47 PM, Staff D, Certified Medication Aide (CMA) said that she was aware of weight parameters for Resident #5, and if/when there was a gain, she would weigh again to verify and then tell the nurse. She thought the nurses had followed through. On 9/26/24 at 2:04 PM, Staff E, LPN said that she was aware that the weights for Resident #5 had been out of parameters at times, and it was usually due to factors such as time of day, in or out of wheel chair, things in her chair etc. She said if the weight had been high, she would have asked the next shift re-weigh. She said that she personally called the doctor about weight gains and they said to keep monitoring. She said that she would have documented in the nursing notes or on the MAR. The MAR and Nursing Progress Notes lacked reference to re-weighs or doctor contact on the dates in question. On 9/26/24 at 10:40 AM, the Director of Nursing (DON) said that they've had challenges getting medication for Resident #5 related to family wishes, and processes at the VA, and the pharmacy. The processed medications are delivered to the home, and then they bring them to the facility. They prefer their chosen pharmacy be used in the instances where there is a lag in time to get medications from VA. The DON acknowledged that if a daily weight had been out of parameters, staff should have reweighed and followed through per doctor order. A facility policy titled: Unavailable Medications last reviewed on 12/23/23 showed that the facility would establish a procedure for handling instance when prescribed medications were not immediately available in the facility to ensure resident safety and continuity of care, while minimizing disruptions to treatment.

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards when a dietary staff member served food without completing hand hygiene prior to or during the meal service with contaminated hands. The facility reported a census of 62 residents. Findings include: During a continuous observation of the breakfast meal service on 11/29/23 at 7:48 AM Staff C, Dietary Aide, placed an English muffin in the toaster using her bare hands. Staff C didn't complete hand hygiene after they entered the kitchenette. Staff C crossed her arms and waited for the English muffin to toast. Staff C then pulled the English muffin out of the toaster with her bare hands, placed the English muffin on a plate, held the English muffin with bare hands and applied jelly. Staff C then scooped eggs on to the plate and took it to a resident. Staff C then returned to the kitchenette, again put toast in the toaster, picked up a plate, scooped eggs on the plate, pulled the toast from the toaster, applied jelly, and took the plate to a resident without completing hand hygiene. Staff C completed this same procedure throughout breakfast meal service without doing hand hygiene. The Hand Hygiene policy updated 1/1/23 defined the purpose of hand hygiene as to clean hands to prevent the spread of potentially deadly infections. Hand hygiene (e.g., hand washing and/or alcohol-based hand rub, ABHR): consistent with accepted standards of practice such as the use of ABHR in all clinical situations except: before eating, when hands are visibly soiled, and after using the restroom. On 11/30/23 at 10:31 AM the Administrator stated that the facility's expectation is to complete hand hygiene prior to food service and anytime they contaminated or soiled their hands.

Based on observations, facility record review and staff interview the facility failed to properly administer medications for 1 of 16 residents reviewed (Resident #58). Findings included: Resident #58's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 13, indicating no cognitive impairment. The MDS included diagnoses of type II diabetes mellitus, a stroke, and cancer. Resident #58 received a hypoglycemia (low blood sugar) medication (insulin) for 7 out of 7 days in the lookback period. Resident #58's Active Physician Orders listed an order dated 11/29/23 for Novolog FlexPen insulin 100 units based on a sliding scale insulin, inject subcutaneously twice a day per blood glucose result. Resident #58's November 2023 Medication Administration Record (MAR) reflected that he received the wrong dose of Novolog as directed on the sliding scale: a. Per the sliding scale a blood sugar between 250 and 299 milligram per deciliter (mg/dl) required 6 units of Novolog. i. On 11/19/23 at 5:00 PM Resident #58 received an incorrect dose of 8 units of Novolog for a blood sugar of 259. b. Per the sliding scale a blood sugar between 376 and 399 mg/dl required 14 units of Novolog. i. On 11/28/23 at 5:00 PM Resident #58 received an incorrect dose of 10 units of Novolog for a blood sugar of 383. The Preparation for Medication Administration policy revised in 2020 directed to administer medications in accordance with written orders of the attending physician. If the dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider's pharmacy for clarification prior to the administration of medication. In an interview on 11/30/23 at 12:05 AM, the Director of Nursing (DON) stated she expected the staff to administer sliding scale insulin per the physician's orders.

Based on resident interview, resident family interview, record review, staff interview, and policy review the facility failed to provide sufficient nursing staff to assure residents' safety by not responding to call lights in a timely manner (less than 15 minutes) to 1 of 8 residents reviewed (Resident #10). Findings include: Resident #10's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident #10 required total assistance of two persons with transfers. In addition, Resident #10 required extensive assistance of two persons for bed mobility, dressing, toilet use, and personal hygiene. The MDS identified Resident #10 as frequently incontinent of bowel and bladder with no toileting program. The MDS listed that Resident #10 frequently had pain of 4 out of 10, indicating moderate pain, that has limited his day-to-day activities and mad it hard to sleep at night. On 11/28/23 at 10:30 AM Resident #10 reported that it takes a while for someone to answer their call light. On 11/28/23 at 10:30 AM Resident #10's Family Member added that Resident #10 often states that the staff take a while to answer their call light. The Device Activity Report (call light time logs) for room E105, Resident #10's room, from 11/22/23 through 11/29/23 reflected 8 call time responses of longer than 15 minutes. On 11/29/23 at 10:19 AM Staff A, Certified Nurse Assistant (CNA), reported when a resident turns on their call light, the pagers the staff carry vibrate. Staff A added that he expected staff to answer the call lights in 10 minutes or less. Staff A then revealed that if the pager went off for longer than 10 minutes, this causes the nurse manager's pager to alert during the day shift. After receiving the pager alert, she comes out to try and figure out why the call light is still on. On 11/29/23 at 10:37 AM Staff B, Registered Nurse (RN), said she expected staff to answer call lights in 15 minutes or less. On 11/29/23 at 10:52 AM the Director of Nursing (DON) reported she expected the staff to answer the call lights in 15 minutes or less. The DON added the expectation is the facility's policy. The Call Light/Call Pendant policy reviewed 8/18/23 instructed to answer call lights in a timely manner. The goal is to answer them within 15 minutes.

Based on observations, record review, staff interviews, and policy reviews, the facility failed to change and label oxygen tubing for 1 of 2 residents reviewed (Resident #118). Findings included: Resident #118's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. The MDS included diagnoses of Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), hypertension (high blood pressure) and pneumonia. Resident #118 used oxygen while a resident in the last 14 days. Resident #118's Active Physician Orders included an order dated 11/10/23 for oxygen 1-4 Liters per nasal cannula (L/NC) to keep his oxygen saturation above 90%. The facility lacked a physician's order to change oxygen tubing. The Care Plan revised 11/21/23 indicated that Resident #118 received oxygen 1-4 L/NC to keep his oxygen saturation above 90%. The Care Plan failed to identify when to change oxygen tubing. On 11/28/23 at 9:49 AM, observed Resident #118's oxygen concentrator tubing not labeled with a date. In an interview on 11/28/23 at 9:50 AM, Resident #118 could not recall when someone last changed his oxygen tubing. In an interview on 11/29/23 at 1:45 PM, Staff L, Registered Nurse (RN), reported physician orders should include an order to change oxygen tubing every Monday during the PM shift. The Administration of Oxygen Therapy policy reviewed 1/7/23 directed to change the oxygen tubing weekly and as needed. The policy also directed the staff to document it on the medication/treatment record. In an interview on 11/29/23 at 1:58 PM, the Director of Nursing (DON), reported the physician's orders include the order to change the oxygen tubing weekly. The nurse documents when they change the oxygen tubing on the Medication Administration Record. The DON reviewed Resident #118 orders then confirmed the facility lacked an order to change Resident #118's oxygen tubing weekly.

Based on clinical record review, policy review, and staff interviews the facility failed to provide a comprehensive care plan that adequately reflected the resident's medications for 3 of 6 residents reviewed (Resident #2, #57, and #58). Two of the residents (Resident #57 and #2) required the use of a pain medication (tramadol), but the Care Plan lacked the use of and what to monitor for tramadol. Finding include: 1. Resident #57's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 99, indicating she couldn't complete the interview. The MDS included a diagnosis of pain in an unspecified hip. The MDS indicated that he used an opioid in the lookback period. Resident #57's November 2023 Medication Administration Record (MAR) included an order dated 10/10/23 for tramadol (an opioid), 50 milligrams (mg) one tablet every 6 hours as needed (PRN). The MAR reflected she received Tramadol 25 times in the month. Resident #57's Care Plan last reviewed 11/28/23 lacked the use of an opioid and what to monitor due to the use of the medication. On 1/30/23 at 11:35 AM Staff D, Registered Nurse Manager, said she completed Resident #57's Care Plan. The Care Plan expectation is to include an opioid, if a resident used one. On 11/30/23 at 9:46 AM the Director of Nursing (DON) reported she talked to the facility's Pharmacist who said the Care Plan did not require the use of an opioid if ordered as needed and not scheduled. The DON said she would address the opioid on the Care Plan if scheduled. The DON explained that if she wrote the Care Plan, she would include what side effects to look for; such as an overdose or severe constipation. 48004 2. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of congestive heart failure (impaired heart function), diabetes mellitus, and rheumatoid arthritis (a disease that makes your immune system attack your own joints, causing pain, swelling and stiffness). Resident #2's Active Orders included an order for Tramadol 50 mg tablet give 1 tablet by mouth four times a day. Resident #2's November 2023 MAR reflected that she received Tramadol 50 mg four times a time for the period reviewed. Resident #2's Care Plan lacked what to monitor due to the use an opioid. 44420 3. Resident #58's MDS assessment dated [DATE] identified a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of type II diabetes mellitus, a stroke, and cancer. Resident #58 received a hypoglycemia (low blood sugar) medication (insulin) for 7 out of 7 days in the lookback period. Resident #58's Active Physician Orders listed an order dated 11/29/23 Levemir FlexPen insulin (used to treat diabetes) to inject 38 units subcutaneously (under the skin into the fatty tissue) every morning and evening. In addition, he used a Novolog FlexPen insulin 100 units based on a sliding scale insulin injected subcutaneously twice a day per blood glucose result. Resident #58's November 2023 Medication Administration Record included the following orders a. Levemir FlexPen insulin 38 units every morning and evening b. Novolog FlexPen insulin 100 units sliding scale insulin twice daily per blood glucose result. Resident #58's Care Plan revised 11/22/23 lacked the use of insulin in the treatment of type II diabetes mellitus. The Comprehensive Care Planning policy revised 4/9/23 indicated the comprehensive care plan is person centered, consistent with their rights, and that it includes measurable goals and timeframes to meet the residents medical, nursing, and mental psychosocial needs based on the comprehensive assessment. On 11/30/23 at 12:05 AM, the DON said she expected the Care Plan to include insulin information such as usage, goal, and approach.

Based on observations, clinical record review, policy review, and staff interviews the facility failed provide residents clean and in good repair equipment for 1 of 6 residents reviewed (Resident #29). Finding include: 1. Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 99, indicating she couldn't complete the interview. Resident #29 required a wheelchair for mobility. An observation on 11/27/23 at 1:06 PM revealed yellow foam hanging out of Resident #29's wheelchair headrest. An observation on 11/28/23 at 9:50 AM revealed yellow foam hanging out of Resident #29's wheelchair headrest. An observation on 11/29/23 at 10:43 AM revealed yellow foam hanging out of Resident #29's wheelchair headrest. On 11/29/23 at 10:51 AM Staff F, Certified Nurse Aide (CNA) explained if she found a resident's equipment in need of repair, there is a spot on the computer to report it, and she needed to tell the nurse. Staff F said after making a work order, maintenance received a notification. Staff F reported Resident #29's headrest did not have the tear for long, only about a week. Staff F stated she didn't fill out a work order or notify a nurse, but thought someone else did. On 11/29/23 at 10:54 AM Staff G, CNA, explained that if she found a wheelchair in need of repair and it one of the facility's, the staff would fill out a work order. The restorative department would fix the wheelchair. Staff G stated if the facility did not own the wheelchair, the facility would contact the family. Staff G reported that Resident #29's had his headrest like that for about a week or so. Staff G added that she didn't think the facility owned the wheelchair. She would tell the nurse if she found a wheelchair in need of repair. Staff G stated she told Staff H, Licensed Practical Nurse (LPN), and Staff I, LPN, Resident #29's headrest needed repaired. On 11/29/23 at 10:58 AM Staff J, CNA, said if she found a wheelchair that needed repaired she usually talked to the restorative department and then they would fix the wheelchair. Staff J stated if hospice owned the wheelchair, then they would have it repaired. Staff J stated she noticed Resident #29's headrest had a tear but did not know how long. On 11/29/23 at 11:00 AM Staff H reported Resident #29 used hospice services before but not at the time. Staff H explained if someone notified her about a headrest that needed repaired, she would trade out the headrest. Staff H stated she had noticed the tear in Resident #29's headrest but has not had time to look for one. Staff H stated she didn't know how long Resident #29's headrest had the tear. She noticed that week that it was torn. Staff H stated she had not reported the torn headrest to anyone. On 11/29/23 at 1:31 PM Staff K, Environmental Director, said if a wheelchair needed repaired whoever found the item broken, they would fill out a work order. Staff K added they did not have a work order turned in for Resident#29's wheelchair or headrest. On 11/29/23 at 1:20 PM Staff D, Registered Nurse Manager, stated she would have expected someone to replace Resident #29's headrest. The Maintaining Equipment policy updated 1/7/23 instructed upon identification that equipment needed repair, the staff member will mark the item as out of service, and complete the maintenance request on the computer. If the equipment needed emergency repairs due to an immediate need, the staff will inform maintenance immediately to allow them to prioritize the immediate repair of the equipment. On 11/30/23 at 10:20 AM the Director of Nursing (DON) stated the facility had a staff member assigned to check the wheelchairs weekly. The staff did miss the wheelchair checks recently. The DON explained if the staff did not get to check the wheelchairs, someone else would follow-up the wheelchair checks. The DON reported that she expected someone to Resident #29's headrest would have been seen and replaced.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure the availability of soap and paper towels at a handwashing sink in the kitchen. The facility did have paper towels available in the kitchen sitting on the garbage can. Observations determined the kitchen had outdated leftovers in the walk-in cooler, staff placed a prepared plate of food on a dirty steam table, and the juice machine had juice draining down the front of it. This had the potential to affect all residents who received meals from the kitchen. The facility reported a census of 69 residents. Findings included: The facility's Dietary Infection Control policy dated 2005, directed that all staff are to wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way such as sneezing, using the restroom, handling poisonous compounds, dirty dishes, or handling clients. The policy further revealed, all leftovers are labeled, covered, and dated when stored. They are to be used within 48 hours (or discarded). During the initial tour of the kitchen conducted with the Certified Dietary Manager (CDM) on 9/19/22 at 10:53 AM, the soap dispenser was observed to be out of soap at the handwashing sink. There were no paper towels observed in the dispenser, but there was a roll of paper towels on the lid of a trash can located beside the handwashing sink. In the walk-in cooler, there was a container of country gravy marked 9/10 Country Gravy and one container of turkey marked 9/9 Med. Per the CDM, the country gravy was prepared and refrigerated on 9/10/22 and the turkey was placed in the walk-in cooler on 9/9/22; these items were observed to be thrown in the trash by the CDM at that time. During an interview on 9/10/22 at 11:45 AM, the CDM stated environmental health staff replaced the soap in the soap dispenser while the surveyor and CDM were outside touring the garbage dumpster. In an interview on 9/22/22 at 9:41 AM, the Registered Dietitian stated the soap in the soap dispenser should have been replaced as soon as it was empty. During the lunch meal observation on 9/20/22 at 11:20 AM, cooked food items were taken to Unit B and placed on a steam table. The steam table was observed to have a liquid spill and a dried substance on the top surface of the table, which was not cleaned by staff before the cooked food items were placed on the steam table. There was also juice observed draining down the front of the juice machine. In an interview on 9/22/22 at 11:56 AM, Staff C, Dietary Aide, stated she cleaned the kitchen to include the steam table and juice machine after the meals were served.

Based on clinical record reviews and staff interviews, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one (Resident #1) of one sampled resident whose MDS assessments were reviewed for timely completion/submission. The facility reported a census of 69 residents. Findings included: Resident #1's Resident Face Sheet documented an admitted [DATE] and discharged date of 5/24/22. Resident #1's medical record lacked a discharge MDS assessment. In an interview on 9/21/22 at 12:42 PM, Staff D, Nurse Manager, stated Resident #1's discharge MDS assessment should have been completed. Staff D explained the MDS was overlooked, and it should be completed as soon as possible. During an interview on 9/22/22 at 8:47 AM, the Administrator confirmed Resident #1's discharge assessment was not done. According to the Administrator, Nurse Managers were to conduct a discharge MDS assessment upon a resident's discharge from the facility. Per the Administrator, this one just got overlooked as there was some turnover in staff at that time; however, the MDS needed to be done on time. In an interview on 9/22/22 at 8:56 AM, the Director of Nursing (DON) explained the Nurse Managers were responsible to ensure the completion of a discharge MDS assessment. The DON reported that a discharge MDS should be done within seven days of a resident's discharge, or death, but ideally as soon as possible. According to the DON, by not completing this MDS it could affect the payments the facility received, and if a resident was receiving skilled nursing care, it could affect the resident's reimbursements. The DON confirmed the facility did not have a policy to address the completion of a discharge MDS.

Based on clinical record reviews, facility policy, and staff interviews the facility failed to ensure that each resident receives adequate supervision for 1 resident (Resident #4), who was transferred via a mechanical full-body lift with one staff member. The facility reported a census of 63 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #4 with severely impaired daily decision making abilities, short and long-term memory impairments. The MDS revealed Resident #4 required extensive assistance of two people for bed mobility, locomotion on the unit, eating, dressing, toilet use, and personal hygiene. The MDS indicated Resident #4 as non ambulatory. Resident #4 required total assistance of two people with transfers. The MDS documented Resident #4 with upper extremity impairments on both sides. The MDS documented Resident #4 usually made herself understood, she usually understood others, and had impaired vision. The MDS added that Resident #4 had no behaviors or didn't resist cares. The MDS included diagnoses of [CONDITION(S)], non-Alzheimer's dementia, and [CONDITION(S)]. The MDS documented that Resident #4 had no falls since the previous assessment or most recent entry. The Care Plan Focus areas and interventions dated 2/17/22, contained extensive information that included the following: a. Full-body mechanical lift with assist of 2 for all transfers. b. Use the size large full body full-body mechanical lift pad. c. Resident #4 used a wheelchair with a cushion and foot board for mobility. Resident #4 didn't not propel herself. At times, Resident #4 could have legs crossed in her wheelchair, but didn't ambulate (walk). d. Decreased range of motion in bilateral (both) upper and lower extremities e. Resident #4 could assist with holding onto the assistive bar during positioning The Facility Self-Report dated 3/9/22 at 3:00 p.m., documented that a full investigation and interviews with staff that worked over the previous few days promptly began on the morning of 3/9/22. During the interview process and staff interviews, staff indicated there was no incidents that occurred to this resident during transfers, one staff member did admit that they did transfer this resident with one person using the full-body mechanical lift on the evening of 3/7/22, but states that this resident did not hit any extremities during the transfer. The staff member who admitted to the one person transfer with full-body mechanical lift was immediate suspended pending further investigation. Immediate re-education provided to all staff regarding two person assist with full-body mechanical lift required at all times. During an interview on 4/28/22 at 10:10 a.m., the Administrator confirmed and verified that the expectation for the staff was to use two people when using the full-body mechanical lift. The Hoyer Lift Policy dated 5/18, documented that a full-body mechanical lift would be used by ALL nursing staff in transfer assistance, transfers of residents as posted, and per the Care Plan for the benefit of residents and staff physical safety. A resident that their Care Plan directed the use of a full-body mechanical lift, shall use a full-body mechanical lift for all transfers. In order to use any other type of transfer assistance, an order must be obtained for re-evaluation. At that time the resident must be re-evaluated by a physical therapist. The Policy directed the following safety measures: a. Lift full-body mechanical lift arm up until the buttocks were above the mattress. Be sure to lock the release valve. One person assisted with raising and supporting the residents head, while the other person raised the full-body mechanical lift. b. One person will support the resident while the other moves the resident to chair. Be sure to spread full-body mechanical lift legs wide apart before removing. c. Employees will be counseled initially if not practicing this policy, but then a written warning will be given. Fall Lift Policy Addendum, reviewed 10/11/17 directed that residents, staff members, and visitors that fall in the main building would be lifted from the floor with a full-body mechanical lift and with two people.

Based on observation, record review and staff interview, the facility failed to serve appropriate portions to 6 of 6 residents on a mechanical soft diet, and 6 of 6 residents on a pureed diet in one unite. The facility reported a census of 51 residents. Findings include: The house mechanical soft diet for noon on 5/18/21 included 1 baked potato with margarine, with no skin. The pureed diet included 1 serving of pureed smoked pork chop with cherry sauce. The Diet Roster printed 5/17/21 showed 6 residents on mechanical soft diets and 6 residents on pureed diets in the [NAME] unit. On 5/18/21 at 7:54 AM Staff G Cook identified 6 residents on pureed diets in the [NAME] unit. At that time, observation showed Staff G wash her hands and apply gloves. Staff G then placed 8 pork chops and 8 slices buttered bread in the robot coupe. She added cherry sauce and water to the robot coupe and pureed. She measured the contents at 7 cups and by checking the chart stated each resident would need a #8 and a #10 scoop of the pureed pork. She portioned out 6 #8 scoops and 6 #10 scoops into a pan for the [NAME] unit. Observation on 5/18/21 at 11:51 AM showed Staff A Dietary Aide begin serving the noon meal (on the [NAME] unit). Staff A served residents on mechanical soft diets 1/2 of a baked potato with the skin removed. She served 6 residents mechanical soft diets. Staff A served residents on a pureed diet 1 scoop of pureed pork. She served 6 residents the pureed pork. On 5/18/21 at 12:23 PM Staff A finished the meal service. Staff A stated she used a #10 scoop to serve the pureed pork and confirmed the pan of pureed pork remained 1/2 full. On 5/18/21 at 2 PM the Dietary Supervisor (DS) stated dietary personnel should check the menu in the kitchen for the scoop size needed for pureed foods. She said Staff A did not check. The residents on pureed diets should have received a #8 and a #10 scoop of the pureed pork. Residents did not receive the appropriate portion of pork and received too little. On 5/20/21 at 9:27 AM the DS revealed no residents in the [NAME] unit on small portions. All residents having baked potato should have received a whole potato. The facility Portion Control 2005 directed staff to provide residents appropriate portions of food as planned on the menu. Serving too small portions resulted in the residents not receiving the nutrients needed.

Based on observation, record review and staff interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety. The facility reported a census of 51 residents. Findings include: 1. Observation on 5/17/21 at 12:05 PM showed Staff B Licensed Practical Nurse (LPN) wash his hands and put peanut butter on bread, handling the bread with bare hands. He left the area and obtained jelly, washed his hands and put the jelly on the bread, handling the bread with bare hands. He cut the sandwich and placed the sandwich on a plate with bare hands and served it to Resident #39. 2. Observation on 5/18/21 at 7:54 AM showed Staff G Cook wash her hands apply gloves. Staff G placed 8 pork chops in the robot coupe. She changed gloves without hand washing, buttered 8 slices of bread, placed them in the robot coupe, and removed the gloves without handwashing. She added cherry sauce and water to the robot coupe and pureed. She measured the contents. She portioned out 6 #8 scoops and 6 #10 scoops into a pan for the [NAME] unit. She put on gloves and prepared 2 additional pork chops, changed gloves without washing her hands and added bread. She placed 8 stuffed peppers into a cleaned robot coupe, put on gloves without washing hands and placed butter on 8 slices of bread and then into the robot coupe. She removed gloves without washing her hands and poured tomato juice into the robot coupe and pureed. She measured the contents and stated residents on pureed diet would receive a #8 and #10 scoop of pureed stuffed peppers. Staff G washed her hands before preparing additional stuffed peppers. On 5/18/21 at 2 PM the Dietary Supervisor (DS) said staff should wash their hands before putting on gloves, when gloves are changed, and when gloves are removed. Staff should not use bare hand contact with food that would be served to residents. The facility policy Handwashing 2005 documented the procedure included washing hands before donning gloves for working with food. The policy updated 6/15/09 Use of Plastic Gloves documented staff should wear plastic gloves when handling food directly with hands to ensure bacteria not transferred from the food handler's hands to the food product being served. Staff should wash hands when entering the kitchen and before applying plastic gloves, and after removing gloves.

Based on record review, observation, staff interview, and policy review, the facility failed to provide appropriate infection control practices during personal care for 1 of 6 residents observed (Resident #34), handling linen during wound care for 1 resident of 3 residents observed (Resident 5), and for 2 residents observed during medication administration (Residents #13 and #30). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set Assessment (MDS) dated [DATE], documented Resident #34 with short term memory impairment, moderately impaired cognitive skills for daily decision making, required extensive assistance with toileting and personal hygiene, and always incontinent of bowel and bladder. The MDS revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, with most recent update on 1/31/21, revealed the resident with a history of urinary tract infections and dementia. Interventions revealed the resident wore incontinence briefs and directed staff to check and change the resident every 2 to 3 hours and when needed and to apply Tena cream to prevent skin breakdown. Observation on 05/18/21 at 12:17 p.m., showed Staff N, CNA (Certified Nursing Assistant) and Staff O, LPN (Licensed Practical Nurse) used a full body lift and transferred Resident #34 from a wheel chair to bed. Staff N provided incontinence care and identified the resident as incontinent of bowel and bladder. Staff N used folded wash cloths and provided anterior incontinence care in an appropriate manner. Staff turned the resident to her side and used several folded wash cloths to provide incontinence care in an appropriate manner for a large amount of soft stool until the resident clean. Staff N failed to change gloves, patted the resident dry with clean wash cloths, placed a clean brief under the resident's buttocks, removed her gloves, and secured the brief tabs before sanitizing her hands. On 5/19/21 at 4:30 p.m., the Applewood Unit Manager verified Staff N needed to remove gloves and wash hands or sanitize after completion of bowel incontinence before the clean brief applied. The facility procedure, Hand Hygiene Techniques, dated 5/2018, directed staff to remove gloves when hand contamination activities completed and when moving from one procedure to another during cares and to wash hands after glove removal. 2. A 5/1/21 to 5/31/21 Medications Flowsheet documented Resident #13 received Calcitonin (salmon) non aerosol nasal spray (used to slow down bone loss due to osteoporosis), 200 units, 1 spray daily. Observation of the resident's medication administration on 5/18/21 at 10:00 a.m., revealed Staff M, LPN (Licensed Practical Nurse) dropped the Calcitonin box on the floor while preparing medication for administration. Staff M picked the box up and placed the box in the resident's medication storage cabinet without sanitizing the box. Staff M placed the Calcitonin bottle into the box after administered to the resident. On 5/20/21 at 8:50 a.m., the DON (Director of Nursing) stated since the Calcitonin box fell on the floor, staff member needed to obtain a plastic bag to store the Calcitonin bottle since a box can not be sanitized. 3. A 5/1/21 to 5/31/21 Medications Flowsheet documented Resident #30 received [MEDICATION(S)] eye drops (used to treat dry eyes), one drop to each eye 3 times daily. Observation showed on 5/19/21 at 9:10 a.m., Staff D, LPN remove the [MEDICATION(S)] eye drops from a plastic bag, place the plastic bag on the resident's bedspread without a barrier underneath, and administered the [MEDICATION(S)] eye drops. Staff D placed the [MEDICATION(S)] bottle into the same bag and placed the bag into the medication cart. On 5/19/21 at 8:50 a.m. the DON stated staff should have replaced the plastic bag with a clean bag before storing the [MEDICATION(S)] in the medication cart. 4. A Minimum Data Set (MDS) assessment, dated 2/18/21, revealed Resident #5 scored 10 on the Brief Interview for Mental Status indicating moderate cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] a. Observation revealed on 5/19/21 at 9:21 AM Staff C Certified Nursing Assistant (CNA) enter the resident's room to get the resident on the bath chair. Staff C called for the nurse because the resident refused a bath. Staff C threw the resident's pajamas on the floor and removed the sheets from the bed. She picked the pajamas up from the floor and the sheets from the bed and held them up against her uniform as she exited the room. b. Observation showed on 5/19/21 at 9:21 AM Staff D Licensed Practical Nurse (LPN) enter the resident room with dressing/treatment supplies and place them on the resident's dresser without a barrier. She then placed some items directly on the floor, 2 rolls of tape, 2 paper measuring devices, and a plastic medicine cup with what she identified as Vaseline. She put barriers with gauze on them on the floor as well. She used one of the barriers under the resident's foot. She removed the dressing (from the left heel) that appeared dark brown, indicating she thought from [MEDICATION(S)] (antiseptic). She picked up one of the measuring tapes from the floor and measured the wound. The area to the medial left heel measured 1.2 by 0.8 centimeters (cm) and appeared white. Staff D walked over to the sink and soaked a 2 by 2 guaze with [MEDICATION(S)] and applied it to the ulcer, covered it with a 4 by 4 gauze , picked up the tape from the floor and applied pieces of tape over the 4 by 4 gauze. She removed her gloves, opened a drawer of the resident's dresser and obtained clean socks, put them on the resident and then washed her hands. She donned gloves, removed a dressing from the resident's chest revealing a dark area. She picked up the 2nd measuring device from the floor, and held it to her chest to measure the area at 1 by 0.7 cm. She applied the Vaseline (from the med cup on the floor) and covered the area. After handling the items from the floor, she handled both the bottle of [MEDICATION(S)] and the plastic bag it came in. After taking the resident out of the room, she returned and placed the [MEDICATION(S)] in the med cart. On 5/19/21 at 2:15 PM the Director of Nursing (DON) stated staff should not hold linen against their uniforms, or place treatment/dressing supplies on the floor. The policy Infection Control-Linen Handling dated 7/2020 included directives that soiled linen should not come in contact with the floor or furniture, and do not hold linens against clothing when transporting.

Based on record review and staff interview, the facility failed to follow physician's orders for weekly weights for 1 of 4 residents reviewed for nutrition (Resident #6). The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) assessment, dated 2/18/21, revealed Resident #6 scored 8 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, ambulation, dressing, and toilet use. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician Order Report dated 4/1/21 to 5/31/21 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated of 2/25/21 included information that revealed the resident received a scheduled diuretic and directed staff to obtain weight weekly and notify the Primary Care Provider of weight gain/loss of 3-5 lbs. A Weight Record showed no weights documented between 11/24/20 and 12/28/20 (1 month), 12/28/20 and 1/12/21 (2 weeks), 2/9/21 and 2/27/21 (over 2 weeks), 3/5/21 and 3/18/21 (2 weeks), 3/18/21 and 4/1/21 (2 weeks), 4/1/21 and 4/16/21 (2 weeks), and 4/16/21 and 5/4/21 (over 2 weeks). On 5/19/21 at 7:32 AM Staff E Unit Manager stated the order for weekly weights was entered on the general flow sheet so the staff did not see it and it would not populate for them to sign off. She said they did weights every 2 weeks, so the order not followed.

Based on observation, record review and staff interview, the facility failed to provide perineal care in a manner to prevent urinary tract infection (UTI) for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) assessment, dated 2/18/21, revealed Resident #5 scored 10 on the Brief Interview for Mental Status indicating moderate cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan dated 2/25/21 included toileting with 1-2 assist and 4 wheeled walker for transfers. The resident needed assistance with peri-cares, had urinary incontinence and occasional incontinence with bowel. A Microbiology Routine Culture of urine collected 4/17/21 and verified 4/20/21 showed the resident with greater than 100,000 colony forming units per milliliter of the bacteria Enterococcus Faecium and citrobacter freundii. A Physician's Telephone Order dated 4/22/21 directed to administer [MEDICATION(S)] (antibiotic) 250 mg 2 times a day (BID) for 7 days for UTI. On 5/19/21 at 7 AM Staff D Licensed Practical Nurse (LPN) responded to reports from housekeeping of the resident trying to get up. The resident stated she needed to go to the bathroom. Staff F Certified Nursing Assistant (CNA) also responded and staff put a gaitbelt and shoes on the resident to transfer to the wheelchair, which required several attempts. Staff wheeled the resident to the bathroom and transferred her to the toilet and removed the wet incontinent pad. The resident stated she had a bowel movement. Staff D took the resident's pants and an incontinent pad to the bathroom area. She put the resident's pants on the grab bar and laid the new incontinent pad on the floor at the residents feet before placing the pad around the resident's thighs. The resident had a bowel movement and staff assisted the resident to stand and hold on to the grab bar. Staff D wiped the resident in the anal area with a wet washcloth turning the side of the cloth 3 times, handling with both gloved hands, then said she would wipe her in the front, and turned the cloth a 4th time and wiped the front perineal area. She then pulled up the new incontinent pad and pants before removing her gloves and doing hand hygiene. On 5/19/21 at 2:15 PM the Director of Nursing (DON) stated if staff cleaned the resident in the anal area during perineal care, she would expect staff would not use the same cloth to then clean the front perineal area. On 5/20/21 at 8:50 AM Staff E Unit Manager stated staff should not place incontinent pads, or supplies on the floor, because that would contaminate them. The facility Incontinence Care policy dated 7/2020 directed washing all soiled skin areas from front to back.

Based on observation, record review and staff interview, the facility failed to provide pressure reduction devices per wound nurse recommendation and physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 51 residents. Findings include: A Minimum Data Set (MDS) assessment, dated 2/18/21, revealed Resident #5 scored 10 on the Brief Interview for Mental Status indicating moderate cognitive impairment. The resident required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS described the following pressure sores: a Stage I: intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. b. Stage II: partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. c. Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. d. Stage IV: full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. e. Unstageable: known but not stageable due to coverage of wound bed by slough and/or eschar. A Progress note dated 12/2/20 at 3:28 PM documented the nurse noted the resident's left heel appeared purple and soft to touch, measuring 4 by 5 cm. The Physician's Order Sheet and Progress Notes by the Wound Nurse documented: a. On 12/10/20 the resident seen for a stage 2 pressure injury of the left medial heel measuring 4 by 3 cm with slight encrusted light brown tissue base with clear periwound (surrounding) skin. The wound nurse could not palpate a left dorsal pedis (foot) or posterior tibial (ankle) pulses. The resident used her feet to propel the wheelchair, and wore gripper socks. Unsure if shoes would be beneficial. b. On 12/24/20 the resident seen for the pressure injury measuring 2.6 by 3 cm, with eschar (necrotic tissue) measuring 2 by 2 cm, and the remainder of the wound base pink with a small amount of red drainage. The resident used her feet to move the wheel chair. The Wound Nurse Recommended [MEDICATION(S)] solution moistened 4 by 4 (gauze) to the left heel, secured with tape 2 times a day, no cleansing with dressing changes, and a Prevalon boot to the left lower leg on at all times. c. On 2/16/21 the resident seen regarding the unstageable pressure injury measuring 1.5 by 1.9 cm with black eschar tissue base, starting to demarcate (separate). The resident had a Prevalon boot. d. On 2/16/21 the heel pressure injury measured 1.5 by 1.5 cm with a light yellow tissue base, removed easily with cleaning. The resident wore a Prevalon boot. e. On 3/17/21 the resident seen for follow up of a resolving unstageable pressure injury of the left medial heel which measured 0.9 by 1.3 by 0.2 cm with pink tissue base and clear/intact peri-wound skin A Physician's Telephone Order dated 12/24/20 directed a Prevalon boot to the left lower leg at all times. The Progress Notes dated 4/6/21 at 11:53 AM the resident's daughter returned staff's phone call and the nurse asked her about getting slip on shoes for the resident so they could possibly keep the Prevalon boot off and assist with ambulation. The Care Plan with a start date of 2/25/21 included assessing skin per facility protocol, notifying the physician and family of any changes, and administering treatments as ordered. On 12/2/20 they noted a pressure injury to the back of the resident's left heel, the resident wore gripper socks or soft slippers instead of shoes, and encouraged to float heels while in bed. On 12/10/20 the resident seen by the Wound Nurse for a Stage II pressure injury, with orders for Skin Prep 3 times a day (TID). On 12/24/20 the resident seen by the Wound Nurse and Skin Prep discontinued. They started [MEDICATION(S)] Solution treatment and a Prevalon boot to the left foot at all times. On 2/4/21 seen by Wound Nurse, the left heel unstageable, continued with current treatment and Prevalon boot, improving. On 4/10/2021 the resident could wear shoes, put Prevalon boot to left foot on while in bed. Observation showed on 5/17/21 at 11:40 AM the resident seated in the wheelchair, with a cushion in the chair. The resident wore shoes and moved around in the wheelchair. Observation showed on 5/18/21 at 11:43 AM the resident seated in the wheelchair at the dining room table wearing shoes bilaterally. Observation showed on 5/19/21 at 7 AM Staff D Licensed Practical Nurse (LPN) and Staff F Certified Nursing Assistant (CNA) responded to reports from housekeeping of the resident trying to get up. Staff put the resident's shoes on and assisted with morning cares. Staff made no attempt to place the boot to the left foot. On 5/19/21 at 7:45 AM Staff E Unit Manager stated the resident wore the boot and still scooted around in the wheel chair. The boot would get displaced. She forgot they had an order to wear the boot at all times. She did not consult with the wound nurse. She said she actually retired in mid April. She wanted to have the resident seen by an actual wound doctor to find out if the wound might be vascular in nature. She revealed the resident hospitalized with Covid prior to admission and she felt the ulcer probably originated during that time and not assessed until after the resident lived at the facility a short time. On 5/19/21 at 2:15 PM the Director of Nursing (DON) stated she expected staff to follow the physician's order. The facility Skin Prevention Program reviewed 7/2020 included once a risk identified, staff should initiate preventative measures including using devices that relieved pressure on the heels.

Based on record review, staff interview and review of the facility policy/procedures, the facility failed to provide adequate supervision to protect Resident #2 against hazards from self and failed to use a gait belt as directed by the Care Plan which resulted in a fracture of the resident ' s upper arm (humerus bone). The sample consisted of 4 residents. The facility identified a census of 67 current residents. Findings include: 1. According to the MDS (minimum data set) dated 10/3/15 Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility, transfers and toilet use. According to the MDS the resident not steady and only able to stabilize self with staff assistance when moving from a seated to standing position. The MDS identified the resident had impairment on 1 side of the upper & lower extremities. Review of the care plan dated 10/8/15 revealed the resident with cerebral vascular accident and right sided hemiparesis. The care plan directed staff to transfer the resident with 1- assistance with a gait belt to the wheel chair for mobility or 1-assist with gait belt and cane for ambulation to and from the bathroom. Review of the Physician's Order Sheet and Progress Notes dated 11/25/15 revealed the resident had a right proximal humerus fracture. The order included a right arm sling and to recheck in 3 weeks. Review of the Fall Risk assessment dated [DATE] revealed the resident with a total score of 6. A total score of 10 or higher considered a high risk. Review of the Progress Notes dated 11/24/15 at 4:49 PM revealed Staff transferred the resident into the wheel chair from the recliner when she heard a pop. The resident raises that arm just so far, and had not been able to raise it above his/her head for awhile, finger nail beds blanche well, range of motion adequate for him/her in that arm and didn't have sling or splint on. He/she stated that the pain level at a 3 on a scale 0 to 10. The Physician notified and planned to see the resident on 11/25/14 at 10:00 AM. Message left with family. At 10:18 PM a bruise noted on the right bicep area 3.5 by 3.5 cm (centimeters). At 6:30 AM staff documented that the resident slept through the night with no complaints of pain and will continue to monitor. No swelling noted. The progress note dated 11/25/15 at 9:08 AM revealed a light purple discoloration noted to the right upper arm. Complaints of discomfort and he/she refused pain medication. A sling applied to help support the arm. At 9:30 AM the resident transferred to the Physician's office per van. At 10:45 AM The resident returned to the facility with family. The order revealed the resident had a right proximal humerus fracture with an order for [REDACTED]. Review of the written statement by Staff O, CNA (Certified Nursing Assistant) dated 11/25/15 revealed that on 11/24/15 around 3:30 PM she went into the resident's room. The resident asked her to help him/her transfer into the wheelchair from the recliner. She helped the resident up and he/she lost his/her balance along with the staff. When she caught her balance she grabbed on the the resident's arm and waist to keep the resident from falling and heard a pop. She immediately reported to the nurse and also the DON. (Director of Nursing). During an interview with the DON on 12/18/15 at 11:00 AM she stated that Staff O, CNA reported the incident to her immediately. The staff member had been in tears and admitted that she transferred the resident and did not use a gait belt. She further stated that she did something wrong and only going to pivot transfer the resident and didn't even think about the gait belt. The resident had lost his/her balance and she caught him/her. The DON said that she went and assessed the resident right away and called the Doctor. She further stated that staff are expected to always use a gait belt on a resident when assisted. Review of the Policy and Procedure titled Safe Resident Handling Policy dated 11/26/14 directed staff to do the following for Gait Belt Assistance of 1 person: a. Resident able to stand for at least 5 seconds, using mobility equipment if needed (i.e. walker or cane). b. Resident requires supervision or contact assistance when ambulating. c. Assistance with sitting to standing may be required by pulling the resident to a standing position using the gait belt. At no time will a caregiver lift the resident.

Based on observation, record review, policy review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents for five of eight residents reviewed (Resident #1, #3, #5, #6, and #7). The facility reported a census of 61 residents. Findings include: 1. Resident #1 ' s Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was totally dependent on two staff members for bed mobility, transfer, dressing, toileting and bathing. Resident #1 required total dependence on one staff member for locomotion on and off the unit and personal hygiene. Resident #1 utilized a wheelchair for transportation. A balance during transitions and walking test identified Resident #1 as not steady only able to stabilize with staff assistance when turning around and surface to surface transfers. Resident #1 exhibited bilateral upper extremity impairments. The MDS dated [DATE] identified Resident #1 as severely cognitively impaired with short and long term memory deficits. The MDS listed [DIAGNOSES REDACTED]. The Care Plan dated 4/23/13 listed an intervention for Resident #1 as required extensive assistance from 1-2 staff due to [DIAGNOSES REDACTED]. a. Resident #1 was totally dependent on staff for bathing and can be very rigid and resistive with cares. b. Resident #1 was non-ambulatory and transferred via Hoyer lift and 2 assist with wheelchair for mobility. (A Hoyer lift is a mechanical lift utilized by staff to transfer a resident.) Resident #1 was listed as dependent on staff to reposition in bed or wheelchair. c. Side rails used at the head of bed for boundary identification. Monitor for sliding out of wheelchair. Resident #1 used a reclining back wheelchair. d. Resident #1 was completely incontinent of bowel and bladder. Staff check and change every 2-3 hours and as needed and provide peri-care every shift and after each incontinence episode. An event report for Resident #1, dated 1/25/15 at 12:42 a.m., revealed a fall to the floor when the CNA (certified nursing assistant) rolled Resident #1 in bed. No injuries were noted per nursing assessment. The event report indicated Staff T CNA rolled Resident #1 away from her to change Resident #1 ' s incontinent brief and the resident's legs/body slid off the bed and Resident #1 fell to the floor. Review of the hospital radiology reports revealed the following. On 1/25/15 at 3:06 p.m. Resident #1 ' s left knee revealed a total left knee joint prosthesis with a displaced fracture noted in the distal femoral metaphysis at the level of the prosthesis. The radiology report of the left elbow dated 1/25/15 at 4:38 p.m. revealed severe osteoarthritic changes of the elbow joint especially along the ulnar aspect. No joint effusion or specific fracture or subluxation is noted. The computed tomography scan (CT-Scan) of the left knee revealed a slightly impacted comminuted distal femur fracture involving portions of the distal femur at the level of the femoral component of total knee arthroplasty. Mild displacement as described. On 2/10/15 at 11:17 a.m. Staff A, restorative aide, interviewed and indicated Resident #1 was totally dependent on staff for activities of daily living and was stiff, resistive and always tight. Staff A, indicated Resident #1 did not pull away but was rigid in posture and would relax after staff talked with him/her. Staff A stated Resident #1 as able to lift his/her legs approximately an inch or two off the bed but his/her legs appeared thick, and if Resident #1 started to slide off the bed he/she was not able to self-correct from falling. On 2/10/15 at 12:57 p.m. Staff C (Certified Nurse Aide), CNA, indicated after breakfast on the morning after Resident #1 fell out of bed, Staff A assisted Staff Q, CNA, transfer Resident #1 to bed to provide peril care. Staff C confirmed Resident #1 is normally tense and tight during peril-care, but felt something was different because Resident #1's leg was not as tense. Staff C stated Resident #1's knee was a little swollen, and the day before no changes were noted during cares. Staff C indicated she informed Staff B, registered nurse (RN). Staff C and Q transferred Resident #1 prior to lunch with no change noted. At lunch staff noted Resident #1 had facial drooping. The aides transferred him/her to bed and noted Resident #1's knee was swollen. The aides notified the nurse (Staff B). On 2/11/15 at 5:07 a.m. Staff H, CNA, indicated until approximately 1.5 months ago, one staff member could roll Resident #1. Staff H observed Resident #1 had some mobility and could move his/her feet forward as he/she was rolled by staff. Staff H indicated from that time forward she always requested the nurse assist with cares for safety. Staff H indicated Resident #1 would move his/her midsection as if he/she was attempting to sit up as his/her feet would go forward. Staff H stated she informed the nurse she was not comfortable providing cares with only 1 staff member and always had another staff member present for personal care assistance for Resident #1. Staff H indicated she always rolled Resident #1 towards her because if you roll Resident #1 away from you, there's nothing to stop him/her if start to roll off the bed. On 2/12/15 at 11:42 a.m. Staff B, RN, indicated at breakfast Staff A reported Resident #1's mouth appeared a little droopy. Staff B aware of Resident#1's fall and at approximately 11:45 a.m. staff notified Staff B of Resident #1's left leg. Staff B stated Resident #1's knee was approximately 2-3 times larger than his/her norm and the left hand appeared swollen. Staff B indicated an assessment was completed, physician and family notified and Resident #1 was transferred per ambulance for evaluation and treatment. On 2/12/15 at 3:12 p.m. Staff Q, CNA, indicated after breakfast the morning after Resident #1 fell out of bed she assisted Staff C transfer Resident #1 to bed. Staff Q indicated something was "off" and informed the nurse that Resident #1 was not as stiff as usual. At lunch time, Staff Q stated she knew something was wrong as Resident was noted to be pale, tired and drowsy. Resident #1 was transferred back to bed and at that time staff aides noted Resident #1's knee and his/her left hand was swollen. Staff Q stated the affected knee was approximately twice the normal size. The aides notified Staff B RN. On 2/12/15 at 7:14 p.m. Staff S, RN, indicated just after midnight Staff T, CNA, came to the hall and told me Resident #1 was on the floor. Staff S, RN entered Resident #1's room and observed Resident #1 sitting on his/her buttocks with his/her back resting against the bed. Staff T informed Staff S she rolled Resident #1 away from her during peri-cares and Resident #1's legs went off the bed and Resident #1 just slid out of bed. Staff S and Staff T positioned Resident #1 on the floor. The nursing assessment revealed no apparent injury. Resident #1 was assisted per mechanical lift back to bed. Staff S stated she checked Resident #1at approximately 2:00 a.m., 3:00 a.m. and 4: 00 a.m. and included the application of a topical ointment to Resident #1's knees at approximately 3:00 a.m. and no signs or symptoms of injury were observed. Staff S indicated at the end of her shift at approximately 5-6:00 a.m. Staff S and Staff T got Resident #1 up for the day and no signs or symptoms of pain or injury were observed at that time. Staff S stated when she returned to work the next night and learned Resident #1 sustained a fracture she was shocked. Staff S indicated she provided education to Staff T to always roll the resident towards you for safety at the time of the incident. On 2/16/15 at 10:45 p.m. Staff T, CNA, confirmed she provided peri-care when Resident #1 slid out of bed. Staff T stated she always rolled the resident away from her while performing peri-care, but Staff S provided education after Resident #1 fell and always roll resident towards me for safety. Staff T indicated she performed peri-care independently for Resident #1 because he/she was usually rigid "like a board" and was aware that approximately once per month Resident #1 would just pul his/her knees up and scoot his/her feet to the side during cares. Staff T stated she attempted to pull the resident back as the resident slowly went to the ground with his/her legs straight out in front. Staff T confirmed the resident's bed was raised approximately 2.5 feet above the floor. Staff T informed Staff S, and the nursing assessment was completed, and no injuries were noted upon assessment. Staff T and Staff S transferred Resident #1 to bed per mechanical lift. Staff T stated she usually can roll Resident #1from side to side alone now, but when Staff T first began at the facility she learned she had to build muscle to complete cares along because Resident #1 was probably 2.5 times larger than her. Staff T demonstrated how Resident #1 slid out of bed in the presence of Staff S. Staff T placed her feet off the side of the bed and slowly slid onto the floor onto her buttocks. Staff T stated it was a slow slide. According to the facility Turning and Repositioning policy dated 2010 staff members are to review the care plan for the resident and instructions. The staff members are directed in the procedures to raise the side rails on the opposite side and lower the side rails on the working side of the resident. Move the resident toward the side of the bed nearest the staff member. If two CNA ' s used and a lift sheet then gently lift the resident towards the side of the bed the resident will be turned away from. 2. Resident #3's MDS with a reference date 11/15/14 identified a BIMS (Brief Interview for Mental Status) score of 6 reflected severe cognitive impairment. Resident #3 exhibited the following signs and symptoms of delirium: inattention and disorganized thinking. Resident #3 had the behavior symptom wandering identified. According to the MDS Resident #3 required extensive assistance from two staff for bed mobility and toileting and required extensive assistance of one staff for transfer, dressing personal hygiene and bathing. Resident #3 used a wheelchair for mobility. The MDS balance test section listed Resident #3 as not steady and only able to stabilize self with staff assistance. Resident #3 ' s [DIAGNOSES REDACTED]. Resident #3 had no falls with injury since the previous assessment. The MDS identified the resident's weight was 240 pounds and was 70" tall (5'10"). The Care Plan dated 11/20/14, identified Resident #3 at risk for fall and had a personal alarms at all times and required two staff members to assist transfer Resident #3 with an EZ Stand to wheelchair for mobility due to a fall on 2/5/15 while using the EZ Stand. The same Care Plan identified a safety concern and directed staff to check safety loop placement on the EZ Stand before transferring after the 2/5/15 incident. (An EZ Stand is a mechanical lift used to transfer a resident that is able to bear weight by lifting a resident who is in a standing position while the resident is strapped in the mechanical lift. A strap is placed around the mid abdominal area, around the waist and around the calves.) An incident report, dated 2/5/15 at 3:45 a.m., revealed Resident #3 fell to the floor when a CNA transferred Resident #3 in the EZ Stand and sustained 2 skin tears. Both skin tears are noted on the left foot. Skin tear #1 measured 2.4 centimeters (cm) by 2.2 cm with a skin flap noted to the left great toe. Skin tear #2 measured 0.6 cm by 0.2 cm on the left later upper left foot area. Staff treated the skin tears after the incident. On 2/11/15 at 5:27 a.m. Staff J, Licensed Practical Nurse (LPN), stated Staff O, CNA, called for assistance because Resident #3 fell during transfer with the EZ Stand. According to Staff J, Staff O stated Resident #3 removed a hoop from the EZ Stand and when Staff O raised Resident #3 in the EZ Stand the EZ Stand tipped and Resident #3 fell . Staff J stated Resident #3 failed to have a history of removing the straps. The intervention was 2 staff to assist with EZ Stand transfers. On 2/11/15 at 6:12 a.m. Staff O, CNA, confirmed Resident #3 fell during the EZ Stand transfer. Staff O stated she responded to an alarm and discovered Resident #3 up at the edge of the bed with his/her legs against the bed. Staff O stated she positioned the EZ Stand in front of Resident #3, secured the straps on top and at the waist but was unable to secure the strap around Resident #3's legs, so Staff O decided to raise the EZ Stand in order to move Resident #3's legs and secure the strap. As Staff O raised Resident #3, the EZ Stand and resident began to tip and Resident #3 fell forward in the lift prior to being lowered to the floor. Staff O stated as the EZ Stand with Resident #3 began to tip Staff O pushed upright to prevent Resident #3 from falling to the ground. (An EZ Stand is approximately 3.5 feet wide and 4' tall. The device has a large base in order to lift a resident that is secured with 3 straps to transfer.) Staff O demonstrated the EZ Stand transfer with the restorative aide. As Staff O demonstrated the incident, as the EZ Stand was raised the base slid forward. Staff O stated as the resident went up, he/she leaned forward against the bar/front of the EZ Stand and became tangled up in the waist strap. Staff O stated that as Resident #3 and EZ Stand tipped, Resident #3 was lowered to the ground and landed on his/her buttocks and sustained skin tears to his/her foot. Staff O stated she failed to check to ensure the hoops were all connected prior to raising Resident #3 in the EZ Stand. 3. Resident #5 MDS assessment with a reference date 1/10/15 identified Resident #5 exhibited short and long term memory deficits and was rarely/never understood with severe cognitive impairment. Resident #5 had the following signs and symptoms of delirium: inattention and disorganized thinking. Resident #5 required extensive assistance from two staff for mobility, transfers, dressing and toileting and required extensive assistance of one staff for locomotion on the unit. Resident #5 did not ambulate. A balance during transitions and walking test identified Resident #5 as not steady only to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and surface to surface transfers. Resident #5 utilized a wheelchair for mobility and had [DIAGNOSES REDACTED]. Resident#5 had two or more falls with no injury since the previous assessment. The Care Plan, updated and dated 1/15/15, identified Resident #5, required increased assistance with activities of daily living (ADLs), and required a wheelchair for mobility per self or staff. Observation on 2/10/15 at 4:10 p.m. revealed Staff N propelled Resident #5 from the shower room, through the doors to enter the dementia unit, to the resident's room. Staff N carried the wheelchair foot pedals in her left hand. Interview with the Administrator on 2/11/15 at 8:00 a.m. acknowledged staff members are not to propel residents in wheelchairs without foot pedals. 4. Resident #6 Minimum Data Set (MDS) assessment with a reference date 12/13/14 identified a BIMS score of 7 that reflected severe cognitive impairment. Resident #6 had the following signs and symptoms of delirium: disorganized thinking. Resident #6 required extensive assistance of one staff member for mobility, transfers, locomotion in his/her room, dressing, toileting and personal hygiene. Resident #6 ' s MDS section for balance during transitions and walking, identified Resident #6 as not steady only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet and surface to surface transfers. Resident #6 utilized a walker and wheelchair for mobility. The MDS listed Resident #6 ' s [DIAGNOSES REDACTED]. Resident #6 experienced two or more falls with no injury since the previous assessment. The Care Plan for Resident #6 dated 12/18/14, identified Resident #6 as a fall risk and required a wheelchair for mobility per self or staff. The Care Plan identified Resident #6 could wander in the unit in his/her wheelchair with wheelchair pedals off. The Care Plan dated 12/18/14 directed staff members to apply personal alarm and hip pads on at all times when Resident #6 up in the wheelchair. Resident #6 listed with a history of falls. Observation on 2/11/15 at 7:55 a.m. revealed Staff W propelled Resident #6 from his/her room to the dining room with no foot pedals. Observed Resident #6 propelled by the CNA approximately 12 feet with lower extremities suspended. Interview with the Administrator on 2/11/15 at 8:00 a.m. acknowledged staff members are not to propel residents in wheelchairs without foot pedals. 5. Resident #7 " s MDS dated [DATE] identified Resident #7 exhibited short and long term memory deficits and was rarely/never understood with severe cognitive impairment. Resident #7 required, extensive assistance from two staff members for mobility, transfers, walking in the room and toileting and required extensive assistance of one staff member for dressing and personal hygiene. A balance during transitions and walking test identified Resident #7 as not steady only able to stabilize with staff assistance when moving from seated to standing, walking, moving on and off the toilet and surface to surface transfers. Resident #7 utilized a walker and wheelchair for mobility. The MDS [DIAGNOSES REDACTED]. Resident #7 had one fall with no injury, and one fall with injury (i.e. skin tear, abrasion, laceration or complaint of pain) since the previous assessment. The Care Plan dated 1/29/15, identified Resident #7 required safety awareness and at risk of falls. Resident #7 required a wheelchair for mobility per self or staff or walker for short distances in room with a gait belt. The Care Plan directed a pressure alarm in bed or recliner. The bed in low position when Resident #7 was in bed and a mat on the floor beside the bed. On 2/11/15 at 6:12 a.m. Staff O, CNA, stated one night she transferred Resident #7 in the EZ Stand to toilet him/her. While Resident #7 was on the toilet attached to the EZ Stand another resident fell . Staff O left Resident #7 on the toilet attached to the EZ Stand. Staff O confirmed awareness that she should not have, but felt that was the only option. On 2/12/15 at 2:40 p.m. the DON stated the facility staff are not to leave a resident on the toilet attached to the EZ Stand at any time and was not aware of the incident Staff O reported. The DON stated Staff O should have called for assistance and systems were in place for her to call for assistance.

Based on observation, record review, staff and resident interviews, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for 3 of 4 residents in the sample (Residents #1, #2 and #4). Record review revealed the facility used personal alarm/s to alert staff of Resident #1's need to self transfer. Staff interviews identified Resident #1 would remove and or manipulate the clip alarm in the week prior to the 6/2/14 fall. On 6/2/14 Resident #1 fell and sustained a worsened L2 vertebral fracture and a new T12 vertebral fracture. Resident #1 fell again on 6/4/14 and the alarm was not attached to the resident. Observations during the investigation showed alarm intervention/s were not implemented to maintain the resident ' s safety. Resident #2 fell fracturing a hip when the motion sensor was in the improper place and did not sound when the resident got up from bed and attempted to use self transfer to the bathroom. When interviewed, staff did not know how long the motion sensor had been in the wrong place in the room. Resident #4 used a motion sensor that did not function at 2 observations during the investigation. The facility identified a census of sixty-eight (68) residents. Findings include: 1. A hospital discharge summary prior to admission to the nursing home dated 4/18/14 identified Resident #1 with a long history of smoking, bad lung disease and severe osteoporosis. The resident had a L4-L5 lumbar fusion with pedicle screw placement in the summer of 2013. The resident fell recently and suffered a mild approximately 20% displaced L2 compression fracture. The resident admitted to the hospital for pain control and stabilization of fracture using the orthotic back brace. A care area assessment dated [DATE] revealed the resident fell prior to admission. The resident did not have any falls at the facility since admission. The resident does not try to get up per self and uses the call light. An occupational therapist (OT) progress note dated 5/1/14 identified the OT instructed staff on proper donning of the resident's back brace. The OT recommended the use of one person assistance for all transfers. The OT discussed the resident's increased confusion and limited balance sitting and standing over the past 2 days. The nurse was going to request a UA (urinalysis) to rule out possible urinary tract infection. A UA completed on 5/1/14 was negative for infection. A Minimum Data Set (MDS) with assessment reference date of 5/16/14 assessed Resident #1 with a brief interview for mental status (BIMS) score of 12, which indicated he/she had moderate cognitive impairments. The resident required one staff to assist with bed mobility, transfers, dressing, and ambulation in room; and two staff for toileting. The resident used a wheelchair for mobility. The resident was occasionally incontinent of bowel and bladder. The facility had not attempted a trial of a toileting program (scheduled voiding, prompted voiding) and the resident was not on a toileting program. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the prior assessment. The 5/16/14 MDS identified the resident admitted to the facility on [DATE]. 5/10/14 fall: An event report dated 5/10/14 at 7:13 a.m. revealed staff found the resident facing the bed kneeling. The resident did not sustain injury. The resident was last toileted at 4 a.m. The call light was in reach and not on. Event report progress notes identified that staff found the resident on the floor next to the bed at 5:45 a.m. The resident did not recall how or why he/she ended up on the floor. Staff U (unit manager) documented on a summary form dated 6/18/14 that the resident was in bed prior to the fall and that staff was in the room 15 minutes prior to the fall to administer medication. Staff U documented that the intervention following the fall was "personal alarm when in room". A care plan dated 4/20/14 identified staff toileted the resident per request. 6/2/14 fall: An event report dated 6/2/14 at 6:15 p.m. and recorded at 9:38 p.m., revealed the resident fell while attempting to toilet self. The resident stated he/she thought he/she was going to the bathroom when the fall occurred. The resident stated his/her lower back and hips hurt. Observation showed the resident seated with legs bent to his/her right side leaning on the left arm with the resident's back leaned against the chair in front of the resident. The event report identified the resident removed his/her alarm. The report identified that staff did not toilet the resident on that shift. The resident did not use the call light and the resident unhooked the personal alarm. The event report listed the new intervention after the fall as: Pressure alarm in wheelchair and bed at all times. The evaluation section of the event form identified the resident as very confused at this time. The resident's medications were under review as well as cognition and pain due to the confusion. Resident progress notes dated 6/2/14 at 9:59 p.m., identified the resident transported to the emergency room (ER) after the fall. The physician called at 9:35 p.m. and stated the resident would return to the facility if he/she responded to pain medication and if not, the resident would spend the night at the hospital. The physician also reported the resident's previous L1-L2 fracture worsened. Progress notes dated 6/3/14 at 1:04 a.m., identified the resident admitted to the hospital for complaints of back pain. On 6/4/14 at 2:58 p.m., the resident returned to the facility via facility van. A hospital history and physical dated 6/2/14, identified the resident's chief complaint as back pain after a fall. The history and physical revealed the L2 compression fracture appeared worse than it did in April 2014. A discharge summary dated 6/3/14, identified an x-ray of the lumbar spine 2 to 3 views showed an intermediate compression deformity of the superior aspect of T12 vertebral body with approximately 30% loss of height and no retropulsion posteriorly. The summary identified the T12 vertebral compression deformity as new compared to previous examination on 4/12/14. The L2 compression deformity remained stable. An x-ray report dated 6/2/14 identified the T12 vertebral body fracture as age indeterminate and new compared to previous examination on 4/12/14. When asked, on 6/17/14 at 7:41 p.m. if the resident was known to remove or manipulate the alarm prior to the incident, Staff U (unit manager) stated no. Staff Interviews: Staff Working when the Fall Occurred: On 6/17/14 at 3:43 p.m. Staff C (licensed practical nurse) stated he returned from break and went to Resident #1's neighbor's room. He then observed the resident's chair in front of the resident with the resident on the floor. Staff C assumed the resident took his/her alarm off because it was on the end table with the string hanging down. He saw it attached shortly before that. He stated the resident attempted to get out of bed by self in the past but he had not seen the resident take the alarm off. He stated staff offered the resident toileting between 4:30 p.m. and 5 p.m. and the resident refused it. The resident was toileted per his/her request at that time. On 6/19/14 at 2:22 p.m. Staff I (nurse aide) stated 6/2/14 was the first time she worked with the resident. When she got report from the previous shift, she asked if the resident could use the call light and they said yes. Staff I checked on the resident at 2:30 pm. At 5:10 p.m. she went to the resident room with a room tray and asked the resident if he/she needed anything. The resident said no. Staff I made sure the resident had the call light and that the alarm was on. Staff I left the room with the resident seated in an easy chair with his/her feet elevated. Staff I went to break and when she returned, the resident was on the floor. Staff I received an employee warning dated 6/4/14 for not toileting Resident #1 for four (4) hours. The employee notice reported the resident fell at 6:15 p.m., and had a fractured. On 6/17/14 at 3:24 p.m. Staff O (nurse aide) stated Staff C informed him the resident was on the floor around 6:15 p.m. Prior to finding the resident on the floor, he/she was seated in a chair in the resident's room. The resident used a clip alarm and the alarm did not sound and Staff C did not know why. Staff O stated the resident did know how to take the alarm clips off. The resident told people he/she removed them. The resident didn't tell Staff O this information and he had not seen the resident take it off. Staff O stated staff checks alarms when they come on duty and before they leave at the end of the shift. Staff O received an employee warning dated 6/4/14 for not toileting Resident #1 during his shift. The employee notice reported the resident fell and fractured his/her spine. Other staff: On 6/19/14 at 11:33 a.m. the surveyor asked Staff E (registered nurse) if she ever saw the resident remove or manipulate the alarm prior to the 6/2/14 fall. Staff E stated yes the resident always messed with the metal clip on the alarm. If Staff E sees it she puts it back on and tells the resident he/she needs to keep it on. She may try to put it on a different side after she witnessed the resident manipulate it or she shortened the string. On 6/23/14 at 4:48 p.m. Staff E stated she misunderstood the question and stated she never saw the resident remove the alarm or tamper with it. On 6/17/14 at 3 p.m. Staff Q (nurse aide) stated a week before the fall on 6/2/14, the resident started a new medication which caused the resident to act differently. During that time, the resident had been unclipping the personal alarm. Staff Q did not recall who she had informed of this. On 6/17/14 at 7:05 p.m., Staff T (registered nurse) stated she observed the resident mess with the alarm clip prior to the 6/2/14 fall. When she had observed this, Staff T ran over and asked the resident what he/she needed. She passed the information on to the next shift and/or the nurse aides to watch the resident because he/she is trying to manipulate the alarm. In a written summary dated 6/18/14 Staff U (unit manager) wrote the intervention after the 6/2/14 fall was for a pressure pad to the bed and chair/wheelchair. The care plan contained an addendum dated 6/2/14 that directed staff to apply a wheelchair alarm when in wheelchair/chair. The care plan did not contain the new intervention regarding the pressure alarm in bed and chair/wheelchair. The Hollister care plan for the nurse aides dated 5/12/14 and in place until 6/4/14 identified the resident should use a personal alarm when in room. The Hollister care plan did not contain any new intervention after the 6/2/14 fall. On 6/24/14 at 9:32 a.m. Staff U (unit manager) emailed the surveyor and stated the only alarm in place when the 6/2/14 fall occurred was the personal alarm. The resident started using the pressure pad alarm in bed and wheelchair on 6/3/14. The pressure pad alarm was inadvertently left off the addendum page but was on the care plan in the approach dated 6/4/14. This information is available via point of care and care plan on the computer for staff to access even though it was not included on the Hollister care plan for nurse aides. 6/4/14 fall: An event report dated 6/4/14 at 2:05 a.m., identified staff found the resident sitting on his/her bottom on the floor by the bed with legs bent at the knees and back against the bed. The resident stated he/she fell out of bed. The resident complained of tailbone pain. The incident report identified the resident removed the alarm. The clip was not attached to the resident's night gown. New interventions after the 6/4/14 fall were: the metal clip was changed to the blue button clip after the incident and staff also provided 1/2 hour checks for 2 weeks. The current Hollister nurse aide care plan dated 6/10/14, directed staff to use a personal alarm when in room with blue clip, a wheelchair alarm pressure pad in wheelchair or recliner, pressure pad alarm in bed and 2 motion sensors when in bed. Observation: Observation showed on 6/17/14 at 12:30 p.m. the resident in a wheelchair with a metal clip alarm and sensor alarm. Staff toileted the resident and then placed the resident in bed with a metal clip alarm, sensor alarm and 2 motion sensors with one on each side of the bed. On the same date at 4:20 p.m. Staff O assisted the resident to bed and applied the personal alarm with metal clip, motion sensors and bed sensor alarm after placing the resident in bed. On the same date at 5:15 p.m., observation showed the resident in the dining room in the wheelchair with the personal alarm attached with a metal clip and sensor alarm. At 5:50 p.m. the resident finished eating and Staff O wheeled the resident to his/her room. The surveyor followed Staff O and the resident into the resident's room. At that time, the surveyor did not observe a flashing light on the sensor alarm box. When checked to see if the sensor alarm was functional, it was found in the "off" position. At 6:15 p.m., the surveyor asked Staff U (unit manager) about the resident using the metal clip alarm and not the blue clip as the 6/10/14 Hollister care plan for nurse aides directed. Staff U went to the resident room and identified that the resident should use the blue clip not the metal clip (that the resident could remove). 2. A Minimum Data Set (MDS) with assessment reference date of 5/12/14, assessed Resident #2 with a brief interview for mental status (BIMS) score of 13 which revealed he/she had no cognitive impairments. The MDS identified that the resident had been admitted to the facility on [DATE]. The resident required two staff to assist with bed mobility, transfers, dressing, toileting, and bathing. The resident ambulated once or twice with assistance of one person in his/her room during the assessment period. A balance test identified Resident #2 as not steady and only able to stabilize with staff assistance when walking, when turning around, when moving on and off the toilet, when moving from seated to standing position and during surface to surface transfers. The resident utilized a walker and wheelchair for mobility. The assessment revealed Resident #2 had been continent of bowel and bladder and not on a toileting program. The resident had [DIAGNOSES REDACTED]. The resident had no falls since admission to the facility. A care area assessment (CAA) dated 5/12/14 revealed the resident fell at home prior to admission and the resident fell while in the facility trying to transfer self. The CAA identified the resident with weakness and impaired balance during transitions. The resident used antidepressants and hypnotics. The resident suffered a compression fracture in the fall prior to admission. A hospital encounter form dated 5/2/14 (prior to admission) documented Resident #2 got dizzy and fell down. The resident then had severe back pain, throbbing in nature. A lumbosacral x-ray showed a new L2 vertebral body superior endplate 25% compression fracture. Progress notes following admission and prior to the resident's first fall at the facility identified the following information: a). On 5/8/14 at 2:14 p.m. Resident took self to the bathroom. Educated on importance of letting staff assist for safety. b). On 5/12/14 at 11:48 a.m. Resident continues to take self to bathroom at times. Strongly encouraged to wait for staff assistance. Fall: On 5/13/14 at 7:34 a.m., a nurse responded to resident yelling in room. Observation showed the resident lying on the ground with his/her back against the wall and the walker on the resident. The resident identified self as going to the bathroom. The resident did not use the call light. The resident stated he/she thought he/she could do it by him/her(self) but got dizzy. The resident reported hitting his/her head. The resident received a skin tear to the right elbow that measured 2 centimeters (cm.) by 0.5 cm. The resident rated pain to the back of the head as a 2 out of 10 (with 10 being the worst pain. )The resident also complained of low back pain and rated it as 6 out of 10. An event report dated 5/13/14 at 5 a.m. identified the resident fell in room while self transferring. The resident's last toileting had been at 9:30 p.m. The event form listed the new intervention following the fall as motion sensor when in bed. Staff Interviews: On 6/19/14 at 11:12 a.m. Staff J (nurse aide) stated that prior to the resident's fall, the resident would get up for meals and then put self into bed. The resident wouldn't use the call light unless staff set it in the resident's hand. Staff would keep telling the resident that he/she could not go on their own. On 6/19/14 at 11 a.m. Staff L (nurse aide) stated the resident did not use the call light reliably and would try to get up per self. This behavior took place before and after the fall. In a written summary dated 6/19/14 Staff V (unit manager) stated the resident was toileted on request and a motion sensor was added to the care plan after the fall. The Hollister nurse aide care plan in place prior to the fall identified the resident as a fall risk but did not identify the resident would not reliably use the call light and would make self transfer attempts. Fall: Resident progress notes dated 5/19/14 at 5:22 a.m. and documented by Staff F (registered nurse) reported the resident thought he/she fell and the resident had pain in the right upper thigh. The resident rated the pain as a 5 out of 10, with 10 being the worst pain. Staff administered Hydrocodone (narcotic) for pain. On the same date at 7:30 a.m., the resident informed staff that he/she fell in the bathroom during the night and his/her left hip hurts. The resident transferred with 2 staff and limped on the left leg. On the same date at 8:30 a.m., the resident spoke with occupational therapy and a nurse about falling in the night. The resident complained of left hip pain. On the same date at 10:40 a.m., the physician returned the facsimile about the unwitnessed fall during the night with no new orders received. On 5/19/14 at 11:02 a.m. the resident's family requested an x-ray of the left hip. On the same date at 2 p.m. the resident transported to the hospital. On the same date at 3:31 p.m. the physician's office called and stated the resident would be admitted to the hospital for a hip fracture. On 6/18/14 at 3:19 p.m. Staff F (registered nurse) stated she worked with a nurse aide the night of the incident. Staff F reported this had been her second night working at the nursing home. The nurse aide called Staff F into the room and the resident was in bed. The resident got him/her (self) back into bed. Staff F assessed the resident. Staff F stated she thought the resident had an alarm but the nurse aide said it was in a chair and did not sound. Staff F did not know when the resident last used the toilet. Staff F also stated the resident's room was at an end of a hall making it not as easy to monitor. On 6/19/14 at 1 p.m., Staff F stated she documented the alarm as on the floor in the resident progress notes because after they found the alarm in the chair, they placed it on the floor. She did not know how long the alarm was in the chair. The surveyor attempted to call the nurse aide that worked the night of the fall. She no longer worked at the facility and was not able to be contacted. In a written summary, dated 6/19/14 Staff V (unit manager) asked Staff F if the motion sensor had been in the chair all night or at shift change. Staff F reported she did not know. The Hollister nurse aide care plan, in place when the 5/19/14 fall occurred, identified staff toileted the resident on request and that the resident might attempt to take self to toilet. The Hollister care plan identified that staff should ensure the motion sensor had been " on " when the resident had been in the room. A major injury determination form identified the resident fell on [DATE] and sustained a left hip fracture. The resident's previous functional ability had been assist of one staff for transfers to wheelchair for mobility. The physician documented on 5/21/14 at 8:45 a.m. that the left hip fracture was NOT a major injury. A hospital history and physical dated 5/19/14 identified the resident presented with a left hip fracture secondary due to fall. An operative report dated 5/20/14 identified the resident with a subcapital displaced left femur fracture. The resident underwent [REDACTED]. The resident returned to the facility on [DATE] at 12:45 p.m. Observation on 6/17/14 at 11:50 a.m., showed Resident #2 in a wheelchair with a personal alarm on and attached to the resident with a blue clip. The resident wheeled the wheelchair with his/her feet. Two staff assisted the resident to stand and the alarm activated. The resident pivot transferred from the wheelchair into bed. Staff reattached the personal alarm with the blue clip. When asked about the fall, the resident stated he/she didn't know what happened. The resident stated he/she planned on strength that he/she didn't have. The resident stated he/she was 93 and since he/she turned 90, he/she lost considerable leg strength. The resident stated, "If you depend on it and don't have it, you fall". 3. A Minimum Data Set (MDS) with assessment reference date of 6/7/14 assessed Resident #4 with short and long term memory impairments. The resident had severe cognitive impairments for daily decision making skills. The resident required one staff to assist with transfers, ambulation, dressing, toileting, personal hygiene and bathing. A balance during transitions and walking identified the resident as not steady but able to stabilize without staff assistance in all areas of testing. The resident used a walker and wheelchair for ambulation. The resident had [DIAGNOSES REDACTED]. A care plan dated 6/12/14 identified the resident used a pressure seat/bed alarm when in the chair or bed, personal alarm at all times when resident in wheelchair, recliner or bed and motion sensor when alone in room. Observation showed, on 6/17/14 at 2:08 p.m. the resident in his/her room by self. The resident had two alarms on (pressure and clip). A motion sensor sat in front of the television and did not sound when the surveyor passed in front of it. At that time, the surveyor summoned Staff X (certified medication aide) who stated the motion sensor was "off". Staff X turned the motion sensor on and placed it on the floor facing the resident. On 6/17/14 at 4:13 p.m., Staff P (unit manager) stated the resident's spouse turns the motion sensor off and when the spouse leaves he/she does not alert staff or turn the sensor back on. Staff P stated the resident ' s spouse was very confused. On 6/19/14 at 3:45 p.m. observation showed the resident alone in his/her room with a clip personal alarm on. The motion sensor sat in front of the resident in the "chime" position. The motion sensor did not sound when the surveyor passed in front of it. At that time, the surveyor summoned Staff C (licensed practical nurse) to check the motion sensor. Staff C stated the battery on the sensor was dead. On 6/19/14 the Administrator provided information that identified the facility self identified and corrected the following issues: a). The 6/3/14 problem: The facility needed to look further for the root cause analysis of falls in order to implement the best interventions for residents. The facility conducted an inservice on 6/3/14 and 6/4/14 to discuss the importance of rounding, educations of the 4 P's (positioning, pain, personal needs and placement of important items the resident needs). The facility conducted an inservice on 6/10/14 that introduced the "fall huddle". b). The 5/20/14 problem: The facility was not always able to determine the time of the last offer of toileting by staff. The facility determined that in conversion to the electronic health record charting, not all staff understood the path to chart the information. An in-service 6/11/14 provided staff education on the fall program, which included the importance of toileting and offering toileting and documenting timely to the record. The facility provided further education to reinforce the electronic record charting path. c). The 6/3/14 problem: The facility identified an issue with timely update of fall interventions on the care plan by the charge nurse to prevent reoccurring falls. The facility provided education via in-service regarding this on 6/3/14, 6/4/14 and 6/10/14. 6/17/14 The facility used two types of alarms- a metal clip and a blue clip. The resident was less likely to remove the blue clip in several instances. On 6/17/14 a nurse aide placed the wrong clip type alarm on a resident. On 6/18/14 the facility decided to completely do away with the metal and replace all metal clips with the blue clip. In an email dated 6/23/14 at 4:54 p.m. the Administrator wrote that the facility intended to put an alarm compliance monitoring system in place before the end of the week with the ultimate goal to decrease alarm use. The facility also conducted an in-service on 6/20/14 regarding the following: a). Care plan interventions that included: Staff needs to be certain they know the correct care plan intervention for each resident. If staff notices care plan interventions are not effective, they need to report to the charge nurse and be certain the proper alarm is on the resident and that it is working. b). Supervision that included: Ensure each resident has the proper oversight. The nurse shall observe the residents on her neighborhood and periodically evaluate the interventions are in place. c). Rounding/Communication: This is the time to assess resident location, position, comfort level, last toileting and that staff reports on the care plan interventions for the resident. d). Fall huddles/ Root Cause Analysis: Staff to carry huddle cards in pocket and be ready to review the questions immediately after a fall. Look deeply into what really made the fall happen.

Based on observation, record review, and staff interviews, the facility failed to provide wound care by performing an adequate assessment and timely intervention to promote healing and failed to prevent additional skin issues from development for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 69 residents. Resident #1 had a history of [REDACTED]. Resident #1 sat for prolonged periods of time without repositioning or off-loading to the buttocks on 08/29/13, and 08/30/13. On 09/03/13, Resident #1 had 4 substantial ulcers to the buttocks. The facility failed to promote dietary and nursing interventions to promote healing. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 06/30/13, Resident #1 scored a 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #1 required extensive assistance with activities of daily living (ADL's) including transfer, toilet use and personal hygiene. The MDS identified Resident #3 as always incontinent of bowel and bladder. Resident #1's [DIAGNOSES REDACTED]. Resident #1 suffered a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDS documented Resident #1 had a Stage 2 pressure ulcer. The Braden Scale for Predicting Pressure Sore Risk dated 07/02/13 scored Resident #1 at 12 indicating high risk for developing pressure sores. The Daily Notes dated 05/15/13 at 3:30 a.m. documented Resident #1 had a 1 cm (centimeter) round open area on the left buttock, surrounded by a brown scabbed area measuring 2.2 cm by 1.8 cm. The Resident Progress Notes dated 07/01/13 at 10:01 a.m. documented the annual nutrition note. Resident #1 weighed 161#, down 5# per month and 21# per 180 days, an 11% loss, showing severe losses. Resident #1 ate per self and needed to encourage adequate food and fluids to keep weight stable. He/she took an antibiotic for a wound to his/her buttock. Resident #1 had a history of [REDACTED]. Would encourage meals, snacks and add to plan of care regarding weight change and goals. Do need to attempt weight control now to aid wound healing. A Wound Clinic Instruction form directed to have Resident #1 lay down more to keep pressure off his/her buttocks. A Wound Clinic Appointment form documented the wound resolved, see discharge instructions. The Wound Clinic Instructions included discontinuing the previous wound treatment to the left buttock, cleanse after each incontinence episode with incontinence cleanser and apply incontinence moisture barrier to bilateral buttocks. The physician's orders [REDACTED]. The Care Plan dated 07/03/13 identified Resident #1 with a nutrition problem and the approaches included: a. Feeds self, observe for need of assist. Does need cueing at times. b. Enjoys condiments with meals. c. Resident had always desired weight control and gained weight after admission, but further losses needed to be curbed. Would discuss liquid supplements or snacks with the family. The care plan identified a urinary problem and the approaches included: d. Positioning every 2 to 3 hours. e. Encourage toileting every 2 hours. A facsimile (fax) dated 08/19/13 notified the physician Resident #1 had a superficial open area to the left gluteal crease measuring 2 cm by 2 cm. The right gluteal crease had 3 small superficial areas; 0.5 cm scabs. The physician ordered staff to apply [MEDICATION NAME] prn (as needed) until healed; noted 08/21/13. A Non Pressure Skin Condition Report dated 09/01/13 at 3:14 p.m. documented an open area to Resident #1's right buttock measuring 5 cm by 2 cm proximal and distal 3 cm. The area appeared superficial with a small amount of serous drainage. The surrounding skin looked bright red and had deteriorated. Another report on 09/01/13 at 3:33 p.m. documented a left ischial open area measuring 4.8 by 6.3 cm with a scant amount of serous drainage. The surrounding skin appeared bright red. The area had deteriorated. Another report at 3:22 p.m. documented an open area to the left buttock measuring 1 cm by 2 cm with 0.1 cm depth, and a small amount of serous drainage. The surrounding skin appeared bright red. Another report dated 09/01/13 at 3:29 p.m. documented an open area to the gluteal crease/coccyx measuring 2.2 by 0.5 cm with a small amount of serous drainage. The surrounding skin appeared bright red. During an observation on 08/29/13 at 6:10 p.m. Staff C CNA and Staff G CNA took Resident #1 to his/her room. Staff C stated they just got Resident #1 up before she got there at 2:30 to 3:00 p.m. and this was the 1st time they had repositioned him/her (3 hours 10 minutes to 3 hours 40 minutes without repositioning off buttocks). Resident #1 screamed when they cleansed his/her buttocks. Staff put Resident #1 back in the wheelchair and said he/she would get a bath. During an observation on 08/30/13 at 8:35 a.m. Staff E CNA and Staff H LPN took Resident #1 to his/her room to change clothes and toilet. Staff E and Staff H transferred Resident #1 to the toilet with the sit to stand lift. Resident #1 had stool over the open areas of the buttocks. After cleaning the resident staff transferred him/her back to the wheelchair at 8:45 a.m. At 12:10 p.m. Resident #1 remained in the wheelchair (3 hours and 25 minutes without repositioning). During an interview on 09/03/13 at 11:50 a.m. Staff B Registered Nurse (RN) Unit Manager stated Resident #1 should be repositioned more than every 2 to 3 hours with ulcers on his/her buttocks. Staff B had not seen the ulcers. Staff B stated in early July they talked about supplements. She tried to get a hold of Resident #1's family about it, but couldn't reach them, so no supplements were started. She said they had a time issue with getting things done. During an observation on 09/03/13 at 2:02 p.m. Resident #1 laid in bed on his/her right side. At 2:07 p.m. Staff B Registered Nurse (RN) stated she talked with Resident #1's family and they okayed (approved) health shakes 3 times a day with meals. Staff A Licensed Practical Nurse (LPN), with the assistance of Staff B, measured Resident #1's skin breakdown: a. The left ischial wound measured 9 cm by 3 cm with minimal yellow tissue in the wound bed, otherwise red. b. The left buttock wound measured 3 cm by 3.3 cm with a red and white base. c. The gluteal crease measured 2 cm by 1.5 cm with a red base. d. The right buttock wound measured 1 cm by 0.9 cm with a red base The surrounding skin was red. Resident #1 cried out it hurt, and when asked what hurt, he/she said his/her bottom hurt like the devil. Staff B stated Resident #1 always screamed when they worked with him/her. When asked if he/she always complained of pain, Staff B said no. During an interview on 09/03/13 at 1:46 p.m. the Dietician stated the Dietary Supervisor notified her of Resident #1's skin issues so she looked at him/her 09/02/13 at home. The Dietician saw then that resident #1 had lost another significant amount of weight. She said apparently they had difficulty contacting the family. She did not know if the facility contacted them in early July about a supplement. She stated she would definitely recommend a supplement with his/her continued declining weight and multiple skin issues. During an interview on 09/03/13 at 12:04 p.m. Staff H LPN stated they had no documentation of the left gluteal fold/ischial wound, although it had been there for a while. She stated she had not personally tried to lay Resident #1 down during the day. She stated they put Resident #1 in the recliner sometimes during the day. She heard Resident #1 put up such a fight, they just gave up trying. During an interview on 09/04/13 at 10:33 a.m. Staff I Licensed Practical Nurse (LPN) stated she didn't know the date, but she found an open area on Resident #1's left buttock near the crack of the buttocks above the anal area. She didn't know about an area near the ischial/gluteal fold area. She also noted 3 scabbed areas on the right buttock. Staff I stated the last Thursday Resident #1 still had the area to the left buttock, but didn't notice anything on the right buttock. Staff I stated sometimes after lunch, Resident #1 would lay down for them. She said in the morning Resident #1's repositioning consisted of checking and changing him/her 1 time. Staff I did not think that was enough especially since Resident #1 had skin breakdown, but they did not have enough staff to meet Resident #1's acuity. Staff I did not know why Resident #1 didn't receive supplements due to his/her weight loss and skin issues; the resident did not eat well. Staff I stated she would usually attempt to assist or encourage Resident #1 at meals and sometimes the resident would get irritated. She said normally she tried to get all the residents who needed assistance, cues, or supervision at 2 tables so they could know they were doing and assist, cue, and encourage as needed. She stated on 08/29/13, they (staff) were all spread out (in areas of the building) and she couldn't keep track of how the resident was doing. They did not get the assistance, cues or encouragement they needed that day. She stated some days they didn't have enough staff to meet the resident's needs at meals. She said on days when residents were feeding themselves and doing well, the staff they had was adequate. The facility policy for Skin Prevention Program identified the purpose is to prevent pressure ulcers and other problematic skin concerns from developing unless the resident's clinical condition demonstrated they were unavoidable. Once at risk, the following should be initiated and documented on the resident plan of care: a. Turning and repositioning every 2 hours. b. When sitting in a chair, encourage or assist with small weight shifts every 15 minutes

Based on observation, clinical record review and interview, the facility failed to document assessment of an area of fragile skin previously identified as a Stage II (a partial thickness and loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure sore for 1 of 8 current residents reviewed (Resident #3). The facility reported a census of 69 residents. Findings included: According to a Physician order [REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 required extensive assistance from staff with bed mobility and transfer. A facility Braden Scale (skin assessment) report dated 11/5/13, identified the resident at moderate risk for skin breakdown. The same skin assessment included documentation to continue the resident's current care plan. A Care Plan with a last conference date of 8/8/13 included a problem in regards to the resident not always being able to express his/her wants and needs. The same Care Plan documented the resident as being seen at a local wound clinic for treatment of [REDACTED]. The Care Plan lacked any approach for facility staff to assess the resident's right ischium on a routine basis. Review of Resident #3's Skin-Pressure Ulcer Skin Report forms revealed the following: On 7/28/13 - Staff documented a Stage II pressure ulcer, with a date of onset 7/3/13, on the resident's right ischium. Staff documented the area of impairment as 2 small scabs. Staff documented the areas as not measured as the resident not being able to sit still. Staff documented the areas as almost healed. Further record review and request a for further skin sheets and/or assessment of the resident's right ischium area between 7/28/13 and 8/30/13 revealed no further assessment of the resident's right ischium and no documentation of the same area as healed. Not until 8/30/13 - ( greater than 1 month later), staff documented a Stage 1 pressure ulcer on the resident's right ischium, with an onset date of 7/28/13. Staff documented the area measured 0.3 centimeters (cm) by 0.5 cm. Staff documented the area as cleansed and Xenoderm ointment applied. Staff documented the resident would be seen at a wound clinic for assessment and a treatment order. 9/5/13 - Staff documented a Stage 2 pressure ulcer on the resident's right ischium. Staff documented the area measured 3.3 cm by 0.8 cm. Staff documented area as pink/beefy red with serosanguinous drainage. Staff documented the surrounding tissue with peripheral tissue [MEDICAL CONDITION] and documented the area as deteriorated. Not until 10/15/13 (greater than 1 month later), staff documented the resident's right ischium pressure ulcer as healed. On 11/13/13, record review and request by the Surveyor for ongoing documented assessment of the resident's right ischium since 10/15/13, revealed no further assessment. Observation on 11/13/13 at 1:05 P.M., revealed Staff A, Registered Nurse/RN changed a [MEDICATION NAME] dressing (used for protection) on the resident's right ischium. Observation revealed the right ischium area as bright red with possible superficial open areas. Staff A cleansed the area and applied a new [MEDICATION NAME] dressing. During interview on 11/14/13 at 9:00, the Director of Nursing (DON) stated staff did not document an assessment of the resident's right ischium on 11/13/13. The DON stated she expected staff to continue to document ongoing assessment of the resident's right ischium, even though staff documented the area as healed on 10/15/13. Observation on 10/14/13 at 11:10 A,AM. revealed Staff B, Licensed Practical Nurse/LPN, assessed and measured Resident #3's right ischium. Staff B removed a [MEDICATION NAME] dressing over the resident's right ischium. Further observation of the dressing revealed a small amount of thin yellow/serosanguinous drainage. Staff B measured a 5 cm by 6 cm red area over the resident's right ischium and identified 4 superficial open areas within the red area. Staff B measured the superficial areas as follows: 1. 0.2 cm by 0.8 cm 2. 0.2. cm by 0.2 cm 3. 0.5 cm by 0.5 cm 4. 0.5 cm by 0.8 cm During interview on 11/14/13 at 11:50 A.M., the RN Unit Manager for the living area the resident resided in stated the resident had difficulty with skin breakdown of his/her right ischium off and on over 2 years. The Unit Manager stated the resident visited the wound clinic at varying times re: weekly, every 2 weeks or monthly. The Unit Manager stated the staff at the wound clinic assessed and measured the resident's right ischium. She stated because the staff at the wound clinic assessed and measured any areas on the resident's right ischium, the facility staff had not measured or documented any assessment. The Unit Manager stated the facility lacked documentation from the wound clinic in regards to the measurements and/or assessment of the resident's right ischium completed at the wound clinic. During telephone interview on 11/14/13 at 12:15 P.M., Staff A described Resident #3's right ischium (at the time she completed his/her dressing change on 11/13/13 at 1:05 P.M.) as red and maybe with a couple of open areas. Staff A stated she chose not to measure or document an assessment of the resident's right ischium on 11/13/13 as the facility completed a weekly skin assessment of Resident #3's right ischium and that assessment had not been scheduled for 11/13/13.

Based on observation, record review and staff interviews, the facility failed to assure 2 of 5 residents maintained acceptable parameters of nutrition (Resident #1 and #4). The facility reported a census of 69 residents. Resident #1 had multiple skin problems and had lost weight. The facility did not implement dietary measures to promote weight loss and promote skin healing. Resident #4 required assistance with meals and the facility did not always provide assistance. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #1 scored 4 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #1 required extensive assistance with activities of daily living (ADL's) including transfer, toilet use and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #1's [DIAGNOSES REDACTED]. Resident #1 suffered a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDS documented Resident #1 had a Stage 2 pressure ulcer. The Resident Progress Notes dated 07/01/13 at 10:01 a.m. documented the annual nutrition note. Resident #1 weighed 161#, down 5# per month and 21# per 180 days, an 11% loss, showing severe losses. Resident #1 ate per self, and staff needed to encourage adequate food and fluids to keep weight stable. He/she took an antibiotic for a wound to his/her buttock. Resident #1 had a history of [REDACTED]. Would encourage meals, snacks and add to the plan of care regarding weight change and goals. Did need to attempt weight control to aid wound healing. Resident #1's weights: a. 07/01/13 161# per nutrition progress note. b. 07/14/13 157.2# per Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] c. 07/18/13 158# per MAR. d. 07/29/13 153.4# per MAR. e. 08/19/13 157# per vitals report. f. 08/28/13 144# per vitals report, a loss of 17# or 10% in 2 months, 13# or 8% loss in 9 days (5% in 1 month and 10% in 6 months = significant losses). The Care Plan dated 07/03/13 identified Resident #1 with a nutrition problem and the approaches included: a. Feeds self, observe for need of assist. Does need cueing at times. b. Enjoys condiments with meals. c. Resident had always desired weight control and gained weight after admission, but further losses needled to be curbed. Would discuss liquid supplements or snacks with the family. The clinical record lacked any documentation of discussion with Resident #1's family regarding supplements. A Progress Note dated 09/02/13 at 11:18 a.m. documented a nutrition note. Resident #1's weight continued to decline as did intakes per records. Weight now 144# down 9# per month and 17# per 2 months. Resident #1 continued to show severe weight losses this month. The quarterly review note of last month also indicated significant weight losses. Resident #1 also had very poor meal and fluid intakes, often sips or bites, and declined assistance with meals. Nutrition needs remained increased for healing. Current intakes did not meet nutritional needs of Resident #1. Increased morbidity/mortality rates were noted. Would continue to follow the directives of family as per plan of care regarding any further nutrition interventions. During an interview on 08/30/13 at 12:10 p.m. the Dietary Supervisor stated she did not know of dietary interventions related to Resident #1's skin issues. She would look to see if they received notification of the areas. During an interview on 09/03/13 at 1:58 p.m. the Dietary Supervisor stated she notified the Dietician about Resident #1 after the surveyor asked her about him/her on 08/30/13. She did not receive anything from nursing (regarding the skin issues or significant weight loss). During an interview on 09/03/13 at 1:46 p.m. the Dietician stated The Dietary Supervisor notified her of Resident #1's skin issues so she looked at him/her yesterday at home. The Dietician saw then that Resident #1 had lost another significant amount of weight. She said apparently they had difficulty contacting the family. She did not know if the facility contacted them in early July about a supplement. She said she would definitely recommend a supplement with his/her continued declining weight and multiple skin issues. During an interview on 09/03/13 at 11:50 a.m. Staff B Registered Nurse (RN) Unit Manager stated Staff B stated in early July they talked about supplements. She tried to get a hold of Resident #1's family about it, but couldn't reach them, so no supplements were started. She said they had a time issue with getting things done. During an interview on 09/04/13 at 10:33 a.m. Staff I Licensed Practical Nurse (LPN) stated she did not know why Resident #1 didn't receive supplements due to his/her weight loss and skin issues. Resident #1 did not eat well. Staff I stated she would usually attempt to assist or encourage Resident #1 at meals. Sometimes Resident #1 would get irritated. She said normally she tried to get all the residents who needed assistance, cues, or supervision at 2 tables so they could know how they were doing and assist, cue, and encourage as needed. She said on 08/29/13 they were all spread out and she couldn't keep track of what/how they were doing. They did not get the assistance, cues, encouragement they needed that day. She said some days they didn't have enough staff to meet the resident's needs at meals. She said on days when residents were feeding themselves and doing well, the staff they had was adequate. 2. According to the MDS assessment dated [DATE] Resident #4 demonstrated long and short term memory problems and severely impaired cognitive skills for daily decision making. Resident #4 required extensive assistance with Activities of daily living (ADL's) including transfer, locomotion and toilet use. Resident #4 needed supervision and set up with eating. Resident #4's [DIAGNOSES REDACTED]. Resident #4 suffered a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The Care Plan with a Care Conference date of 08/29/13 identified Resident #4 with a nutrition problem. The approaches included: a. General diet with ground meat per family request. b. Likes [MEDICATION NAME] fruit drink with meals, give with ice in a glass. c. Likes cottage cheese. d. Encourage snacking. e. Continues to sleep for long periods of time; offer food when resident gets up. f. Give cold food/drink, ie: ice cream, Coke. The Resident Progress Notes dated 08/26/13 at 8:47 a.m. documented the quarterly nutrition note. Resident #4's weight at 129#, down 4# per month and 15# per quarter. Resident #4 continued to show poor intakes with refusals to 24% average in observation period. Resident #1 had orders for juice supplement plus 2-cal (high calorie) supplement. Resident #4 refused these also per Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. They would continue to offer food favorites, snacks and fluids. Resident #4 had a great risk for dehydration, weight loss and further declines as unable to meet nutritional needs at current level of intake. During an observation on 08/29/13 at 11:55 a.m. staff brought Resident #4 to the dining room table. At 11:58 a.m. staff brought Resident #4 water and red juice. At 12:00 p.m. staff served Resident #4 salad. At 12:17 p.m. a CNA asked Resident #4 if he/she wanted chocolate milk and the nurse asked if he/she wanted coffee. At 12:19 p.m. Resident #4 received his/her meal. Resident #4 stirred his/her coffee. Staff brought Resident #4 chocolate milk. Resident #4 used a spoon to take drinks of his/her coffee. At 12:30 p.m. Resident #4 had taken no bites of his/her food. All staff were positioned at least 2 tables away. At 12:32 p.m. Resident #4 had his/her eyes closed at the table. At 12:38 p.m. Resident #4 continued with eyes closed. No staff had approached the resident to encourage eating. At 12:40 p.m. the nurse said someone should check on Resident #4 (20 minutes after receiving food). Staff E Certified Nursing Assistant (CNA) asked Resident #4 if he/she would try his/her lunch and told him/her what it consisted of. Resident #4 tried a bite of potato and said it was cold. Staff E had already gone to another table. Another staff member came to the area and the nurse said she could check on Resident #4's table. Staff went to the nurse and she then approached Resident #4 and asked if he/she had pain. The nurse asked if his/her coffee was warm enough. At 12:48 p.m. staff asked if they could warm Resident #4's mashed potatoes and did warm them in the microwave. Staff brought the warmed food back to Resident #4 and also brought him/her ice cream. Resident #4 started eating the ice cream. At 12:50 p.m. the Dietary Supervisor went by and asked Resident #4 if he/she wanted toast or a sandwich. Resident #4 said okay to a peanut butter and jelly sandwich. At 12:55 p.m. the DS brought Resident #4 a sandwich and he/she continued to eat ice cream. During observation on 08/29/13 at 4:56 p.m. staff brought Resident #4 to the dining room table. At 5:10 p.m. Resident #4 sat drinking juice. Staff D LPN sat 2-cal on the table by Resident #4. At 5:15 p.m. Resident #4 received his/her meal and staff encouraged him/her to eat. At 5:24 p.m. Resident #4 had not eaten anything. Staff went over to Resident #4 and gave him/her a bite of food, left for a minute and returned and gave him/her another bite. The staff person then went and sat with another resident. At 5:32 p.m. staff got Resident #4 chocolate ice cream (without offering any more bites from his/her meal). At 5:45 p.m. Resident #4 ate ice cream. At 6:05 p.m. staff sat with Resident #4 and he/she ate his/her cookie. At 6:20 p.m. Resident #4 left the table without drinking the 2-cal and without staff encouragement to do so. During an observation on 08/30/13 at 10:06 a.m. staff assisted Resident #4 with toileting and hygiene. After refusing multiple times, Resident #4 agreed when Staff F CNA asked if he/she wanted a Pepsi. At 11:40 a.m. Staff H LPN stated she took supplements in to Resident #4, but he/she would not drink them. Resident #4 did not like the 2-cal, so the [MEDICATION NAME] a better option. Staff H took the [MEDICATION NAME] to Resident #4 at 11:45 a.m. Staff H stated Resident #4 drank about 1/3 of it and Staff H threw the rest away. Staff F stated Resident #4 did not get a Pepsi (after cares this a.m.) because he/she didn't have any and they didn't have it in the vending machine, so he/she didn't get anything. Resident #4 remained in his/her room and did not receive a meal tray for breakfast or lunch. During an interview on 09/03/13 at 10:12 a.m. Staff B RN Unit Manager stated they asked the family at care conference if they wanted them to continue to offer the 2-cal and they did. She did not know if they offered other supplements. Staff B didn't think they took Resident #4 a tray to his/her room if he/she didn't come out for meals, because he/she would not eat. She said she would expect staff to take food and fluids to Resident #4. During an interview on 09/04/13 at 1:46 p.m. the Dietician stated Resident #4 had a significant weight loss and did not eat well. She said she would expect they would at least offer Resident #4 a meal tray in his/her room if he/she didn't come out. She said the care plan directed to offer food when Resident #4 got up. She said that meant in his/her room or out when he/she was awake. During an interview on 09/04/13 at 10:33 a.m. Staff I LPN stated at times Resident #4 did not come out at noon for meals. They did not take him/her a meal tray because someone would have to supervise. If Resident #4 came out soon enough he/she could still get a tray, otherwise they could get something for him/her, like ice cream or peanut butter and jelly sandwich. Staff I didn't think Resident #4 liked the 2-cal but she always attempted to give it to him/her, and sometimes he/she would take it. She said they needed more assistance when residents were not feeding themselves. She said they had more residents needing more assistance. The facility policy for the Nutrition Intervention Program indicated residents identified at high risk would be placed on the Nutrition Intervention Program. High risk residents would be identified and supplemented with increased calories and protein through 2-cal, health shakes, Boost, Ensure and Ensure liquid. Supplements chosen based upon resident's preference or trials. High risk residents would be identified by: a. Weight loss, 5% in 1 month, 7.5% in 3 months, 10% in 6 months. b. Skin care policy, has total of 17 or less. c. Poor food intake, food intake 50% or less. d. Low [MEDICATION NAME], less than 3.5.

Based on record review, observations, staff interviews, and review of the facility policy, the facility failed to assess and provide timely intervention for a resident who had an onset of adverse symptoms which presented a change in a physical condition (Resident #6). Resident #6 expressed pain because of a red and swollen right hand when first observed on 3/28/2011. Review of the record revealed an assessment of the right had not been performed and therefore, lack of interventions to promote healing and decreased discomfort. The facility identified a census of 82 residents and the sample consisted of 14 residents. Findings include: 1. Resident #6 had an MDS (Minimum Data Set) assessment with a reference date of 1/23/11 which identified [DIAGNOSES REDACTED]. The BIMS (Brief Interview for Mental Status) revealed a score of 15 which signified the resident's cognitive skills for decision making as intact. On 3/28/11 at 10:35 a.m. the surveyor observed Resident #6 sitting in a wheelchair in the resident's room. The resident's right hand had a swollen and reddened appearance. At 4:50 p.m. the resident self propelled the wheelchair to the dining room and the resident voiced complaints of difficulty with propelling the wheelchair with the use of the right hand. On 3/29/11 at 8:30 a.m. the resident laid in bed. Observation revealed the resident's right hand swollen and reddened. At 8:37 a.m. Staff F and Staff T entered the room. Staff F and Staff T provided the resident with incontinence care and placed the resident onto a Hoyer lift sling to transfer the resident to the wheelchair. The resident voiced complaints to the staff of the right hand pain and requested the staff not to use the right hand to turn him/her. The staff transferred the resident to the shower room. After the resident's whirlpool, the staff returned the resident to the resident's room and transferred the resident to the bed. The resident again voiced complaints of right hand pain. The right hand remained swollen and reddened. Staff A entered the room and implemented the resident's sacral area dressing change. The resident complained to the staff about the right hand pain. At 2:55 p.m. the resident sat in a wheelchair in his/her room. The resident's right hand remained reddened and swollen. During an observation on 3/31/11 at 4:10 a.m., Staff S (Registered Nurse) performed irrigation to the resident ' s Foley catheter. During the process, the resident complained to Staff S about the right hand hurting. The resident asked Staff S not to touch the hand and appeared protective of the hand. Observation revealed the right hand swollen and reddened. Staff S felt the resident's hand and told him/her the hand felt warm to the touch. Staff S placed a cold cloth on the resident ' s right hand. At 9:05 a.m., Staff A entered the resident's room and asked the resident if his/her right hand felt better. Staff S looked at the arm and reminded the resident his/her left hand had swelled like the right hand. Staff S spoke to the resident about the left hand and told the resident the right hand could have the same concern. Review of the Physician's Orders, dated 11/26/10 revealed a [DIAGNOSES REDACTED]. Treatment included [MEDICATION NAME] 200 milligram (mg) (an anti [MEDICAL CONDITION]) 1 pill daily x 10 days and Keflex 500 mg 1 pill three times a day x 10 days. Review of the Pain Management Log for the resident revealed on 3/27/11 at 5:30 a.m. the resident complained of pain to the right hand and received Tylenol (A pain medication) 650 mg. The resident rated the pain at 8 out of a scale of 10 with 10 the most painful. Review of the Daily Notes on 3/31/11 at 6:00 a.m. revealed the nurse touched the resident's hand and the resident complained of pain secondary to his/her position in bed. The nurse documented the resident stated the pain occurred due to staff repositioning the resident. Although the resident complained of pain to the right hand, the resident's record did not reveal notification to the resident's physician concerning the inflammation and redness to the right hand. Record review of the Daily Notes did not reveal an assessment of the right hand's change of condition. On 3/31/11 at 8:12 a.m., Staff F was interviewed and revealed the resident complained of the right hand hurting when transferred to the shower chair. Staff F stated the resident had not complained of the right hand hurting prior to the transfer. Staff F stated she/he reported the resident ' s hand hurting to Staff A. On 3/31/11 at 9:45 a.m. Staff A was interviewed and stated the resident complained of pain to the right hand a few days ago. Staff A stated the resident had similar problems with his/her left hand. The left hand also had swelled and became reddened. Staff A confirmed the physician had treated the left hand for cellulites with oral medication. Staff A confirmed the right hand as swollen and warm to touch and had not contacted the physician with the concerns the condition change.