Every finding on record at The Estates at Bloomington LLC

Based on interview and document review, the facility failed to provide a written transfer notice and notice of bed hold for 1 of 1 residents (R4) reviewed for hospitalization.Findings include:R4's admissions Minimum Data Set, dated [DATE] identified R4 with impaired cognition, required assistance with all personal cares, and diagnoses of hemiplegia (form of paralysis affecting one side of the body), diabetes and anxiety.R4's electronic medical record (EMR) progress notes lacked indication of a hospitalization or emergency room visit since admission to facility on 2/18/26.R4's hospital after visit summary dated 4/14/26, identified R4 was transferred to the emergency room for diarrhea.During interview with R4 on 4/20/26 at 1:27 p.m., R4 stated she had had a hospitalization for diarrhea recently but did not know what the date was. In addition, R4 could not recall whether she was offered or provided a transfer form or bed hold notice at the time of the emergency room visit.R4's emergency contact was called on 4/22/26 at 11:25 a.m., with no answer.During interview with registered nurse (RN)-C on 4/22/26 at 11:50 a.m., RN-C stated expectations of staff to offer and provide a signed transfer form and bed hold to resident or guardian to accompany the resident to the hospital upon transfer for higher level of treatment. Also, the nurse is expected to document in the electronic medical record (EMR) that they offered and provided the transfer form and bed hold to the resident or guardian in a progress note. If the nurse left a message, then the nurse was to document that a message was left, and the facility was expected to follow up with the resident or guardian until they received an answer. RN-C stated the original transfer form and bed hold should be downloaded into the EMR under the Forms tab by the facility. RN-C verified that he was the nurse that sent R4 to the hospital on 4/14/26. RN-C stated he believed he had called and left a message with R4's guardian but did not document it. During interview with licensed practical nurse (LPN)-A on 4/22/26 at 12:01 p.m., LPN-A stated expectations of nursing staff to offer and provide a signed transfer form and bed hold to accompany the resident to the hospital upon transfer for higher level of treatment. Also, the nurse is expected to document in the electronic medical record (EMR) that they offered and provided the forms to the resident or guardian in a progress note. If the nurse left a message, then the nurse was to document that a message was left, and the facility was expected to follow up with the resident or guardian until they received an answer.During interview with director of nursing (DON) on 4/22/26 at 1:22 p.m., the DON stated expectation of staff to offer and provide a signed transfer form and bed hold to accompany the resident to the hospital upon transfer for higher level of treatment and the nurse was expected to document it in a progress note. If the nurse left a message, then the nurse was to document that a message was left, and the facility was expected to follow up with the resident or guardian until they received an answer. DON verified R4's EMR did not have a transfer form or bed hold notice and that facility failed to follow up on obtaining it. DON stated, should be done.Facility policy titled Bed-Holds and Returns, updated 2/26/26 identified, Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds;b. The reserve bed payment policy as indicated by the state plan (Medicaid residents);c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); andd. The details of the transfer (per the Notice of Transfer).

During observation and interview, the facility failed to maintain a safe, comfortable, and homelike environment for 2 of 2 residents (R9, R13) reviewed whose main bedroom ceiling light did not function properly.Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with impaired cognition, no limitation in upper extremity range of motion and dependent on staff for turning, repositioning, transfers, and all personal cares. R9's diagnoses include dementia. In addition, R9 was enrolled in hospice. R13R13's quarterly MDS dated [DATE] identified R13 with intact cognition and diagnoses of fibromyalgia, anxiety, depression and chronic pain.During observation and interview with R13 on 4/20/26 at 2:31 p.m., R13 pointed to flickering ceiling light and stated it had not worked for a long time. R13 stated she was frustrated, to have that strobe light [NAME] on and off which caused her headaches. R13 stated she had to currently use the pull string light over the head of her bed instead, otherwise the room was dark. During interview with nursing assistant (NA)-D on 4/22/26 at 1:39 p.m., NA-D stated expectation of staff to use the electronic messaging system, called TELS, to request maintenance repairs. NA-D stated all staff were trained and aware of putting in requests for maintenance to address. NA-D stated she was aware of R9 and R13's ceiling light not working for at least a month. No one likes [their light] flickering.During interview with director of nursing (DON) on 4/23/26 at 6:50 a.m., DON stated expectations of all staff to use the electronic messaging system, called TELS, to request maintenance repairs. DON stated the maintenance director (MT-D) would then receive the requests and prioritize them and address them.During interview with MT-D on 4/23/26 at 10:31 a.m., MT-D stated expectations of all staff to use the electronic messaging system, called TELS, to request maintenance repairs. He would then prioritize the requests and address them. MT-D verified no TELS requests were ever submitted for R9 and R13's ceiling light. I cannot fix something if it is not in the TELS system.Facility policy on reporting maintenance concerns was requested and not received.

Based on observation, interview and record review, the facility failed to develop and implement, or revise as needed, a comprehensive, person-centered care plan with individualized interventions for 1 of 1 resident (R67) reviewed for fluid management, related to the resident's diagnosis of polydipsia (excessive, persistent thirst or compulsive, excessive water consumption) and ongoing fluid-seeking behaviors Findings include:R67's quarterly Minimum Data Set (MDS), dated [DATE], indicated R67 was admitted to the care facility on 10/25 and had severe cognitive impairment. R67's Diagnoses, dated 10/25/24, indicated R67 had a diagnosis of polydipsia. R67's care plan, dated 10/29/24, indicated a risk versus benefit form was completed and on file for R67 for not following the recommended diet related to the diagnosis of polydipsia. The care plan also indicated R67 was observed trying to get drinks from other residents and drinking water out of the bathroom sink. The care plan contained interventions, dated 3/24/25 of an 1800 milliliter fluid restriction and to offer fluids and snacks between meals. The care plan however lacked any updated or resident specific interventions to reduce fluid seeking behaviors and to increase R67's comfort related to polydipsia despite R67's continued repeated attempts to obtain more fluids. R67's April 2026 Treatment Administration Record (TAR), indicated R67's fluid intake and fluid seeking behaviors were being monitored but lacked resident specific interventions to assist with R67's fluid seeking behavior. During observation and interview on 4/21/26 at approximately 1:30 p.m., R67 was pacing between her room and hallway, asking to get into the bathroom. A sign hung on R67's door indicating to keep door closed and not allow R67 access to the bathroom. Two unnamed staff members were talking and stated R67's bathroom door remained lock to prevent R67 from drinking water from the bathroom sink, the other stating I think she needs more reminders. During an interview on 4/22/26 at 9:30 a.m., nursing assistant (NA)-C stated staff monitored R67's food and fluid intake during meals and tracked intake as part of care. The NA-C reported that fluids provided in R67's room were thickened and offered in small cups, and when R67 requested fluids, staff provided thickened liquids in small amounts using the small medication cups. The NA-C further stated the resident frequently requested fluids.During an interview on 4/22/26 at 10:43 a.m., registered nurse (RN)-B stated R67's fluid intake was monitored due to a history of hospitalization for aspiration concerns and returned to the facility with aspiration pneumonia and fluid retention while on furosemide. The RN reported the resident was currently on daily weights and a fluid restriction. The RN further stated staff manage R67's excessive thirst through frequent redirection when she requested additional fluids; however, the resident continued to request fluids frequently and became upset and call staff names when additional fluids were not provided. The RN indicated R67 was provided fluids in the form of pudding, ice cream, supplements, and one water jug per shift. The RN also stated the resident's bathroom door was kept closed and a commode was used as part of management. During an interview on 4/23/26 at 9:00 a.m., nurse manager and registered nurse (RN)-D and the director of nursing (DON) stated R67's fluid intake was monitored and when the resident reported feeling thirsty, staff provided recommended fluids. The nurse manager reported staff were aware of the resident's excessive thirst and a risk-versus-benefit approach was utilized, including direction for float staff to check with the nurse; however, they acknowledged the resident's polydipsia was not specifically care planned. The Nurse Manager further stated interventions such as lemon oral swabs were available but had not been trialed to address the resident's thirst. It was also stated that while the behavior was documented in the nutrition section of the record, it lacked individualized interventions to guide staff in managing the resident's excessive fluid-seeking behavior and should be care planned so new staff know how to address R67's polydipsia. A facility policy titled Care Planning, revised 11/2024, indicated, The interdisciplinary team (IDT), in conjunction with the resident and the resident representative, will develop and implement a comprehensive individualized care plan no later than the 21st day of admission of the resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to ensure accurate and complete respiratory care documentation and resident-specifc ordered settings for the use and management of a BIPAP device (bilevel positive airway pressure device - a non-invasive ventilation machine to helps in breathing) for 1 of 1 resident (R17) reviewed for respiratory care. Findings include:R17's quarterly Minimum Data Set (MDS), dated [DATE], indicated R17 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 14 (indicating intact cognition), and utilized a non-invasive mechanical ventilator.R17's physician orders, printed 4/23/26, indicated an order for a BIPAP machine to be applied at bedtime (HS), to remain on during nocturnal hours, and to be removed in the morning. Additional orders directed staff to change the BIPAP water daily, including emptying, drying, and refilling the chamber with distilled water to the fill line without overfilling each evening shift. Weekly orders included cleaning the BIPAP water chamber with gentle soap and allowing it to air dry, as well as cleaning the BIPAP mask and tubing with gentle soap and warm water and allowing them to air dry every Sunday on the evening shift. The orders, however, lacked specific BIPAP settings and did not include clear direction for staff to verify or maintain prescribed settings.During an interview on 4/22/26 at 10:43 a.m., registered nurse (RN)-B stated that for residents with a CPAP or BIPAP, the machines typically arrived pre-set and staff were instructed not to adjust the settings unless there was a malfunction. RN-B stated nurses checked the machine to ensure the settings remained as originally set, particularly for residents who may attempt to alter the device; however, no documented settings were identified for R17 to verify accuracy.During an interview on 4/23/26 at 9:00 a.m., nurse manager and registered nurse (RN)-D stated when a BIPAP was ordered, the facility typically faxed the order to a respiratory company (such as Northwest Respiratory), who then came to the facility to set up the machine. RN-D stated staff were expected to have specific settings documented in the orders and that nurses assisted residents with donning and doffing the BIPAP and ensuring the setting are correct. RN-D further stated she had recently reviewed R17's record and was unable to locate documentation identifying the respiratory company responsible for setup or the specific BIPAP settings, noting R17 was the only resident for whom this information could not be found and that follow-up was in progress.A facility policy on respiratory care/BIPAP care was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) narcotic/opioid and non-narcotic medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 2 of 6 residents (R5, R28) reviewed for unnecessary medication use. Findings include: R5 R5's admission Minimum Data Set (MDS) assessment, dated 3/19/26, identified R5 had intact cognition with no hallucinations, delusions, verbal or physical behaviors. R5 did reject cares 1-3 times during observation period. In addition, the MDS outlined R5 received both scheduled and PRN pain medications during the review; however, did not receive any non-medication intervention for pain. Further, R5 indicated they had occasional pain which they rated at four (4) out of 10 (10 being the worst possible). R5's care plan, initiated on 3/17/26, identified R5 had an alteration in pain due to low back pain with a list goal of adequate relief from pain as evidenced by verbalization and freedom from signs/signs of non-verbal indicators of pain. The care plan listed intervention to help R5 meet this goal which included, provide non-medicinal forms of pain relief such as positioning, rest, massage, etc., and pain medication as ordered my MD, and document on effectiveness of pain medication. R5's April Medication and Treatment Administration Report (MAR/TAR) for 4/1/26 to 4/22/26 was reviewed and identified the following relevant information: -hydrocodone-acetaminophen 5-325 mg tablet – give one tablet by mouth as needed for severe pain twice a day for 10 days, separate doses by at least 6 hours with a start date of 3/23/26 and end date of 4/6/26 which had been administered 5 times. One administration was marked with an I which indicated ineffective and one with an U which indicated unknown per follow-up code guide. The remaining 3 administrations were documented with an e indicated effective. All administrations were documented with pain scale. There was no documentation with administration of a nonpharmacological intervention being offered prior to administration. - hydrocodone-acetaminophen 5-325 mg tablet – give one tablet by mouth as needed for severe pain for 7 days with a start date of 4/6/26 and end date of 4/13/26 which had been administered 5 times. Administrations documented with an e indicating effective along with a pain scale prior to administration. There was no documentation on the MAR of nonpharmacological interventions prior to administration. -hydrocodone-acetaminophen (opioid pain medication)5-325 milligram (mg) tablet – give one tablet by mouth as needed for pain for 10 days with a start date of 4/13/26 and end date of 4/24/26 which had been administered 6 times. Administrations documented with an e indicating effective along with a pain scale prior to administration. There was no documentation on the MAR of nonpharmacological interventions prior to administration. -methocarbamol (medication used to relieve pain) 600 mg tablet – give 600 mg by mouth as needed for pain / spasms with a start date of 3/19/26 which had been administered 22 times. The MAR/TAR lacked any orders or documentation for nonpharmacological interventions offered or attempted prior to administration of PRN medication administrated for pain. R5's progress notes, dated 4/1/26 to 4/22/26, were reviewed. Progress notes lacked evidence of nonpharmacological interventions being offered or attempted prior to administration of PRN pain medication. R5's medical record was reviewed and lacked evidence of what, if any, non-pharmacological interventions were offered or attempted prior to the administration of the PRN narcotic medication all the administered doses from 4/1/26 to 4/22/26. During an observation and interview on 4/20/26 at 3:22 p.m., R5 was observed lying in bed. R5 stated he had chronic pain and took muscle relaxants and narcotics to manage the pain. During the interview, R5 was administered pain medication (hydrocodone-acetaminophen and methocarbamol). During the observation, R5 was asked about a pain scale but was not offered any nonpharmacological interventions prior to the administration. R5 stated sometimes they will sometimes offer him alternatives prior to pain medications which are helpful such as putting a pillow underneath him to help reposition him. During an interview on 4/22/26 at 2:05 p.m., registered nurse (RN)-C stated when a resident reported pain, an assessment would be completed which included location of pain and vital signs. RN-C stated they would offer PRN pain medication and contact the provider if needed. RN-C stated if the resident was offered any non-pharmacological interventions, it would be documented on the MAR/TAR or in a progress note. During an interview on 4/23/26 at 9:14 a.m., licensed practical nurse care coordinator (LPN)-B stated the expectation would be a nurse completed a full evaluation on a resident when pain was reported. LPN-B stated the expectation would be a nonpharmacological intervention would be offered and documented prior to administration of PRN pain medications. During a follow up interview on 4/23/26 at 9:51 a.m., LPN-B verified there were no documented non-pharmacological interventions for R5 prior to administration of PRN pain medications. R28 R28's Minimum Data Set (MDS), dated [DATE], indicated R28 was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and received PRN pain medication. The MDS further indicated R28 did not receive non-medication pain interventions. R28's care plan, initiated 2/20/26, indicated the resident was to receive non-pharmacological pain interventions, including positioning, rest, massage, and other comfort measures. However, the electronic medical record lacked documentation identifying resident-specific non-pharmacological interventions that had been attempted, what interventions were effective, or what interventions were ineffective for R28's pain management. Record review of physician orders indicated Cymbalta (Duloxetine) 60 mg daily for fibromyalgia and Methocarbamol (a muscle relaxant) 500 mg every 6 hours as needed for pain/spasm. The record lacked any individualized, resident-specific non-pharmacological interventions associated with the PRN (as needed) pain regimen. R28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated R28 received 7 doses of Methocarbamol in April, with no corresponding documentation of non-pharmacological pain interventions provided prior to administration. During an interview on 4/22/26 at 10:43 a.m., registered nurse (RN)-B stated that when residents requested pain medication, they may receive PRN medication as needed. RN-B stated non-pharmacological interventions should be offered prior to PRN administration and documented in the MAR/TAR. RN-B stated residents with pain should have an associated order to offer specific non-pharmacological interventions and document via number association in the MAR/TAR. During an interview on 4/23/26 at 9:00 a.m., the nurse manager and (RN-D) and the Director of Nursing (DON) stated the expectation was that non-pharmacological pain interventions, such as repositioning, distraction, and other comfort measures, were to be implemented and documented prior to or in conjunction with PRN pain medication use. RN-D further stated that individualized non-pharmacological interventions should be identified in the care plan and documented to reflect what is effective or ineffective. At 9:52 a.m. on 4/23/26, follow-up with the DON indicated that non-pharmacological interventions for R28's muscle relaxer use could not be located, and the DON acknowledged that interventions must be documented to determine effectiveness and guide ongoing care. A facility policy titled Pain Management Protocol, dated 3/23/23, identified nursing will evaluate for appropriate non-pharmacological interventions to address the individual's pain.

Based on observation and interview, the facility failed to ensure dignity was maintained for 2 of 2 residents (R9, R13) reviewed for dignity when staff failed to knock, introduced themselves, and wait for permission to enter resident rooms prior to entry.Findings include: R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with dementia, psychosis and dependent on staff for all cares. In addition, R9 was enrolled in hospice.R13R13's quarterly MDS dated [DATE] identified R13 was cognitively intact and had diagnoses of fibromyalgia, anxiety, depression and chronic pain.During observation and interview on 4/20/26 at 2:30 p.m., the State Agency (SA) surveyor was in process of screening R13 in their room which was shared with R9. The bedroom door to hallway was closed and a privacy curtain was pulled around R13 who was lying on bed. Nursing assistant (NA)-A entered the room with R9 who was seated in Broda wheelchair. During this time NA-A failed to knock, introduce herself, and wait for permission to enter the room. NA-A wheeled R9 into the middle of the room and then turned around and left the room without speaking. At 2:35 p.m., NA-A and NA-B entered room again without knocking. Both looked at SA and then exited room with R9. During interview both NA-A and NA-B verified they did not knock, introduce themselves, and wait for permission to enter the shared room. Both NA-A and NA-B stated it was important to knock before entering and NA-B stated, Did not think of it.During interview with R13 on 4/20/26 at 2:47 p.m., R13 stated most staff failed to knock and wait for permission to enter her room which she did not like. R13 stated an instance where a staff member popped her head into my room and the curtain [facing the hallway] while I was naked and she did not even knock or introduce herself. R13 was upset and verbalized this is my home. Why would anyone do that?During interview with director of nursing (DON) on 4/23/26 at 6:45 a.m., DON stated expectation of all staff to knock and wait for permission to enter any resident room.Facility policy was requested and not received.

During observation, interview, and record review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 1 of 1 residents (R9) reviewed for call lights.Findings include:R9R9's quarterly Minimum Data Set (MDS) dated [DATE] identified R9 with impaired cognition, no limitation in upper extremity range of motion and dependent on staff for turning, repositioning, transfers, and all personal cares. R9's diagnoses include dementia. In addition, R9 was enrolled in hospice.During observation on 4/20/26 at 2:30 p.m., nursing assistant (NA)-A wheeled R9 into the middle of their room without placing a call light in reach and then turned around and left the room without speaking. R13's call light was on R13's bed which was approximately 15 feet away. During interview upon leaving R13's room, NA-A confirmed R13 was not able to use her legs and would not have been able to reach the call light while seated in the middle of the room. During observation on 4/21/26 at 9:00 a.m., R9 was lying in bed positioned partially on her right side. The head of the bed was elevated to 45 degrees, and two pillows were under her head. One pillow was positioned along the left side of her body, and one pillow was positioned to her right side. The call light was attached to bed sheet under right sided pillow hanging down to the bed frame and out of sight of R9.During interview with nursing assistant (NA)-A on 4/22/26 at 8:24 a.m., NA-A verbalized familiarity with taking care of R9 and, [R9] is able to use the call light. NA-A stated expectation of call light to be in reach of residents if they need assistance.During interview with director of nursing (DON) on 4/23/26 at 6:47 a.m., DON stated expectation of every resident should have a call light in reach and It is their lifeline to ask for help if needed.Facility policy titled Call Light, updated 5/16/23 identified, Call cords, buttons, or other communication devices must be placed where they are within reach of each resident.

Based on observation, interview and document review, the facility failed to ensure community use glucometers (machines to check blood sugar) were properly cleaned and disinfected between patient use, and failed to ensure staff who performed blood glucose checks were knowledgeable of process for cleaning and disinfecting blood glucose devices prior to and after use per manufacturer instructions. This had the potential to affect 9 of 9 (R10, R13, R15, R26, R29, R41, R49, R54, and R118) residents who were diabetic, had orders for blood glucose monitoring, and used a community glucometer. Findings include: The manufacturer's instructions for use of the Arkray Assure Platinum Blood Glucose Monitoring System in Section B: To reduce the chance of infection, the clinician is to, Wash hands thoroughly with soap and water before putting on a new pair of gloves and performing the next patient test. And, prior to obtaining blood sample, Step 1: Wash patient's hands with soap and warm water. Guidelines for cleaning and disinfecting the unit state, To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed. Per the manufacturer's instructions, the clinician is to utilize the approved and recommended Environmental Protection Agency (EPA)-registered wipe to cleanse and disinfect the unit after each use. One of the approved wipes is, Super Sani-Cloth Germicidal Disposable Wipes[Saniwipe]. General guidelines for use of the wipe is to Allow treated surface to remain wet for two (2) minutes. Let air dry. The procedure for cleaning and disinfecting the Assure Platinum Blood Glucose Monitoring System is to wear appropriate protective gear such as disposable gloves, wipe the surface of the meter to clean it, and wipe around the test strip port with unit facing down to prevent the disinfectant liquid from entering the meter. Treated surface must remain wet for recommended contact time per the wipes manufacturer's instructions. The product description for Super Sani-Cloth Germicidal Disposable Wipe list the Overall Contact Time (time a cleaner needs to kill germs on a surface or device) as two minutes. During continuous observation and interview on 1/27/25 at 5:44 p.m., registered nurse (RN)-A stated she was familiar with the residents. RN-A walked to the nursing medication cart and removed a yellow plastic container from the cart with R10's name written on top of it. From the container RN-A removed an Arkray Assure Platinum Blood Glucose Monitoring System glucometer, one lancet, container of test strips, two cotton balls, and two alcohol wipe towelettes. RN-A walked to R10's room with the supplies. RN-A entered R10 room and asked if she could take your blood sugar before you eat? R10 had started to eat dinner and was holding silverware and his wheelchair armrest when RN-A entered room. RN-A sanitized hands and applied gloves, then placed supplies directly on top of bedside table next to dinner tray. There was no barrier used between the supplies and the bedside table. RN-A did not wash R10's fingers with soap and water. RN-A wiped R10's right pointer finger with an alcohol wipe, then inserted a glucometer strip into the machine turning it on. RN-A then used the lancet to the right pointer finger and obtained a sample of blood. RN-A wiped the finger with a cotton swab and then applied a drop of blood to the glucometer strip. RN-A obtained the result, wiped the finger with second alcohol wipe, and removed the strip from glucometer. RN-A then disposed of the lancet in a Sharps container (puncture-resistant waste container), and disposed of the used strip, cotton ball, alcohol towelettes, and gloves into the resident garbage container. RN-A walked back to medication cart with glucometer after sanitizing hands and placed supplies on top of medication cart to document results on a care sheet. RN-A then obtained a facial tissue from top of medication cart, pumped hand sanitizer onto the tissue, and wiped the entire glucometer. RN-A obtained second facial tissue and immediately wiped the entire glucometer with a dry tissue. RN-A unlocked the medication cart and returned the supplies back into R10's box, closed the lid and placed it back into the medication cart. RN-A did not use an approved and recommended Environmental Protection Agency (EPA)-registered wipe to cleanse and disinfect the unit prior to and/or following use. Immediately afterwards at 5:51 p.m., RN-A removed a blue plastic container from the cart with R54's name written on top of it. RN-A obtained an Arkray Assure Platinum Blood Glucose Monitoring System glucometer and supplies and walked to R54's bedroom and knocked on the door before entering the room. RN-A did not clean glucometer prior to use. RN-A asked permission to obtain blood sugar result and then placed supplies directly on top of bedside table next to his dinner tray. There was no barrier used between the supplies and the bedside table. RN-A did not wash R54's fingers with soap and water. RN-A wiped R54's left pointer finger with an alcohol wipe, then inserted glucometer strip into the machine turning it on. RN-A then used the lancet to the left pointer finger and obtained a sample of blood. RN-A wiped the finger with a cotton swab and applied a drop of blood to the glucometer strip. RN-A obtained result and wiped finger with second alcohol wipe and removed the strip from the glucometer. RN-A then disposed of the lancet in a Sharps container, and disposed of the used strip, cotton ball, alcohol towelettes, and gloves into the resident garbage container. RN-A walked to medication cart, sanitized her hands, applied gloves, and used a facial tissue with hand sanitizer applied to it and then wiped the glucometer and dried it immediately with a dry facial tissue. RN-A then placed R54's glucometer and supplies into the blue container with his name on it and put it in the locked medication cart. RN-A did not use an approved and recommended Environmental Protection Agency (EPA)-registered wipe to cleanse and disinfect the unit it prior to and/or following use. RN-A opened her care sheet and wrote the information on it. RN-A stated, I always clean the glucometer with that sanitizer [pointing to an 8 fl ounce (oz) container of McKessan brand hand sanitizer on the medication cart]. It's what I have always done. During observation and interview with RN-C on 1/28/25 at 7:12 a.m., RN-C obtained communal Arkray Assure Platinum Blood Glucose Monitoring System, used for multiple residents in the facility, and supplies from medication cart and entered R26's room. RN-C did not clean glucometer prior to use. RN-C asked permission to obtain blood sugar result and then placed supplies directly on top of bedside table. There was no barrier used between the supplies and the bedside table. RN-C did not wash R26's fingers with soap and water. RN-C wiped right pointer finger with alcohol wipe, then inserted a glucometer strip into the machine turning it on. RN-C then used the lancet to the left pointer finger and obtained a sample of blood. RN-C wiped the finger with a cotton swab and then applied a drop of blood to the glucometer strip. RN-C obtained result and wiped finger with second alcohol wipe and removed the strip from the glucometer. RN-A then disposed of the lancet in a Sharps container and disposed of the used strip, cotton ball, alcohol towelettes, and gloves into the resident garbage container. RN-C then walked to medication cart and sanitized hands prior to applying gloves. RN-C wiped glucometer with Saniwipe cloth and immediately placed it back into the medication cart. This was not done according to the Saniwipe recommendations. RN-C stated, no hand sanitizer for cleaning glucometer. During interview with licensed practical nurse (LPN)-A on 1/28/25 at 10:54 a.m., LPN-A stated the process for cleaning and disinfecting the glucometer was clean it with the purple Saniwipe for thirty seconds and put on a paper towel and let it dry. LPN-A stated, hand sanitizer would not be ok to clean a glucometer because I think it needs more of the Saniwipe thing, it says two minutes. LPN-A provided surveyor a list of facility residents requiring blood glucose monitoring using the Arkray Assure Platinum Blood Glucose Monitoring System. The list was marked with icons that identified the residents who had personal dedicated glucometers in the locked medication carts and the residents who used the shared glucometers. Personal dedicated glucometers were identified as R10, R13, and R54. Shared glucometers were used for R15, R26, R29, R41, R49, and R118. During interview with LPN-B on 1/28/25 at 11:26 a.m., LPN-B stated glucometer cleaning and disinfecting was done by the nurses. LPN-B stated expectation of glucometer cleaning as, [sic] must use the Saniwipe or the alcohol wipe. LPN-B then opened a locked medication cart and removed an alcohol towelette and showed it to the surveyor. This is what we can use. During interview with registered nurse (RN)-C on 1/29/25 at 7:12 a.m., RN-C removed an Arkay Assure Platinum Blood Glucose Monitoring System glucometer from a medication cart and wiped it with a Saniwipe, then placing it on a facial tissue. RN-C stated, no. [hand] sanitizer does not apply [to cleaning] it. During interview with RN-B on 1/30/25 at 9:31 a.m., RN-B stated the procedure to clean and disinfect the Arkay Assure Platinum Blood Glucose Monitoring System glucometer was to wipe down the machine with one of the [Saniwipe} wipes and to do this procedure before and after use. RN-B stated, I don't not usually wash fingers with soap and water before obtaining result. During interview with trained medication aide (TMA)-A on 1/30/25 at 9:35 a.m., TMA-A stated staff were expected to clean and disinfect the glucometer with a Saniwipe not alcohol wipe or hand sanitizer before resident use. TMA-A also stated, I don't know if the last person cleaned it or not. TMA-A stated, I do not use soap and water to wash [resident] finger before poking finger [obtaining result]. During interview with assistant director of nursing (ADON) who was also the facilitys infection control preventionist on 1/30/25 at 10:43 a.m., ADON stated, we use the purple Saniwipe between glucometer use and allow it sit for three minutes. ADON stated the expectation of nurses was to clean and disinfect the glucometer always before and after use. I expect staff to follow manufacturers guidelines and instructions to wash hands with soap and water before testing and to clean and sanitize the machine with Saniwipe before and after use. ADON stated, alcohol wipes are not the same as a Saniwipe and they are not appropriate to clean a glucometer. Facility policy on cleaning and disinfecting medical equipment was requested and not received.

Based on observation, interview and document review, the facility failed to ensure an unsecured bed mattress was assessed for correct fit for a resident's bed for 1 of 1 residents (R59) reviewed for safety hazards. Findings include: R59's quarterly Minimum Data Set, dated dated dated [DATE] identified R59 had intact cognition and was independent with most mobility related activities (i.e., dressing, toileting and personal hygiene, and ambulation). In addition, R59 had diagnoses of cellulitis (bacterial infection of the skin that can cause redness, pain and swelling at the site) of left lower extremity, anxiety, and depression. During observation and interview with R59 on 1/27/25 at 1:26 p.m., R59 was observed to be lying in bed which was positioned along the wall with the foot of the bed just inside door to hallway. The bed had no footboard, and the unsecured mattress hung over the foot of the bed frame by about 12 inches. There was no retainer bar at the foot of the bed frame to prevent mattress from sliding down. R59 stated, it is hard to get on and off of it and I have to move my feet to allow roommate and others to open and close the door to the hallway. During observation on 1/28/25 at 8:04 a.m., R59 unsecured mattress continued to hang off the foot of the bed frame by about twelve inches. During observation and interview with nursing assistant (NA)-B on 1/28/25 at 11:00 a.m., NA-B stated she was familiar with R59 and pointed to his bed mattress. [R59] is tall and a big guy. That mattress does not fit him. I haven't noticed it or said anything to anyone about it and I haven't heard anyone saying or doing anything about it. During observation and interview with RN-C on 1/28/25 at 1:10 p.m., RN-C stated she was familiar with R59. RN-C pointed out no footboard. I would expect it to be there. All beds should have headboards and foot boards. I don't know why it is like that. RN-C identified the unsecured mattress as a safety risk. During interview with the maintenance director (MD) on 1/28/25 at 1:21 p.m., MD stated, [R59] should have footboard. He kicked it off. [Facility] don't have bed extenders for these beds. We don't have alternatives, and I haven't looked for any. MD stated he was aware of R59's unsecured mattress sliding down past the bedframe and was not responsible for assessing the appropriateness of the mattress and bedframe. MD stated, no I have not asked [R59] for alternatives or options to the overhanging mattress. During interview with R59 pm 1/28/25 at 1:28 p.m., R59 stated he kicked off the footboard. R59 stated, [mattress] is uncomfortable. I was not told about any alternative to the mattress or bed. R59 stated facility staff were aware of the missing footboard because staff put it in my closet. During interview with licensed practical nurse (LPN)-C on 1/28/25 at 2:06 p.m., LPN-B stated he was also the nurse manager for the resident wing R59 resided on. LPN-B stated he was told that R59's missing footboard and slipping mattress was his preference. The staff removed the foot board. Since then, I did not visit back with him about it. LPN-B stated, I think [R59] would benefit from an extension to the mattress or bed[frame]. He is at risk for pressure ulcers to feet. LPN-B stated the electronic medical record (EMR) failed to address the footboard and his unsecured mattress sliding down past the frame of the bed. During observation and interview with assistant director of nursing (ADON) on 1/28/25 at 2:30 p.m., ADON and surveyor walked to R59's room. ADON stated R59 would rest his feet on top of the footboard and it is not appropriate and [R59] said he likes to hang his feet over it. [R59] did not want the footboard. He slides down in the bed. I don't know if maintenance addressed the mattress or bed. As far as I know, we do have extensions for beds. [R59] is very much alert and oriented and knows what his wants and needs are. ADON stated, it is awkward and facility did not have documentation of assessing [R59's] bed frame and unsecured mattress. During interview with MD on 1/28/25 at 3:10 p.m., MD stated, [facility] do[sic] have extensions and longer mattresses and bed[frames]. I do not document or have anything about offering alternatives for extending the bed frame or mattress. MD stated R59 slides down. During interview with ADON on 1/30/25 at 11:17 a.m., ADON stated, [facility] did not assess and reassess for the mattress to stay secured on the bed frame. The mattress does slide down off the foot of the bed without the foot board and his feet do dangle off the mattress at times. Facility policy on Bed Safety was requested and not received.

Based on interview and document review, the facility failed to ensure an order for an audiology (medical specialty assisting with hearing) referral was acted upon promptly to promote better hearing and quality of life for 1 of 1 residents (R13) reviewed who expressed difficulty with hearing. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition with no delusional thinking. The MDS indicated R13 had adequate hearing (i.e., no difficulty in normal conversation) and did not use hearing aids. R13's referral form dated 2/22/24, indicated R13 had an order from her provider for an audiology consult for a diagnosis of hearing loss. R13's provider note dated 7/1/24, indicated R13 had reported worsening hearing loss and as a result, withdraws from social interaction and stays in her room. The note indicated the plan for the resident's hearing loss was to provide an audiology consult. During an interview on 1/27/25 at 1:46 p.m., R13 stated she had needed her ears checked for a while and did not recall anyone offering to help her set up an appointment to see the ear doctor. R13 stated she thought she had told someone that her hearing was getting worse but was unsure who. During an interview on 1/30/25 at 9:03 a.m., the interim director of nursing (DON) stated the health information manager (HIM) oversaw making resident appointments and recommended questions regarding whether resident appointments were scheduled/attended be directed to her. During an interview on 1/30/25 at 10:29 a.m., the HIM stated she oversaw making resident appointments for things such as seeing the audiologist. The HIM confirmed she had reviewed R13's medical and found an order from the provider for R13 to see the audiologist in February of 2024 but did not find that this appointment had ever been made or refused by R13. The HIM stated she would make this appointment now, but it would take about four months for the resident to be seen by an audiologist. A policy regarding audiology services was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure acute, potentially distressing psychoactive symptoms were recorded and non-pharmacological interventions were attempted or recorded to ensure efficacy of as-needed (i.e., PRN) psychotropic medication for 1 of 5 residents (R2) reviewed for unnecessary medication use. Findings include: R2's quarterly Minimum Data Set (MDS), dated [DATE], identified R2 had severe cognitive impairment and continuous inattention, disorganized thinking, and altered consciousness. The MDS recorded R2 having multiple signs of potential depression, including appear or feeling down and being short-tempered, but demonstrated no behaviors (i.e., physical, verbal, other). Further, the MDS identified R2 consumed multiple psychotropic's including both antipsychotic and antianxiety medications. R2's Doctor's Order, dated 1/6/25, identified an order from hospice was received which read, Restart lorazepam concentrate . 0.5 mg [milligrams] (0.25 ml) PO/SL [by mouth] Q4H PRN [every four hours as needed]. The order listed a diagnosis which read, Terminal agitation [a state of extreme restlessness, anxiety, and confusion that can occur in people who are nearing the end of their life]. On 1/27/25 at 1:28 p.m., R2 was observed seated in a geri-chair in the hallway by the nurses' station. R2's eye were open and she was alert as registered nurse (RN)-E held up her right leg and exposed a large, dark area on her right heel. R2 demonstrated no physical signs of pain or anxiousness at this time but had little, if any, verbal response to RN-E or the surveyor. Two days later, on 1/29/25 at 8:45 a.m., R2 was observed lying in bed while in her room. R2 was alert with her eyes open and speaking aloud with I want to tell you something, however, just mumbled a response afterward. R2 appears comfortable and without obvious physical signs of pain or anxiousness at this time. R2's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 1/2025, identified R2's administered medications and treatments for the period. The MAR recorded a total of five (5) administrations of PRN lorazepam including: On 1/9/25 at 7:20 p.m., with the results listed as, E [effective]. A corresponding progress note, dated 1/9/25, identified the medication was given but lacked any recorded symptoms or behaviors which supported use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. On 1/13/25 at 9:32 a.m., with the results listed as, E. A corresponding progress note, dated 1/13/25, identified the medication was given but lacked any recorded symptoms or behaviors which supported use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. On 1/23/25 at 11:07 a.m., with the results listed as, E. A corresponding progress note, dated 1/23/25, identified the medication was given but lacked any recorded symptoms or behaviors which supported use of the medication, nor any non-pharmacological interventions being attempted or done prior to the medication. None of the recorded doses or corresponding notes for the 1/2025 administration(s) contained any recorded symptoms or behaviors which supported use of the PRN psychotropic medication, nor any non-pharmacological interventions being attempted or done prior to the medication. R2's care plan, printed 1/29/25, identified R2's current identified problems, goals, and interventions to help R2 meet those goals. The care plan identified R2 was on hospice care and had an alteration in her mood and behavior related to her medical complications. The care plan outlined, Resident has hx [history] of refusing all cares, meds and food. Resident speaks another language [and] understands a little English. The care plan directed, Monitor and document mood state/behaviors upon occurrence. Further, the care plan identified R2 was at risk for psychotropic medication adverse reactions due to using them daily, and directed staff to update the provider regarding the efficacy of the medications or, if any, adverse reactions noted. When interviewed on 1/29/25 at 8:49 a.m., trained medication aide (TMA)-B stated they had worked with R2 multiple times prior and described her as having good days and bad days with her care needs. TMA-B explained R2 would, at times, help staff complete basic cares like dressing and expressed she (R2) used to have more behaviors, such as hallucinations, but those had subsided adding, [She's] very calm now. TMA-B stated R2 was very loving and often would tell you she loves you to the staff members. TMA-B stated they recalled one episode of R2 being a little anxious a week ago but otherwise had not seen any indications R2 was anxious or distressed. TMA-B stated when they witnessed the episode the week prior, the nurse stepped in and gave R2 medication which made it much better. TMA-B stated R2 seemed to speak in her native language when anxious or upset and, in response, staff just remind her they're not able to understand her and to use English, if able. However, TMA-B verified they had a translator service available and could use it, if needed. R2's medical record was reviewed and lacked evidence what, if any, physical or verbal symptoms were present to warrant use of the medication on each of the administered doses of the PRN lorazepam; nor evidence what, if any, non-pharmacological interventions had been attempted prior to using the medication to see if the behaviors deescalated without medication intervention. When interviewed on 1/29/25 at 11:02 a.m., registered nurse (RN)-B stated they had worked with R2 multiple times and described R2 as being total cares. RN-B stated R2 could have very different behaviors including yelling, screaming and, at times, throwing items at the staff. However, RN-B stated then, I think in the last month she's been doing better. RN-B stated it was now mostly outbursts here and there. RN-B stated if R2 had behaviors, they themselves had tried to wheel her around the hallways and noticed R2 seeing other people tended to make her more calm. RN-B verified R2 had an active order for PRN lorazepam and stated they typically gave it to R2 only after non-pharmacological interventions failed. RN-B reviewed R2's completed MAR and associated charting and acknowledged it lacked any recorded symptoms or non-pharmacological interventions prior and expressed staff possibly were just giving it and not recording those things. RN-B stated staff should be attempting to figure out why R2 was agitated or anxious, and expressed behavior monitoring and non-pharmacological interventions were tracked on the TAR. RN-B reviewed R2's TAR and stated aloud, Her's is different here. RN-B verified it did not have the typical order set used to track non-pharmacological interventions and reiterated, [Maybe] it's something they don't put in [interventions] and just give it [medication]. Further, RN-B stated they were unsure if anyone from nursing leadership had ever told them to record symptoms or non-pharmacological interventions with PRN psychotropic medication administration adding aloud, I'm not sure. On 1/29/25 at 11:52 a.m., the regional nurse consultant (RNC)-A was interviewed. RNC-A verified they reviewed R2's medical record and it lacked the behavior monitoring order set which was used to document non-pharmacological interventions on each shift to support medication' use. RNC-A stated it should have been in there as it was used to show resident specific target behaviors and interventions. RNC-A stated staff could have also completed a progress note with such information. RNC-A verified symptoms and non-pharmacological interventions were to be attempted and tracked as doing such helped determine if the medication was actually helping with it [symptoms]. When interviewed on 1/30/25 at 9:29 a.m., the consulting pharmacist (CP) explained specific behavior monitoring was more completed on the nursing end, however, verified witnessed behaviors should be recorded with any PRN medication administration. CP explained non-pharmacological interventions were also to be attempted adding aloud, They definitely should attempt non-[NAME] prior. However, CP reiterated doing such things was, again, more up to the nurses and nursing leadership to ensure it was done. A provided Psychotropic Medication Use policy, dated 11/2024, identified such medications could be considered for resident with symptoms which have been identified by the interdisciplinary team (IDT) and whom have deemed such medications would benefit the resident. The policy directed, Pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented. Further, the policy outlined, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record.

Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were fully addressed or acted upon for 1 of 5 residents (R13) reviewed for unnecessary medications. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition and utilized antipsychotic, antianxiety, and antidepressant medication. R13's diagnostic report dated 7/1/24, indicated R13 was diagnosed with major depressive disorder, bipolar disorder, and an anxiety disorder. R13's Order Summary report dated 1/30/25, included the following orders: -dated 6/2/23 for 200 milligrams (mg) of quetiapine (an antipsychotic medication used to treat bipolar disorder) daily for bipolar disorder. -dated 8/14/23 for 300 mg of bupropion XL (an antidepressant) daily for major depressive disorder. -dated 8/14/23 for 120 mg of duloxetine (an antidepressant) daily for major depressive disorder. -dated 8/14/23 for 400 mg of lamotrigine (an anticonvulsant sometimes used to treat bipolar disorder) daily for a bipolar disorder. -dated 12/29/23 for five mg of aripiprazole (an antipsychotic medication used to treat bipolar disorder) daily for bipolar disorder. -dated 12/29/23 for three mg of melatonin (a dietary supplement used to assist with sleep) daily for insomnia. -dated 1/23/24 for 10 mg of buspirone (an anti-anxiety medication) twice a day for an anxiety disorder. R13's Consultant Pharmacist Recommendation to Physician dated 12/23/24, indicated R13 received psychotic medication including five mg of aripiprazole daily, 10 mg of buspirone twice a day, 400 mg of lamotrigine daily, 300 mg of bupropion XL daily, and 120 mg of duloxetine daily. The pharmacist recommended the prescriber review if R13 was on the lowest effective doses of the medications listed above. The pharmacist indicated if a dose reduction was contraindicated, that the clinical rationale be documented below. The recommendation had a blank for a signature, date, and prescriber response that were left blank. R13's Consultant Pharmacist Recommendation to Physician dated 1/27/25, indicated R13 received psychotropic medications including five mg of aripiprazole daily, 10 mg of buspirone twice a day, 400 mg of lamotrigine daily, 300 mg of bupropion XL daily, 120 mg of duloxetine daily, three mg of melatonin daily, and 200 mg of quetiapine daily. The pharmacist recommended the prescriber review if R13 was on the lowest effective doses of the medications listed above. The pharmacist indicated if a dose reduction was contraindicated, that the clinical rationale be documented below. The recommendation had a blank for a signature, date, and prescriber response that were left blank. R13's medical record was reviewed and did not include a provider response to the above pharmacist recommendations. During an interview on 1/30/25 at 9:26 a.m., the consulting pharmacist (CP) stated when she had reviewed R13's medication record she had not found evidence the provider had attempted or declined to attempt a dose reduction of her psychotropic medications in the current quarter. The CP stated she had given a similar recommendation in January as the previous CP had in December, as she could not find that the provider had responded to the recommendation given in December, and it was important that they attempt to reduce psychotropic medication use when possible. During an interview on 1/30/25 at 11:43 a.m., the interim director of nursing (DON) confirmed she had reviewed R13's medical record and could not find that a response was received from the provider regarding the pharmacist's recommendation for a dose reduction. The interim DON stated she thought the recommendation should have been sent to R13's psychiatrist as they managed her psychotropic medications but as R13 had changed psychiatrists recently, was unsure who this was sent to as the previous DON oversaw this task. The interim DON stated she expected these to be faxed to the provider and the response uploaded to the medical record. The facility's Medication Regimen Review policy dated 8/19, indicated the pharmacist would review each resident's medication regimen at least monthly, and the recommendations would be acted upon and documented by facility staff and/or the prescriber. The prescriber would accept and act upon the suggestions or reject the suggestion and give an explanation for disagreeing.

Based on observation, interview, and document review, the facility failed to accurately or comprehensively assess the use of side rails and ensure installed side rails were secured to prevent injury or potential entrapment for 1 of 1 resident (R33) reviewed who used bilateral quarter-sized side rails on their bed. Findings include: R33's admission Minimum Data Set (MDS), dated [DATE], identified R33 had intact cognition and demonstrated no delusional thinking. Further, the MDS outlined R33 required substantial and/or maximum assistance for bed mobility. On 1/27/25 at 1:14 p.m., R33 was observed lying in bed while in her room. R33 used a standard-size hospital bed and each side had a mounted, affixed metallic one-quarter side rail attached to the frame via a center arm. The rail on the open side of the bed (opposite the wall) was loose when touched and allowed movement of approximately eight to 10 inches back-and-forth towards and away from the bed which increased the spacing between the mattress and rail. R33 stated the rail had been loose since she got the bed and expressed she told staff about it but staff responded, They keep telling me that's OK but I don't know. R33 stated the whole side rail on the open side wiggles like that and she was concerned about falling out when they roll her but staff kept telling her it wasn't an issue as they are standing right there. R33 stated nobody from nursing maintenance had been in to review the side rail despite it being loose adding, Not that I'm aware of anyway. R33 repeated, I think somebody should tighten that up. Further, R33 stated she couldn't recall being offered or told what, if any, other options instead of a side rail were available to help her roll side-to-side in bed adding, I don't know if there are any other options. R33's most recent MHM (Monarch Healthcare Management) Bed Mobility Device Evaluation 7/18, dated 1/3/25, identified a section labeled, What type of bed mobility device does resident/legal representative prefer[?], which was answered, Bilateral grab bars. The evaluation identified R33 or their representative was educated on the risks of such device and R33 had no history of injury using such device, either. A section labeled, Evaluation of Alternatives, listed a radio-button response of, Yes, along with dictation reading, . is an assist of 2-3 with a lift . has been educated on the devised [sic] being used and is aware reason why its being used. However, the evaluation lacked further information what which specific devices had been attempted or discussed with R33 (i.e., smaller grab bar, trapeze). The evaluation continued and identified, Assist/Grab bar(s), would be used along with a summary reading, Resident uses grab bars to assist with turn and repositioning. The evaluation was signed by the interim director of nursing (DON) on 1/7/25. R33's care plan, printed 1/28/25, identified all of R33's current or potential medical or mobility issues along with their corresponding goals and interventions. The care plan outlined R33 was at risk of falls and injury, and had an alteration in mobility due to edema and wounds. The care plan directed to assist R33 with movement in-and-out of bed and use a mechanical lift for transfers. However, the care plan lacked information or direction on R33's use of side rails. When interviewed on 1/28/25 at 10:46 a.m., nursing assistant (NA)-A stated they had worked with R33 prior and described her as needing total assistance with most cares. NA-A stated R33 used a mechanical lift and two people to transfer in-and-out of bed, adding R33 would help with repositioning when in bed by hold[ing] on to the thing on the side of the bed. NA-A verified R33 used the side rails to help with turning and brief changes, indicating she had them attached to the bed when she moved in to their recall. NA-A stated they had noticed the one rail, on the open side of the bed, was loose adding aloud, It wiggles. NA-A stated it had been loose awhile and they were unsure if other alternatives (i.e., grab bar, trapeze) had ever been installed on the bed but reiterated the loose rail needed to be fixed adding, I think it needs to be tightened. NA-A stated staff could notify maintenance to have it done on TELS (the maintenance software system) but expressed they themselves had not completed one as they wasn't [weren't] pay attention that much. On 1/28/25 at 1:10 p.m., the director of maintenance (DOR) was interviewed. DOR stated staff had just brought it up about R33's side rail being loose and, as a result, they were going around to everyone with such device to ensure they were tight and secured. DOR verified nobody had alerted him or completed a 'TELS' about it prior to that day (1/28/25,) and expressed side rails and grab bars should be tight and secured for safety reasons. DOR stated grab bars or side rails were not routinely checked for fit and condition by their department because they felt nursing would let them know if a device was loose. DOR stated a monthly check of the devices moving forward would possibly help the issue. When interviewed on 1/28/25 at 1:22 p.m., the interim director of nursing (DON) verified they had reviewed R33's medical record. DON stated the evaluation (dated 1/7/25,) was completed in error and should have reflected side rail use versus grab bars being installed. DON explained R33's bed was rented and no alternatives were able to be done because of that, adding the usual u-bars wouldn't attach to it. However, DON stated they were unsure if maintenance or an outside person set the bed up. DON stated side rails and bars should be checked just with every day care and, if needed, a 'TELS' should be done so it can be fixed. DON added, [We] put it in TELS right away so we can get it fixed. Further, DON stated a loose side rail could cause falls or entrapment adding, It can cause harm to the patient. A facility' policy on side rail evaluation and maintenance was requested, however, none was received.

Based on observation, interview, and document review, the facility failed to ensure ongoing monitoring of resident oxygen use was completed to reduce the risk of respiratory complications for 1 of 1 residents (R13) reviewed for oxygen use. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had intact cognition and was diagnosed with heart failure, kidney failure, Chronic Obstructive Pulmonary Disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness), and respiratory failure. The MDS indicated R13 required setup help with eating and oral hygiene and maximum assistance with dressing. The MDS indicated R13 was on oxygen therapy. R13's care plan dated 9/7/24, indicated R13 had an alteration in respiratory status and would remove her oxygen cannula and adjust her oxygen administration rate herself. R13's care plan indicated oxygen was to be administered as ordered and oxygen saturations were to be monitored. The care plan indicated staff were to monitor and document R13's respiratory status. R13's medication and treatment record dated 1/1/25 through 1/26/25, indicated R13 ' s oxygen saturations were taken (approximately) every shift with values ranging from 92 to 99 percent but did not indicate how many liters per minute (LPM) of oxygen R13 was receiving at the time of the reading. The record included an order dated 3/1/24 to wean oxygen back to baseline of two to three LPM to keep oxygen saturation above 92 percent. This order was documented on (approximately) every shift with oxygen saturation values ranging from 92 to 99 percent but did not indicate how many LPM of oxygen R13 was receiving at the time of the reading. R13's medical record was reviewed and did not include correlating a measurement of the LPM of oxygen used to assist R13 in reaching the oxygen saturations measured. R13's provider note dated 1/10/25, indicated R13 had complained of bouts of shortness of breath so a chest x-ray and labs were ordered on 1/10/25. The note indicated R13's chest x-ray showed lung congestion, so a diuretic was ordered on 1/17/25. The note indicated R13 had a history of acute on chronic respiratory failure with hypercapnia (a condition that can lead to shortness of breath that is caused by a buildup of a waste product that your body gets rid of with exhale) that had led to a prior hospitalization in 8/24. R13's progress note dated 1/28/25 at 2:09 p.m., indicated R13 was sent to the hospital related to shortness of breath. During an interview and observation on 1/27/25 at 4:16 p.m., R13 was observed sitting in a recliner in her room receiving oxygen via a nasal cannula. The oxygen concentrator was observed running at a rate of four LPM. R13 stated she had been feeling very short of breath that day and so her nurse had increased her oxygen. R13 was observed taking breaks between words to take deep breaths before she continued talking. During an observation on 1/28/25 at 8:06 a.m., R13 was observed sitting in a recliner in her room receiving oxygen via a nasal cannula. The oxygen concentrator was observed running at a rate of four LPM. During an interview on 1/28/25 at 12:41 p.m., registered nurse (RN)-C stated the computer system they used did not allow nursing staff to put in how many LPM of oxygen they were administering to the resident so she could only see what oxygen saturation the previously nurse had recorded but not the dosage of oxygen being administered at the time of the measurement. RN-C stated R13 had a history of increasing her oxygen administration level and she thought she had done that this morning, so RN-C had decreased her oxygen to three liters. RN-C stated the previous nurse had not passed along how many LPM of oxygen R13 had needed the previous shift and confirmed she was unable to find this information in the medical record. RN-C stated R13 had been feeling very short of breath that day and if it did not get better, she was going to have to go to the hospital. During an observation on 1/28/25 at 1:53 p.m., R13 was observed telling outside emergency medical personnel she can't breathe and it started about four days ago. During an interview on 1/30/25 at 8:22 a.m., nurse practitioner (NP)-A stated she would expect nursing staff to document how many liters of oxygen were administered when documenting oxygen saturation so the facility could track respiratory status changes. During an interview on 1/30/25 at 11:37 a.m., the interim director of nursing (DON) confirmed she had reviewed R13's medical record and stated the facility usually included an order for recording how many LPM of oxygen was administered to a resident and then it would allow nurses to document how many LPM were being administered, but it had been missed for R13. The DON stated it was important her oxygen flow rate was recorded so changes in respiratory status could be tracked, and interventions could be attempted as needed. A policy regarding oxygen use was requested and not received.

Based on observation and interview, the facility failed to ensure a comfortable and homelike environment for 2 of 2 residents (R19, R23) who shared a room with a large area of the wall patched but left unfinished, unsanded, and unpainted. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 had intact cognition. R23's annual MDS dated [DATE], identified had intact cognition. During observation and interview on 1/27/25 at 6:01 p.m., a shared wall of R19 and R23's room had an area of white joint compound that measured one hundred and three inches long by thirty-seven inches tall spanning most of the wall. The area was not sanded, smoothed out, or painted to match the rest of the wall and room. R23 stated, the wall has been like this since [sic] moved to this room in October of 2024. During interview with registered nurse (RN)-B on 1/28/25 at 10:01 a.m., RN-B stated she was familiar with all the residents. RN-B stated there was an expectation of staff to notify the maintenance staff for repair work through an email request form. All staff can do it. RN-B denied noticing the unfinished wall repair in R19 and R23's room or submitting a maintenance request to complete the sanding and painting. During interview with nursing assistant (NA)-A on 1/28/25 at 10:25 a.m., NA-A stated she was familiar with all the residents. NA-A stated staff were expected to notify the maintenance staff for repair work, online. If [maintenance director] is not here, I may talk to the nurse manager. NA-A denied noticing the unfinished wall repair in R19 and R23's room or submitting a maintenance request to complete the sanding and painting. During interview on 1/28/25 at 10:44 a.m., R23's stated, I don't like it because it tells me the place has not been totally taken care of and not necessarily clean. I would never stand for that in my own home. During interview with NA-B on 1/28/25 at 11:00 a.m., NA-B stated she was familiar with the residents. NA-B stated expectation of staff to notify the maintenance staff for repair work in the computer. NA-B denied noticing the unfinished wall repair in R19 and R23's room or submitting a maintenance request to complete the sanding and painting. During interview with NA-C on 1/28/25 at 11:12 a.m., NA-C stated she was familiar with all the residents. NA-A stated expectation of staff to notify the maintenance staff for repair work through an email request form. NA-C denied noticing the unfinished wall repair in R19 and R23's room or submitting a maintenance request to complete the sanding and painting. During observation and interview on 1/28/25 at 11:26 a.m., LPN-B looked at R19 and R23's shared wall and stated, I don't know when they [maintenance staff] did that work on the wall but it is not finished. It does not look good. I have not noticed that before. At 2:02 p.m., LPN-B stated staff was expected to use a communication system with the maintenance department if a repair was needed, like for painting a hallway or resident room. During observation and interview with the maintenance director (MD) on 1/28/25 at 12:14 p.m., MD looked at R19's and R23's bedroom wall and stated, I have patched this. In order for me to paint, I have to pull everyone out of their rooms, and we have been full lately. And we don't have the colors in here anymore. We don't have rooms to put [R19 and R23] in. If I had extra room to put these residents in while I fix the paint, then I would be able to do something about it. MD stated he could not remember when he patched their wall. MD stated he did not have a work order or documentation of ever working on the wall but that he was aware of it needing to be fixed. During interview with R19 and R23 on 1/30/25 at 9:25 a.m., R19 stated, it [wall patch] has been here since I got here. I think at one point [maintenance] was fixing something on the wall over there [pointing to R23's side of the room] and he did this. Looking at it makes me think it is dirty, not cared for. I don't like it. I would like it painted. R23 stated, I am embarrassed by it. During interview with assistant director of nursing (ADON) on 1/30/25 at 10:50 a.m., ADON stated, the wall should be painted. Don't know how long that is has been there. It is not appealing. Facility policy on building maintenance and repair was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure dental appliances (i.e., dentures) were offered or provided to promote safety and independence with eating for 1 of 4 residents (R60) reviewed for activities of daily living (ADL). Findings include: R60's quarterly Minimum Data Set (MDS), dated [DATE], identified R60 had severe cognitive impairment and demonstrated no rejection of care behaviors. Further, the MDS outlined R60 needed substantial and/or maximum assistance to complete oral hygiene (inc. dentures). R60's most recent MHM (Monarch Healthcare Management) Oral/Dental Evaluation, dated 11/18/24, identified R60's oral cavity had no issues and R60 used an upper and lower denture with their condition being recorded, Good condition. R60 was recorded as edentulous (no natural teeth) and a summary outlined, Resident wears full upper and lower dentures. He denies pain with chewing. He is dependent on staff to perform oral hygiene. No mouth sores noted with oral inspection. The completed evaluation lacked evidence R60 refused to wear his dentures. On 1/27/25 at 1:36 p.m., R60 was observed seated in his wheelchair while in the hallway. R60 stated he was unsure how long he had lived at the care center and often mumbled his speech with responses. R60 had no visible natural teeth or dentures in place at this time. R60 stated his dentures were at the dentist office, however, just mumbled a response when asked if he had issues with chewing his food without them. The following day, on 1/28/25 at 10:36 a.m., R60 was again observed in his wheelchair while in his room. R60 had no visible teeth or dentures in and, when asked, opened his mouth to show edentulous palates. R60 was again asked where his dentures were and responded aloud at the dentist again. R60 stated he would wear them if he had them adding aloud, yea, why not, with a mumbled tone. When interviewed on 1/28/25 at 10:46 a.m., nursing assistant (NA)-A stated they had worked at the center for a few months and had worked with R60 prior. NA-A described R60 as needing help with transfers and could be restless at times. NA-A stated R60 was typically accepting of cares but added, It depends on the day. NA-A stated R60 would sometimes refuse oral care adding, He doesn't like to be touched too much. NA-A stated R60 did not wear dentures to their recall nor had they ever seen him with any placed adding, I don't think so. NA-A stated dentures, if he had them, would be kept in his room. NA-A and the surveyor then inspected R60's room and found a single, lower denture in his bedside dresser in a pink-colored cup. NA-A stated aloud, I didn't even know that [he had one]. NA-A verified they had helped R60 with his morning cares that day and acknowledged they didn't offer the dentures to R60 due to not knowing about them. NA-A stated resident's with dentures should have them offered and placed before meals as it helps to eat them for the food. R60's care plan, printed 1/28/25, identified all of R60's current or potential medical or mobility issues along with their corresponding goals and interventions. The care plan outlined R60 wore dentures and listed a single intervention which read, Provide mouth care as per ADL personal hygiene. The care plan lacked when or how often to provide R60 his dentures nor evidence R60 refused to wear his dentures prior to 1/28/25. When interviewed on 1/28/25 at 11:02 a.m., registered nurse (RN)-D stated they had worked with R60 prior and we unsure off-hand if he used dentures or not adding aloud, I'd have to check his room or record. RN-D stated R60 consumed a soft diet and had not, at least to their recall, ever voiced complaints about his mouth or eating. RN-D stated if a resident used dentures, they should be offered with morning cares and placed if able. R60's medical record was reviewed and lacked evidence R60 had been offered or refused his dentures on 1/27/25 and 1/28/25 when observed without them. On 1/28/25 at 1:16 p.m., the interim director of nursing (DON) was interviewed, and verified R60 had dentures but expressed he would often refuse to wear them when offered. DON stated staff were expected to offer them to him and expressed refusals were not documented. DON stated it was important to offer and, if able, provide dentures as it helps the resident with their food and it was just good quality care. A provided Activities of Daily Living (ADLs)/Maintain Abilities Policy, dated 3/2023, identified the facility would provide necessary care and services to ensure a resident' abilities in ADLs did not diminish unless unavoidable. The policy included, 3. The facility will provide care and services for the following . d. Dining-eating, including meals and snacks, .

Based on observation, interview, and document review, the facility failed to ensure routine nail care was provided for 1 of 1 resident (R58) reviewed for activities of daily living (ADLs) who needed assistance from staff for nail care. Findings include: R58's quarterly Minimum Data Set (MDS) dated [DATE] indicated, R58 was cognitively intact, had no behaviors and did not refuse cares. MDS indicated R58 was independent with ADLs and needed set up or clean up assistance with showers. R58's Clinical Diagnosis Report printed 1/30/25, indicated diagnoses of gout (a form of arthritis that causes severe pain, swelling, redness and tenderness in joints), generalized muscle weakness, other reduced mobility, need for assistance with personal care, protein calorie malnutrition and failure to thrive. R58's ADLs care plan printed 1/30/25 indicated R58 needed assistance with personal cares. An undated Group Report Sheet used by nursing assistants to know how to care for the residents, indicated R58 needed assistance of one staff for bathing and grooming. R58's Weekly Skin Assessments forms printed on 1/30/25, completed on 1/11/25, 1/18/25, 1/25/15 and 1/26/25, indicated under the Bath and Nail Care, R58's fingernails and toenails did not need to be trimmed. During observation and interview on 1/27/25 at 1:00 p.m., R58 was laying on top of the bed and not wearing socks. R58's fingernails were about half an inch long. His nails were yellow and had dark orange matter underneath most of them. R58's toenails were also about half an inch long and the toenail on his right big toe was cracked with a sharp edge. R58 stated, They don't help me cut my fingernails or toenails; they are like an inch long. When my family or friends come to see me, they said I could do better with my personal care. I would like them to help me cut my nails. The last time they help me was 4 weeks ago. You ask them and they never come back. During observation and interview on 1/28/25 at 11:16 a.m., R58 was in bed watching TV and not wearing socks. R58's nails were still long. During observation and interview on 1/28/25 at 1:13 p.m., nursing assistant (NA)-C stated they cut the residents nails on shower days. If a resident is diabetic, the nurses will cut their nails. NA-C verified R58's fingernails and toenails were long. She said they were, yellow/orange and had stuff underneath the fingernails. NA-C asked R58 if somebody offered to help him. R58 said, No, it's been at least a month since they helped me with my nails. During interview on 1/29/25 at 8:29 a.m., R58 stated the staff set up the shower room for him, gave him towels, and he was able to shower by himself. R58 said the nurses had not checked his skin or cut his nails. R58 said, This morning, a short nice blonde lady came to cut my fingernails. It feels so good, so much better. R58 toenails were not clipped. R58 was not sure who this person was. During interview on 1/29/25 at 8:49 a.m., the admission coordinator, who is a trained medical assistant and NA-D, stated sometimes she was pulled to help on the floor, and she visited all the residents and offered nail care. NA-D stated, she cut R58's fingernails and said, they were about half an inch long, they were yellow and there was stuff underneath the pinky nails. NA-D added, the podiatrist would cut his toenails that day. During interview on 1/29/25 on 9:31 a.m., nurse manager, a licensed practical nurse (LPN)-B, stated the residents' nails and toenails were trimmed on bath day by the nursing assistants. The nurses were responsible to take care of diabetic residents' nails, while some of the residents were seen by the podiatrist. LPN-B verified the Weekly Skin Assessments forms dated 1/11/25, 1/18/25, 1/25/25 and 1/26/25, under section C, Bath and Nail care, indicated R58's nails did not require trimming. During interview on 1/29/25 at 9:05 a.m., the assistant director of nursing (ADON) stated the expectation was nail care needed to be completed and documented, and if a resident refused nail care, it also needed to be documented. Residents with long nails were a concern because residents could scratch themselves and develop skin problems. Dirty nails are an infection control problem. ADON stated we will need to provide education to the staff and make sure those cares get done. Facility policy title Activities of Daily Living dated 3/31/23, indicated a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and document review, the facility failed to assess and, if needed, develop interventions or refer to contracted therapy services to address poor wheelchair posture for 1 of 2 residents (R60), and failed to provide assessed interventions from occupational therapy to reduce the risk of skin injury or further mobility loss (i.e., contracture worsening) for 1 of 1 resident (R15) reviewed for limited range of motion (ROM). Findings include: R60 R60's quarterly Minimum Data Set (MDS), dated [DATE], identified R60 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R60 had a functional limitation in range of motion (ROM) to both lower extremities and used a wheelchair for mobility. On 1/27/25 at 1:36 p.m., R60 was observed seated in a standard wheelchair in the hallway. R60 stated he was unsure how long he had lived at the center and presented with mostly mumbled responses which, at times, were non-sensical. R60's feet were flat on the floor while seated and he had a upright posture while seated, however, his arms overhung the wheelchair's armrests despite being seated upright with his arms coming to rest on the top of the wheels. The wheelchair had a visible, thick black cushion on the seat. Further, the wheels of the chair were worn down with a large portion of the gray-colored rubber material being worn away exposing the orange-colored resin below with cracks and crevices on the wheel surface. Later, on 1/27/25 at 2:28 p.m., R60 was again observed while seated in the same wheelchair. R60's posture remain upright with his arm's bent approximately 90-degrees at the elbow; however, again, his arms weren't able to rest on the wheelchair' armrests without him having to hunch up his shoulders. R60 was pushing himself backward down the hallway while seated in the wheelchair, and the wheels of the chair remained in disrepair as had been observed earlier. R60's care plan, printed 1/28/25, identified all of R60's current or potential medical or mobility issues along with their corresponding goals and interventions. The care plan outlined R60 had an alteration in mobility due to multiple medical diagnoses and listed a goal, Resident will move safely within their environment. The care plan listed several interventions including physical therapy as ordered, assistance with bed mobility and transfers, and a low bed for safety. However, the care plan lacked any information on R60's wheelchair (i.e., type used, positioning interventions). The following day, on 1/28/25 at 10:04 a.m., R60 was observed seated in the same wheelchair as the day prior. R60 was in the commons area for an activity and his positioning while seated remained poor with his arms being bent 90-degrees and remaining down at the side of the wheelchair and at wheel-level when at rest. The armrests of the chair were up between his torso and arms. Later, on 1/28/25 at 10:36 a.m., R60 was asked about his wheelchair, including if it was comfortable to be seated in, and responded aloud, [It] could be tighter. R60 did not elaborate further when asked. The wheel's of the chair were inspected at this time and, again, remained in disrepair with the gray-colored rubber coating being nearly worn off in the middle of the wheel causing cracks and a large circumference divet in the middle of the wheel. When interviewed on 1/28/25 at 10:46 a.m., nursing assistant (NA)-A stated they had worked with R60, and described R60 as needing help to transfer adding he could be restless at times. NA-A stated R60 had used the same wheelchair for awhile to their recall and expressed they noticed R60 seemed to be sliding down in it causing poor posture. NA-A stated R60 often slept in a near fetal-position and expressed they were not sure what had been causing R60's posture while seated in his wheelchair adding, I don't think about what's causing it. NA-A stated they tried, at times, to boost R60 up to be more upright sitting, however, acknowledged even with doing such his arms would often remain down past the armrests when seated. NA-A stated they were unsure if OT (occupational therapy) had ever worked with R60 for his positioning or not adding aloud, I don't know When interviewed on 1/28/25 at 11:02 a.m., registered nurse (RN)-D stated they had worked with R60 prior. RN-D explained they felt R60's arm's were typically rested on the armrests when seated, however, mentioned they had noticed he does kind of slouch over adding such posture was typically seen for him. RN-D stated they didn't recall OT working with R60 recently and was unsure if OT had ever addressed R60's positioning in the wheelchair adding aloud, That is a good question. R60's medical record was reviewed and lacked evidence R60 had been evaluated recently for his wheelchair positioning despite having potentially poor, uncomfortable posture and direct care staff being aware of the same observation. When interviewed on 1/28/25 at 12:56 p.m., the director of rehabilitation (i.e., PT, OT) (DOR) stated R60 was last on their service in November 2024 and, at that time, had not been using the wheelchair he was currently seated in. DOR stated R60 had multiple hospitalization s and the chair had potentially been switched out at some point. DOR verified they had just observed R60 while seated in the wheelchair and, from that, placed a referral for the OT to review him adding his posture was not terrible but could be improved. DOR stated the chair's armrests were possibly too tall and expressed they had noticed the wheelchair's wheels in disrepair, so they went and obtained a new wheelchair and cushion which was better fitting. DOR verified nobody from nursing had reported any concerns to them about R60's wheelchair or positioning and expressed if staff saw a concern they could report it to be acted upon. DOR expressed poor posture while seated in a wheelchair could cause skin concerns but also low back tightness or discomfort. On 1/28/25 at 1:16 p.m., the interim director of nursing (DON) was interviewed. DON stated they were notified of the wheelchair concern just prior and were working to get one with a suitable fit and position-wise. DON verified they had observed R60's wheelchair and the wheels were in disrepair, adding it appeared like it had seen a good few thousand miles. DON stated nobody had reported any concerns to them about R60's wheelchair condition or positioning and expressed it should have been reported so it could be addressed. A provided Range of Motion (ROM) and Positioning policy, undated, identified a procedure to ensure proper positioning while seated in a chair including ensuring the patient's buttocks are firmly against the back of the chair and spine is straight; however, lacked further information on how to ensure ongoing concerns are addressed (i.e., referred to therapy). 49034 R15 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 had severely impaired cognition with no rejection of care behaviors. The MDS indicated R15 had highly impaired hearing, had no speech, and was rarely/never able to express her ideas or wants with either verbal or non-verbal expression. The MDS indicated R15 had a limited ROM for all extremities and was dependent on staff for all activities of daily living. R15's care plan dated 7/10/24, indicated R15 had alterations in skin integrity related to dementia, malnutrition, immobility, and contractures of all extremities. The care plan indicated R15 had a history of refusing palm protector use while she was in treatment with therapy. The care plan indicated R15 was to wear palm protectors daily and they were to be removed daily to inspect skin and observe for skin breakdown. The care plan indicated nursing staff were to monitor skin integrity daily during cares and weekly skin inspections were to be completed by the nurse. R15's Weekly Skin Inspection reports dated 12/8/24 through 1/19/25 were reviewed and indicated R15 received a bed bath but fingernail trimming was not necessary, leaving refused unchecked. A Weekly Skin Inspection report for the week of 1/20/25-1/26/25 was not found. R15's occupational therapy note dated 12/11/24, indicated the occupational therapist had assessed the resident and recommended R15 wear palm protectors, and her bilateral elbows be positioned in a slight extension with the use of rolled towels/ a small pillow to maximize function and decrease the risk of skin breakdown. The note indicated R15 had previously not tolerated hand splints related to the severity of her contractures. The note indicated the occupational therapist recommended gentle hand/elbow hygiene daily to protect skin integrity. R15's medication/treatment administration record dated 1/1/25 through 1/28/25, indicated R15 had an order dated 3/30/23 for palm protector application. The order also indicated staff were to remove them once a shift for hand cleaning and skin inspection. The order was documented on every shift with 24/81 shifts documented as on, 53/81 shifts documented as off, and 4/81 shifts not documented on, or documented as 0. The record included an order dated 12/20/24 for positioning of R15's elbows in a slight extension with the use of a rolled towel or small pillow to increase the angle and protect skin integrity was documented as completed (approximately) every shift. R15's medical record was reviewed for this period and did not indicate refusal of palm protectors/alternatives for hand protection or refusal of the towel/pillow for R15's elbow extension. The undated 100 Hallway- Group 1 Report Sheet, indicated R15 was to be turned and repositioned every two to three hours with a pillow placed between her legs but did not include towels/ palm protector application to her hands or towels/pillows between her elbows and body. During an observation on 1/27/25 at 12:40 p.m., R15 was lying in bed with her hands balled into fists with no towels, palm protector, or other device noted in her hands. R15's arms were observed tightly against her body with each hand close to the opposite shoulder with no noted towels or small pillows between her arms and her body. During an observation on 1/28/25 at 8:10 a.m., R15 was lying in bed with her hands balled into fists with no towels, palm protector, or other device noted in her hands. R15's arms were observed tightly against her body with each hand close to the opposite shoulder with no noted towels or small pillows between her arms and her body. During an observation and interview on 1/28/25 at 2:02 p.m., R15 was lying in bed with her hands balled into fists with no towels, palm protector, or other device noted in her hands. R15's arms were observed tightly against her body with each hand close to the opposite shoulder with no noted towels or small pillows between her arms and her body. Nursing assistant (NA)-B stated they had just repositioned R15, and pillows were observed between her knees. NA-B stated she was not aware R15 needed a pillow between her body and her elbows, so she had not been placing one when she was working with R15. NA-B stated she did do gentle range of motion with R15's arms and hands every day. NA-B was observed demonstrating this range of motion to R15's arms. NA-B was then observed to do range of motion to R15's hands and a white/ yellow build-up was noted on both of R15's palms as well as four bright pink nail marks on R15's left hand. R15's fingernails were observed over 1/4 of an inch beyond the end of the fingertip with a white build-up noted underneath. NA-B confirmed R15's hands had a strong odor when she opened them. NA-B stated R15's hands looked dirty and thought nursing staff was to clean her hands only on bath days so it should have been cleaned last Sunday (1/26/25) but thought that must not have been completed. During an interview on 1/28/25 at 2:21 p.m., registered nurse (RN)-B stated R15's nails were getting long. RN-B stated nursing staff should cut them every week on her bath day but was unsure if this had been completed. RN-B confirmed she had not attempted to clean R15's hands today and had not assessed her palms. RN-B stated R15 had refused to let her place palm protectors or towels in her hands in the past and she had not attempted to apply either yet today. RN-B stated that R15's palm protectors had gone down to the laundry and had been damaged, so she had informed the former director of nursing but was unsure if new ones were ever ordered. RN-B stated she thought the therapy department had been told of R15's refusal to use the palm protector but was not given a different intervention to try instead and was unsure if the therapy department had been told the palm protectors were damaged. RN-B stated she was not aware pillows/towels needed to be applied between R15's body and her elbows so she had not been ensuring this was completed. During an interview on 1/28/25 at 2:27 p.m., the director of rehabilitation (DOR) stated R15 was last seen by occupational therapy on 12/11/24 when they did an evaluation for the appropriateness of a splint which R15 did not qualify for, so they had recommended palm protectors be applied. The DOR stated they were not aware R15 had been refusing to wear the palm protector. During a follow-up interview on 1/28/25 at 3:01 p.m. with the DOR and occupational therapist (OT)-A, the DOR stated she had checked with nursing that day and thought R15's palm protectors had gone down to the laundry department and were damaged. The DOR stated she was unsure when they had been damaged, but they do have extra palm protectors R15 could have used. OT-A stated if they had been made aware of R15 refusing the palm protectors they would have reassessed her for an appropriate alternative as the palm protectors were important in protecting R15's skin and ensuring contractures did not worsen. OT-A stated applying towels in R15's hands would have been an appropriate intervention to attempt if R15 was refusing the palm protectors. During an observation on 1/29/25 at 9:05 a.m., R15 was in bed with bilateral palm protectors applied with eyes closed and no observed signs of pain such as grimacing, furrowed brow, or agitation. During an observation on 1/30/25 at 10:33 a.m., R15 was in bed with bilateral palm protectors applied with eyes closed and no observed signs of pain such as grimacing, furrowed brow, or agitation. During an interview on 1/30/25 at 11:42 a.m., the interim director of nursing (DON) confirmed that she had reviewed R15's medical record and did not find that staff had documented refusals to applying the palm protectors or alternatives and would expect staff to clean R15's hands every shift when they were assessing her hands for skin breakdown. A policy regarding range of motion, mobility, and palm protector application was requested and an undated Range of Motion and Positioning procedure was received. The procedure indicated staff should reposition a resident as needed, per protocol and written RN instructions but did not when occupational therapy should be reconsulted and address palm protector application.

Based on interview and record review, the facility failed to verify orders written by a provider for one of one resident (R1) reviewed. R1 had orders for wound care treatments and the facility thought the orders were written in error but did not verify the orders with the provider. Findings include: R1's medical records indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of cellulitis of right lower limb. R1's additional diagnoses included venous insufficiency, muscle weakness, chronic kidney disease stage three, and anemia. R1's wound care progress note dated 7/24/24 indicated nurse practitioner (NP) ordered staff to clean vascular ulcer dorsum second interdigital on R1's right side daily and paint daily with Betadine. R1's wound care progress note dated 7/31/24 indicated nurse practitioner (NP) ordered staff to clean vascular ulcer dorsum second interdigital on R1's right side daily and paint daily with Betadine. R1's treatment administration record dated July 2024 indicated R1 did not have an order for staff to clean vascular ulcer dorsum second interdigital on R1's right side daily and paint daily with Betadine. During an interview on 9 /4/24 at 2:11 p.m., registered nurse (RN)-C stated once the wound care nurse sees the resident with the wound care provider, the wound care nurse would update or change the resident's orders and treatment plans. During an interview on 9/4/24 at 2:35 p.m., RN-A stated once the wound care provider see's the residents who have wounds, the clinical manager (CM) would review the plan written by the plan, notes, and instructions and she would make orders based off those plans, notes, and instructions. During an interview on 9/4/24 at 2:40 p.m., CM stated once the facility received the wound provider progress notes, CM would enter new orders and update the treatment plan. CM stated if there were not new orders from the wound care provider, the facility would continue with the current care plan. CM stated the provider note transcriber would not remove treatment plan recommendations on the wound progress notes. CM stated, I think the wound care provider, or her transcriber made a mistake by putting the treatment recommendations in that wound progress note from 7/24/24 and 7/31/24. During an interview on 9/4/24 at 3:32 p.m., the nurse practitioner (NP) stated if she had written orders for a resident and there was questions or confusion from the facility nursing staff, her expectation would be for the nurses to clarify orders with me. NP stated if she had written orders, her expectation is that those orders would be followed. NP stated the nurses did not clarify orders from 7/24/24 or 7/31/234 with her. During an interview on 9/4/24 at 4:04 p.m., the administrator stated her expectation is the facility would follow orders written by the provider. The administrator stated if a nurse did not understand orders written by the provider, the nurse should go to the CM or the provider to clarify them. A treatment order policy was requested, and none was received.

Based on interview and document review, the facility failed to implement transfer interventions for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who hit her head and sustained a skin tear on the left forearm. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 required extensive assistance of two staff with the use of a mechanical lifting device for transfers. R1's Brief Interview for Mental Status (BIMS) indicated a score of 15, cognitively intact. R1's care plan last revised on 10/03/23, indicated R1 had a diagnosis of rheumatoid arthritis, adult failure to thrive, hypertension, depression, anxiety, obesity, and peripheral vascular disease. Self-care interventions included transfer assist of two using a mechanical lift. A progress note, dated 07/12/23, indicated that R1 fell during a transfer with the mechanical lift due to a strap falling off. R1 fell on to the wheelchair. R1 hit her head and sustained a skin tear on her left forearm. R1 declined an evaluation at the emergency department. A Written Warning, dated 07/14/23, stated that the nursing assistant (NA)-A, failed to use the mechanical lift properly by not checking if the straps were secure. NA-A also failed to wait for a second staff to assist with the transfer, as directed in R1's care plan. The warning stated the incorrect usage of mechanical lift resulted in resident falling. NA-A was provided re-education by the facility. A note from the physician, dated 07/12/23 at 10:04 p.m., directed staff to complete neuro assessments for several shifts following the fall. During an interview on 01/05/24, at 3:25 p.m. the director of nursing (DON) verified NA-A did not use the lift correctly and did not follow the care plan for transfers.

Based on interview and record review, the facility failed to provide adequate supervision to 1 of 3 residents (R1) reviewed for supervision. R1 eloped from the facility and was found one block from the facility on a busy road. A bystander called 911 and EMS took R1 to the hospital where R1 was examined and could not identify where she lived. The hospital contacted the facility and discovered that she was a resident at the facility. R1 was sent back to the facility with no injuries sustained. The immediate jeopardy began on 6/17/22, when the facility failed to supervise R1, and she eloped from the facility and was identified on 6/24/22. The Administrator and the director of nursing (DON) were notified of the immediate jeopardy at 4:15 p.m. on 6/24/22. The immediate jeopardy was removed, and the deficient practice corrected on 6/17/22, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's MDS dated [DATE] indicated R1 admitted [DATE] and had a diagnosis of dementia with a brief inventory of mental status score of a three indicating severe cognitive impairment and is ambulatory with a walker. R1's MDS did not identify as a risk for elopement. R1's elopement assessment dated [DATE] did not indicate R1 was an elopement risk. R1 elopement assessment 6/17/22 indicated R1 enjoys sitting near the front entrance watching people come and go from the the facility. R1 left the building from the front door. R1 had no history of elopement. The facility intervention was to place a wander guard on R1. Per interview on 6/24/22, at 9:05 a.m. and 12:13 p.m. the reception stated R1 often sits in the front lobby, but she never goes outside. If she did, I would redirect her, she can't be out there. The receptionist verified R1 did not have a wander guard until 6/17/22. The receptionist stated she knows which residents are at risk for elopement because when they go close to the door the alarm goes off. When she sees a resident with a wander guard, she redirects the resident before they can exit door. Per interview on 6/24/22, at 12:33 the director of nursing (DON) indicated staff should be aware of a resident's risk of elopement by looking at the computers home page that identifies residents at risk for elopement and there is a paper binder at each nurse's station. Per interview on 6/24/22, at 12:44 p.m. Nursing Assistant (NA)-A reported she is aware who an elopement risk because the resident wears a wander guard and if they try to exit an alarm sounds. NA-A stated she checks all rooms on her shift. NA-A verified R1 is currently wearing a wander guard. NA-A reported she is aware what a wander guard is and when the door alarm goes off to report and make sure the resident has not eloped. Per interview on 6/24/22, at 1:10 p.m. RN-A stated that when she works with R1 she always provides additional supervision due to R1's cognitive status and stated R1 likes to have a bag packed to go home and sits near the front and back doors. RN-A stated R1 has never seen R1 elope from the facility. A facility policy dated 11/2017, indicated the facility is committed to provide a safe environment for all residents. Assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. The past noncompliance immediate jeopardy began on 6/17/22. The immediate jeopardy was removed, and the deficient practice corrected by 6/17/22, after the facility implemented a systemic plan that included the following actions: On 6/17/22, the facility completed another elopement assessment on R1 and placed a wander guard on her wrist. R1's care plan was updated. The nursing staff have physician orders dated 6/17/22 and are currently monitoring the wander guard placement every shift in the treatment administration record (TAR). All direct care staff received notification on 6/17/22 of elopement and the placement of a new wander guard on the team homepage in the electronic health record. All staff are oriented upon hire on the use of wander guards and how to respond to the door alarm. The wander guard function is checked weekly by maintenance staff.

Based on observation, interview and document review, the facility failed to implement appropriate precautions against [CONDITION(S)] [CONDITION(S)] (CDI) (a inflammation of the colon caused by the bacteria [CONDITION(S)]) including use of appropriate personal protective equipment (PPE) and isolation precautions to prevent the spread of COVID-19 for 1 of 1 resident (R23) who required quarantine. This practice resulted in an immediate jeopardy (IJ) situation for residents and staff as a result of the facility not implementing proper transmission based precautions (TBP). This non-compliance has the potential to spread infections to other residents in the facility. The IJ began on 8/23/21, at 2:30 p.m. when the facility failed to continue with transmission based precautions (TBP) when R23 was to be on quarantine for COVID-19 and failed to initiate contact precautions for active C-diff while R23 continued to display symptoms of CDI, including loose stools. In addition, the staff present on the 300 wing were not wearing appropriate PPE prior to entering R23's room. The administrator and director of nursing (DON) were notified of the IJ on 8/26/21, at 12:15 p.m. The IJ was removed on 8/27/21, at 2:47 p.m.,but noncompliance remained at the lower scope and severity level of F - widespread scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: CDC guidance Create a Plan for Managing New Admissions and Readmissions indicates Residents with confirmed [CONDITION(S)]-CoV-2 infection who have not met criteria to discontinue Transmission-Based Precautions should be placed in the designated COVID-19 care unit, regardless of vaccination status. In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The Centers for Disease Control and Prevention (CDC) guidance on confirmed clostridioides difficile infection (CDI) isolating and initiating contact precautions for confirmed dated 7/12/21, recommended placement of patients on [MEDICATION(S)] contact precautions in a single patient room with a dedicated toilet. [MEDICATION(S)] precautions indicated staff to wear a gown and gloves and wash hands with soap and water. For patients with confirmed CDI should remain on contact precautions for at least 48 hours after diarrhea has resolved or longer. Adhere to recommended hand hygiene practices, use dedicated patient care equipment (blood pressure cuffs and stethoscopes), and implement daily patient bathing or showering with soap and water. The Centers for Disease Control and Prevention (CDC) guidance on perform environmental cleaning to prevent CDI dated 7/12/21, recommended to create a daily terminal cleaning protocols and checklist for patient care areas and equipment, perform daily cleaning of CDI patient rooms using a C-Diff sporicidal agent (EPA List K), clean and disinfect the patient care environment including the immediate vicinity around CDI patient and high touch surfaces at least once a day, and all shared equipment prior to use with another patient. The CDC further provided guidance for cleaning additional areas which are contaminated during transient visits by patient with confirmed CDI such as physical therapy (PT) room. The CDC Progression of a CDI infection dated 7/12/21, identified risk factors for getting CDI infection occur if a person had a previous infection with CDI, being over the age of 65, recent stay at a hospital or nursing home. CDC further indicated a person with a weakened immune system. The Safety Data Sheet (SDS) for Sani-Cloth Bleach Germicidal Disposable Wipe dated 8/12/16, indicated efficacy use for the CDI. The SDS indicated the active ingredients of sodium hypochlorite which is commonly referred to as bleach. The facility list of quarantine residents indicated only R165 was on quarantine and ended on 8/26/21. The facility provided list of residents on antibiotics in the last 14 days indicated R17, R24, R42, R214 were identified at risk. The facility's list lacked R61 who was R23's roommate who was taking an antibiotic for her chronic obstructive pulmonary disease. R23's admission minimum data set (MDS) assessment dated [DATE], indicated R23 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's MDS further indicated R23 was frequently incontinent of stool and had a indwelling catheter. R23's care area assessment (CAA) dated 6/17/21, indicated R23 required a total assist of two for all activities of daily living (ADL), and required a Hoyer lift for transfers. R23's CAA further indicated R23 needed assistance for toileting every two to three hours and Foley catheter care. R23's Care Plan initiated 8/23/21 indicated R23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R23 care plan lacked direction to place R23 on [MEDICATION(S)] precautions (general contact precautions, gloves and gown. Handwashing with soap and water must be performed; an alcohol-based hand rub is not sufficient. Equipment, such as stethoscopes, should be wiped down when leaving patient rooms in all contact precautions). R23's care plan for Covid 19 date initiated 6/15/21 included an intervention to screen for signs and symptoms upon return for 14 days. R23's Admission Record printed 8/25/21, indicated R23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's immunization record printed 8/25/21, indicated R23 had first COVID-19 vaccine on 7/21/21. R23 had not received the second dose for Covid. R23's order summary for 8/21, indicated R23 was on [MEDICATION(S)] (antibiotic) 125 mg by mouth every 6 hours for CDI. R23's order summary further indicated on 8/24/21, R23 was placed on 14-day quarantine droplet precautions related to unvaccinated to Covid-19 until 9/4/21. The order summary further indicated on 8/24/21, R23 was placed on [MEDICATION(S)] precautions for CDI and may be discontinue if R23's stools are formed and only having one stool a day. R23's Hospital History and Physical (HP) dated 8/18/21, indicated R23 had diarrhea present for several weeks of five or more watery stools a day. R23's HP further indicated R23 had a recent history of CDI and was recently treated with antibiotics for infected kidney stone. R23's Hospital progress note (PN) dated 8/18/21, at 10:47 p.m. indicated R23 was positive of CDI and was started on [MEDICATION(S)] (medication to treat infection) 125 milligrams (mg) four times a day for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Hospital nurse progress note dated 8/19/21, at 6:11 p.m. indicated R23 had multiple loose stools. R23's Hospital nurse progress note dated 8/20/21, at 6:03 a.m. indicated R23 had been on [MEDICATION(S)] precautions for CDI and was incontinent of stool at times. R23's Hospital Transfer Form dated 8/21/21, indicated R23 was treated while in the hospital for diarrhea from CDI [CONDITION(S)]. R23's Hospital Transfer form directed the facility to start R23 on [MEDICATION(S)] 125 mg by mouth four times a day. R23's PN dated 8/21/21, indicated R23 was readmitted to the facility after hospitalization for a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's nursing assistant (NA) note dated 8/21/21, indicated R23 had a large loose diarrhea stool. R23's NA note dated 8/23/21, indicated R23 had a large loose diarrhea stool. R23's PN dated 8/23/21, indicated R23 continued on antibiotics for CDI. R23 requested a BRAT (Bananas, Rice, Applesauce, Toast) diet (restrictive diet recommended for people with gastrointestinal distress like vomiting, diarrhea, or gastroenteritis). R23's special instruction dated 8/23/21, had no indication R23 was on contact precautions or quarantine. R23's NA care sheet dated 8/25/21, indicated R23 was an assist of two for all ADL's and was Hoyer lift transfer. R23's NA care sheet lacked indication R23 was on precautions for CDI or quarantine for COVID-19. During an observation on 8/23/21, 11:30 a.m. R23's room lacked PPE supplies outside the room. There was no signage indicating transmission-based precautions were in place. During an interview with R23 on 8/23/21, at 11:45 p.m. R23 stated she was recently hospitalized with a urinary tract infection and was diagnosed with CDI. R23 stated she was not aware she was on precautions. R23 further stated staff wear only goggles and a mask. R23 stated staff used the vital machine equipment on her and than on her roommate. R23 further stated this is her second time of having CDI. R23 stated she had loose diarrhea stool since she returned to the facility on [DATE], and they do not bag her clothes, garbage, or meal tray separate. R23 stated she had stomach pain, diarrhea, nausea, some tenderness, and R23 further stated she requested a BRAT diet until she felt better. During an interview on 8/23/21, at 12:00 p.m. housekeeping (HSKP)-B stated he was not aware R23 was on precautions. HSKP-B further stated he had just finished cleaning R23's room like he normally did. During an observation on 8/23/21, at 12:30 p.m. an aide was observed entering R23 room wearing only surgical mask and face shield. NA-F brought in R23's lunch meal tray and placed it on the over the bed table. NA-F repositioned the table over R23 who was lying in bed and assisted with repositioning the water pitcher. NA-F left room and gathered R23's roommate's tray. NA-F did not wash her hands after repositioning R23's table or when she left the room. During an observation on 8/23/21, at 12:55 p.m. NA-F walked into R23's room wearing a mask and goggles. NA-F, removed R23 lunch tray, repositioned R23's water cup on the over bed table prior to leaving R23's room. NA-F was observed using hand sanitizer. During an interview on 8/23/21, at 1:00 p.m. registered nurse (RN)-D stated he was not aware R23 was on precautions. RN-D further stated if R23 was placed on precautions than R23 should have her supplies outside the room and signs on the door. RN-D stated when he started working today there were no precautions signs or personal protective equipment (PPE) outside R23's door. RN-D stated when he reviewed 23's chart there was no indications R23 was on precautions for C-Diff or quarantine for COVID-19. RN-D stated it is important for the staff who provide direct care to know if a resident is on precautions so we do not spread infections to other residents. During an observation on 8/23/21, at 1:30 p.m. R23 was observed in the therapy department standing with hands on the parallel bars. PT-A who did not have a gown on or N95 mask was observed to have direct contact with R23. Four other unidentified residents attended rehab in the same room following R23. PT-A was observed to have worked with the other residents after R23. During an interview on 8/23/21, at 2:00 p.m. NA-F stated she was notified by the previous shift, R23 had a large loose diarrhea stool recorded in her nursing assistant documentation. During observation on 8/23/21, at 2:30 p.m. NA-F was observed providing peri-care to R23. NA-F had on a mask and goggles. NA-F was observed leaning on the edge of the bed during the provision of cares. NA-F exited the room and used alcohol-based hand sanitizer and did not wash her hands with soap and water. NA was observed to go into R212's room to provide cares. During observation on 8/24/21, at 8:45 a.m. R23's door to the room was open. No sign on door indicating precautions. R23 was lying in her bed. During an interview on 8/24/21, at 8:45 a.m. HSKP-A stated R23 was not on precautions on 8/23. HSKP-A further stated she would see the precautions sign on the door and would talk with nursing staff before entering the room to see what is required. HSKP-A stated if R23 did not have a precautions sign on the door the non-direct care staff would not be aware of the precautions and use the same supplies to clean the rooms as all the other rooms which means we could spread germs. During observation at 8/24/21, at 8:49 a.m. R23's roommate was observed to have left the room without wearing a mask and left the door open. During an interview on 8/24/21, at 8:50 a.m. R23's roommate stated she was not aware of any concerns regarding needing to quarantine or concerns about special precautions. R23's roommate further stated no one explained precautions to her and stated she felt it was not fair she needed to keep the door shut when she was not ill. R23's roommate stated she gets claustrophobic with the door is shut. During an interview on 8/24/21, at 9:00 a.m. NA-C stated R23 had a large loose diarrhea stool 8/23/21, and had multiple loose stools since R23 returned to facility. NA-C stated she had been wearing only a mask and goggles when providing cares to R23. During observation on 08/24/21, at 9:03 a.m. two unidentified maintenance staff, wearing only a surgical mask and goggles, opened R23's door touching the handle, and entered R23's room. The maintenance staff moved R23's overhead bedside table to the side of the room, cleaned off the sprinkler head, before the staff moved the table back. The maintenance staff than closed the door touching the handle as they left R23's room. The maintenance staff was observed not sanitizing or washing hands before entering R212 room, when they opened R212 door using the handle and walked in. The maintenance staff cleaned the sprinkler head in R212 before they opened the door and left the room. R23's special instructions dated 8/24/21, indicated R23 was on 14 day quarantine droplet precautions related to R23 being unvaccinated with an end date of 9/4/21. During an interview on 8/24/21, at 9:14 a.m. RN-C stated R23 was now on contact and droplet precautions, and that is why the cart was outside the door. During an interview on 8/24/21, at 9:20 a.m. RN-C stated R23 had loose stools at least twice since returning to the facility according to the nursing assistant documentation. RN-C stated the nursing progress notes from 8/23/21, does not indicate loose stools. RN-C stated if R23 had CDI she should be on precautions and RN-A would direct us. RN-C stated staff should be wearing gowns and booties with the other PPE when entering R23's room. RN-C further stated R23's roommate should be educated on what precautions to protect herself which includes leaving the door shut. During an interview on 8/24/21, at 9:21 a.m. HSKP- B stated he would follow and wear whatever the precautions directed on the sign placed on the door. During observation on 8/24/21 at 9:53 a.m. signs were affixed to R23's door which alerted staff to stop and see the nurse prior to entering R23's room and advised droplet precautions were required. During an interview on 8/24/21, at 10:00 a.m. RN-A stated R23 was placed on precautions for CDI when she was readmitted after her hospitalization and was placed on [MEDICATION(S)]. RN-A stated R23 did not need to be on precautions because R23 was not having loose diarrhea stools. RN-A stated she only reviewed the nursing notes and not the nursing assistance documentation. RN-A stated she was not aware of R23 having loose stools. RN-A stated after she reviewed the nursing assistant documentation and found the aide documented large loose diarrhea stool. RN-A further stated if R23 had one stool a day she does not need precautions anymore per the doctor's order. RN-A stated since R23 was not fully vaccinated for COVID-19 and was recently hospitalized R23 should be on quarantine. RN-A stated no precautions were being used on 8/23/21, for the quarantine status for the COVID-19. RN-A further stated she is not sure why there was no precautions cart outside the room or precautions sign on the door and said maybe the morning nurse removed it. During an interview on 8/24/21, at 11:00 a.m. the assistant director of nursing (ADON) stated R23 was not on any precautions on 8/23/21, and was unsure of who removed the precautions but should have left the precautions in place. During an interview on 8/24/21, at 2:15 p.m. the medical doctor (MD)-C stated if R23 still had loose diarrhea stool, she should remain on precautions until stools are formed. MD-C further stated giving directions to stop precautions because R23's stools were formed and had no diarrhea. MD-C stated R23 could still spread CDI if she still had even one diarrhea stool. During an observation on 8/25/21, at 8:15 a.m. NA-E entered R23's room wearing a mask and goggles. NA-E emptied R23's overnight catheter bag into a container and removed roughly 700 milliliters and emptied into the toilet. NA-E was observed removing gloves and left R23's room performing hand hygiene with hand sanitizer. NA-E was not wearing a gown when cares were performed. During an interview on 8/25/21, at 10:00 a.m. PT-A stated she provided physical therapy for R23 in the therapy department and used the parallel bars on 8/23/21. PT-A stated R23 had physical therapy on 8/23/21 and 8/24/21. PT-A stated she was not aware R23 was on precautions for CDI or quarantine for COVID-19 at the time therapy was preformed and could not find documentation in R23's chart. PT-A stated the therapy department was cleaned with a bleach based solution by housekeeping on 8/24/21, because of the C DIFF diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . PT-A stated she only wore a mask and goggles during R23's therapy sessions on 8/23/21 and 8/24/21. During a follow up observation on 08/26/21 on 8:03 a.m. of outside R23's room , there was purple top Sani wipes, gloves, mask, garbage bags, red bags, and a bucket with blood pressure kit, oximeter. PPE cart lacked N-95 mask, gown, or bleach disinfecting wipes. During an interview on 8/26/21, at 8:27 a.m. RN-A stated any staff who go into R23's room to assist her are required to wear a gown, mask, goggles, and gloves. RN-A stated her expectation is R23 be on droplet precautions. RN-A stated she was not aware R23 did not have her own vital sign equipment and staff were using the electronic vital equipment wheeled in from the hallway which is used for all the other residents. RN-A stated staff are required to wear the proper PPE if going into R23 room to deliver a meal tray, fill water, assist to the commode , and staff are expected to remove the PPE as directed. During observation on 8/26/21, at 8:58 a.m. NA-B held a clip board as TMA-A put on a N95 mask with the assistance of RN-A, and gown prior to entering R23's room. NA-B handed TMA-A the clipboard as TMA-A entered R23's room. RN-A hands TMA-A a box of vital equipment from the bottom of the PPE cart located outside of R23's room. TMA-A comes out of the room, PPE was removed prior to leaving the room and used hand sanitizer to cleanse hands. During an interview on 8/26/21, at 10:01 a.m. Occupational therapist (OT)-I stated, the normal procedures for cleaning the equipment in the therapy department, is prior to residents coming into the therapy equipment we clean the equipment using the purple top sani wipes, we let it dry for three minutes, and after the resident finishes we use the purple top sani wipes and let it dry for three minutes. The Safety Data Sheet (SDS) for Super Sani Cloth Germicidal Disposable Wipe dated 1/30/18, did not indicate efficacy use for the CDI. The SDS indicated active ingredients containing a quaternary and alcohol-based solution. During an interview on 8/26/21, at 10:30 a.m. NA-B stated during shift report this morning she was told R23 was having an average of two stools a day which are soft to loose in consistency and definitely not a formed stool. NA-C stated she documents every time R23 would have a stool and not just once a day. NA-B further stated nursing assistance should be reporting to the nurse when R23 had loose stools. During an interview on 8/26/21, at 11:59 a.m. Nurse Practitioner (NP)-B stated R23 must have one formed stool a day for three days prior to removing precautions. The facility's policy [CONDITION(S)] dated 10/18, indicated measures are taken to prevent the occurrence of [CONDITION(S)] infections (CDI) among residents. The facility's policy further indicated precautions are taken while caring for residents with CDI to prevent transmission to others. The facility's policy identified residents considered high risk of developing symptoms associated with C Diff included those with advancing age, gastrointestinal manipulation (nasogastric tube insertion), and antibiotic or anti-neoplastic therapy. The facility's policy further identified the primary reservoirs for C Diff are infected people and surfaces where spores can persist on resident care items and surfaces for several months. The facility's policy directed staff to prevention and intervention included ongoing surveillance of CDI, increased awareness of symptoms and risk factors, frequent hand washing with soap and water by staff and residents, wearing gloves when soiled articles are handled. The facility's policy further directed staff to place residents on contact precautions, place resident in private room if available, staff to be vigilant on hand hygiene using soap and water. The facility's policy indicated for environmental cleaning of resident's room with CDI is done with household bleach and water solution or EPA registered germicidal agent effective against C Diff spores. The facility's policy Infection Prevention and Control Program dated 8/17, indicated the major elements of the program is the prevention of infection. The facility's policy further indicated all personnel will be trained on infection control policies and procedures upon hire and periodically thereafter. The facility's policy indicated the prevention of infection included implementing appropriate isolation precautions and following disease specific guidelines as those of Center of Disease Control (CDC). The facility's policy Contact [MEDICATION(S)] Precautions dated 7/14, indicated contact [MEDICATION(S)] precautions will be used in the care of all residents know or suspected to be infected with organisms that are transmitted by contact with the patient or contaminated surfaces and are particular to infections pertaining to gastrointestinal organisms that re difficult to kill or are easily transmissible. The facility's policy specified residents who have acute diarrhea of unknown etiology, with [CONDITION(S)] (CDI), and with Norovirus or rotavirus. The facility's policy directed staff to clean hands with soap and water after direct and indirect contact with the resident or with resident's items which included tables, rails, bathroom fixtures, and knobs, and after removing gloves. The facility's policy further directed staff to wear gloves as necessary for all standard precautions, also wear a gown, mask, eye protection or face shield during cares. The facility's policy further directed staff a gown should be worn when contact with environmental surfaces and items in the resident's room which are like to be contaminated (items close to or used by resident). Staff are directed to remove the gown and discard before leaving the resident's environment. The facility policy's directed staff to dedicate resident equipment to a single resident which included commodes, thermometers, blood pressure cuffs, and stethoscopes. Staff were directed to limit movement of symptomatic resident from the room to essential purposes only. The IJ which began on 8/23/21, was removed on 8/27/21 at 2:47 p.m. when it could be verified through observation, interview and document review the facility: conducted a general higher risk assessment for those who are on antibiotics to ensure they do not have signs or symptoms of C-Diff. The facility reviewed the CDC's guidelines and grid for [MEDICATION(S)] precautions, transmission-based precautions to include appropriate signage, PPE usage, and hand hygiene. The facility provided facility wide education on transmission-based precautions and CDC guideline for [MEDICATION(S)] precautions. Additionally, the facility-initiated education on communication on notification of change of condition, specific precautions based on infection, and documentation. The facility identified monitoring and testing plans for all facility residents, reviewing all admissions and resident with current and new infections to determine if precautions are required.

Based on observation, interview and document review, the facility failed to fully assess 1 of 3 residents (R1) for chemical dependency safety and implement interventions to prevent obtaining non prescribed medications and overdoses from reoccurring. The immediate jeopardy (IJ) began on 3/1/21, when the facility failed to to fully assess R1 for chemical dependency safety or implement interventions to prevent obtaining non prescribed medications and overdosing from these medications. The IJ was identified on 3/8/21, the director of nursing (DON) and administrator were notified at 5:34 p.m. The immediate jeopardy was removed on 3/9/21, at 12:58 p.m. after the facility had implemented an acceptable removal plan. However, noncompliance remained at the lower scope and severity level of D, isolated with no actual harm with potential for re than minimal harm. Findings include: On 3/8/21, at 8:55 a.m. R1 was observed ambulating independent out of the room to the hallway as he held a cellphone on his right hand. During an interview in R1's room, there was cluttered with paper, clothes and other items on the floor and the furniture. R1 stated he preferred to keep his room this way. R1 stated, I had an accidental overdose with these pills I got from on line. I knew what the pills were and every time I have used that[OBSCENITY]before it just knocked me out. R1 stated when the overdoses happened the previous week, he had been given [MEDICATION(S)] (an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression) twice at the facility and taken to the the hospital . R1 stated he was on thin ice with the facility and was told he could not do this again. R1 further stated he had been sober 19 months and relapsed again last year and had gotten the pills delivered to another persons's address who he knew from the [MEDICATION(S)] Clinic. R1 stated he had been to the [MEDICATION(S)] clinic early in the morning around 6:00 a.m. and returned to the facility unescorted. No, one had completed any room searches that he was aware of. On 3/8/21, at 9:06 a.m. as R1 was leaving his room to show the surveyor the social services director's (SSD) office, the DON and the administrator both approached R1 in the hallway. R1 expressed the desire to go to treatment. The DON stated to R1 the facility would have to contact his physician to get the order for treatment. R1 stated the name of the treatment facility and then DON and R1 spoke briefly about the overdose incidents from the previous week. The DON stated to R1 that since the incidents R1 was supposed to be escorted to appointments including the [MEDICATION(S)] Clinic 6 days a week by staff and R1 expressed understanding. R1's Face Sheet dated 3/8/21, indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, was feeling down, depressed, hopeless, had trouble falling asleep or staying asleep or sleeping too much. In addition, the MDS identified R1 had behavioral symptoms not directed towards others 1 to 3 days during the assessment period. R1's behavioral symptoms Care Area Assessment (CAA) dated 7/13/20, indicated R1 triggered behavioral symptoms related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CAA indicated R1 was offered psychiatric services for additional psychosocial support through Associated Clinic of Psychology (ACP) and the referral was made. R1's substance use care plan dated 7/20/20, and revised 3/8/21, identified R1 had a history and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan identified R1 had overdosed in 2011 and 2021. In addition, the care plan indicated R1 current substance use was (benzodiazapines) and R1 had reported he ordered them via phone from a guy in New York, and had them delivered to a friend at the [MEDICATION(S)] clinic. During a review of R1's medical record the following was revealed: -A Suicide Prevention Evaluation dated 10/2/20, identified R1 had [CONDITION(S)] and the facility staff had completed a room search and had found and removed multiple medications. -PN dated 3/1/21, at 12:30 a.m., indicated R1 was found unresponsive. Unknown pills were found on R1's bedside table. 911 was called and R1 was sent to hospital for evaluation for signs and symptoms of overdose of some unknown substance. -PN dated 3/1/21, at 1:10 p.m. indicated the social service director (SSD) and DON met with R1 in his room following overdose on illicit drugs/non-regulated benzodiazepines. R1 indicated he ordered the medications online, from someone in New York and had them delivered to the home of another [MEDICATION(S)] clinic patient. R1 indicated there were no additional medications in his room. R1's room was searched, and additional medications were found and removed. At this time, R1 was placed on sedation monitoring. The note did not indicate what medications were found. -PN dated 3/3/21, at 3:10 p.m. indicated during rounds R1 was found in bed unresponsive, breathing but difficult to arouse. R1 still had pulse and Oxygen saturation read 96% on 2 liters of oxygen via nasal cannula. 911 was contacted and R1 was sent to the hospital for further evaluation. R1 returned to facility at 8:10 p.m. -PN dated 3/4/21, indicated SSD discussed recent substance use and overdoses with R1. R1 talked about recent triggers for relapse. R1 told the SSD he had ten medications in each shoe and directed them to where additional medications could be found hidden in his room. R1 also had identified he had, Etizolam and how he was obtaining them. SSD assisted R1 with calling the person from the [MEDICATION(S)] clinic that he was having the pills delivered to. R1 left a voicemail requesting that the 250 pills that were delivered that day be flushed as he did not want them. Treatment options were discussed. On 3/8/21, at 11:28 a.m. licensed practical nurse (LPN)-A stated she found R1 unresponsive in the room on 3/1/21, and had noted R1's oxygen saturation level was at 76%. R1 was breathing but his oxygen tubing was connected to the nebulizer machine and not the oxygen tank which was odd for R1 to do that. LPN-A stated R1's eyes were pinpointed and was in deep sleep. LPN-A stated when she found R1 she saw a pill on the nightstand and some residue I knew something was not right when I saw that. Last year the hospital had told us this is what was going on. He had also come out of the room one time because he sometimes feels guilty and had brought out these medications to me and I honestly did not know what the pills were, and I had never seen anything like them before. LPN-A stated at the time R1 brought the pills to her she had written a note, left a voice message for the DON and updated the physician. LPN-A stated after R1 was found unresponsive the night staff had searched the room and found these small pills in a cup with salt packets and they had sent them with the paramedics and the hospital pharmacist was not also able to identify them because they were not marked. LPN-A reviewed the nursing notes and verified there was no documentation of room searches in the medical record on multiple days between and after the two overdose incidents. LPN-A further stated no searches had been directed to be completed for R1 and R1 continued to go to the [MEDICATION(S)] clinic alone including that morning as the appointments were very early in the morning and R1 was back before 7:00 a.m. During an interview on 3/8/21, at 11:50 a.m. with the DON and the administrator, the DON stated after the 3/1/21, 12:30 a.m. incident we did suicidal assessment/intervention, reviewed the substance abuse policy with [R1], we initiated withdrawal and sedation monitoring, we did a detailed room search because he was denying, we talked to relocation worker, contacted the provider who put meds on hold, we were to call back if anything was worse and also we called the medical director and she said the same thing too. The DON stated for the 3/3/21, 3:10 p.m. incident, the DON stated after R1 was sent to the hospital they had searched the room and had found 5 pills which they had sent with R1 to the hospital. The DON stated the facility staff was not able identify how R1 was getting the pills and thought maybe a friend was dropping the pills for R1. The DON also stated we called the [MEDICATION(S)] clinic on Friday and we are working on scheduling his appointments every other week and someone will be going with him and when someone brings anything for him, we will be doing a search. Our plan is to do room searches every day. The DON then reviewed R1's medical record and acknowledged between the two incidents 3/2/21, and on subsequent days on 3/5/21, 3/6/21 and 3/8/21, R1 went to the [MEDICATION(S)] clinic unescorted and no room searches were completed. The DON also acknowledged he had been off Friday and half day Thursday and was not aware R1 had shown and given the SSD ten pills which he had in each shoe. The administrator stated she had heard something but was not sure when she was asked if she was aware the SSD had found more pills on 3/4/21 on R1. The DON also acknowledged although the interdisciplinary team had developed these interventions, to keep R1 from future overdoses the room searches had not been completed per the facility policy. In addition, the DON and administrator both acknowledged no education had been provided to staff on what the interventions were and what staff needed to do to keep R1 safe. The administrator stated she was aware of the overdoses however, she had not been at the facility Monday through Wednesday with a return of Thursday 3/4/21, after both incidents. The DON verified R1's plan of care was not updated to reflect the interventions which would keep R1 from obtaining the non-prescription medications to keep him safe. The DON also stated a few months back he had intercepted an envelope with medications addressed to R1. The DON stated he did not even open the envelope. The DON stated ACP had made a recommendation after 3/3/21, incident for the facility to ask the technology company to have firewalls to block R1's access to the sites when at the facility using his phone. The administrator stated the facility was still in the process of getting in touch with the technology company and R1 had agreed to chemical dependence outpatient and the SSD was going to call the facility for referral. During interview on 3/12/21, at 12:22 p.m. the SSD stated she had seen R1 after the 3/1/21, overdose incident and they had discussed the overdose, she had completed a suicide assessment, reviewed the substance abuse policy, and explained the ramification to get approved for the discharge to the group home. The SSD also stated she had offered R1 the rule 25 (chemical use assessment required when using public funds to pay for treatment), did a room search on 3/4/21, and had found more pills on the nightstand in the lock box. The SSD stated she also had been out of the building on Tuesday and Wednesday then had returned on Thursday 3/4/21, and was informed R1 had overdosed again on 3/3/21. The SSD stated R1 had approached her that day in her office and R1 ended up taking two packs out of each sock and told her where there could have been more pills in the room those had been taken out when he had been taken out the second time. The SSD stated R1 had informed her he was ready to start recovery and she started the safety plan as well as assisted R1 to call his friend, sponsor and girl he had the pills delivered to and had left a voice message to destroy them. The SSD stated she had communicated with the administrator and the DON about the pills R1 was hiding on him. The SSD also stated she had communicated with the [MEDICATION(S)] clinic and the primary physician's office and ACP had seen R1. SSD stated she had not found anything on 3/4/21, in the room when she searched. When asked if escorts and room searches had been implemented, the SSD stated she did not know if room searches had happened on the days R1 had gone unescorted to the [MEDICATION(S)] clinic but when she spoke with the clinic counselor Friday and the counselor had told her she was going to lay eyes on R1 the entire time and R1 was not going to see the girl who gave him the pills. The SSD further stated she would not know if the nurses did search R1 and verified R1 had gone out to the [MEDICATION(S)] clinic 3/2/21, 3/4/21, 3/5/21, 3/6/21 and 3/8/21, unescorted. During a follow up interview on 3/8/21, at 2:11 p.m. the DON stated he had heard about the incident when R1 had brought pills to LPN-A. When asked what the medications, the DON stated he did not know and stated he thought they were vitamins and directed surveyor to LPN-A who had written the note. When asked if the pharmacist had been involved to identify the pills, the DON did not respond. When asked what medications were found as documented on the suicidal assessment completed 10/2/20, the DON stated, I think it was over the counter [OTC] medications found was like a whole bag. When asked if the facility pharmacist was involved to identify the pills, the DON stated no. The DON acknowledged there was no documentation of what medications were found. When asked why the room searches and other interventions never happened since 9/1/20 and 10/2/20, neither the DON nor the administrator responded. The facility undated Substance Use policy indicated The facility does not allow for its possession, consumption, or distribution due to its significant contra-indication with the course of clinical treatment. 1) No alcohol, alcoholic containers, alcohol use, Illegal or illicit non-prescribed substances, paraphernalia and usage are not allowed within the facility or the facility premises whether for consumption, possession or distribution. A. Facility premises: The entire building, including the resident's room, the building grounds, including the parking areas, yards, common seating areas and sidewalks extending to the street. 2) If facility staff has a reasonable belief or suspicion that a resident has failed to follow the above policies, this may result in: A. Room search and personal belongings to confirm possession of alcohol, illegal/illicit substances and/or paraphernalia (according to the facility's room search policy). The resident may be present during this search process, if indicated. B. Search of resident's person, unless resident refuses. C. Confiscation and destruction of alcohol or other illicit drugs. D. Police may be notified for incidents of illicit substances, illegal drugs, or paraphernalia. E. Notice of 30-day involuntary discharge notice as allowed by law. F. Withholding of certain medications as directed/ordered by the provider . The immediate jeopardy was removed on 3/9/21, at 12:58 p.m. after it was verified the facility had reassessed R1 for chemical dependence, substance use disorder and the [MEDICATION(S)] maintenance as of 3/9/21. Due to R1's noncompliance with the facility substance use policy, R1 would be escorted to and from the [MEDICATION(S)] clinic visits and a nursing assessment to include the vital signs, mental status, behaviors, or any change in condition. R1 would have room searches according to the facility policy upon return to the facility from the [MEDICATION(S)] clinic. The facility would request R1 to have staff present when delivery of all packages happens. Also, a referral was made to an outpatient chemical dependence facility and the care plan for R1 was reviewed and revised to include [MEDICATION(S)] maintenance appointments, schedules and necessary supervision required for the residents. R1 was re-educated on 3/9/21, on the facility substance policy, room searches, [MEDICATION(S)] maintenance policy and the risks of substance abuse. Also, a full house audit was completed to determine which resident(s) went to the [MEDICATION(S)] maintenance clinics to identify non-compliance. An additional audit was completed for all resident(s) who had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, staff education began on 3/8/21, and was on going on 3/9/21, on facility policies pertaining to room searches, substance abuse use and [MEDICATION(S)] maintenance procedure. The facility revised the substance use policy and developed the [MEDICATION(S)] maintenance policy and protocol.

Based on observation, interview and document review, the facility failed to implement fall interventions and provide supervision to reduce the risk of accident hazards for 1 of 2 residents (R3) who had repeated falls. This resulted in actual harm when R3 sustained a head injury and fracture after a fall on 4/7/19. Findings include: R3's Admission Record dated 4/18/19, indicated [DIAGNOSES REDACTED]. R3's quarterly Minimum (MDS) data set [DATE], identified R3 had severe cognitive impairment and required extensive physical assistance with activities of daily living. R3's Cognitive Loss/ Dementia Care Area Assessment (CAA) dated 7/26/18, identified R3 was unable to be interviewed due to [MEDICAL CONDITION]'s disease. R3's Falls CAA dated 7/26/18, identified R3 had a history of [REDACTED]. R3's Falls Care Plan date initiated 4/9/19, identified R3 was at high risk for falls and directed staff to keep bed in low position with floor mat on both sides of the bed and furniture away from head of bed, Broda chair when out of bed, dycem to chair cushion, visually monitored and supervised when up in chair and not in bed, soft touch call light by hip when in bed, medication review as needed, radio playing in room with aromatherapy, up by 7:00 a.m. daily as she allowed, scoop concave mattress on bed and gripper socks to be worn at night. R3's Nursing Assistant (NA) Care Guide undated, provided by the director of nursing (DON) on 4/18/19, directed staff not to leave R3 where staff cannot see her as she was a huge fall risk and gripper socks on when in bed. R3 was observed on 4/17/19, at 11:36 a.m. to be seated near the nurse station in her Broda chair without any staff around to supervise R3. At 11:38 a.m. staff walked back to the nurse station where they could visualize R3. R3 was observed on 4/17/19, at 3:12 p.m. in her bed with soft music playing and aromatherapy; the bed was low to the floor with mats next to both sides of the bed. R3's soft touch call light was placed near the right side of her head. R3 was observed on 4/18/19, at 8:00 a.m. lying in bed eyes open. R3 did not respond to surveyor when questioned. R3's bed was low, music playing with aromatherapy and soft touch call light next to right hip. During interview on 4/18/19, at 8:25 a.m. NA-A stated R3 was not up out of bed due to not having any pants to wear and indicated they were supposed to get her up out of bed around 7:00 a.m. On 4/18/19, at 9:20 a.m. staff was observed to enter R3's room with pants and assisted R3 into her Broda chair. During this time R3 had no socks on her feet while in bed and there was no dycem in her Broda chair, to prevent her from sliding out of the chair. These were interventions identified on her care plan to help reduce or prevent R3's from falling. During interview on 4/18/19, at 9:42 a.m. NA-A verified R3 did not have gripper socks on when she was in bed and confirmed there was not any dycem on the seat of the Broda chair where R3 was seated. NA-A stated she was unaware R3 needed to have these interventions. R3's progress notes (PN), incident reports and incident review and analysis were reviewed from 3/10/19, through 4/18/19 as follows: -On 3/13/19, the PN identified R3 had moved her buttocks forward in the Broda chair tipping it forward. Her buttocks was on the chair between the cushion and foot res. She was assisted with 3 staff to tip her chair back up; -On 3/25/19, the PN identified the nurse went to R3's room and found R3 lying on the floor in front of her wheelchair (w/c), no injury noted; -The incident report dated 3/25/19, identified the nurse went to R3's room and found R3 on the floor in front of her w/c. R3 had crawled on the floor and moved self towards the other room. Staff did not note any injury and were to monitor R3. The immediate action taken was the staff assisted R3 back to bed; -The incident review and analysis dated 3/30/19, identified R3 was found on the floor on 3/25/19, and was crawling towards the bathroom. Current interventions in place, R3 should be toileted upon rising, after breakfast and lunch, before supper and at bedtime. R3 was toileted prior to supper and that R3 had habits of standing from her w/c and attempting to ambulate without assist as well as crawling from her bed. There were no other interventions identified for R3; -On 4/2/19, the PN identified R3 was attempting to sit forward in her w/c and rise as she appeared restless; -On 4/7/19, the PN identified R3 was observed on the floor face down in her room due to a fall from the chair. R3 was sent to the emergency room for moderate bleeding from her nose and a bump on her forehead above the right eye. A subsequent PN indicated R3 returned from the hospital and had a fractured nose and hematoma; -The incident report dated 4/7/19, identified R3 was observed on the floor face down in her room after falling from the chair at 3:50 p.m. State agency (SA) report was filed and employee was receiving disciplinary action for not following plan of care. R3 was sent to the emergency room and upon return placed under staff supervision per plan of care; -The incident review and analysis dated 4/8/19, identified on 4/7/19, R3 was found on the floor face down following a fall from her Broda chair. Current interventions in place for R3 were supervised when in Broda chair, soft touch call light by hip when in bed and medication review. R3's Emergency Department After Visit Summary dated 4/7/19, revealed R3 had been seen in the emergency department due to a fall and diagnosed R3 with injury of head and closed fracture of nasal bone. CT scan of the head was completed and included the following findings right frontal scalp contusion/ hematoma with right periorbital soft tissue swelling and nasal bone fracture. The facility investigative file identified the following written statements: -DON's statement dated 4/7/19, indicated she called NA-C who stated he left R3 in her room in her w/c. DON reminded NA-C per care sheet, she is not to be left unattended in her w/c, however He was minimizing the care sheet instructions and feeling his decision to leave her in her chair unattended was warranted; -The family member witness statement dated 4/8/19, indicated she was across the hall from R3 while visiting another resident and witnessed R3 stand and fall forward hitting the floor face first .no one was around; -NA-C's statement dated 4/12/19, indicated NA-C assisted R3 to her room around 1:20 p.m. we always leave her in her room after lunch for a nap. Sometimes she would want to lay in bed and some other times she would want to remain in her recliner wheelchair. I left her with her choice of being in her recliner wheelchair and by the time I left the facility at 2:00 p.m., she had already slept off. During interview on 4/18/19, at 10:52 a.m. with NA-C and DON, NA-C stated on 4/7/19, at 1:20 p.m. he found R3 seated in her w/c in the dining room alone without any staff around. He brought R3 to her room and left R3 in her w/c alone with her call light hooked on the w/c and placed across R3's stomach. At 2:00 p.m. he checked on R3 and she was sleeping in her w/c. He stated he was not aware R3 was not allowed to be left in her room in her w/c alone. He explained R3 was not on his assigned group so he did not have the care sheet specific to R3. He further explained he was not expected to carry all resident's care sheets and only needed to carry the group in which he was assigned to. During interview on 4/18/19, at 11:42 a.m. DON stated it was her expectation for all NAs to carry all of the care sheets for that unit and explained the care sheet was how the resident care plan was communicated to the NA. During telephone interview on 4/18/19, at 12:41 p.m. NA-D stated when he arrived to work on 4/7/19, he did not see R3 seated in her w/c at the nurse desk so he assumed she was in her room asleep in her bed. He stated R3 was not to be left alone while in her w/c and that staff needed to be able to see her. He recalled when he was in the hallway someone yelled R3 fell and when he arrived to R3's room he found R3 face down on the floor. During interview on 4/18/19, at 1:43 p.m. R3's medical doctor stated R3 had a [DIAGNOSES REDACTED]. During telephone interview on 4/18/19, at 2:59 p.m. the medical director stated it was his expectation for staff to implement R3's fall interventions per her care plan. During interview on 4/18/19, at 3:12 p.m. DON stated it was her expectation for staff to implement all fall interventions per the plan of care and for NAs to follow the care guide which included gripper socks on when in bed as R3 had a history of [REDACTED]. She confirmed the fall intervention to keep R3 eye sight was developed 12/25/18, and indicated all staff were educated at that time. She explained keeping R3 within eye sight meant for someone to supervise her with their eyes at all times when she was in her Broda chair to prevent further falls. Furthermore, she stated it was her expectation for R3 to have dycem in the seat of her Broda chair when occupied to keep R3 from sliding out of her chair. The facility Fall Prevention and Management Protocol revised dated 7/2018, indicated facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observation, interview and document review, the facility failed to comprehensively assess and provide effective discharge planning for 2 of 2 residents (R4, R23) reviewed for discharge. R4 sustained psychosocial harm when the facility issued an immediate discharge notice to R4 during a hospital stay refusing to allow R4 to return to the facility. R4's psychosocial harm was evidenced by increased anxiety, fear, distress, sadness and mental anguish. Findings include: R4 was interviewed on 2/4/19, at 12:52 p.m. R4 identified he was working on making a list of his personal items missing from a year ago. R4 stated while hospitalized the facility administrator and director of nursing (DON) visited him and asked him to sign an immediate discharge notice. R4 explained I was a sick man and indicated the administrator and DON had no regard for his health well being they just continued to harass me. R4 identified I had no place to go and did not have any money so he had to stay in the hospital awaiting his appeal. R4 explained he refused to sign the notice and after assistance from the Ombudsman and legal aide he was eventually able to return to the facility. R4 indicated upon return all of his personal belongings had been packed and placed in an unlocked storage shed on the facility property. R4 stated, it was the third or fourth time the facility had tried to, get rid of me. R4 verbalized, they don't care and explained the facility had attempted to discharge him to the local motel what would they do for me, I was a sick man. R4 expressed, they have given me emotional anxiety due to feeling he did not have an advocate or a social worker to help him. R4 stated he did not feel the facility honored his rights as he felt he was medically fragile and was unable to live alone in the motel. At this time R4 was observed to have a sign on his room that stated, Please knock before entering please state who you are and purpose of visit please wait for me to greet you at the door or tell you to come in (to protect my privacy and because of diagnosed medical condition of severe anxiety, when startled I get an unpleasant [MEDICATION NAME] rush). R4 stated he had placed the sign on his door due to his anxiety. R4's psychology notes were reviewed prior to the (MONTH) (YEAR), immediate discharge notice: -The note dated 6/5/17, identified R4 had been seen due to follow-up regarding depression and anxiety. The note indicated R4 presents as calm and cooperative .he denies any feeling of sadness or worry; -The note dated 7/17/17, identified R4 appeared to be depressed, endorsed anxiety and sadness, however unable to articulate the reason; -The note dated 10/11/17, identified R4 stated his mood was frustrated due to pain in his back, R4 also expressed he wanted to stay at the facility due to close proximity to his [AGE] year old mother and was hopeful he would remain to get along with everyone at the facility; -The note dated 10/25/17, identified R4 appeared to be in a good mood; -The note dated 11/29/17, identified R4 was feeling stressed out due to significant pain and his mother's declining health; -The note dated 12/13/17, identified R4 was upset regarding his pain medication being decreased; -The note dated 1/24/18, identified R4 had lack of insight and poor judgement, however R4 had a history of [REDACTED]. They should listen .and validate his feelings. It would be useful considering the upcoming stressor for .to have an appointment with his psychiatrist; R4's Brief Interview for Mental Status (BIMS) dated 1/29/19, identified R4 with cognitively intact. R4's quarterly Minimum Data Set ((MDS) dated [DATE], identified R4 had [DIAGNOSES REDACTED]. The MDS lacked evidence of evaluation of R4's cognition. The MDS identified R4 was independent with ambulation and toileting and required supervision- oversight, encouragement or cueing without set-up or physical help from staff regarding activities of daily living. The MDS indicated there was not an active discharge plan in place the resident to return to community and resident's overall goal established during assessment process was left blank. The MDS further indicated R4 preferred to not to be asked about the possibility of leaving the facility and returning to the community with services. Furthermore, the MDS indicated no referral was required to local contact agency. R4's care plan date initiated 9/3/16, with revised date 11/21/18, indicated R4 would likely benefit from a lesser restrictive environment and had been offered many options and directed staff to refer to social services and should R4 change his mind social services would help him in discharge planning. R4's return to community referral Care Area Assessment (CAA) dated 1/19/18, indicated a referral had not been made to local contact agency and further directed to refer to social worker notes. However the medical record lacked evidence of the social worker note to support the CAA. Additional record review revealed: R4's progress notes (PN) dated 1/16/18, identified a care conference was offered for the following day, however R4 declined due to not feeling well, care conference scheduled for 1/25/18. The PN dated 1/22/18, identified referral had been made for a waivered apartment. The PN dated 1/23/18, identified referral had been made to two places for waivered apartments. The PN dated 1/25/18, identified R4 declined care conference due to not feeling well and he was issued a 30 day discharge notification; R4's discharge notification dated 1/25/18, indicated dated of discharge 2/25/18, due to 2. Why others are endangered: Misuse of facility amenities causing risk of food borne illness, violation of safety policies regarding medication storage and hazardous objects such as weapons (knives) and power tools. The resident has failed, after reasonable and appropriate notice, to pay or refused to pay for a stay at the facility AND the resident has not submitted the necessary paperwork for third party payment .discharged to: La Quinta Inn (hotel) . The discharge notification indicated R4 had refused to sign. R4's PN dated 1/26/18, identified the facility contacted the county for relocation services and directed the facility to contact R4's care coordinator through his insurance provider to assist with relocation services. The PN dated 1/29/18, identified the facility contacted R4's care coordinator and informed her that R4 needed to find housing as soon as possible. R4's care coordinator indicated she would make a referral the following day and assist R4 to find housing. The PN dated 1/30/18, identified Resident was very anxious this AM. Resident received a call to remind him of looking for a new facility . The PN dated 1/31/18, identified R4 had a physician order [REDACTED]. The PN indicated R4 refused to meet or talk to his care coordinator. The PN dated 2/7/18, identified R4's care coordinator was meeting with him that day while R4 was at the hospital. R4's bed hold notice for hospital transfer date signed 2/7/18, indicated R4 was transferred to the hospital on [DATE], and medical assistance would pay for a bed hold for hospitalization for 18 days. The PN dated 2/10/18, identified R4 had openly admitted to his hospital care team to usage of illegal drugs/ substances .he tested positive for [MEDICATION NAME] and Opiate usage. The PN indicated the facility was not an appropriate discharge location as it does not have the programming and support to manage active chemical dependency and the increased level of supervision that R4 required. The PN dated 2/12/18, identified Toxicology screens showed positive for [MEDICATION NAME] use .With this additional information it was determined that the facility can no longer meet residents unique medical and psychosocial needs and that his return to this facility would endanger both his and that of other residents. R4's discharge notification dated 2/12/18, indicated date of discharge 2/12/18, due to The resident's welfare and the resident's needs cannot be met in the facility, if so, specify: 1. The specific resident's need(s) that cannot be met: Chemical dependancy (sic) and substance abuse treatment 2. The facility's attempts to meet the resident's needs: Behavior contracts and Re-education with the resident, Psych Services with ACP (psychology), room searches by staff .has refused relocation services continually. 3. The services available at the receiving facility to meet the resident's need(s): Increased level of supervision to manage the patient's complex Psych history and manage behaviors and substance abuse issues .The safety of other individuals in the facility is endangered due to the clinical or behavioral status of the resident. 1. Why the resident is endangered: Unable to provide sufficient supervision to prevent substance abuse which is contributing to his current cardiac complications. 2. Why others are endangered: Resident is bringing in and using inappropriate substances at the facility. These substances put other residents at immediate risk for significant harm .discharged to: hospital. The discharge notification indicated R4 refused to singed and had been delivered in person on 2/12/18 by the facility administrator and director of nursing. R4's PN dated 2/20/18, identified R4's primary medical provider was contacted and could not provide any input into R4's clinical need for services at the facility, due to the inability to obtain final provider approval for discharge the facility decided to retract the discharge notice until further notice and the hospital was informed of the facilities decision to readmit R4 back to the facility tomorrow. The PN dated 2/21/18, identified R4 had returned from the hospital. The psychology note dated 2/23/18, identified R4 had returned from the hospital with assistance from the OMB and a lawyer who was helping him. R4 stated he did not want to be discharge. The PN dated 2/28/18, identified R4 would be seen by psychology weekly. The psychology note dated 3/8/18, identified R4 with an active [DIAGNOSES REDACTED]. The psychology note dated 12/20/18, identified R4 feeling down and upset that the facility continued to accuse him of smoking in his room. R4 was noted to endorse struggling with interpersonal relationships, particularly with the staff, whom he felt just don't like me. The psychology note dated 1/4/19, identified R4 endorsed feeling anxious having staff check on him frequently and he gets a rush of [MEDICATION NAME] when they open his door, making him feel more anxious (i.e. racing heart, flushed face, jittery) and recommended staff knock on R4's door and wait for a response before opening the door. R4's discharge notification dated 2/6/19, (during the survey process) indicated R4 refused to sign. The notification identified The resident's welfare and the resident's needs cannot be met in the facility. If so, specify: 1. The specific resident's need(s) that cannot be met: Resident has failed to pay for his stay while residing at the facility .outstanding balance is $7,481. The facility's attempts to meet the resident's needs: Behavior contracts and re-education with the resident, Psych services with ACP (psychology) room searches by staff .has refused relocation services continually. 3. The services available at the receiving facility to meet the resident's need(s): Increased level of supervision to manage the patient's complex Psych history and manage behaviors that require 1:1. The safety of other individuals in the facility is endangered due to the clinical or behavioral status of the resident. 1. Why the resident is endangered: Resident is non-complaint with smoking safety and compliance with his behavior contract. 2. Why others are endangered: Resident's smoking behaviors are causing other patients to be at risk .discharged to: Extended Stay Motel . The psychology note dated 2/7/19, identified R4 reported feeling as he was treated unjustly and felt wrongfully accused due to the accusation of smoking in his room. The note indicated He has all or none thinking about his staff feeling that they are all against him. R4's medical record lacked evidence of ongoing discharge planning including communication, referrals to other local agencies or other community providers to find appropriate placement, and not a hotel/motel. In addition, the facility failed to develop plans to include resident goals and treatment related to mental and substance use disorders to ensure safe, smooth transition in order to decrease R4's anxiety, fear and emotional distress related to discharge. During an interview on 2/7/19, at 11:50 a.m. with the administrator and director of social services (DSS), the administrator confirmed he and the DON issued a 30 day discharge notice to the nearby motel on 1/25/18, then during R4's hospital stay he indicated an immediate discharge notice had been issued at the beginning of (MONTH) (YEAR). The administrator explained R4 consulted with the OMB and legal aide and following housing court the facility took R4 back to the facility from the hospital. The administrator identified the facility had fought and fought but the OMB would stop the attempted discharges. During an interview on 2/8/19, at 8:15 a.m. the DSS identified the last time she had been in contact with R4's relocation care coordinator was 2/7/18 (a year ago). The DSS stated during R4's care conference on 11/27/18, discharge had not been discussed due to R4 not wanting to participate and when she asked if he had any questions or concerns R4 stated no. Furthermore, the DSS explained R4 did not want to leave the facility so she did not press it if he did not want to look into other options. During a telephone interview on 2/8/19, at 10:36 a.m. the ombudsman (OMB) acknowledged that she had been made aware of the immediate discharge notification following a phone call from R4 and went to the hospital to assist R4 with calling legal aid. The OMB stated while R4 was in the hospital the facility agreed to take R4 back so the appeal hearing was canceled. During an interview on 2/11/19, at 9:59 a.m. R4 stated he had been experiencing an increase in anxiety and undue stress due to the facility pulling stunts then verbalized while his hands were pointed towards the ceiling God, I am having increased anxiety. R4 indicated he had tried to explain himself to the administrator but continued to feel they are picking on me and had threaten him to find a new place. R4 stated he felt as if the administrative staff tried to make him angry or have a reaction to get rid of me. R4 identified he had an increase in anxiety when he would think about all he had to do to put himself together in fear if I do discharge and what would happen to him. R4 explained he was unable to do anything except sit down going over and over his notes and documentation due to a big fight on my hands regarding discharge. R4 stated staff would knock on his door without opening and/ or speaking then would walk away; R4 reported this made him feel startled so he would barricade his door shut to keep people from entering his room without permission. R4 indicated he felt as if staff were constantly checking on him in hopes that they would find him doing something wrong so they would get rid of me. R4 further explained the facility staff would attempt to enter his room without permission as an attempt to catch him so that they would be able to discharge him. At 10:44 a.m. R4 stated he was scared of the administrative staff as he did not want lose this place. R4 indicated he felt as if he had to fight for his health needs. R4 stated he had not spoken to his relocation case manager in a year and would need to contact her to find a place. R4 verbalized I need to get an advocate and identified the facility had distorted the truth to kick me out. R4 explained he had filed grievances and had not received a signed copy when he would complain, but felt the concerns would fall onto deaf ears. R4 identified he had felt, dehumanized, as he became teary, and stated he was too stressed out to pack and would rather be focused on his swollen painful legs. During a subsequent telephone interview on 2/12/19, at 12:17 p.m. the OMB stated that she was unaware R4 was not allowed to return to his original room on 2/21/18. The OMB identified the administrator and DON had attempted to discharge R4 more than once which had caused R4 to feel afraid to speak up and experience an increase in anxiety. The OMB indicated she had requested the facility increase psychology visits with R4 about two years ago and was not aware that this had occurred. The OMB stated, the administrator and DON keep trying to get rid of him. The OMB explained it did not help R4 when he would get angry when the facility staff would remove items from R4's room without his permission. The OMB further explained R4 felt violated. Furthermore, the OMB stated the previous administrator and DON had a history trying to, kick him out which was why R4 was afraid. During a telephone interview on 2/12/19, at 1:08 p.m. the house psychologist indicated she currently saw R4 every month to every quarter and identified she started working with R4 in (MONTH) (YEAR), however R4 had been seen by previous provider. She indicated their session goals were to work within the facility policies. She stated R4's anxiety had increased since she began seeing him. During an interview on 2/12/19, at 2:56 p.m. the DSS reviewed the psychology note dated 3/8/18, and stated she was unaware of what the note indicated when referenced possible chemical abuse. The DSS reviewed the psychology note dated 12/20/18, and identified she did not speak with R4 regarding why he stated the staff did not like him and was not aware of staff not liking him. The DSS reviewed the psychology note dated 1/4/19, and indicated R4 had hung a sign on his door due to reported anxiety, however she was unaware if this was effective as she had not had the opportunity to follow-up with R4. The DSS was not aware of any other times or reports by R4 regarding an increase in anxiety. During an interview on 2/13/19, at 9:31 a.m. with the administrator, the facility regional corporate director and the DON, the administrator identified DSS was responsible for reviewing psychology notes. The administrator reviewed R4's psychology note dated 12/20/18, which indicated R4 struggled with interpersonal relationships particularly with staff, whom he felt just don't like me. The administrator reviewed the psychology note dated 1/4/19, which indicated R4 endorsed feeling anxious, noting that staff were checking in on him frequently and he gets a rush of [MEDICATION NAME] when they open his door, making him feel more anxious (i.e. racing heart, flushed face, jittery). The administrator was unable to locate in R4's medical record where either psychology note had been addressed. The administrator and DON were unaware R4 had a documented opioid use disorder, moderate on R4's psychology notes dated 2/7/19 through 2/6/17. The administrator reviewed R4's care plan and was unsure if R4's discharge care plan should have been updated with further information. Furthermore, the administrator reviewed the 30 day discharge notification that had been issued to R4 on 2/6/19, however he would need to verify with DSS when the last time the relocation worker had been contacted and stated he would expect they would have been called. DON indicated R4's current one to one staff was directly related to R4 smoking in the facility and safety of other residents. The administrator was unaware if the motel listed as R4's location of discharge would be able to provide complex psychology services and indicated he had planned to set-up home care services at discharge. During a telephone interview on 2/13/19, at 2:36 p.m. the facility medical director stated it was his expectation to follow their discharge planning process to identify needs and ensure for a safe discharge plan. The facility policy Involuntary Transfer of a Resident revised 12/2016, indicated Staff at the facility must review resident care plans .The plans of care shall reflect the condition of the resident .The staff at the facility must consider any physical or psychosocial cause of behavioral issues .An additional care conference may be held to identify problem areas and develop special plans and interventions .Several meetings may take place before final plans are make .Social Services will participate in finding appropriate alternative placement and will make referrals to resources. The facility policy Discharge Planning Policy revised 11/2016, indicated 1. The Social Service Director serves as Discharge Coordinator. 2. The Social Service Director is responsible to identify a tentative discharge plan for the resident. 4. Discharge planning beings at the time of admission. 8. The resident's choices, thoughts and feelings are of paramount importance in both pre and post- discharge plans. 13. g. the discharge plan is documented .on the resident's care plan. 14. a. Discharge planning for each resident is reviewed every 3 months (more frequently if indicated) for necessary revisions. R23 was interviewed on 2/5/19, at 9:53 a.m. and stated he was frustrated and wanted to discharge from the facility back to the community six months ago and identified he had spoken to another resident who gave him contact information for a relocation service. R23 stated he had contacted the service and had started working with them about a month ago. R23's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R23 had intact cognition. The MDS identified there was not an active discharge plan and indicated R23 did not want to talk to someone about returning to the community with services. The MDS further indicated no referral had been made to the local contact agency. R23's care plan printed 2/12/19, indicated R23's discharge status was uncertain and identified he did have a discharge goal to a lesser restrictive environment and social services was assisting him with relocation and directed staff to make any necessary referrals to work towards discharge needs and R23 would be involved in discharge planning discussions and goal setting. R23's discharge plan dated 3/23/18, identified R23 would like to eventually discharge to an assisted living facility. R23's psychology notes were review: -The psychology note dated 8/23/18, identified to decrease irritability consider talking with R23 about the discharge process to promote a sense of hope; -The psychology note dated 10/11/18, identified R23 endorsed ongoing depression and hopelessness which he related to feeling that nothing is being done to work towards discharge and recommended updating R23 on what needed to happen before discharge; -The psychology note dated 12/13/18, identified R23 had concerns about being able to discharge and recommended accessing relocation services and update R23 on this; R23's progress note (PN) dated 12/26/18, indicated social services had communicated with R23's case manager passing along the names to four facilities that had openings and requested the case manager to follow-up with the facilities for R23. The PN dated 1/22/19, identified R23 was planning to contact a housing agency recommended by a friend to see if he could obtain an apartment and in-home care services. During an interview on 2/8/19, at 8:15 a.m. the director of social services (DSS) confirmed R23 had expressed a desire to discharge to the community. The DSS explained R23's case manager was assisting him with finding alternative placement and identified she had met with R23 on 1/16/19, to discuss housing options, however the DSS was unaware where the case manager was at in the process. The DSS indicated she would typically give a resident a list of housing options to look into, however the case manager was the primary person to assist with relocation services. The DSS explained when a resident was more independent the case manager would deal mainly with the resident and/ or family and further indicated if a resident asked for help or an update from the case manager she would help them. During an interview on 2/13/19, at 9:39 a.m. the administrator () stated it was his expectation for the social worker to be meeting with the resident and directly involved with the case manager when assisting a resident to return to the community. The facility policy Discharge Planning Policy revised 11/2016, indicated 1. The Social Service Director serves as Discharge Coordinator. 2. The Social Service Director is responsible to identify a tentative discharge plan for the resident. 4. Discharge planning beings at the time of admission. 8. The resident's choices, thoughts and feelings are of paramount importance in both pre and post- discharge plans. 13. g. the discharge plan is documented .on the resident's care plan. 14. a. Discharge planning for each resident is reviewed every 3 months (more frequently if indicated) for necessary revisions.

Based on observation, interview and document review, the facility failed to comprehensively assess, implement and monitor efficacy of interventions to prevent decline and promote healing of pressure ulcers (PU) for 3 of 5 residents (R152, R19, R10) reviewed for pressure ulcers. This resulted in actual harm for R152 whose PU worsened to a stage III (open wound in which damage has occurred into the subcutaneous level and may be painful) wound. Findings include: R152's closed record was reviewed and the progress noted dated [DATE], indicated R152 died on [DATE]. R152's quarterly minimum data set ((MDS) dated [DATE], indicated R152 had moderate cognitive impairment and required extensive assistance with bed mobility, transfers and toileting. The MDS further indicated R152 did not have a PU and was at risk to develop a PU with no skin and ulcer treatments noted other than applications of ointments/medications other than to feet. R152's record review revealed the following inconsistent documentation regarding R152's skin condition: - R152's weekly skin inspection report on [DATE], revealed his skin was clean, dry, and intact. - R152's progress note (PN) dated [DATE], written by registered nurse (RN)-D indicated patient had an open area on his right buttock which measured 2 centimeters (cm) x 1.5 cm which had been noticed today during morning cares. RN-D cleaned area and applied [MEDICATION NAME] dressing. Nurse manager RN-I was notified. However, there was no evidence the facility did a comprehensive reassessment of the risk factors for a newly developed wound in order to identify individualized interventions. There were no weekly wound assessments or measurements initiated at that time. - R152's weekly skin inspection report on [DATE], (three weeks after the pressure ulcer first developed) identified his skin was clean, dry and intact. - R152's weekly skin inspection report on [DATE], revealed his skin was clean, dry and intact. -R152's PN dated [DATE], written by licensed practical nurse (LPN)-E indicated there was a PU noted under folds of right buttocks. Cleansed wound and applied skin paste and foam dressing, however the nurse manager was not notified and there was no evidence the facility did a comprehensive reassessment of the risk factors for a newly developed wound in order to identify individualized interventions. There was no evidence of comprehensive wound assessment or wound measurement. In addition there were no weekly wound assessments or measurements initiated at that time either. - R152's weekly skin inspection report on [DATE], revealed his skin was clean, dry and intact. - R152's PN dated [DATE], included a change of condition regarding resident's right buttock wound noted to be purple/blackened with measurements of 4 cm x 2.5 cm, and the medical director notified. - R152's weekly skin inspection report on [DATE], revealed R152 had a stage 2 PU the size of a quarter. A gel cushion to sit on, and an Ensure supplement drink at all meals to help speed up the healing process were ordered. A physician progress notes [REDACTED]. A facility incident report dated [DATE], was reviewed and included: on the afternoon of [DATE], R152 was noted to have a pressure injury on his left buttock that had a foul smell and was draining dark brown exudate. He was sent to the hospital where he was diagnosed with [REDACTED]. Pressure injury to left buttock was debrided by surgeon and found to be a stage III pressure ulcer. R152's weekly pressure wound evaluation report dated [DATE], indicated the pressure wound was identified on [DATE], and was a stage III PU which measured 2 cm x 2.5 cm x 1 cm. Resident was placed on a repositioning schedule, air mattress for bed, gel cushion for wheel chair, and Ensure dietary supplement every meal. R152's care plan dated [DATE], had an initiated date of [DATE], which directed staff to give client Ensure with every meal, and resident's pressure wound would heal within this review period. An initiated date of [DATE], identified resident had a pressure injury on right buttocks. Even though facility identified treatment measures on the pressure ulcer evaluation report, those interventions were not care planned. On [DATE], additions to the care plan included wound care and dressing changes as ordered and on [DATE], wound assessment weekly was added which included treatments for PU. R152's five day MDS dated [DATE], indicated R152 had a stage 3 (full thickness tissue loss) PU and was at risk for the development of a PU. Treatments listed were pressure ulcer/injury care and application of nonsurgical dressings. Pressure reducing devices for chair or bed, turning/repositioning program and nutrition or hydration interventions were not checked as recommended treatments. R152's quarterly MDS dated [DATE], indicated R152 had a stage 3 PU and was at risk for the development of a PU. Treatments listed included pressure reducing device for chair, turning and repositioning program, nutrition or hydration interventions, and application of nonsurgical dressings. On [DATE], at 1:17 p.m. the director of nursing (DON), stated R152's condition had declined the last six months of his life and he had become more resistive to cares. DON stated she was unaware of R152's PU until she read the nursing progress noted on [DATE], and RN-I should have notified her on [DATE], documented the new PU and ensured the wound would be assessed, monitored and treated and evaluated and comprehensively reassess the resident's clinical condition and risk factors for the development of pressure ulcers, along with other contributing factors. DON confirmed R152 did not have a formal skin assessment completed until [DATE], and staff had not done timely or accurate weekly skin/wound monitoring to evaluate progress and effectiveness of treatments. On [DATE]/ at 2:00 p.m. RN-D stated he had noticed R152's PU on [DATE], when he cleaned it, applied a dressing and then notified his supervisor RN-I. RN-D further stated RN-I should have put in an order for [REDACTED]. RN-D stated he had not worked on R152's unit after he discovered the wound because he had just helped out for one day. On [DATE], at 2:39 p.m. the MDS Coordinator (also registered nurse) stated when staff identify a skin concern they should document it, notify their supervisor and email me so it would be added as a task for the wound nurse to evaluate it. The nurse practitioner (NP) would then assist with the assessment and treatment of [REDACTED]. The MDS coordinator further stated the RN-I had not followed up properly he was notified of R152's pressure wound on [DATE]. On [DATE], at 2:44 p.m. the MDS coordinator stated R152 did not have skin breakdown when the quarterly MDS assessment was done on [DATE], however he was at risk for skin breakdown and the only treatment checked was application of ointments/medications. The MDS coordinator also confirmed the [DATE], MDS was coded with R152's stage 3 PU and should have had treatments checked which included turning and repositioning and nutrition because of the wound healing. The MDS coordinator stated she should have included more treatments when R152 was deemed to be at risk for skin breakdown and was incontinent. On [DATE], at 12:19 p.m. the NP stated she had not been made aware of R152's pressure injury until [DATE], and RN-I should have told her about it right when it was first observed. NP stated her expectation would be for staff to contact her by phone or fax with any change in condition and that had not been done for R152 regarding his pressure injury. On [DATE], at 3:32 p.m. family member (FM)-A stated he was notified of R152's PU one week before he was sent to the hospital with pneumonia. It had been brought up at a care conference meeting the day R152 went to the hospital. On [DATE], at 3:59 p.m. the MDS coordinator stated R152's MDS's were now modified with the turning/repositioning, pressure reducing devices and nutrition treatments added. On [DATE], at 9:55 a.m. the medical director stated when a staff member discovers a pressure wound they would contact their supervisor who would contact the resident's primary care provider, the NP or whoever would be on call for that particular resident. The supervisor should have communicated with the DON after they obtained orders from the provider and this would be discussed at the next interdisciplinary team meeting where we would determine the cause, interventions and put in place a monitoring plan. The medical director stated: I do not know why this did not occur in this instance and I would have to review my notes and call you back. The medical director did not call writer back. Even though R152 was at risk for PU development identified by facility on [DATE], there was no indication the facility implemented interventions to prevent development of PU. R152 developed PU [DATE], which was not reassessed at that time for interventions nor was there ongoing weekly monitoring for the PU. In addition, R152 had another PU on [DATE], which was not re-assessed and interventions implemented. As a result the pressure ulcer continued to progress into a stage 3 PU ulcer, and was surgically debrided during hospital stay in [DATE], resulting in actual harm for R152. The facility's Skin Assessment and Wound Management policy dated ,[DATE], included guidelines for staff to perform routine skin inspections with daily care, notify nurses if skin changes are identified and a weekly skin inspection would be completed by licensed staff. When a pressure ulcer is identified the following actions would be taken: notify MD/treatment ordered, notify resident representative, initiate weekly pressure wound evaluation, notify nurse manager/wound nurse, update care plan, and update resident care lists. Document skin condition on the Pressure Wound Evaluation weekly until healed, update provider and resident/representative as needed, review skin concerns with IDT at least monthly and update care plan as needed. R19 According to the undated Admissions Record R19 was admitted to the facility [DATE]. R19's [DIAGNOSES REDACTED]. The MDS Facility Matrix printed [DATE], showed R19 had a Stage 2 pressure. A review of R19's Admission MDS dated [DATE], indicated R19 had one stage two pressure ulcer, was always incontinent of urine (no episodes of continent voiding), required physical assist of two plus staff for bed mobility, transfers, toileting, and personal hygiene. R19 was not noted to have behaviors. R19's MHM Weekly Pressure Wound Evaluation ,[DATE] were reviewed: - The skin check dated [DATE], indicated a new, 2.5 cm x 2.6 cm x 0 cm, 100% granulated, stage two pressure ulcer on the left buttock. The summary read, Wound caused by shearing when staff used hoyer sling. Cleanse abrasion on left buttock with wound cleaner. Apply skin prep to periphery of wound to protect and assist in final dressing adherence. Apply small amount of sivrstat to wound bed, cover with small piece of petroleum dressing and cover with [MEDICATION NAME]. Care plan has been updated as have NA (certified nurse assistant) care sheets. Risks and benefits were discussed with both (R19's) and her daughters. NP has been notified and(NAME)has been referred to dietary. She is currently in therapies and per PT has been cleared to safely use stand lift. The document lacked if the resident was compliant with the treatment plan. - The skin check dated [DATE], indicated the wound was identified on [DATE]. The 100% granulated, stage two pressure ulcer on the left buttock measured 1.2 cm x 1.1 cm x 0 cm. The summary read, Wound caused by shearing when staff using hoyer sling. Cleanse abrasion on left buttock with wound cleaner. Apply skin prep to periphery of wound to protect and assist in final dressing adherence. Apply small amount Silverstat to wound bed, cover with small piece of petroleum dressing and cover with [MEDICATION NAME]. Care plan had been updated as have NA care sheets. Risk and benefits were discussed with both (R19) and her daughters. NP has been notified and (R19) has been referred to dietary. She is currently in therapies and per PT has been cleared to safely use stand lift. The document lacked if the resident was compliant with the treatment plan. - The skin check dated [DATE], indicated the wound identified [DATE]. The 100% granulated, stage two pressure ulcer on the left buttock measured 1.5 cm x 0.6 cm x 0 cm. The summary read, Wound caused by shearing when staff used hoyer sling shortly after admission. Cleanse abrasion on left buttock with wound cleanser. Apply skin prep to periphery of wound to protect and assist in final dressing adherence. Apply small amount Silverstat to wound bed, cover with small piece of petroleum dressing and cover with [MEDICATION NAME]. Care plan has been updated as have NA care sheets. Risks and benefits were discussed with both (R19) and her daughters. NP has been notified and (R19) has been referred to dietary. She is currently in therapies and per PT has been cleared to safely use stand lift. Using Roho cushion in w/c (wheelchair). The wound is improving. The document lacked if the resident was compliant with the treatment plan. - The skin check dated [DATE], indicated a wound identified [DATE]. The 100% granulated, stage two pressure ulcer was located on the left buttock and measured length: 1.2, width: 0.4, depth: 0. The summary read, Wound caused by shearing when staff used hoyer soon after admission. Cleanse. Apply skin prep to periphery of wound. Apply small amount Silverstat to wound bed, cover with small piece of petroleum dressing and cover with [MEDICATION NAME]. It was noted that the resident was compliant with the treatment plan. - The skin check dated [DATE], indicated a wound identified [DATE]. The 100% granulated, stage two-pressure ulcer on the left buttock measured 1.1 cm x 0.2 cm x 0. The summary read, Resident is toileted every ,[DATE] hours and as needed. Resident is repositioned every 2 hours. Wound caused by shearing when staff used hoyer soon after admission. Cleanse. Apply skin prep to periphery of wound. Small amount of Silverstat to wound bed. Cover with small piece of petroleum dressing and over with [MEDICATION NAME]. It was noted that the resident was compliant with the treatment plan. - The skin check dated [DATE], indicated a wound identified [DATE]. The 100% granulated, stage one pressure ulcer was located on the left buttock and measured 1.1 cm x 1 cm x 0. The summary read, toilet before and after meals every ,[DATE] hours and PRN per residents request, Tx per MD orders to left buttock. It was noted that the resident was compliant with the treatment plan. - The skin check dated [DATE], identified the wound found [DATE] as healed. The summary read, Wound has healed. Resident is toileted every ,[DATE] hours and as needed and she is repositioned every 2 hours. The document lacked if the resident was compliant with the treatment plan. - The skin check dated [DATE], identified a new wound on [DATE]. The 100% granulated stage 2 pressure ulcer measured 1 cm x 1 cm x 0 cm. The summary read, Family and provider have been updated on skin status and plan of care. Resident continues to be a Risk for skin break down r/t dementia, tendency to cuss, hitting and scratching when nursing is trying to peri cares and ADLs and toileting. (skin breakdown, increase buttock pain). Staff will offer and try to take resident to bathroom around 3 p.m. It was noted that the resident was complaint with the treatment plan. - The skin check dated [DATE], identified the wound found [DATE]. The 100% granulated stage two pressure ulcer on her left buttock that measured 1 cm x 1 cm x 0. The summary read, Resident is toileted every ,[DATE] hours and as needed. Resident is repositioned every 2 hours. Resident has 1 cm by 1 cm stage 2 pressure ulcer on her left buttock. Wound bed is beefy read and 100% granulation tissue. There is no odor or drainage present. There is no tunneling or undermining present. Resident denies pain associated with the wound. It was noted the resident was compliant with the treatment plan. - The skin check dated [DATE], identified an ongoing wound found [DATE]. The 100% granulated upstaged pressure ulcer on R19's left buttock measured 1 cm x 1 cm. The document lacked if the resident was compliant with the treatment plan. The summary was not entered and there was evidence the facility comprehensively reassessed effectiveness of the current treatment plan. - The skin check dated [DATE], indicated a wound found [DATE]. The 10% granulated and 90% sluphed wound was now identified as two stage two pressure ulcers on the left buttock. One wound measured 0.5 cm x 0.2 cm x 0.1 cm. The other wound measured 1.0 cm x 0.6 cm x 0.1 cm. The summary read, (R19) has had the stage 2 pressure wound since [DATE]. Despite it being nearly healed a few weeks ago, it has declined due to (R19's) combativeness with cares. Being incontinent of B&B (bowel and bladder) is an added risk. She was started on [MEDICATION NAME] 12.5 mg BID (two times a day) which was too much for her and made her lethargic so was reduced to 6.25 mg daily at 3 PM. The goal is for (R19) to be more accepting of care and ultimately heal her wounds. (R19) will be up for meals only and will be turned side to side in bed until wounds heals. There will be no change to wound care order. Dietary has been updated. (R19) does eat 100% of most meals but a supplement may be beneficial. Pressure mapping to be completed. The document indicated R19 is not compliant with treatment plan. The MHM Weekly Pressure Wound Evaluation completed [DATE], identified the ongoing wound from [DATE]. The unstageable pressure ulcer on R19's left buttock was 100% slough and measured 2.1 cm x 1.3 cm x 0.2 cm. Progress notes reviewed from [DATE] to [DATE], indicated nursing staff identified R19 exhibited increased noncompliance during activities of daily living (ADLs) and repositioning. However, the progress notes lacked pharmacological or non-pharmacological interventions during those behaviors. R19's individualized care plan dated [DATE], indicated that she was at risk for alteration in mood/behavior and instructed staff should have had a kind, calm voice and make eye contact then the resident was approached. It also informed would be alert to mood and behavioral changes, that the resident enjoyed talking about her family when she was upset, and wake her slowly in the morning as they provided her with her glasses, played music softly and allowed time for her to adjust before she was instructed to get ready for the day. The care plan lacked interventions for when R19 refused cares and would become combative/verbally abusive with staff. A progress notes dated [DATE], and [DATE], written by the nurse practitioner (NP) and medical doctor (MD)-B recognized 7. Pressure ulcer of left buttock, stage 1. Treatment included good skin care and monitoring. A progress note dated [DATE] and [DATE], written by the NP and MD-B recognized, 7. Pressure ulcer of left buttock, stage 1. Treatment noted, Good skin care and monitoring Wound care and dressing changes daily No further instruction was noted. No follow-up wound evaluations from the NP or MD-B were provided. During an interview on [DATE], at 9:07 a.m. NA-H attempted to get R19 changed and dressed for the day. R10 refused cares and to be repositioned. NA-H stated she would reproach the resident in a few minutes. At 9:19 a.m. NA-H re-entered the room with the resident's breakfast tray. The resident allowed to sit up in bed and began drinking coffee and eating her breakfast. NA-H remained by her side until she finished eating. At 9:31 a.m. NA-H entered the room with another NA to get the resident ready for the day. R19 was initially resistive with cares, but after NA-H spoke with R19, R19 was compliant. LPN-B was requested to R19's room to assess the noted wound on her left buttock. During an interview on [DATE], at 10:09 a.m. LPN-B removed the [MEDICATION NAME] dressing and identified one pressure ulcer on the left buttock. She stated it had pink margins, a yellowish wound bed, and had darker brown spots with in. LPN-B stated it was worse than the last time she saw it a couple weeks ago. LPN-B measured the one wound as 2 cm x 1 cm. LPN-B explained tries to have R19 lay down between meals as much as possible. On [DATE], at 12:29 p.m. RN-A attempted to re-evaluate the dimensions of R19's pressure ulcer. R19 swung at staff as she yelled, Get away . get away. Attempt was aborted. On [DATE], at 3:18 p.m. RN-A confirmed the pressure ulcer had one wound bed. It had pink edges, darker around the wound, bruising around the wound, yellowish with darker spots with in the wound bed. DON entered the room and instructed RN-A how to measure the wound. Measurements were: 2.1 cm x 1.3 cm x 0 cm. R19 was upset with the staff checking her wound. The undated facility policy Pressure Ulcer Documentation Guide stated, Always measure length, width, and depth and document in that order. Always recorded in centimeters and Describe area up to 4 cm from edge of the wound. Measure in centimeters. Describe its characteristics (light pink, deep red, purple, macerated, ect.). The undated facility policy Skin Assessment and Wound Management described what needed to documented and who needed notified of a non-pressure wound, altered skin integrity, and pressure wounds; however, it does not specifically state where to document the interactions with the provider, resident/representative, and intra-disciplinary team. R10 On [DATE], at 12:33 p.m. R10 was observed to be lying in bed with the air mattress pump not running and the air mattress appeared to be sunken in. At 2:07 p.m. LPN-B entered R10's room and confirmed the air bed pump had been accidentally unplugged and the air bed had deflated. LPN-B was unaware when the air bed had come unplugged. LPN-B pressed onto the air bed and stated there was a firm mattress layer and she was unable to feel the bed frame. LPN-B checked R10's skin and confirmed R10 had an area on his right buttock that was non-blanchable. LPN-B stated R10 did not have any open areas or areas of impairment on his buttock earlier that day. LPN-B indicated she would position R10 onto his side and recheck the area. On [DATE], at 6:58 a.m. LPN-B verified the non-blanchable area (stage 1 PU) had not resolved on [DATE], and a padded dressing was placed over the area. At 7:03 a.m. LPN-B was observed to complete R10's buttock wound care, LPN-B stated the non-blanchable area was now blanchable and considered resolved. LPN-B indicated she would place a dressing over the area for protection and updated the DON. R10's quarterly MDS dated [DATE], identified impaired cognition and at risk for PUs. R10's care plan dated [DATE], identified R10 to be at risk for pressure areas and directed staff to turn and reposition every two to two and half hours when in bed in addition to an alternating air mattress. R10's PN dated [DATE], identified R10 had a circular non-blanchable dark pink area on his right buttock measuring 1.2 centimeters in diameter, dressing applied. R10's medical record lacked evidence of a comprehensive skin risk assessment following the identified [DATE], non-blanchable area. R10's weekly skin inspection dated [DATE], indicated R10 did not have any areas of skin impairment related to PUs. During an interview on [DATE], at 4:08 p.m. DON stated it was her expectation to check air mattress working order every shift. A facility policy related to air beds was requested but not provided.

Based on observation, interview and document review, the facility failed to provide interventions for 1 of 3 residents (R5) and ensure use of wanderguard bracelet functioning for 1 of 3 residents (R34) identified at risk for elopement. Additionally, the facility failed to ensure a system was in place for adequate monitoring and supervision for residents who utilized an exit with an alarm disengaged. This had the potential to affect 12 of 54 residents (R34, R4, R7, R41, R16, R9, R1, R40, R17, R2, R102, R49) who routinely exited the door to the smoking patio. In addition, the facility failed to ensure a comprehensive and ongoing assessment, monitoring and evaluation for safe smoking were completed for 5 of 5 residents (R4, R23, R34, R151, R102) reviewed for smoking. Additionally, the facility failed to ensure root cause analysis, identified interventions and effectiveness were implemented for 2 of 2 residents (R23, R34) reviewed for falls. In addition, the facility failed to ensure supervision was provided for 1 of 1 resident (R23) who utilized an electric wheelchair (w/c) while under the influence of alcohol. Additionally, the facility failed to ensure a comprehensive assessment and evaluation was completed for 1 of 1 resident (R43) who operated a motor vehicle. Findings include: R5's incident report dated 12/19/18, revealed R5 had left the facility via front door. The report indicated a staff member observed R5 on his way to the bus stop and boarded a bus that had stopped for him. The report indicated the police were called to assist R5 off of the bus. The report identified the incident as being the second encounter of R5 attempting to leave the facility and concluded discussion during morning meeting would address how to proceed and keep R5 safe. R5's elopement risk evaluation dated 1/2/19, identified R5 at high risk of elopement due to previous attempts. The evaluation indicated social service would work with resident's power of attorney to get him referred to a secured unit due to safety concerns. The evaluation included R5 had refused to allow wander guard placement so the facility placed him on 30 minute checks for exit seeking behaviors. R5's progress notes (PN) were reviewed: -The PN dated 12/16/18, indicated R5 attempted to exit the facility due to agitation; 911 was called and R5 was transported to hospital; -The PN dated 12/19/18, identified R5 was found outside of the facility and boarded a bus; police were called and escorted R5 off of the bus back into the building then to the hospital; -The PN dated 12/21/18, identified attempted to place a wander guard on R5, however R5 refused. R5 placed on 15 minute checks for safety; -The PN dated 1/5/19, identified R5 had stated he was going to go outside and leave the facility; R5 was reminded the police would be called if he left. R5 returned to his room; -The PN dated 1/17/19, identified R5 was taken off of 30 minute checks for elopement due to no attempts within the past week. R5's admission Minimum Data Set ((MDS) dated [DATE], indicated cognitive impairment. R5's care plan dated 12/13/18, lacked evidence of identified elopement risk and interventions to prevent future occurrences. R5's care area assessment dated [DATE], lacked evidence of R5's risk for elopement. During an interview on 2/6/19, at 12:09 p.m. registered nurse (RN)-B indicated he was unaware how to identify when a resident was at risk for elopement who did not reside on assigned unit. RN-B stated when a resident was identified as being high risk 15 minute checks were started then a wander guard would be placed. During an interview on 2/6/19, at 12:30 p.m. licensed practical nurse (LPN)-A stated she would not be aware when a resident was at risk for elopement unless it was indicated on the medication administration record. LPN-A was unable to identify if R5 was an elopement risk. During an interview on 2/6/19, at 5:15 p.m. RN-A stated R5 was at risk for elopement, however he refused to wear a wander guard bracelet. RN-B indicated R5 had not displayed any exit seeking behaviors in the past three weeks, however he was not happy at the facility so they were looking for alternative placement. RN-B further identified the scheduler who sat at the front desk was able to see the front door so she would notify the nurse if R5 would attempt to leave the building. During an interview on 2/6/19, at 5:22 p.m. the director of nursing (DON) stated R5 was no longer considered an elopement risk due to he's now happy at the facility. During an interview on 2/7/19, at 10:05 a.m. the receptionist confirmed she was also the scheduler and sat at the front desk near the front door. The scheduler was unable to identify R5 as being at risk for elopement. Furthermore, the scheduler stated when a resident was at risk for elopement they would wear a wander guard so once the resident would approach the front door it would alarm and the door would lock. The facility policy Elopement Guideline dated 11/2017, indicated Each facility has a system of identification of resident. The method is designed to assist law enforcement and others in identifying a resident who has left the facility without staff knowledge .The facility will implement interventions to minimize these risks .Care plan that addresses potential to wander or exit facility and the measures taken to prevent wandering/ elopement. R34's annual Minimum Data Set ((MDS) dated [DATE], identified R34 had cognitive impairment. R34's care plan printed on 2/8/19, identified R34 was at risk for elopement and directed staff to If I want to go outside to smoke a cigarette, please redirect me to the enclosed courtyard, wander guard on left ankle check placement every shift, check wander guard function every 88 days, wander guard on his person to alert staff when attempting to leave the building unsupervised, door alarms answered promptly, invite to activities and gatherings and keep family informed. During an interview on 2/6/19, at 11:20 a.m. registered nurse (RN)-B stated the maintenance department had changed the beeping to the door which lead to the smoking patio a day or two ago. RN-B explained prior to the change the door would beep and a message would alert on the call light/ door alarm marque so would be able to know if someone was going outside. RN-B identified since it had been disengaged during the day they were no longer aware who entered or exited the doorway. RN-B explained the disengaged exit door was mainly used by residents who smoked. At this time the smoking patio was observed to be in a gated courtyard with two gate openings neither locked and both openings were propped open which lead to the facility driveway. During an interview on 2/6/19, at 11:27 a.m. the director of maintenance (main)-A explained there was a day night mode for the door alarms located on the door which lead to the smoking patio, after 6:30 p.m. the night mode would alarm which included displaying on the marque and alerted with a beeping sound. The main-A stated daily at 6:30 a.m. the alarm would disengage and would no longer beep and/ or display on the marque. The main-A indicated that there was also a wander alert system on the door leading to the patio, however it too was disarmed from 6:30 a.m. to 6:30 p.m. On 2/6/19, at 11:41 a.m. registered nurse (RN)-A was observed to wheel R34 in his wheelchair near the therapy exit door; RN-A confirmed that R34 did not trigger the alarm for the wander guard system and that as he approached the doorway there should have been a beeping noise in addition to the door remaining locked. RN-A stated R34's wander guard bracelet was not working properly and needed to be replaced. RN-A was unable to verify the last time the wander guard bracelet had been checked for function and unsure the last time it had been replaced. At 11:46 a.m. R34 had a new wander guard bracelet placed. During an interview on 2/6/19, at 12:09 p.m. RN-B indicated he was unaware how to identify when a resident was at risk for elopement who did not reside on his assigned unit. During an interview on 2/6/19, at 12:30 p.m. licensed practical nurse (LPN)- A stated she would not be aware when a resident was at risk for elopement unless it was indicated on the medication administration record. LPN-A stated they would use a wand to check to ensure a resident's wander guard was functioning properly, however she was unable to locate the wand. R34's elopement risk evaluation and progress notes (PN) were reviewed: -The evaluation dated 1/15/18, identified R34 had confusion upon admission, family concerned resident might try to leave facility and concerned for safety, wander guard placed per family request; -The evaluation dated 2/5/18, identified R34 had wander guard removed due to not showing signs of exit seeking behaviors; -The evaluation dated 4/20/18, identified R34 had been looking out of the front door and expressed that he wanted to go home, wander guard placed; -The PN dated 9/7/18, identified R34 had passed through security door way without setting off wander alarm which was attributed to R34 going to hospital on [DATE], and returning to facility on 9/4/18; -The PN dated 9/21/18, identified R34 had walked out of the front door after staff had advised against it while outside R34 had fallen and was sent to the hospital. During an interview on 2/6/19, at 5:22 p.m. the director of nursing (DON) stated it was her expectation to check wander guard bracelet function daily and check to ensure placement every shift. The DON indicated if the wander guard bracelet was not working it should be replaced. Furthermore, the DON stated all exit doors should be have the wander guard system alarmed. The facility policy Elopement Guideline dated 11/2017, indicated Staff will: Establish a process to check bracelet alarm/ device batteries according to manufactures directions. A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents. Only the administrator (or designee) may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm. The facility will identify such environmental hazards such as entrances .or exits that pose a foreseeable danger to residents who wander or have an exit seeking behavior. The facility will implement interventions to minimize these risks and hazards as appropriate. R4's Brief Interview for Mental Status dated 1/29/19, identified R4 as cognitively intact. R4's care plan printed 2/12/19, identified R4 was at risk for smoking related injury and directed staff to keep smoking materials with staff, as concerns arise complete room check, monitor skin and clothing for signs of smoking damage every shift, observe for unsafe smoking behaviors. The care plan further identified R4 had been non-complaint with the smoking policy and directed staff to use of nicotine patch for smoking cessation, supervise with a one to one staff member and notify medical provider of non-compliance. R4's care plan lacked evidence of 15 minute checks related to safety and smoking as indicated on 1/3/19 in R4's progress notes. During an interview on 2/4/19, at 1:07 p.m. R4 stated he did not have a lighter or cigarettes on his person. R4 was observed to have tobacco along the windowsill and three circled burn holes on his window curtains. During an observation on 2/6/19, at 7:26 a.m. R4 was observed to be sleeping in his bed, observation ended at 8:28 a.m. During the observation no facility staff were noted to check on R4 per progress note dated 1/3/19. During an interview on 2/6/19, at 1:00 p.m. the administrator stated he did not think R4 was a safety risk related to smoking as he had been placed on 15 minute safety checks. The administrator explained the staff were expected to lay eyes on R4 and document it on a flow sheet at the nurse station. At 1:18 p.m. the administrator verified as he reviewed the 15 minute check flow sheet from 1/28/19 to 2/6/19, that the 15 minute check flow sheet had not been completed on all days and/ or shifts. The administrator further identified if he did not think R4 was safe he would institute a one to one for supervision. R4's smoking evaluations were reviewed: -The evaluation dated 1/11/19, identified R4 had continued non-compliance with the facility smoking policy in regards to room smelling of cigarette smoke, ashes on the windowsill and floor. The evaluation indicated R4 had been re-educated and to circle current burn areas in room. However, the evaluation lacked evidence of where and how R4's smoking materials would be stored and secured. -The evaluation dated 1/25/19, identified R4 had continued non-compliance with the facility smoking policy and identified re-education and circling of burn holes had been completed. However, the evaluation lacked evidence of where and how R4's smoking materials would be stored and secured. In addition, the evaluation lacked ongoing assessment of previous interventions from R4's 1/11/19, smoking evaluation. During an observation on 2/6/19, at 5:37 p.m. R4 was observed to be outside near the gate to the courtyard smoking a cigarette. R4 did not appear to have [MEDICAL CONDITION] his clothing or fingers however, at 5:43 p.m. upon returning into the facility R4 was observed with ashes on his wheelchair cushion that he had been pushing from behind, R4 stated he had borrowed a cigarette from another resident. At this time R4 was observed to have a one to one staff member supervising him. During an interview on 2/13/19, at 9:49 a.m. DON indicated R4 had been placed on one to one supervision due to unsafe smoking. The facility Smoking Policy Addendum updated 1/14/19, indicated Staff members will no longer supervise smokers .Residents may now retain possession of their cigarettes and lighters if they are complaint with all facility smoking policies and all required safety interventions. R23's quarterly Minimum (MDS) data set [DATE], identified intact cognition. R23's care plan printed 2/12/19, identified R23 was a current smoker and directed staff to educate on potential dangers of oxygen and cigarette smoking, monitor skin and clothing for signs of smoke damage every shift and indicated R23 was an independent smoker. R23's smoking evaluation dated 2/6/19, identified R23 was safe to smoke independently. R23's smoking evaluation lacked evidence of how and where smoking materials would be safely stored and R23 extinguishing expectations for partially smoked cigarettes. During an interview on 2/5/19, at 10:05 a.m. R23 identified he rolled his own cigarettes in his room. R23 was observed with loose tobacco in a bag, lighter and 10 cigarettes on the top of his nightstand unsecured. R23 stated he was able to smoke independently. During an observation on 2/11/19, at 9:56 a.m. the director of nursing (DON) confirmed R23 had an extinguished half of a partially smoked cigarette on the top of his nightstand. During an interview on 2/13/19, at 8:33 a.m. the DON stated it was her expectation for partially smoked cigarettes to be disposed of in a flame retardant container. The facility Smoking Policy Addendum updated 1/14/19, indicated Staff members will no longer supervise smokers .Residents may now retain possession of their cigarettes and lighters if they are complaint with all facility smoking policies and all required safety interventions. R34's annual Minimum Data Set ((MDS) dated [DATE], identified R34 had cognitive impairment. The MDS identified R34 was a current tobacco user. R34's care plan revised on 2/6/19, (after survey began) identified R34 was at risk for smoking related injury currently smoked with supervision at this facility, smoking materials kept in the transitional care unit medication cart and directed staff smoking must be done in designated smoking area, educated regarding potential danger of butane lighters, monitor skin and clothing for signs of smoking damage, observe unsafe smoking behaviors, nurse to remove half-smoked cigarettes from room, smoking allowed at agreed times and review smoking policy. R34's smoking evaluations were review: -The smoking evaluation dated 11/21/18, identified R34 was safe to independently smoke; -The smoking evaluation dated 12/19/18, identified R34 was safe to independently smoke outside, however indicated R34 had smoked inside this week and directed staff to provide cigarettes at the door and ensure cigarette was left in the ash tray outside before returning into the building; -The smoking evaluation dated 2/6/19, after survey began, identified R34 was safe to smoke with assistance and had agreed smoking times and directed staff to provide one to one while R34 was smoking. The smoking evaluation indicated R34 had behavior of bringing in used cigarettes and indicated they must be disposed of before entering the building. R34's smoking evaluations lacked evidence of how and/or where the smoking materials would be safely stored. During an observation on 2/5/19, at 10:25 a.m. R34 was observed to have a half smoked extinguished cigarette on his bedside table and another full cigarette laying on the floor between his bedside table and bed. During an interview on 2/6/19, at 1:00 p.m. the director of maintenance confirmed R34 had a half extinguished cigarette on his bedside table and indicated it was his expectation once a cigarette had been lit to discard into a flame retardant reciprocal and not brought back into the building. During an observation on 2/6/19, at 5:32 p.m. R34 was observed seated in wheelchair, wheeled himself outside to the smoking patio, removed a cigarette from behind his ear and a lighter from his pocket and lit his cigarette. [MEDICAL CONDITION] his person or clothing were observed. R34 disposed of the lit cigarette into the ash tray on the patio. R34 stated he stored his own cigarettes and lighter in his room and that he did not require any assistance when smoking. During an interview on 2/6/19, at 5:39 p.m. registered nurse (RN)-B stated he was unsure if R34 could store his own smoking materials and independently smoke. During an interview on 2/6/19, at 5:40 p.m. RN-A identified R34 as an independent smoker. During an interview on 2/11/19, at 4:03 p.m. the director of nursing stated it was her expectation for all half smoked cigarettes to be disposed of in the ash tray on the patio before returning into the building and as of 2/6/19, R34 should be supervised when smoking. The facility Smoking Policy Addendum updated 1/14/19, indicated Staff members will no longer supervise smokers and there will no longer be designated smoking periods. Any resident who is deemed incapable of smoking safely with reasonable safety interventions will not be allowed to smoke on the facility grounds. Residents may now retain possession of their cigarettes and lighters if they are complaint with all facility smoking policies and all required safety interventions. R23's admission record printed 2/12/19, identified R23 [DIAGNOSES REDACTED]. R23's quarterly Minimum (MDS) data set [DATE], identified intact cognition. R23's care plan printed 2/12/19, identified R23 has had previous falls without injury . and directed staff to check room daily for alcohol, if intoxicated electric wheelchair (w/c) will replaced with manual w/c, keep personal items within reach, gripper socks at night and keep w/c at bedside with brakes locked. During an interview on 2/5/19, at 10:00 a.m. R23 stated he had fallen out of bed three times and the staff now place his w/c next to his bed to catch him. R23's fall incident reports, evaluations and progress notes (PN) were reviewed from 11/2018, to current: -The fall report dated 11/1/18, identified R23 was found seated on the floor with an empty bottle of alcohol near him. R23 stated he slid out of his electric w/c when he tried to apply the brakes; -The PN dated 11/1/18, identified R23 had slipped to the floor when intoxicated, a room search was completed and R23 was advised to be in bed for his, other resident and staff's safety; -The fall report dated 11/2/18, identified R23 was found on the floor after turning the corner quickly when he was under the influence of alcohol; -The PN dated 11/2/18, identified R23 had quickly applied his electric w/c brakes to avoid a collision as he was turning the corner while intoxicated from alcohol and indicated narcotics would be held per doctor's order; -The fall risk evaluation dated 11/28/18, identified R23's medication use and [DIAGNOSES REDACTED]. -The fall report dated 12/20/18, identified R23 had lowered himself to the floor between his bed and electric w/c due to a recent surgery to his toe which affected his ability to transfer; -The PN dated 2/5/19, at 11:10 p.m. identified R23 smelled of alcohol and was to have his w/c moved to the therapy room. R23's medical record lacked evidence of evaluation of interventions and effectiveness to prevent further falls, addressing R23's alcohol use and risks. During an observation on 2/6/19, at 6:18 a.m. R23 was observed in bed with his eyes closed and his electric w/c next to his bed. During an interview on 2/13/19, at 8:33 a.m. the director of nursing stated it was her expectation for falls to be thoroughly investigated and interventions to be evaluated. During an interview on 2/13/19, at 9:11 a.m. the administrator stated R23's electric w/c should be removed for 24 hours following suspicion of alcohol consumption. The facility policy Power Operated Vehicle and Scooter Policy revised 2/2012, indicated 3. Residents shall operate POV's (power operated vehicle) in a conservative and safe manner .Residents shall not operate their vehicles in any way that creates a disturbance or threat of harm to the driver or to others . R34's annual Minimum Data Set ((MDS) dated [DATE], identified R34 had cognitive impairment and required extensive assistance with activities of daily living which included transfers and toilet use. R34's care plan printed on 2/8/19, identified R34 was at risk for falls and directed staff to educate regarding locking wheelchair (w/c) brakes, red tape to easily identify w/c brake, lock w/c bedside bed when occupied, keep needed items within reach, do not leave alone in room at bedtime unless you have assisted with cares and into bed, gripper socks or shoes and toilet every two to three hours. During an observation on 2/8/19, at 1:25 p.m. R34 was alone in his room seated in his w/c without any observed interaction from staff. At 2:48 p.m. registered nurse (RN)-A entered R34's room and confirmed R34's care sheet indicated Do not leave in room alone. Assist to bed right away. RN-A explained the care sheet was how a resident's care plan was communicated to the nursing assistants. R34's fall incident reports, incident analysis and progress notes (PN) were reviewed: -The fall report dated 10/6/18, identified R34 was found seated on the floor in his room after attempting self transfer from bed to his wheelchair (w/c). The report indicated to lock w/c brakes and ensure w/c was in good position beside bed; -The PN dated 10/6/18, identified R34 had a witnessed fall without injury and did not call for help prior to the attempted transfer and directed staff to watch whereabouts of R34 and monitor him when alone in room; -The fall report dated 10/18/18, identified R34 was heard yelling for help and when staff entered the room R34 was seated on the floor between the bed and w/c without injury. The report indicated R34 stated he was trying to get into his w/c and fell to the floor. The report indicated R34 was educated regarding risks of not utilizing his call light for assistance. -The incident review and analysis dated 10/22/18, identified R34 frequently attempted to self-transfer and directed staff to ensure his bed height was correct for him to be able to stand with w/c locked at bedside when in bed; -The fall report dated 1/3/19, identified R34 had self transferred from w/c to bed and had slipped landing on the floor without injury. R34 was educated to lock w/c brakes prior to transfers; -The incident review and analysis dated 1/3/19, identified long w/c brake handles with red tape were placed on R34's w/c; -The fall report dated 1/7/19, identified R34 had self transferred and did not have his w/c brakes locked and R34 landed onto the floor next to his bed without injury. The report indicated R34 was to have anti-roll back device installed on w/c; -The incident review and analysis dated 1/8/19, identified R34 was to have staff check on him when they walk past to assure w/c is locked at bedside. R34's medical record lacked evidence of root cause analysis related to falls and assessment and monitoring of the effectiveness of current interventions. During an interview on 2/11/19, at 4:03 p.m. the director of nursing (DON) stated it was her expectation for fall interventions to be in place before the end of the day the fall occurred. The DON identified R34's intervention regarding not being left alone in room while seated in w/c should have been removed once the anti-roll device was placed. The facility Falls Prevention and Management Protocol policy revised 7/2018, indicated If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. a. After an observed .fall, the staff will clarify the details of the fall, such as when the fall occurred, where it occurred and what the individual was trying to do at the time the fall occurred. 3. b. Staff will evaluate chains of events or circumstances preceding a recent fall, including: 5) When was the last time the resident was repositioned or toileted; 6) Time of the last meal; 8) Whether there is a pattern of fall for this resident. 2. 6. Care plans will be updated to reflect fall interventions. R151 R151's closed record was reviewed. The admission record noted R51 was admitted to the facility on [DATE]. A Progress Note, dated 12/9/18, noted R151 was discharged from the facility 12/9/18. An Incident Report Summary submitted to SA on 12/9/18, at 1:30 p.m. identified R151 for possible self-abuse. The report noted R151 was seated in a wheelchair in a hallway of the facility. R151 had an unlit cigarette in her possession which she took from another resident without permission. When a licensed practical nurse (LPN) took the cigarette away, R151 lit her own hair on fire with a lighter she also had in her possession. R151 was not injured and extinguished the fire herself. An on-call medical doctor (MD) was contacted and gave an order to send R151 to emergency room (ER). R151's family was notified. A Licensed Practical nurse (LPN)-A and an activities assistant (A-B) witnessed the incident. A Smoking Evaluation dated 10/16/18, identified R151 as safe to smoke. Nursing to store cigarettes and give one at a time. The assessment did not address storage of lighters or other smoking material. Another Smoking assessment dated [DATE] Identified R151 as a safe smoker. The assessment noted R151 did nor smoke when she was admitted but started borrowing cigarettes from other residents and stated she wanted to smoke. The assessment did not address the storage of smoking material. The admission Minimum Data Set, dated dated [DATE], identified R151 as a smoker. The Care Plan effective date 10/11/18, identified R151 as a smoker with the following interventions: independent with smoking per evaluation, smoking evaluation per evaluation, education on potential dangers of Butane lighters and smoking evaluation annually and prn (as needed). Nursing to store cigarettes at the station and give R151 one at a time. when she requests. Monitor R151's skin and clothing for signs of smoking damage. R151 observed frequently asking other residents for cigarettes. On 11/9/18 R151 was witnessed taking cigarette and lighter from another resident's room. The Progress Notes noted the following: - On 11/5/18, at 7:21 p.m. RN-G noted R151 was going up and down the hallways and on the smoking patio to get or buy cigarettes from other residents. - On 11/6/18, at 2:53 p.m. RN-G noted R151 told the head of rehab that she had a lighter in her room last night and lit it. RN-G confiscated the lighter. RN-G also noted R151 was again asking other residents for cigarettes. -On 11/12/18, 9:44 p.m. RN-G informed R151 that her parents would no longer provide money for her to purchase cigarettes. - On 11/19/18, at 8:48 p.m. while wearing a nicotine patch, R151 was observed asking for cigarettes. RN-G reminded R151 she could not smoke while wearing a nicotine patch. Later that evening R151 stated she did not want to quit smoking and wanted the nicotine patch removed. - On 11/24/18, at 3:11 p.m. LPN-C noted R151 witnessed R151 going into various residents rooms looking for something. - On 12/9/18, at 9:25 a.m. LPN-A noted the lighter confiscated from R151 was not seen or known to be in R151's possession. - On 12/9/18, at 1:23 p.m. A-B witnessed R151 entered room [ROOM NUMBER] at 8:30 a.m. and removed a cigarette from the coat pocket of another resident. When R151 would not give the cigarette, LPN-A noted the lighter in R151's possession, which was not seen or known to be in R151's possession. A-B reported the incident to nursing. - On 12/9/18, at 3:45 p.m. at approximately 8:30 a.m A-B witnessed R151 go into another resident's room and take a cigarette. At 9:05 a.m. LPN-A noted R151 holding a new cigarette. After LPN-A removed the cigarette from R151's possession she turned away. R151 then took a lighter and lit her own hair on fire. The director of nursing (DON) was notified as well a medical professional who gave an order to send R151 to the ER. On 2/8/19, at 2:36 p.m. during interview A-B stated she observed R151 on the day of the incident, she could not state date or time, with a cigarette and reported it to nursing because she was aware R151 was not allowed to have smoking materials in her possession. A-B stated an unidentified staff member approached R151 and attempted to take the lighter away. A-B stated she returned awhile later and witnessed R151 with another cigarette in her possession. A-O stated after the staff took the cigarette and turned away, when R151 took a lighter and started her own hair on fire. A-B stated she did not believe R151 sustained any injury and staff stayed with R151 until she was safe. A-B stated this is what she remembered to the best of her ability. R102 During an initial interview on 2/5/18, at 8:48 a.m. R102 stated she routinely smoked cigarettes. R102 stated she had never been assessed for safe smoking and kept her cigarettes and lighter either in her coat pocket, in her purse or on her bedside table. R102 pointed to her opened purse to show an exposed pack of cigarettes and lighter. On 2/7/19, at 9:27 a.m. R102 stated she was told by a nursing assistant (NA-B) that she could no longer put her cigarette out and keep partial butt in her purse. R102 stated she did it all the time before, especially when it was so cold outside. R102 stated she still kept her cigarettes and lighter in her possession. A pack of cigarettes was observed on her bedside table and a lighter was noted in her coat pocket. R102 stated she did not remember anybody assessing her or asking her about safe smoking practices. The Admission Record noted R102 admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], noted R102 had no cognitive loss and her short and long term memory were intact. A Smoking Evaluation da

Based on observation, interview and document review, the facility failed to complete accurate and ongoing nutritional assessment for 1 of 1 resident (R24) reviewed for nutrition. R24 sustained harm when the facility failed to accurately assess nutritional status, address risk factors for impaired nutritional status, and implement approaches to maintain acceptable nutrition parameters after R24 had clinically severe weight loss of 13% over three months. Findings include: R24's Admission Record indicated R24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R24's Admission Minimum Data Set (MDS) assessment reference date 11/25/18, indicated cognitive impairment with need for supervision, oversight, encouragement or cueing for eating. The MDS identified R24 had an active [DIAGNOSES REDACTED]. R24's Medicare 30 day MDS identified R24 with an active [DIAGNOSES REDACTED]. On 2/4/19, at 6:32 p.m. R24 was observed seated in his wheelchair (w/c) at a table in the dining room, nursing assistant (NA)-A set R24's food which consisted of three separate bowls of unidentifiable pureed food, one cup of nectar thickened water and one cup of nectar thickened milk in front of him and walked away without providing any cues or assistance. At 6:35 p.m. NA-A returned and stood next to R24 as he was feeding himself independently and walked away without any interaction from NA-A. At 6:41 p.m. NA-A was observed seated behind R24; at that time licensed practical nurse (LPN)-A offered Ensure (oral caloric dense supplement) to R24 and remained seated next to R24 without providing further encouragement or cueing. R24 was observed to have eaten 50% of his meal, 100% of his two cups of fluids and 100% of his Ensure, which was 240 milliliters. On 2/6/19, at 8:33 a.m. R24 was observed seated in his w/c at a table in the dining room with two bowls of unidentifiable pureed food and one cup of nectar thicken water, milk and juice, nurse was seated next to R24 then stood up and walked away. At 8:38 a.m. an unidentified NA sat next to R24 then stood up without cueing or encouragement and left R24. At 8:42 a.m. an unidentified nurse returned and asked R24 if he was done eating R24 stated yes, even though R24 had only eaten 25% of his food and drank 100% of his fluids. The nurse did not encourage or cueing R24 to eat more of his meal. R24's care plan dated 11/18/18, identified R24 had poor food intake, dysphagia and dx (diagnosis): Adult Failure to Thrive and directed staff to provide ordered diet, supplements as recommended by dietician and ordered by medical provider, monitor food and fluid intake, offer substitutes for dislikes or when not eating, monitor weights as ordered and dietician visits as needed. It further indicated Resident unable to complete meal without limited (non-weight support) of staff and directed staff to provide one to one supervision and physical assist with meals due to dementia and does not realize what his meal plate and fluids are for. The update on 12/3/18, identified R24 needed physical assistance for meals to ensure he was taking in adequate nutrition and to explain to him each item on his tray. R24's nutritional care area assessment (CAA) dated 11/30/18, identified R24 was on an altered textured diet and received Ensure twice daily. The CAA further indicated He generally consumes 75 to 100% of his meals. Please refer to dietary notes for further information. The CAA lacked evidence of addressing R24's poor food intake upon admission and risk for malnutrition. R24's Clinical Nutrition Evaluation signed dated 11/30/18, identified R24's weight as of 11/24/18, as 138.5 lbs and directed to monitor need for supplements, record intake daily, record weight at minimum monthly, labs when available and monitor for signs and symptoms of altered hydration. R24's weights and vitals summary dated 2/12/19, were reviewed since admission: -On 11/19/18, at 9:46 p.m. weight was 140 lbs (w/c); -On 11/24/18, at 11:22 a.m. weight was 138.5 lbs (chair); -On 12/3/18, at 6:14 p.m. weight was 136.9 lbs (chair); -On 12/22/18, at 10:39 a.m. weight was 136.5 lbs (sitting); -On 12/29/18, at 1:45 p.m. weight was 137.3 lbs (w/c); -On 1/5/19, at 9:13 a.m. weight was 120.2 lbs (standing); -On 1/5/19, at 10:08 a.m. weight was 120.2 lbs (standing); -On 1/5/19, at 11:48 a.m. weight was 120.2 lbs (standing); -On 1/12/19, at 11:57 a.m. weight was 120.5 lbs (sitting); -On 1/19/19, at 7:49 a.m. weight was 127.2 lbs (w/c); -On 1/23/19, at 7:21 p.m. weight was 116 lbs (standing); -On 1/26/19, at 4:04 p.m. weight was 120 lbs (chair); -On 2/2/19, at 12:11 p.m. weight was 120.5 lbs (w/c). R24's weights and vitals summary revealed a 13% weight loss from 11/24/18 to 2/2/19. R24's medical record lacked evidence of addressing inconsistent weights which method and how R24 should be weighed and R24's usual body weight. R24's meal intake log reviewed from 1/16/19 through 2/13/19, revealed the following: -On 1/16/19, only breakfast and lunch were recorded; -On 1/18/19, only lunch and dinner were recorded; -On 1/19/19, all 3 meals were recorded at 25-50% of meal eaten; -On 1/20/19, only 1 meal was recorded at 5:00 p.m.; -On 1/22/19, only lunch and dinner were recorded; -On 1/25/19, all 3 meals were recorded at 25-50% of meal eaten; -On 1/26/19, only breakfast and lunch were recorded at 25-50% of meal eaten; -On 1/27/19, only breakfast was recorded at 25-50% of meal eaten; -On 1/28/19, only breakfast and lunch were recorded; -On 1/29/19, only two meals were recorded unable to identify meals as both were inputted at 1:24 p.m.; -On 1/30/19, only two meals were recorded unable to identify meals as both were inputted at 1:05 p.m.; -On 2/1/19, only two meals were recorded unable to identify meals as both were inputted at 1:36 p.m.; -On 2/3/19, only breakfast and lunch were recorded; -On 2/4/19, 2/5/19, 2/6/19, 2/7/19 lacked evidence of any meal intake; -On 2/8/19, only dinner was recorded at 25-50% of meal eaten; -On 2/9/19, only breakfast was recorded at 0-25% of meal eaten and lunch at 25-50% of meal eaten; -On 2/11/19, only breakfast and lunch were recorded; -On 2/12/19, only two meals were recorded, however unable to identify meals as both were inputted at 1:10 p.m. R24's medical record lacked evidence of any meals refused by R24 during the above time period. R24's provider PN dated 12/4/18, identified R24 had an appetite poor most of the time and current weight was documented as 136 lbs. R24's medical record lacked evidence of the 13% weight loss being assessed and evaluated. The record lacked evidence of comprehensive nutritional assessment which would include past personal weight history, overall nutritional condition, establishment of R24's usual body weight and the development of how to consistently weigh R24. In addition, R24's medical record lacked evidence of identified factors which placed R24 at risk for inadequate nutrition/ hydration, there was no evidence the facility tried to identify R24's usual body weight he had prior admission, and didn't comprehensively re-assess R24, when a weight loss was identified on 1/5/19, that would have addressed the potential of significant weight loss. R24's medical record lacked evidence of any laboratory tests completed that addressed R24's nutritional status. During an interview on 2/6/19, at 9:36 a.m. NA-G stated the NA sheet indicated R24 was to have supervision and assist for all meals. NA-G further indicated R24 was weighed with every shower and by request from the nurse and then recorded into the electronic medication administration record (e-MAR) and if there was variability from the previous weight they would notify the nurse immediately. NA-G stated there was not a designated method in which R24 would be weighed. During an interview on 2/6/19, at 9:39 a.m. LPN-B stated the NA would obtain the resident weight and would either record it into the e-MAR or give the weight to the nurse to record. LPN-B identified the e-MAR would alert staff when there was a weight loss or gain outside of the normal range. LPN-B explained the NA would weigh the resident, however was unsure if use of the w/c or standing were the preferred method. LPN-B stated if there was a weight concern the nurse would update the medical provider, the facility registered dietitian (RD), nurse manager and director of nursing (DON). During an interview on 2/6/19, at 10:24 a.m. the facility registered dietician (RD) indicated when a resident triggered a significant weight fluctuation of 5% loss in one month or 10% in six months an assessment would be completed. RD stated the time frame for the assessment to be completed was one to two weeks. The RD stated when a resident had a significant change in weight a re-weight would be expected. The RD viewed R24's weight summary in the e-MAR and confirmed R24 triggered a significant weight loss and she would have expected the weight loss would have been addressed. During an interview on 2/6/19, at 10:47 a.m. the culinary director (CD) indicated she completed nutritional assessments and evaluations upon admission. The CD reviewed R24's nutritional evaluation in e-MAR and confirmed the assessment was completed based on R24's weight of 138.5 lbs. The CD explained the nurse manager, DON, RD and herself met weekly to review residents who were at risk for weight loss. The CD indicated during the weekly meetings interventions were reviewed and adjusted as needed. The CD identified that R24 had been reviewed during the meetings, however was unable to recall any specifics and indicated the DON kept notes of the meetings. During a telephone interview on 2/7/19, 10:20 a.m. the RD recalled a conversation during the weekly weight meetings when she was made aware of R24's weight fluctuations. The RD explained they had thought the weights for R24 were entered in error, however the RD identified the weights were not struck out due to method used to obtain weights was inconsistent. The RD recalled being aware of R24's weight change, however stated the nursing department was to follow-up due to the inconsistent weights. At this time the RD was unaware what follow-up had occurred. During an interview on 2/12/19, at 10:03 a.m. R24's nurse practitioner (NP) stated the last time that she had seen R24 was 12/4/18, and identified R24 to have had a poor appetite most of the time. The NP reviewed R24's weight summary and confirmed a 13% weight loss since admission. The NP indicated the weight loss was not due to diuretic use. The NP revealed that at times she had noticed on the medication administration record the nurse would record R24 had drank his Ensure, however when she would ask the NA or other staff they would indicate he had not drank it. The NP stated she was unaware of the weight loss and would have expected the RD to assess R24's weights, Ensure intake and then reach out to her with concerns. During an interview on 2/7/19, at 1:34 p.m. the DON stated they meet weekly to review residents with weight loss. The DON identified R24 was not a good eater. The DON indicated the resident should be weighed on the facility scale to establish a base weight. The DON stated she had not completed any nursing staff education regarding obtaining weight and/ or addressing identified weight loss. During a telephone interview on 2/13/19, at 2:36 p.m. the facility medical director stated it was his expectation for high risk weight loss resident's and/ or changes to be assessed and evaluated with the RD and CD in addition to a discussion with the nurse manager, DON and NP when significant weight loss was noted. Even though the DON did not believe R24 sustained a significant weight loss, R24's the medical record lacked evidence regarding establishment of baseline weight, comprehensive assessment and evaluation of R24's risk for malnutrition, identification of significant weight loss as identified in R24's weight record. Also there was no indicia that staff were assisting, directing or cuing R24 to eat during the meals, also there were no consistent recoding of how much R24 actually consumed. Furthermore, the facility failed to address inconsistencies in R24's weight record and lacked evidence regarding the method the staff should have been using to weigh R24, which resulted in actual harm for R24. The facility policy regarding weight monitoring was requested but not provided.

Based on interview and document review, the facility failed to timely notify the family and physician of the re-development of pressure ulcers for 1 of 3 (R1) resident's reviewed. This resulted in actual harm for R1, when wound care was delayed and the pressure ulcers worsened. Findings include: R1's medical record was reviewed, R1 was admitted to the facility on [DATE] with a sacral pressure ulcer. A 5/5/16 progress note indicated the pressure ulcer healed on 2/13/16 and re-opened on 4/16/16. A 5/11/16 progress note indicated R1's pressure ulcer healed again. R1's Weekly skin review dated 7/9/16, identified R1 had two new open areas to his buttocks. The first open area to R1's crack measured 6 centimeters (cm) long by 0.2 cm wide and was red/dark pink in color. A second open area to R1's left buttocks measured 0.3 cm wide by 0.3 cm long with 50% yellow adherent slough and 50% red. Staff cleansed the areas with soap and water, applied a skin barrier, and a Tegafoam dressing. The medical record lacked provider notification of the pressure ulcer development, orders for treatment, or family notification. A progress note, 3 days later, on 7/12/16, indicated the open area to R1's crack measured 1.1 cm in length. The documentation lacked width and depth measurements. The open area to R1's left buttocks increased in size to 0.4 cm long by 0.4 cm wide. Both areas were beefy red in color with scant bloody drainage. Areas were cleansed with a wound cleanser and a skin barrier and a foam dressing were applied. Although the progress note identified 2 open areas, a Weekly Nursing Summary form dated the same date, indicated R1's skin was intact. The medical record lacked physician notification of the worsening pressure ulcers, orders for treatment, or family notification.A 8/2/16 progress note indicated R1 had red dots to his coccyx. Scant amount of bloody drainage when cleansing with soap and a cloth. Non-compliant at times with cleansing needing staff re-approach. R1's medical record lacked provider notification or treatment orders of the pressure ulcers from the time the the pressure ulcers developed on 7/9/16, until 8/5/16, when a Weekly Skin Review identified a total of 4 open areas to R1's buttocks and staff notified Nurse Practitioner (NP)-O. R1's physician orders [REDACTED]. Change the dressing every 3 days and as needed.On 8/9/16, a Wound Evaluation Flow Sheet identified an unstageable pressure ulcer to R1's coccyx measuring 4 cm x 1 cm with a depth of 0.2 cm. The area was scabbed and dark purple in color with some white discharge noted. The wound bed was 80% [MEDICATION NAME] and 20% slough. An area on the left buttocks, superficial layer was gone. Wound bed bright red in color measuring 1 cm x 3 cm. Area on right buttocks, superficial layer was gone. Wound bed bright red and measured 1.5 cm x 1 cm. Cleansed with wound cleanser and applied foam dressing to all three areas. R1's medical record lacked notification of the provider for the worsening pressure ulcers, or family notification.A progress note dated 8/14/16 indicated R1's pressure ulcers worsened. Coccyx and buttocks wound-Noted redness of buttocks with scaling patches yellow in color with serous drainage. Open Black area above coccyx. Noted foul smell coming from the wound. Infected wound-Stage 3 with tunneling occurring. Dressing changed. Compliant with turning schedule tonight. This was the first time R1's medical record identified family notification of the pressure ulcers. When interviewed on 8/31/16 at 8:45 a.m. family member (FM)-Q stated she was not informed of R1's pressure ulcers until 8/14/16, when she was present for a dressing change. FM-Q stated she was shocked over the horrific smell and sight of the wound. When interviewed on 9/6/16 at 1:05 p.m., IDON-A stated staff should have contacted the provider on 7/9/16, when staff first observed the pressure ulcers and each time R1's pressure ulcer worsened. IDON-A stated staff are expected to follow the policy and obtain wound care orders from the provider. IDON-A confirmed staff did not contact the provider when R1 re-developed the pressure ulcers and did not obtain an order for [REDACTED]. Physician (R) stated he was unaware R1's pressure ulcers worsened. Physician (R) stated he would have expected staff to notify him for wound care orders and/or referral to a wound specialist. When interviewed on 9/20/16 at 9:00 a.m. NP-O stated R1 had history of pressure ulcers. NP-O stated she never examined R1's pressure ulcer, as R1 had always refused. NP-O could not remember if staff informed her the pressure ulcer healed in May 2016. NP-O stated whenever she asked staff about the pressure ulcer, she was always informed the pressure ulcer was healing. NP-O stated she was not informed of the pressure ulcers which developed on 7/9/16 until 8/15/16, when for the first time, she was informed by a staff nurse the pressure ulcers had worsened. NP-O stated she examined the pressure ulcers on 8/15/16 and was taken aback at how bad the pressure ulcer had progressed. NP-O stated the pressure ulcers covered 1/2 of both buttocks, had granulation, slough, and was odorous. NP-O stated she would have expected to be notified when the new pressure ulcers developed and anytime the pressure ulcers worsened. NP-O stated the lack of monitoring and delay in treatment contributed to R1's pressure ulcers worsening. The facility's policy, dated 11/11/15, titled Notification of Change in Resident Health Status indicated The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family member when there is: Development of stage 2 pressure sore when no ulcers were previously present at stage 2 or higher. Appropriate notification time is immediate. Immediate defined as soon as possible no longer than 24 hours. In addition, notification immediately to 48 hours when a need to alter or start a new treatment.

Based on interview and document review, the facility failed to comprehensively assess, monitor, and implement interventions to prevent and heal pressure ulcers for 1 of 3 (R1) residents reviewed. This resulted in actual harm for R1, when coccyx/sacral/buttocks pressure ulcers redeveloped multiple times at the facility and worsened. Findings include: R1's medical record was reviewed, R1 was admitted to the facility on [DATE] with a sacral pressure ulcer. A 1/21/15 quarterly minimum data set (MDS) identified R1 was at risk for pressure ulcers and identified R1 had a stage 2 pressure ulcer. The MDS indicated interventions of a pressure reducing mattress, a pressure reducing wheelchair cushion, and dressing changes to heal and prevent pressure ulcers. A 5/5/16 progress note indicated the pressure ulcer healed on 2/13/16 and re-opened on 4/16/16. R1's care planned interventions for pressure ulcers, updated on 5/9/16, changed R1's bed mobility from an assist as needed (PRN) to staff assist of 1. R1's May, June and July care plan did not direct staff on the frequency of repositioning. Interventions of a pressure relieving mattress and a pressure reducing wheelchair cushion remained unchanged. A 5/11/16 progress note indicated R1's pressure ulcer was healed. R1's Weekly skin review dated 7/9/16, identified R1 had two new open areas to his buttocks. The first open area to R1's crack measured 6 centimeters (cm) long by 0.2 cm wide and was red/dark pink in color. A second open area to R1's left buttocks measured 0.3 cm wide by 0.3 cm long with 50% yellow adherent slough and 50% red. Staff cleansed the areas with soap and water, applied a skin barrier, and a Tegafoam dressing. The medical record lacked provider notification of the pressure ulcer development, orders for treatment, staging of the pressure ulcers, or implementation of additional interventions to promote healing. A Weekly Nursing Summary form, dated 3 days later on 7/12/16 indicated R1's skin was intact; however, a progress note on the same date indicated the open area to R1's crack measured 1.1 cm in length. The documentation lacked width and depth measurements. The open area to R1's left buttocks increased in size to 0.4 cm long by 0.4 cm wide. Both areas were beefy red in color with scant bloody drainage. Areas were cleansed with a wound cleanser and a skin barrier and a foam dressing were applied. The medical record lacked physician notification of the pressure ulcers, orders for treatment, or implementation of additional interventions to promote healing.A 7/14/16 MDS assessment identified R1 had 2 pressure ulcers. The MDS indicated R1 now required assistance of 2+ staff for bed mobility.Although a progress note dated 7/19/16 indicated R1 had no open areas to his buttocks, a 7/28/16 progress note indicated R1 had 2-stage 2 pressure ulcers at this time, which are smaller than the previous week. A 8/2/16 progress note indicated R1 had red dots to his coccyx. Scant amount of bloody drainage when cleansing with soap and a cloth. Non-compliant at times with cleansing needing staff re-approach. R1's medical record lacked documentation of a comprehensive assessment, including measurements of the pressure ulcers since 7/12/16. R1's medical record lacked provider notification or treatment orders of the pressure ulcers from the time the the pressure ulcers developed on 7/9/16, until 8/5/16, when a Weekly Skin Review identified a total of 4 open areas to R1's buttocks and staff notified Nurse Practitioner (NP)-O. R1's physician orders [REDACTED]. Change the dressing every 3 days and as needed.R1's pressure ulcers lacked a comprehensive assessment, including measurements between 7/13/16 and 8/8/16. On 8/9/16, a Wound Evaluation Flow Sheet identified an unstageable pressure ulcer to R1's coccyx measuring 4 cm x 1 cm with a depth of 0.2 cm. The area was scabbed and dark purple in color with some white discharge noted. The wound bed was 80% [MEDICATION NAME] and 20% slough. An area on the left buttocks, superficial layer was gone. Wound bed bright red in color measuring 1 cm x 3 cm. Area on right buttocks, superficial layer was gone. Wound bed bright red and measured 1.5 cm x 1 cm. Cleansed with wound cleanser and applied foam dressing to all three areas. Reposition every 2 hours. Message left for MDS coordinator to make sure care plan and nursing assistant sheets are updated. R1's medical record lacked notification of the provider for the worsening pressure ulcers. Although R1's 7/14/16 MDS indicated R1's bed mobility changed from 1 to 2+ staff assistance, the intervention was not changed on R1's care plan until 8/10/16 (27 days later.) In addition, the frequency of turning and repositioning of R1 was not added to the care plan until 8/10/16, when the care plan was updated to assist of 1-2 staff to turn and reposition every 2 hours. On 8/10/16 an additional care plan intervention directed staff to explain the risk/benefits when refusing to turn/reposition every 2 hours. When interviewed on 9/6/16 at 1:05 p.m., the interim director of nursing (IDON)- A stated nursing assistants follow aide sheets when providing cares. IDON-A stated, although the aide sheets should be updated daily with changes, staff have only been updating the aide sheets quarterly. IDON-A stated R1's aide sheet lacked direction to turn and reposition R1 until 8/9/16.A progress note dated 8/14/16 indicated R1's pressure ulcers worsened. Coccyx and buttocks wound-Noted redness of buttocks with scaling patches yellow in color with serous drainage. Open Black area above coccyx. Noted foul smell coming from the wound. Infected wound-Stage 3 with tunneling occurring. Dressing changed. Compliant with turning schedule tonight.R1's physician orders [REDACTED]. Physician (P), a wound care specialist, examined R1 on 8/16/16. The Wound Care Specialist Evaluation form identified a bilateral buttocks/sacrum unstageable pressure ulcer. The wound measured 14 cm x 9.5 cm with 100% eschar (necrotic tissue.) A surgical debridement was completed with a post-debridement depth of 0.6 cm. Physician-P implemented the following new daily wound care orders. After cleansing, liberally apply Santyl then calcium Alginate and cover with super absorbent foam. Use Saline wet to moist dressings twice daily until Santyl available. Low air loss mattress and ROHO cushion for chair. Vitamin C and Zinc Sulfate were ordered. R1's physician orders [REDACTED]. On 8/19/16 NP-A evaluated R1 again, and ordered a CBC and BMP (lab tests.) R1 was [DIAGNOSES REDACTED]. A 8/19/16 progress note later that same day, indicated R1 became less responsive with a temperature of 101.6. Staff transferred the R1 to the hospital. Hospital documentation indicated R1 was admitted with a diagnosis, which [MEDICAL CONDITION], likely due to infected decubitus ulcer/[MEDICAL CONDITION], as well as catheter associated urinary tract infection (UTI.) R1's August 2016 TAR and progress notes revealed R1's wound treatment was completed as ordered between 8/5/16 and 8/19/16. When interviewed on 9/6/16 at 1:05 p.m., IDON-A stated staff should have contacted the provider on 7/9/16, when staff first observed the pressure ulcers. IDON-A stated staff are expected to follow the policy and obtain wound care orders from the provider and comprehensively monitor the pressure ulcers weekly. Staff should notify the provider when a change in a pressure ulcer occurs. IDON-A confirmed staff did not timely notify the provider and obtain an order for [REDACTED]. IDON-A confirmed between the dates of 7/9/16 to 8/4/16, R1 did not have wound care orders to refuse. IDON-A further stated staff should have looked at other interventions, such as an air mattress sooner. When interviewed on 9/20/16 at 9:00 a.m. NP-O stated, R1 had history of pressure ulcers. NP-O stated she never examined R1's pressure ulcer, as R1 had always refused. NP-O could not remember if staff informed her the pressure ulcer healed in May 2016. NP-O stated whenever she asked staff about the pressure ulcer, she was always informed the pressure ulcer was healing. NP-O stated she was not informed of the pressure ulcers which developed on 7/9/16 until 8/15/16, when for the first time, she was informed by a staff nurse the pressure ulcers had worsened. NP-O stated she examined the pressure ulcers on 8/15/16 and was taken aback at how bad the pressure ulcer had progressed. NP-O stated the pressure ulcers covered 1/2 of both buttocks, had granulation, slough, and was odorous. NP-O stated she would have expected to be notified when the new pressure ulcers developed and anytime the pressure ulcers worsened. NP-O stated the lack of monitoring and delay in treatment contributed to R1's pressure ulcers worsening. The facility's policy, undated titled Skin Integrity Guideline, indicated a licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review. A licensed nurse documents weekly on the identified wound using the Wound Evaluation Flow Sheet. The care plan is to be implemented, evaluated and revised based on the needs of the resident. If a patient/resident is refusing or choosing not to receive treatment, review risks, benefits and alternatives. Re-evaluate and attempt other interventions. The policy identified treatments protocol and interventions with directions to complete treatment per MD order.

Based on observation, interview, and document review, the facility failed to ensure comprehensive assessments were completed and individualized interventions were developed and implemented to minimize the risk for falls for 1 of 3 residents, (R2), reviewed for falls. This resulted in actual harm for R2 after falling and obtaining a Subdural hematoma (bleeding around the brain). Findings include: R2's admission Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment, required extensive assistance with all activities of daily living (ADL's), and had 3 falls in the prior 30 days. Review of R2's medical record included an undated Immediate Plan of Care for falls, also identified as an admission short term care plan, identified R2 was at risk for falls related to falling in the past 31-180 days. However, there were no specific individualized interventions identified to prevent and/or reduce the risk of falls. R2's current plan of care dated 6/23/16, indicated under the focus area of falls, At risk for falls related to: hx (history of falls with injury, restless, impulsiveness. Medicated with anti-psychotic daily. Non- ambulatory. The interventions included activity programming, assess for pain, bed in low position so feet touch the floor, call light or personal items available and in easy reach, footwear to prevent slipping, keep environment well lit and free of clutter, observe for side effects of medications, therapy referral, and toilet schedule. All interventions were dated as being initiated on 6/23/16. R2's Nursing assistant care sheet (used by nursing assistants which identified specific resident care needs) dated 6/29/16, indicated R2 did not walk, was a fall risk, and had a bed/ chair alarm in place. During observation on 6/30/16, at 8:15 a.m. R2 was sitting in a reclining wheelchair across from the nurses station. R2 was reclined approximately 20 degrees, and his feet were hanging down off the foot pedals. The wheelchair was labeled with another residents name. R2 was sleeping on and off, and there were no staff in the area. During observation on 6/30/16, at 12:20 p.m. R2 was laying in bed sleeping. The bed was in low position, a pressure alarm mat was on the bed, and R2 had a regular mattress on the bed. A Incident Report dated 6/10/16, at 8:00 a.m. indicated R2 had gotten up and fell backwards from the wheelchair, hitting the back of the head, resulting in a hematoma. The Incident report included a section titled, Action Taken, which identified, Request for a W/C (wheelchair) seat belt. R2's Progress Note dated 6/10/16, at 10:40 a.m. indicated the resident was up in the wheelchair about 7:45 a.m. and had gotten up and fell backward on to the hard wood floor hitting the back of the head on the floor. R2 received a 3 cm hematoma on the back of the head. A Progress Note dated 6/10/16, at 7:12 p.m. indicated R2 had been sent to the emergency room due to hitting his head and R2 was on Coumadin (a blood thinner). R2 returned to the facility on [DATE], at 9:00 p.m. and was started on antibiotics while at the hospital for possible urinary tract infection (UTI). A corresponding Post Fall Analysis/ Plan form identifying the date of the fall was 6/10/16, at 7:45 a.m. indicated R2 slid out of the wheelchair, had a history of [REDACTED]. The form was signed off on 6/14/16, by the IDT team which consisted of the licensed social worker, a minimum data set (MDS) nurse, and the director of nursing (DON). A Incident Report dated 6/10/16, at 10:15 p.m. indicated R2 was witnessed by staff sliding off the bed. A Fall Scene Investigation dated 6/10/16, at 10:15 p.m. indicated R2 had a bed alarm on which was sounding, and the bed was in the low position. The corresponding Post Fall Analysis/ Plan identified R2 had a fall on 6/10/16, at 10:15 p.m. and had rolled and/or slid out of bed. The interventions which had been identified as being in place at the time of the fall were 1/2 bedrails, bed in low position, call light within reach, bed/ chair alarm, and to keep items within reach. The IDT team recommendations were a concave mattress (a mattress with raised sides to define the perimeters of the edge of the bed) to R2's bed. The IDT team dated the review 6/20/16, 10 days after the fall. A Incident Report dated 6/11/16, at 10:00 a.m. indicated R2, Took W/C (wheelchair) lap buddy off and self transferred, and fell , striking (R2) forehead on the desk. R2 sustained, A 2 cm (centimeter) gash above the left eye. A Fall Scene Investigation dated 6/11/16, at 10:00 a.m. identified R2 fell from the wheelchair, had a regular cushion in the wheelchair, and had no alarm in place. The corresponding Post Fall Analysis/ Plan identified R2 had a fall on 6/11/16, at 10:00 a.m. The analysis indicated R2 was attempting to self transfer when in the wheelchair and had no adaptive equipment in place at the time of the fall. The IDT team recommendations were a pharmacy consult to review R2's medication. The IDT team dated the review 6/14/16. The facility was unable to provide any pharmacy consult had been completed for R2. R2's Progress Note dated 6/11/16, at 10:53 a.m. indicated the resident was up in the wheelchair and took off the lap buddy and fell and hit the left side of his/her head on the desk. A Progress Note dated 6/11/16, at 1:42 p.m. indicated since R2 fell earlier in the day family had been with R2, as R2, Continue(s) to try to get out of his wheelchair. A Progress Note dated 6/11/16, at 11:10 p.m. indicated, OK for lap buddy every shift for falls not available as of yet. Although the Incident Report from 6/11/16, at 10:00 a.m. indicated R2 fell after removing the lap buddy, there was no indication where the facility had obtained the lap buddy and if R2 had been assessed to safely use a lap buddy. A Progress Note dated 6/11/16, at 11:16 p.m. indicated R2 was in wheelchair and restless all evening, and resident, Will need to be watched carefully to prevent additional falls .Have kept (resident) at desk where he could be observed. (Resident) wanders with wheelchair. Took hallway phone apart. A Progress Note dated 6/13/16, at 10:56 a.m. indicated the resident was up in the wheelchair all evening, and staff did, 1:1 d/t (due to) frequent falls; resident did attempt to self transfer a couple times and staff had to catch resident before falling. A Progress Note dated 6/16/16, at 10:16 p.m. indicated R2 was in his room and staff heard a noise. When staff opened the door R2 fell to the floor on his right side, and the alarm in the wheelchair was sounding. R2 had no injury, and, Continues to be restless; needing 1:1 to keep resident safe. There was no corresponding assessment, IDT review, or interventions implemented from the fall on 6/16/16, nor was there any corresponding fall assessment to determine when the wheelchair alarm had been implemented. A Progress Note dated 6/18/16, at 8:30 p.m. indicated R2 had been agitated since after supper. R2 was laid down at 8:00 p.m., But crawled out of bed. Up in tilt chair (wheelchair that can recline) with table in front with water pitcher and a sandwich and other resident visiting with him. Patient was able to get up and stand 4 feet from the wheelchair. When writer came in hallway seeing patient standing. Unable to get to patient in time and he turned back to the chair and lost his balance and went head first striking the right side of his forehead. R2 was sent to the emergency room for evaluation of brain bleed. There was no further assessment of the fall, IDT review, or interventions implemented after the fall on 6/18/16. A Hospital discharge note dated 6/23/16, indicated R2 was admitted to the hospital on [DATE], and discharged back to the nursing home on 6/23/16, with a [DIAGNOSES REDACTED]. R2 was discharged on end of life cares with hospice. A Progress Note dated 6/30/16, at 3:09 a.m. indicated the resident was laying on his left side on the floor at 2:30 a.m. next to the bed. Resident was, Assisted into W/C (wheelchair). Assisted in front of nursing station to observe for safety. There was no further assessment, IDT review, or interventions implemented after the fall on 6/30/16. When interviewed on 6/30/16, at 1:00 p.m. LPN-G stated staff tried to keep R2 near them to prevent falls, however, R2 was fast and able to stand up before staff could assist. LPN-G stated when a resident falls, staff filled out an incident report with the details of the fall, puts immediate interventions in place if needed, and forwards the report to the DON, who will review the fall with the IDT team, and develop new interventions and update the residents plan of care. LPN-G stated staff had asked for a self releasing seat belt for R2, but was unsure why that had not been implemented. LPN-G stated staff had tried a lap buddy they had found in the facility, however, R2 was able to remove it so it was not continued. LPN-G stated staff try to keep R2 reclined back in the wheelchair, however, the resident was still able to get out of the wheelchair when it was tilted back. LPN-G reviewed R2's care plan, and stated a plan of care directing staff on interventions to prevent R2 from falling was not implemented until 6/23/16, after R2 had returned from the hospital after falling and sustaining a Subdural hematoma. LPN-G stated there was no documentation to determine what interventions had been put in place to prevent falls prior to 6/23/16. When interviewed on 6/30/16, at 2:05 p.m. family member (FM)-F stated family was concerned about R2's frequent falling resulting in injury. FM-F stated the facility had provided R2 with a tilt and space wheelchair shortly after being admitted to the facility, however, when the resident was reclined in the chair he still attempted to get out of the chair and stand. FM-F stated the facility had told family they were going to, Get something to hold (R2) in (the wheelchair), however, that had not been implemented and family heard nothing more regarding this. When interviewed on 6/30/16, at 2:40 p.m. LPN-H stated R2 had been provided the tilt and space wheelchair shortly after admission to the facility. LPN-H was not aware if the tilt and space wheelchair was assessed to ensure it was safe for R2, nor did she know where the wheelchair came from. When interviewed on 6/30/16, at 3:20 p.m. RN-I stated although R2 was at risk for falls, a falls plan of care was not completed to ensure staff were implementing interventions to prevent falls until the resident returned from the hospital on [DATE]. RN-I stated based on the documentation, it could not be determined how R2 was assessed to determine appropriate fall interventions, when and if interventions were put into place, and how the interventions were monitored. RN-I stated IDT discusses each resident fall and determines if an intervention can be added to prevent further falls, and if current interventions in place were appropriate and/ or effective in preventing further falls. RN-I stated the MDS nurse (who was part of the IDT meetings) were responsible to update the care plan and ensure the interventions were implemented. RN-I verified the concave mattress recommended after the fall on 6/10/16, had not been implemented or added to R2's care plan. RN-I was unable to determine when R2 was assessed for the tilt and space wheelchair, when alarms were added to the bed and wheelchair, and stated from R2's assessment/ care plan it was difficult to determine what fall interventions had been assessed to be in place. When interviewed on 6/30/16, at 3:15 p.m. nursing assistant (NA)-A stated R2 had a low bed and alarms on the wheelchair and bed. NA-A stated staff try to watch R2, however, the resident moves so fast, it is difficult to get to him before he falls. When interview on 7/1/16, at 9:10 a.m. licensed practical nurse (LPN)-B stated staff tried to keep R2, reclined back in the wheelchair to prevent the resident from getting out of the chair and falling. LPN-B was unsure when R2 received the tilt and space wheelchair, but thought it was shortly after being admitted to the facility. When interviewed on 7/1/16, at 9:30 a.m. NA-C stated R2 was usually in bed, however, if the resident was in the wheelchair staff tilt R2 back to prevent him from getting out of the wheelchair and falling. NA-C was unaware of specific instructions regarding how far R2 was to be reclined back in the wheelchair. NA-C stated R2 had not had a concave mattress on the bed since being admitted to the facility, and currently did not have any special mattress. When interviewed on 7/1/16, at 9:50 a.m. NA-D stated when R2 was not laying in bed, staff usually had to do a 1:1 with the resident because when he, Wants to get up he is gone. When interviewed on 7/1/16, at 10:00 a.m. occupational therapy assistant (OTA)-E stated R2 had been seen for wheelchair positioning after nursing had placed him in the tilt and space wheelchair, which she believed was on or around 6/13/16. OTA-E stated the focus was on keeping the resident comfortable in the chair, and no specific assessment had been completed by OT to determine how far the tilt and space wheelchair should be reclined, nor to determine R2's safety while in the tilt and space wheelchair. OTA-E stated R2 was not currently working with therapy because the resident was receiving hospice services. When interviewed on 7/1/16, at 9:05 a.m. RN-J, who was also an MDS nurse, stated the IDT team reviewed resident falls and determined if the current interventions in place were appropriate, and if any further interventions could be added to prevent further falls. RN-J stated when discussing interventions to be implemented, it is either up to the MDS nurse or the DON to implement any new interventions, as well as to update the care plan. RN-J verified R2 had no comprehensive assessment completed to ensure adequate interventions were in place to prevent falls. The facility policy titled, Falls Management Guideline, dated 10/21/15, directed, During preadmission intake, determine if the potential resident has a history of falling or is unsteady in gait. Assure that the appropriate fall interventions are in place prior to the residents admission. Following a residents fall; the licensed nurse assesses the resident for injuries .and provides necessary treatment and initiates the Change in Condition Report- Post Fall/ Trauma .Appropriate interventions are implemented .care plan is updated. The Interdisciplinary team (IDT) reviews the Change of Condition Report- Post Fall/ Trauma and makes additional recommendations within 72 hours of the fall.

Based on observation, interview and document review, the facility failed to provide preventive measures including assessment and monitoring, and failed to provide appropriate care and treatent for pressure ulcers (PUs) for 2 of 3 residents (R93, R46) reviewed for PUs. R93 and R46 suffered actual harm when PUs developed and worsened at the facility. Findings include: R93 was observed on 11/2/15, at 2:37 p.m. sitting up in bed with the head of the bed at an approximate 45 degree angle (known to add pressure to the buttocks area). Although the bed mattress included a alternating pressure-reducing powered air mattress, the air pump at the foot of the bed had no indicator lights on, and no sound was emitted from the pump. At 2:52 p.m. on 11/2/15, a licensed practical nurse (LPN)-C was asked by the surveyor to look at the pump. LPN-C stated the pump had been turned off and said, I wonder if it's gotten unplugged. She unsuccessfully tried several ways to restart the pump before getting assistance from LPN-H. LPN-H was able to turn the pump back on and acknowledged, It was turned off. LPN-H said they'd need to get staff to assist R93 out of bed so the mattress could fill with air. At 2:55 p.m. on 11/2/15, nursing assistant (NA)-C was and a second NA, were observed to help R93 get out of bed. During the observation it was noted R93 had been incontinent of feces. The resident was also observed to have a wound on the right sacral area of the buttock. Although the NAs were observed to cleanse the resident's rectal and buttock areas, there was still fecal matter noted in the resident's wound. NA-C told the second NA, You have to get (LPN-H) to change the dressing. It's soiled. The wound's dressing was observed to have slid off the wound and down into the incontinent garment. The dressing appeared soiled with what appeared to be drainage from the wound and feces. When the surveyor inquired when R93 had last been repositioned or changed, NA-C stated, We turn him every two hours, I've just changed shifts so I don't know know what time he was turned last. At 3:11 p.m. on 11/2/15, LPN-H was observed to redress the wound. At that time, LPN-H stated, the hospice nurse does his wound care. LPN-H also stated the hospice nurse had measured the resident's wounds and updated the dressing orders the previous day. LPN-H further indicated the goal for the wounds included, .just pain relief and odor control. During the wound care, it was observed the resident had the pressure ulcer on the right side of the sacrum/coccyx (tailbone) and another on the right ischial tuberosity (lower buttock near upper thigh). R93's admission progress note indicated the resident had been admitted to the facility on [DATE], with Hospice services due to [DIAGNOSES REDACTED]. The admission notes indicated R93 had existing pressure ulcers (PUs) on his feet. However, an admission Minimum Data Set assessment completed 8/27/15 (five days later) was coded to indicate R93 had no stage 1 or greater pressure ulcers. Subsequent progress notes indicated R93 developed two additional PUs while residing in the facility frequently referred to as buttocks wounds. On 9/11/15, a note by the wound nurse indicated the resident had a sacrum/coccyx wound. However, the note lacked documentation of measurement, physical description of the wound, or wound staging. An Allina Hospice and Palliative Care Facility Visit Record also dated 9/11/15, indicated R93 was seen by the hospice wound nurse from Allina. The note only referenced previously existing foot wounds. However, hospice orders dated 9/11/15, included orders for zinc oxide barrier cream to be applied to Buttock and sacral wounds. Additional wound documentation included: 1) 9/14/15 hospice nursing note (NN), Wounds in buttocks are larger (not deeper) due to sitting in wc (wheelchair) all day The hospice nurse recommended off loading to relieve pressure to the wounds. The documentation did not include assessment of the wound including measurement, staging, description of wound appearace, or identification of potential causal factors. 2) 9/18/15, hospice NN indicated a visit had been conducted for wound care. The documentation did not include assessment of the wound including measurement, staging, description of wound appearace, or identification of potential causal factors. 3) 9/21/15, hospice NN included notes about the resident's foot wounds, but did not include informaiton about the 'buttock' wounds. The documentation did not include assessment of the wounds including measurement, wound appearace, or identification of potential causal factors. An order dated 9/21/15, was written to change the toe wound dressing and included, continue other wound cares as previously ordered. 4) 9/22/15, a facility NN indicated R93 had gone on an outing to the casino with family at 9:30 a.m. with plans to return at 6:00 p.m. The note lacked evidence the resident and/or family had been educated regarding the risks of prolonged sitting for potential worsening of the resident's PUs. In addition, upon the resident's return to the facility, there was no follow up note documented to identify whether or not the resident's skin was assessed after he'd been out all day. 5) 9/29/15, hospice NN indicated wound care had been provided however, no wound assessment such as measurement, staging, description of wound appearace, or identification of potential causal factors was recorded. 6) 9/28/15, a significant change facility NN indicated R93 had fallen and was found sitting on foot pedals. The note indicated, no injuries. The record lacked any assessment of the resident's buttock wounds after the fall onto the metal food pedals to determine wether there had been any increased skin damage as a result. Multiple post-fall notes followed and at no time were the buttock wounds mentioned. 7) 10/5/15, hospice NN revealed order changes including: cream to coccyx changed to a clear critic barrier from zinc as staff reports zinc barrier too harsh to skin. The documentation did not include assessment of the wounds including measurement, staging, description of wound appearace, or identification of potential causal factors. 8) 10/11/15 NN included the first measurements since R93's 'buttock' wounds had been identified on 9/11/15. The wounds were documented as, Right buttock and inner thigh wound: Open area near coccyx is 8 centimeters (cm) x 4 cm, wound bed dark tissue, inferior region measures 3 cm x 2 cm open area without slough (soft non-living tissue), inner thigh open area measures 4 cm x 1.8 cm. The note also included some description of wound appearances, and indicated a wound nurse visit had been requested to re-evaluate and provide a new treatment order as current order is not effective. 9) 10/11/15, hospice NN also documented wound measurements however, the measurements were inconsistent with the measurements by the facility. The hospice NN included, RN assessment of R (right) buttock and sacral area, sacral wound is now larger, Stage IV (full thickness tissue loss with exposed bone) w(with)/necrosis (dead tissue), scant sang (sanguinous) drainage (small amount of bloody drainage). 8 cm x 3 cm. R buttock ulcer now 4.5 x 2.25 cm. [MEDICATION NAME] and Allevyn dressings were applied. The 10/11/15 assessments documented by the facility and hospice nursing staff lacked consistent staging and/or full descriptions of the appearance of each wound. 10) 10/12/15, hospice NN showed R93 went out with family, so unable to assess the worsened right buttock wound. The plan was for the nurse to return later that week to assess the wound. There was no documentation of education on PU cause/prevention with the resident. No follow up NN indicating how long the resident sat, nor a skin exam and description of skin condition after prolonged sitting. 11) 10/13/15, at 9:44 p.m. NN indicated, .complaint of butt pain, with no indication wound assessment was then performed, nor education provided related to prolonged sitting and wound deterioration, nor any cosideration of how long the resident had been potentially sitting on the PUs. 12) 10/25/15, NN .wound black in color and has a foul odor . Although the wound description was minimal, it did represent a change to the wound from previous noted descriptions. In addition, as a result a wound nurse consult had been arranged. The NN indicated the coccyx wound had deteriorated due to being near rectum/stool. 13) 10/29/15, a hospice NN indicated a visit had been made after an Allina home health aide had reported a declining coccyx wound. The NN included: POC (plan of care) coordinated with staff. R93's care plan was reviewed and included: 9/2/15, right foot abrasion, 9/8/15, Left toe abrasion, 9/11/15, PU (actual or at risk), and 10/11/15, two open areas to right buttock/sacral area. There had been no additional changes to the resident's care plan after 10/11/15. 14) 10/30/15, hospice NN noted coccyx wound had increased in size. The coccyx wound measurement was identified as 12 x 5 x 3 (depth) cm. The right lower buttock wound measured 3 x 2 cm. The notes indicated: Coccyx wound edge borders were non-blanchable and crusted. Wound bed necrotic. 30-40% loose necrotic tissue noted. Serosanguineous (blood-tinged clear) drainage observed in large amounts. Due to where wound is located near rectal opening, stool becomes lodged into wound crevices and must be thoroughly cleansed of stool after each incont episode and wound cares repeated. POC reviewed with unit nurse on duty. However, the facility's wound interventions for the POC remained unchanged. The hospice NN indicated the nurse planned to try to return the following week to coordinate with wound nurse. 15) 10/30/15 an order was written to discontinue previous wound care (Allevyn to larger and [MEDICATION NAME] to smaller buttock wounds. Although a reason for the change was not documented, a new change procedure directed staff to .loosely pack wound with moist dressing) 16) 10/31/15, NN indicated R93 returned from an outing at 6:00 p.m. and refused to lie down. NN's did not reflect a departure time, nor risk/benefit education. Documentation lacked a follow up note to indicate when the resident did lie down and whether the resident's skin was examined. 17) 11/1/15, NN noted the nurse practitioner (NP) was providing cares and hospice nurse measured the wounds. 18) 11/1/15 hospice NN, Sister requested hospice nurse visit to assess wound care. Wound care was provided by facility and hospice nurse. Coccyx wound was 10.5 x 4.5 cm with black necrotic tissue on 30 to 40% of wound. Ischial wound was 3.5 x 2 cm with odor, and [MEDICATION NAME] (antibiotic) was ordered with each dressing change for wound odor. Wound care three times daily and as needed for stooling or loosening of the dressing. Although the measurements were smaller, the assessment was incomplete, lacking depth measurement and wound appearance description that would have shown actual or lack of progress toward healing. 19) 11/2/15, NN regarding wound care provided, observed by surveyor as above 20) 11/3/15, facility dietary note revealed the first nutrition assessment since an 8/25/15, admission Nutrition Assessment form (with check boxes but no information relevant to wound healing issues). The note indicated the resident was receiving hospice and had skin concerns on toes and buttocks, which was contradicted later in the note when it indicated Skin is intact. 21) 11/4/15, wound NN indicated R93 had an unstagable wound on the right buttock measuring 11 x 5 x 3.5 cm. Undermining from 3 to 6 o'clock (larger than visible at skin level and face of clock used to describe direction) 5.5 cm to 9.0 cm. New treatment with [MEDICATION NAME] packing was recommended daily and as needed. The two wounds were measured and staged as ischial tuberosity wound (first measurement of this wound) was Stage III measure 3.3 cm x 2.0 cm, scrotal--1.5 cm x 1.0 cm. Recommend Triad wound paste twice daily and as needed. New orders were written. A rationale for the change in treatment was not documented. A physician order [REDACTED]. and/or eschar (tan, brown or black) in the wound bed) Right buttock pressure ulcer dressing packing was changed to one inch [MEDICATION NAME] (anti-infection material) packing strips into the wound and right ischial tuberosity wound dressing was changed from [MEDICATION NAME] to Triad wound paste. A NN showed the physician saw R93 the following day, but did not indicate whether the physician visualized any wounds. The past four Weekly Skin Reviews were reviewed and were vague and incomplete. All noted a check mark for foot wounds. On both 9/19/15 and 10/3/15, a brief description was documented. A NN note 10/3/15, included a brief description of the buttocks wounds including, open area to coccyx; zinc barrier cream applied. On 10/17/15, a brief description of buttocks wounds indicated drainage and wound cleanser was used for stool removal. On 10/31/15, 2 open areas to right buttock area; drsgs (dressings) dry and intact tonight. An interview was conducted on 11/4/15, at 9:20 a.m. with a wound nurse from Allina home care, the director of nursing (DON) and the assistant director of nursing (ADON) while waiting for the hospice nurse to arrive. The wound and the hospice nurse planned to perform ulcer cares and measurements together. The wound nurse reported, I consult with hospice for wounds. This is the first time I'm seeing these wounds. The hospice nurse then joined the interview. The ADON said the physician had been notified of R93's wounds but was unsure whether he or the nurse practitioner (NP) had visualized the wounds yet. The ADON stated, The goal is to maintain the wounds, not to heal. The hospice RN reported they documented in their own electronic medical record in the hospice interdisciplinary team (IDT) notes. She added, But the facility cannot see them, because they lacked access. In addition, hospice nurses did not read the facility's NN, rather relied on verbal exchanges of information regarding progress and changes in condition. On 11/4/15, at 9:49 a.m. the wound nurse and a hospice case manager were observed during wound dressing changes and measurements for R93. The wound nurse measured and reported the coccyx wound had depth and undermining. She stated, I'd say it was unstageable. There's granulation tissue (pink or red tissue of the healing process) with about 50% eschar (dark colored dead tissue). We'll change the dressing order to [MEDICATION NAME] ribbon (for potential bacteria from dead tissue). The wound nurse measured the ischial tuberosity wound and said it was Stage III but noted no depth, although slight depth was observed by the surveyor. Following the observation the hospice nurse said the physician was notified of wound healing at hospice interdisciplinary (IDT) rounds, but had not visualized the ulcer adding, Our docs (doctors) rarely come out to view wounds. On 11/4/15, at 10:40 a.m. the hospice RN (RN-F) said she found out R93 had wounds from facility staff, and the wounds developed from pressure and excoriation (open skin due to moisture). She had not measured them since her initial measurements this week. I used barrier cream. I'm not sure how they knew it was getting deeper without measurements. RN-F explained she took over on 10/30 from the previous hospice nurse. Preventive measures were the responsibility of both hospice and the facility and hospice did suggest turns, (repositioning), etc. RN-F stated regarding R93, His wounds are declining as he is declining. His mood and affect were also declining and he participated in fewer hobbies and in the past week had less of an appetite. Communication of this observation, however, was not noted on the registered dietitian note the previous day. The following day hospice notes were requested, however, were not provided. On 11/4/15, at 12:17 p.m. the DON reported he was aware of R93's PUs, but though hospice was completing wound assessments, as there was a note indicating they would be treating the ulcers. Regarding the policy the DON stated he would have expected documentation including measurements, physician notification. He would expect the facility nurses to follow standard training, and that the care plan would be updated with the change in condition in September when the wounds were first noted. The DON said most communication was via telephone with the hospice agency, and NN should have reflected this. R46 was observed on 11/4/15, at 7:45 a.m. 11/5/15, at 8:30 a.m. and again on 11/6/15, at 7:10 a.m. R46 was observed lying in bed on his back with his knees bent with his heels pressing directly on the mattress. R46's quarterly Minimum Data Set ((MDS) dated [DATE], indicated [DIAGNOSES REDACTED]. The resident required extensive assistance with all activities of daily living (ADLs). It was noted R46 was at risk for developing PUs, and had unhealed Stage I and II PUs. The current skin and ulcer treatment included a pressure reducing device for his bed and chair, PU care, ointments and medications. It was also noted the resident was receiving hospice services. The Braden Scale (for predicting PU risk) dated 8/20/15, was scored 15 classifying the resident at high risk for PUs. The facility completed sporadic weekly skin monitoring and PU measurements from 5/7/14 to 4/8/15. The weekly skin monitoring lacked wound measurements and descriptions. A hospice care plan dated 6/13/14, directed the hospice nurse to provide weekly services including to monitor and assess the wounds on his legs, to monitor skin on his buttocks and scrotum, and for the facility staff to provide left heel treatment in hospice nurse's absence. R46's care plan dated revised 8/31/15, instructed staff to coordinate care plan with hospice, evaluate effectiveness of medications and interventions, diabetic foot monitoring, float heels with placement of pillow, boots or Heelzup cushion, weekly skin assessments and notify hospice of any change in condition or medication change. The hospice and palliative care visit records were requested and the following was provided: 1) 5/19/15, indicated R46 had three open areas on his buttocks 2) 8/10/15, heel wound measured 4 x 3 cm and no other ulcers identified 3) 8/16/15, heel measurements 2 x 1.5 cm and no drainage 4) 9/11/15, comfort and wound care, right heel PU measured 3 x 1.4 cm and there was a new open area on the left great toe. 5) 9/14/15, wound care with heel measured 1.7 x 1.7 cm with slight foot odor and drainage. Also new open area to left buttock (not specified). Instruction was to continue barrier cream to buttocks, encourage offloading and lying down after meals. 6) 9/21/15, included wound care and the heel was measuring 3 x 2.4 cm was very tender to touch, no new orders. 7) 9/28/15, wound care provided and wounds assessed, however, no measurements, staging, or wound descriptions were documented 8) 10/2/15, wound care using Medi-honey in wound bed and covered with [MEDICATION NAME] border. The facility staff had reported increased odor and secretions. 9) 10/5/15, New wound care orders included, wash with normal saline, apply 500 mg crushed [MEDICATION NAME] to wound bed for 14 days, cover with Tegafoam or [MEDICATION NAME] dressing. Wrap with Kerlix for added cushion and call hospice with any changes in wound status. 10) 10/12/15, intervention included assess effectiveness of [MEDICATION NAME] in wound bed of right heel, no measurements, staging, or description of the various wounds were documented. 11) 10/22/15, plan to request wound nurse consult to evaluate heel, and no new measurements, staging or descriptions of the wounds were documented. 12) 11/2/15, wound care performed and right heel measured 6 x 4.5 x .5 cm with 100% yellow slough, no odor. 13) 11/4/15, right heel now unstageable PU, measuring 5.0 x 5.0 cm. No staging to description of the wounds was documented. Recommended iodine and foam dressing changing every one to two days, no open areas on the buttocks noted. Continue use of barrier cream to prevent ulcers. In addition, a hospice wound nurse evaluated the right heel and provided suggestions and new orders. The coccyx was also observed to be red, blanchable and excoriated. Continue to monitor and measure areas. 14) 11/6/15 updated orders instructed the staff to clean the wound on heel area, apply [MEDICATION NAME] to wound base, apply foam dressing, measure wound and document with each dressing change, change every two days or as needed. NN and weekly nursing summary notes reiterated the hospice nurse's observations and only generally noted the right heel wound, red buttocks, and daily treatments. However, weekly wound measurements, staging, and descriptions of the skin was not specifically documented. When interviewed on 11/4/15, at 8:30 a.m. the hospice nurse verified R43 developed a PU on the heel which had worsened. She was unaware of wound measurements, or the current treatment plan and interventions for the PU. She was also unaware of the PUs on the resident's coccyx, and wound information had not been provided by facility staff. The hospice nurse reported she had only worked with R46 for the past couple months, and another hospice nurse worked with the resident prior to this. LPN-C reported on 11/6/15, at 7:40 a.m. that the NAs were supposed to follow the resident's care sheets. She said R46 had refused to wear the protective boots at times, so they stopped offering them as an intervention, although was unsure the date they were discontinued. LPN-C said instead, he was currently wearing gripper socks, and some new boots had been ordered. R46's current NA assignment sheet instructed the staff to turn and reposition the resident every two hours side to side, to ensure he was only up for ½ hour after meals due to wounds, and ensure he was wearing the blue Prevalon boots on both feet at all times. On 11/5/15 at 7:30 a.m. NA-B explained that the facility nurse took care of R46's PUs. NA-B said the only interventions she provided for R46 was to make sure he was wearing socks and offload the resident at times. NA-B said R46 did not utilize heel protectors and had refused to wear protective boots. The hospice care plan included weekly skin monitoring by facility staff, and then contacting the hospice nurse with any change in skin condition and/or the status of the PUs. On 11/5/15, at 9:02 a.m. the DON verified the weekly wound measurements had not been completed, stated the resident just saw a hospice wound nurse yesterday and it was determined the heel ulcer was now unstageable. The facility's undated Skin Integrity Guideline's purpose was, To provide a comprehensive approach for monitoring skin conditions. To decrease pressure ulcer and wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions; To promote healing of any wounds of any etiology, whether admitted or acquired. The policy directed the DON to implement and monitor the skin integrity program, develop a routine schedule to review wounds or persons at risk weekly, utilize IDT approaches such as addressing problems, goals, and interventions directed toward prevention of skin concerns, notifying persons such as therapy and the registered dietitian for nutritional interventions. The licensed nurse was to perform weekly skin evaluations and identity wounds on the Wound Evaluation Flow Sheet. The care plan was to be implemented evaluated and revised based on the needs of the resident. If patient/resident is refusing or choosing not to receive treatment, review risks, benefits, and alternatives. Re-evaluate and attempt other interventions. The undated Wound Evaluation Flow Sheet was to be completed for each pressure and non pressure wound. The accuracy and thoroughness of the Flow Sheet will assist in identifying risks and appropriately establishing a Plan of Care .It is updated at least weekly, reviewing status/changes in wound from the previous week, updating MD and family. The assessment was to include staging, measurements and a description of the wound as specified in the policy.