Every finding on record at The Oaks at Longview

Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 4 residents (Resident #1) reviewed for therapeutic diets. The facility failed to ensure Resident #1 received a diabetic diet (CCHO). This failure could place residents at risk for altered nutritional status and decreased quality of life.Findings included: Record review of Resident #1's electronic face sheet indicated a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included type 2 diabetes mellitus (high blood sugars), noninfective gastroenteritis and colitis (inflammation of the digestive tract), and gastrointestinal hemorrhage (bleeding from the digestive tract). Record review of Resident #1's Quarterly MDS assessment, dated 12/2/2025, indicated she usually understood others and was sometimes understood by others. Resident #1 had a BIMS score of 03, which indicated her cognition was severely impaired. Resident #1 required setup or clean-up assistance for eating. The MDS assessment did not indicate Resident #1 required a therapeutic diet. Record review of Resident #1's electronic Order Summary Report indicated she had an order for a regular diet with regular texture and thin consistency with a start date of 7/2/2024. Record review of Resident #1's care plan, last reviewed 5/12/2025, indicated she had the potential for nutritional problem/malnutrition related to diabetes mellitus with interventions that included: .2. Provide, serve diet as ordered. Monitor intake and record every meal. 3. RD to evaluate and make diet change recommendations PRN. Record review of Resident #1's care plan, last reviewed 5/12/2025, indicated she had GERD (gastroesophageal reflux disease) with interventions that included: .Avoid overeating. Provide small frequent meals rather than 3 large ones. Record review of Resident #1's electronic health record indicated the last nutrition assessment was completed was on 04/25/2025, and it did not address Resident #1's requirement of small frequent meals or diabetes mellitus. The nutrition assessment was signed completed on 04/25/2025. Record review of Resident #1's electronic health record indicated Resident #1 had a HGBA1C (blood test showing your average blood sugar levels over the past 2-3 months) level on 2/6/2025 of 7.3 (normal levels 4.7-5.7). Record review of Resident #1's electronic health record indicated Resident #1 had a HGBA1C (blood test showing your average blood sugar levels over the past 2-3 months) level on 11/21/2025 of 9.6 (normal levels 4.7-5.7). Record review of the facility's Concern/Grievance Report, dated 12/1/2025, filed by Resident #1's family member indicated Resident #1's family member was concerned about Resident #1's HGBA1C level had increased. The grievance indicated the report was received by the Administrator and did not include a resolution regarding Resident #1's family member's concern of Resident #1's HGBA1C level. The grievance indicated a care plan meeting would be scheduled to address concerns. During an observation on 12/11/2025 at 12:39 PM, LVN A showed the state surveyor her phone text messages to Resident #1's MD. At 10:35 AM, after state surveyor intervention, LVN A asked Resident #1's MD if Resident #1 could have a diabetic order diet. Resident #1's MD responded to the request and said yes, she could have an order for Resident #1 to have a diabetic diet. During an interview on 12/11/2025 at 9:45 AM, Resident #1's family member said Resident #1 had diabetes mellitus and GERD and was told she was supposed to have frequent small meals and a diabetic diet. Resident #1's family member said Resident #1 was supposed to have a diabetic diet and the facility could not accommodate her. She said she called the facility on 11/21/2025 and inquired about Resident #1's blood sugars and was told her HGBA1C level was a 9.6 (normal levels 4.7-5.7). She said when she asked about Resident #1 getting a diabetic diet, the ADON told her the facility did not offer a diabetic diet, and everybody received the same diet. During an interview on 12/11/2025 at 10:00 AM, Resident #1's family member #2 was at the facility and said when Resident #1 was at home they had always eaten healthy. He said they were able to control Resident #1's diabetes at home with her diet. He said since Resident #1 had been in the facility her blood sugars have been out of control. He said they feed Resident #1 hamburgers, hot dogs and all kinds of things a diabetic should not be eating. He said he addressed it with the facility, and nothing had changed. Resident #1's family member #2 said he had not been invited to attend any care plan meeting since Resident #1's family member had addressed concerns regarding her HGBA1C level. During an interview and record review on 12/11/2025 at 11:50 AM, the Dietary Manager said if a resident required a special diet the nursing staff notified dietary, and they tried to accommodate the diet. The Dietary Manager said a diet order should be completed and given to the kitchen. The Dietary Manager said she was not aware Resident #1 requested a diabetic diet and required small, frequent meals, and she was not provided with a diet order. During the interview with the Dietary Manager Resident #1's physician orders were reviewed and indicated Resident #1's diet order had been changed on 12/11/2025 at 11:10 am after State Surveyor intervention, to a diabetic diet (CCHO). During an interview and record review on 12/11/2025 at 11:55 AM, the RD said she had not assessed Resident #1, because she had taken over the facility in October of 2025 and Resident #1 had not triggered for her to be assessed. She said triggers for residents to be assessed consisted of weight gain, weight loss, and wounds which Resident #1 did not have. She said she would assess Resident #1 while she was at the facility that day. During an interview on 12/11/2025 at 12:50 PM, the DON said she changed Resident #1's diet order to a diabetic diet on 12/11/2025 at 11:10 AM after state surveyor intervention based on the RD's recommendation of a diabetic diet. She said she had a verbal discussion with the RD regarding Resident #1's HGBA1C level and the RD's recommendation was to change Resident #1's diet order to a diabetic diet (CCHO). When asked if it was normal to have a discussion with the RD regarding resident's lab values, she said yes, she called the RD at times to notify her of resident's lab values. When asked why Resident #1's lab values were discussed with the RD on 12/11/2025 instead of when Resident #1's lab values were received on 11/21/2025, she stated this was the first time the RD had been to the facility since Resident #1's lab values were received. During an interview on 12/11/2025 at 1:45 PM, the MD said he visited Resident #1 while at the facility on 12/11/2025. He said he changed Resident #1's medication on 11/21/2025 when he was notified of Resident #1's HGBA1C level of 9.6. He said had he known Resident #1 or her family wanted Resident #1 to have a diabetic diet he would have ordered it, but he was not told. He said he did not think a diabetic diet was sufficient in managing Resident #1's diabetes. He said he had previously spoken with Resident #1's family regarding insulin but they did not want her to take insulin but said he was going to speak with the family again about putting Resident #1 on insulin. During an interview on 12/11/2025 at 2:35 PM, the ADON said on 11/21/2025 Resident #1's family member found out Resident #1 had a hypoglycemic (low blood sugar) episode and requested Resident #1 have a HGBA1C level done. He said Resident #1's family member called the facility and requested a diabetic diet, and he told her the facility did not offer a diabetic diet. He said he was not aware the facility offered a diabetic diet and would go and find out what that was. During an interview on 12/11/2025 at 3:00 PM, LVN B said on 11/21/2025 she received a call from Resident #1's family member asked about Resident #1 having a diabetic diet. She said she explained to Resident #1's family member that the facility did not offer a diabetic diet. She said Resident #1's family member got upset that they did not offer a diabetic diet, so she transferred the call to the ADON. She said she did not know the facility had a diabetic diet, and she had never heard of a CCHO diet. Record review of the facility's policy titled, Therapeutic Diets: dated 1/1/2025, indicated: Purpose: To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders. Policy: Therapeutic diets are diets that deviate from the regular diet and require a physician's order. Per the physician's order, therapeutic diets are planned prepared and served in consultation with the registered dietician. The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by state law. Record review of the facility's, undated, Resident admission Guide indicated: Food and Nutrition Services: Our food and Nutrition Services Department offers therapeutically planned meals that are specially designed to meet each resident's nutritional needs. A registered dietitian will evaluate and review your diet and nutritional status on a regular basis and will coordinate your nutritional needs with you, your physician, and the facility staff.

Based on interview and record review, the facility failed to promptly resolve grievances for 6 of 6 Anonymous residents reviewed for grievances during a confidential meeting. The facility failed to ensure 6 of 6 Anonymous residents' grievances related to wet napkins on room trays were promptly resolved. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect or hopelessness. The findings included: During a confidential interview on 8/26/25 at 2:00 P.M. 6 of 6 Anonymous residents indicated grievances were not addressed or resolved promptly. Anonymous residents indicated they had made complaints about the napkins being wet on the hall trays in several resident council meetings. Anonymous residents indicated the Activity Director was present during the resident council meetings and was aware of complaints about the wet napkins. Anonymous residents stated it was still happening during meal pass and made them feel like no cared how they felt. Record review of the resident council minutes for 6/2/25, 6/23/25, 6/30/25, 7/14/25, 7/21/25, 7/28/25, 8/4/25 and 8/12/25 indicated Napkins on trays are being wet when served to residents. During an interview on 8/27/25 at 12:25 P.M., the Activity Director stated she believed that complaints during resident council were considered grievances. The Activity Director stated she wrote down the minutes for the resident council meetings. She stated she wrote that the residents had been complaining about their napkins being wet on their trays. She stated the residents were saying the drinks on the tray was getting on the napkins. She stated she did not know exactly how many months the residents had complained about the wet napkins. She stated she wrote it down when the residents complained, she reported it in a stand down meeting and she reported it to the Dietary Manager. She stated she felt the wet napkins were an issue and if the residents were complaining about it the facility needed to fix it. She stated a negative effect of the wet napkins on the trays was the residents could not use the napkins. During an interview on 8/27/25 at 12:55 P.M., the Dietary Manager stated she thought she was notified about the wet napkins on the resident hall trays during the last resident council meeting and she thought the issue was resolved. She stated she was not aware that the residents had complained about the wet napkins for 3 months. She stated if she would have known the residents had complained that many times, she would have monitored the trays for wet napkins herself. She stated she did an in-service on the wet napkins before, and she thought it was all clear. She stated if the residents complained about something it should be taken care of. She stated a negative effect of residents having wet napkins would be they could not clean their hands and face. During an interview on 8/27/2025 at 1:07 P.M., the ADON D stated he was unaware of the numerous complaints of residents getting wet napkins with their meals. He stated a negative effect of wet napkins on trays was it would not allow residents to clean themselves appropriately and that no one wanted a wet napkin. He stated not resolving the complaints gave residents a sense that the facility did not care about them. During an interview on 8/27/25 at 1:11 P.M., the DON stated she was unaware of the resident council complaints. She stated she was not aware of the numerous complaints of wet napkins on trays. She stated she had never passed a tray with a wet napkin. She stated a negative effect of being served a wet napkin was the residents could not properly clean their hands with a wet napkin. She stated the residents' concerns needed to be addressed. She stated the residents needed to feel like they were being heard, because the facility was their home. During an interview on 8/27/25 at 1:25 P.M., the ADM stated that complaints during resident council were considered grievances. She stated she was unaware of the numerous complaints of wet napkins on the residents' trays. She stated the wet napkins was never brought up in a meeting. She stated she did not have an answer as to why the wet napkins were not corrected, because no one had mentioned it to her until today. She stated the Activity Director had never said a word to her about the residents complaining about wet napkins. She sated she truly did not know there was an issue with the napkins on the trays being wet. She stated the ADON had started an in-service to try to figure out why the napkins were getting wet on the trays. She stated a negative effect of wet napkins on the resident's food tray was they could not use them and the appearance of the wet napkins on the tray would not look nice. She stated it was important to address grievances and resident council complaints promptly, but she could not address what she did not know. Record review of Grievances and Complaints policy revised on February 2025 revealed Grievances Investigation: . A. Upon receiving a resident grievance/complaint form, the Grievance Official or designee begins an investigation into the allegations. The Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. The department director of an involved employee is notified of the nature of the complaint and that an investigation is underway. Record review of Resident Council policy revised on 06/2020 revealed Responsibilities of the Resident Council: . C. If the Council raises an issue of concern, the Department responsible for the issue or service is responsible for addressing the item(s) of concern promptly. D. The Facility will respond in writing to written request or concerns of the family council in a prompt and timely manner.

Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for 4 of 19 residents reviewed for resident rights. (Resident #16, Resident #33, Resident #40, and Resident #64). The facility failed to ensure Resident #16, Resident #33, Resident #40, and Resident #64 were allowed to smoke two cigarettes during the facility smoking times. This failure could place dependent residents at risk for feelings of depression or lack self-determination and decreased quality of life.Findings included: 1. Record review of Resident #16's face sheet, dated 08/25/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #16's admission MDS assessment, dated 07/14/25, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/25/2025 at 10:06 AM, Resident #16 said she wished that she was able to smoke 2 cigarettes when she goes out to smoke at the designated smoking times. She said she had asked before and the staff always gave an excuse such as I forgot or I have to ask someone. She said the Administrator told her I have to ask corporate. She said she was going to go to the 10:30AM smoke time on this day and was going to ask the staff if she could have a second cigarette. During an interview on 08/25/25 at 10:41AM Resident #16 said at the 10:30AM smoke time on this day, she asked Dietary Aide B if she could have a second cigarette and Dietary Aide B would not let her have a second cigarette. She said the staff that supervised the residents during smoke times only brought enough cigarettes outside for each resident to have one cigarette. During an interview on 08/26/25 at 9:57AM Resident #16 said it made her upset that she was unable to have a second cigarette at the smoke times. She said she did not understand why she could not have 2 cigarettes in this facility when other nursing facilities allowed her to have two cigarettes at a smoke time. 2. Record review of Resident #33's face sheet, dated 08/25/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #33's quarterly MDS assessment, dated 06/27/25, indicated he had a BIMS score of 12, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. During an interview on 08/25/2025 at 9:50 AM, Resident #33 said he wished that he could have 2 cigarettes when he goes out to smoke at the designated smoking times. He said he thought the residents could not have 2 cigarettes when they go out to smoke. During an interview on 08/26/25 at 9:55AM, Resident #33 said it made him upset that the facility did not allow him to have two cigarettes at a smoking time. He said he has asked in the past and the staff would not let him have a second cigarette. 3. Record review of Resident #40's face sheet, dated 08/26/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a chronic lung disease that causes inflammation and narrowing of the airways, leading to airflow obstruction). Record review of Resident #40's admission MDS assessment, dated 08/15/25, indicated she had a BIMS score of 15, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/26/25 at 10:04AM Resident #40 said the staff did not allow the residents to smoke 2 cigarettes at a smoke time. She said she has asked in the past and the staff told her No, we cannot do that. She said the staff only brought enough cigarettes for each resident to have one. She said it made her upset she could not have two cigarettes at a smoke time because she was not always able to make it to all of the smoking times. She said she took a diuretic medication that makes her use the bathroom often and she was not always able to make it outside at the smoking times. 4. Record review of Resident #64's face sheet, dated 08/26/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively). Record review of Resident #64's quarterly MDS assessment, dated 05/23/25, indicated she had a BIMS score of 14, which indicated intact cognition. She was able to make herself understood and she was able to understand others. During an interview on 08/25/25 at 10:50AM Resident #64 said the staff that took the residents outside to smoke would not allow them to have 2 cigarettes at a smoke time. She said she has asked the staff before, and they told her it was against facility policy. She said it made her upset that she could not have a second cigarette. During an observation on 08/25/25 at 10:31AM, there were 5 residents outside smoking, including Resident #64, Resident #16, and Resident #33. Dietary Aide B was outside supervising the residents. During the observation Resident #16 asked if she could have a second cigarette and Dietary Aide B told her no. During an interview on 08/25/25 at 10:39AM, Dietary Aide B said that she would allow the residents to smoke a second cigarette if they asked. She said she did not deny Resident #16 a second cigarette. She said Resident #16 said she was going to have a second cigarette at the next smoke time. During an anonymous resident group interview on 08/26/2025 at 2:00 PM, the group said the staff had never let them smoke more than 1 cigarette during a session. They further indicated they were told by staff that the staff made a decision on 08/25/25 that the residents were allowed to have 2 cigarettes and they were only still getting one. They said they felt degraded, and one resident in the group said they came to this facility because they allowed the residents to smoke. They said they felt it was their right to smoke more than one cigarette if they wanted. Record review of a Resident Council Report, dated 08/04/25, reflected: .Smokers would like to know if they can have 2 cigarettes instead of 1. During an observation on 08/27/25 at 9:35AM, ADON A pulled out the smoking supplies safe at the nursing station to show to the surveyor. The box had a sign taped to it and the sign reflected: 08/25/25 [Attention] Staff:Residents will be allowed to smoke 2 cigarettes during smoke break. The sign had the Administrator's signature at the bottom. During an interview on 08/27/2025 at 12:17 PM, ADON A said she had been one of the ADONs for about 4 months. She said the procedure was that the residents were only able to have 1 cigarette at each smoke time. She said it had been that way since she started at the facility. She said she did not think it was her place to question the residents only being allowed to have one cigarette. She said on Monday 08/25/25 the Administrator let the staff know that they should allow the residents to have 2 cigarettes at the smoke times. She said the residents should be allowed to have the right to have 2 cigarettes. She said if she was unable to have more than one cigarette she would be upset. During an interview on 08/27/25 at 12:31PM the DON said she felt the residents had the right to smoke 2 cigarettes at each smoke time. She said the staff recently had a discussion with the Administrator to allow the residents to smoke 2 cigarettes. She said they were now allowed to have two cigarettes when they smoked. She said the procedure that the residents were only allowed 1 cigarette came from everyone thinking it was common practice. She said a resident could be offended if they were denied 2 cigarettes. She said the facility was their home and they should be allowed to smoke two if they desire. During an interview on 08/27/25 at 12:39PM the Administrator said she was unaware of the residents only being allowed 1 cigarette. She said it was not a rule. She said she was okay with the residents having more than one cigarette if they wanted. She said she put a note on the smoking supplies box that the residents could have more than 1 cigarette if they wanted. She said there was not a policy or document that reflected the residents could only have one resident. She said she figured that the staff only gave each resident 1 cigarette because it was how they thought things were done. She said she thought the residents would be frustrated. She said she feels like it is a resident right to have more than one cigarette. Record review of the facility's policy, Resident Rights, last revised August of 2020, reflected: .residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. Record review of the facility's policy, Smoking by Residents, last revised June of 2020, reflected: .X. Smoking session will be limited to 15-minute segments.The policy did not address the number of cigarettes a resident would be allowed to smoke at a time.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 19 residents (Resident #3 and Resident #12) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's and Resident #12's MDS assessments accurately identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs.Findings included: 1. Record review of Resident #3's face sheet, dated 08/26/25, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (a group of conditions that cause a progressive decline in cognitive abilities), and type 2 diabetes mellitus (chronic disease where your body either doesn't produce enough insulin or doesn't use insulin properly, leading to high blood sugar levels). Record review of Resident #3's quarterly MDS assessment, dated 08/04/25, indicated she did not have a BIMS score due to her rarely/never being understood. She rarely/never understood others. The assessment further indicated she took an anticoagulant medication. Record review of Resident #3's physician's orders, dated 08/25/25, indicated the following orders:*Aspirin Low Dose oral tablet chewable 81mg (an antiplatelet medication used to prevent cardiovascular events like heart attacks and strokes) Give 1 tablet by mouth one time a day. The start date was 07/11/24.* Clopidogrel Bisulfate oral tablet 75mg (an antiplatelet medication used to prevent heart attack, stroke, and other cardiovascular problems) Give 1 tablet by mouth one time a day for cerebrovascular disease. The start date was 07/11/24.There was not an order for an anticoagulant medication. Record review of Resident #3's care plan, indicated a focus dated 05/10/25 of Resident #3 was on anti-platelet medication related to cerebrovascular accident (stroke). Interventions included monitor/document/report to MD PRN signs and symptoms of anti-platelet complications. 2. Record review of Resident #12's face sheet, dated 08/26/25, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively) and chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood). Record review of Resident #12's quarterly MDS assessment, dated 07/17/25, indicated he had a BIMS score of 11, which indicated moderate cognitive impairment. He was able to make himself understood and he was able to understand others. The assessment further indicated he took an anticoagulant medication. Record review of Resident #12's physician's orders, dated 08/25/25, indicated the following orders:*Aspirin Low Dose oral tablet chewable 81mg Give 1 tablet by mouth one time a day. The start date was 09/15/24.* Clopidogrel Bisulfate oral tablet 75mg Give 1 tablet by mouth one time a day. The start date was 09/15/24.There was not an order for an anticoagulant medication. Record review of Resident #12's care plan, indicated a focus dated 09/21/24 of Resident #12 was on anti-platelet therapy related to disease process. Interventions included monitor/document/report to MD PRN signs and symptoms of anti-platelet complications. During an interview on 08/27/25 at 12:08PM, the MDS Coordinator said she would have to modify the MDS assessments for Resident #3 and Resident #12. She said she was not sure how the residents' assessments were marked for anticoagulants. She said anticoagulant should have been marked no on both residents' assessments. She said the residents were taking antiplatelet medications. She said there was no risk to the residents because of the inaccurate MDS. During an interview on 08/27/2025 at 12:17 PM, ADON A said she had been one of the ADONs for about 4 months. She said the current MDS Coordinator was new. She said her expectation was that the MDS assessments were completed accurately. She said she was going to in-service and make sure the MDS assessments for Resident #3 and Resident #12 were corrected. During an interview on 08/27/25 at 12:31PM, the DON said she expected the MDS for Resident #3 and Resident #12 to be accurate. She said there was no risk to the resident due to the MDS being marked wrong for anticoagulant. During an interview on 08/27/25 at 12:39PM, the Administrator said she expected the MDS to be accurate. She said she did not think there was a risk to the resident due to the MDS being marked for anticoagulant. Record review of the facility's policy, Minimum Data Set Policy, last revised 03/14/24, reflected: .Procedure1. IDT to utilize RAI for all processes pertaining to MDS.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, homelike environment maintaining a comfortable noise level for 1 of 18 residents (Resident #39) reviewed for dining services. The facility failed to ensure the noise level in the dining room was kept at a comfortable level for Resident #39 on 08/25/25 during the lunch meal. This failure could place residents at risk for a decreased quality of life.The findings included: Record review of the face sheet, dated 09/02/25, reflected Resident #39 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss), history of a stroke, and a history of traumatic brain injury. Record review of the annual MDS assessment, dated 07/19/25, reflected Resident #39 had unclear speech, was usually understood by others, and was usually able to understand others. Resident #39's BIMS score was 3, which indicated severe cognitive impairment. The MDS reflected Resident #39 had no behaviors or refusal of care during the look-back period. Record review of the comprehensive care plan, revised 05/12/25, reflected Resident #39 had impaired cognitive function or thought processes. The interventions included: .reduce any distractions - turn off TV, radio, close door, etc. The care plan further reflected Resident #39 had potential for communication problems related to unclear speech. The interventions included: anticipate and meet needs. During an observation on 08/25/25 beginning at 11:44 AM, there were 18 residents sitting in the dining room. Gospel music was playing loudly, over a speaker. Resident #39 was sitting across the room in front of the television, which was on and playing. During an observation and interview on 08/25/25 beginning at 11:50 AM, Resident #39 placed her hands over her ears and stated, too loud. Resident #39 pointed at the television and shook her head side-to-side. Resident #39 shook her head yes, when asked if the music was often played too loudly. The surveyor alerted staff to Resident #39's request, and the music was turned down. During an interview on 08/27/25 beginning at 10:16 AM, LVN C stated the music was not normally played loudly with the television going at the same time in the dining room. LVN C stated Resident #39 had not complained about the music prior to 08/25/25. LVN C stated she was not in charge of the music in the dining room and was unsure who set it up. LVN C stated if the resident's complained about the noise level she would request the music be turned down. LVN C stated it was important to ensure the noise levels were kept at a comfortable level to make sure the environment remained comfortable. LVN C stated the facility was their home and it was hard to understand things happening elsewhere if the noise was too loud. During an interview on 08/27/25 beginning at 10:29 AM, the DON stated the AD was responsible for the entertainment in the dining room. The DON stated there had not been any complaints about the noise level in the dining room. The DON stated Resident #39 had not complained about the music being too loud. The DON stated it was important to ensure the noise level was kept at a comfortable level to maintain the residents best interest, cater to the residents, and ensure activities were conducted. During an interview on 08/27/25 beginning at 12:22 PM, the AD stated she was responsible for playing the music in the dining room. The AD stated the music and television were not usually playing at the same time. The AD stated if any resident's complained about the noise level of the music, it would have been turned down. The AD stated Resident #39 had not complained about the noise level of the music. The AD stated Resident #39 used to watch television in her room but had been watching television in the dining room more frequently. The AD stated it was important to ensure the noise level was kept at a comfortable level in the dining room because it was the residents right. During an interview on 08/27/25 beginning at 12:33 PM, the Administrator stated Resident #39 had not been herself recently because her long-time roommate was leaving the facility. The Administrator stated Resident #39 usually loved to listen to gospel music. The Administrator stated if any residents complained of the noise level of the music it should have been turned down. The Administrator stated all staff were responsible for monitoring the noise levels at the facility. The Administrator stated she expected the noise level to be kept at a comfortable level. The Administrator stated it was important to ensure the noise level was kept at comfortable levels so residents could hear what was going on during activities. Record review of the Resident Rooms and Environment policy, revised 08/2020, reflected .Facility staff aim to create a personalized, homelike atmosphere, playing close attention to the following.comfortable noise levels.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 2 of 2 (Resident #1 and Resident #2) residents reviewed for gastrostomy tube. 1. The facility failed to ensure Resident #1 received potassium chloride (supplement), acidophilus (probiotic), Bactrim DS (antibiotic), and valproic acid (anticonvulsant) within the scheduled time frame on 08/26/25. 2. The facility failed to ensure Resident #2 received apixaban (anticoagulant), ferrous sulfate (iron supplement), furosemide (diuretic), and valproic acid (anticonvulsant) within the scheduled time from on 08/26/25. These failures could place residents at risk for medication errors and adverse effects from medication.The findings included: Record review of face sheet, dated 08/27/25, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of mild cognitive impairment and dysphagia (difficulty swallowing). Record review of the admission MDS assessment, dated 08/11/25, reflected Resident #1 had unclear speech, was sometimes understood by others, and was sometimes able to understand others. Resident #1 had a BIMS score of 4, which indicated severe cognitive impairment. The MDS reflected Resident #1 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #1 used a feeding tube while a resident. Record review of the comprehensive care plan, revised 08/08/25, reflected Resident #1 required a feeding tube related to dysphagia. Record review of the order summary report, dated 08/27/25, reflected Resident #1 had the following orders:1. acidophilus probiotic - give 1 capsule via gastrostomy tube two times a day for probiotic support x 7 days with antibiotics.2. Bactrim DS 800-160 mg - give 1 tablet via gastrostomy tube two times a day for UTI x 7 days.3. potassium chloride solution - give 40 mEq via gastrostomy tube one time a day for supplement.4. valproic acid oral solution 250 mg/5 mL - give 5 mL via gastrostomy tube one time a day for mood disorder. Record review of Resident #1's MAR, dated August 2025, reflected the following:1. potassium chloride solution - give 40 mEq via gastrostomy tube one time a day for supplement was scheduled for 8 AM.2. acidophilus probiotic - give 1 capsule via gastrostomy tube two times a day for probiotic support x 7 days with antibiotics was scheduled for 8 AM.3. Bactrim DS 800-160 mg - give 1 tablet via gastrostomy tube two times a day for UTI x 7 days was scheduled for 8 AM.4. valproic acid oral solution 250 mg/5 mL - give 5 mL via gastrostomy tube one time a day for mood disorder was scheduled for 8 AM. 2. Record review of the face sheet, dated 08/27/25, reflected Resident #2 was a [AGE] year-old female who initially admitted on [DATE] with diagnoses of history of stroke, dysphagia (difficulty swallowing), and gastrostomy status (opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of the quarterly MDS assessment, dated 08/06/25, reflected Resident #2 had no speech, was sometimes understood by others, and was sometimes able to understand others. Resident #2's staff assessment for mental status reflected a short-term memory problem, long-term memory problem, and severely impaired decision making skills. Resident #2 was unable to recall current season, location of own room, staff names and faces, and that they are in a nursing home. The MDS reflected no behaviors or refusal of care during the look-back period. Resident #2 had a feeding tube while a resident at the facility. Record review of the comprehensive care plan, revised 04/04/25, reflected Resident #2 required a feeding tube related to dysphagia secondary to stroke. Record review of the order summary report, dated 08/27/25, reflected the following:1. apixaban 2.5 mg - give 1 tablet via gastrostomy tube every morning and at bedtime for atrial fibrillation (irregular heart rhythm).2. ferrous sulfate oral solution 5 mg/20 mL - give 30 mL via gastrostomy tube two times a day for supplement.3. furosemide 40 mg - give 1 tablet via gastrostomy tube two times a day for edema and atrial fibrillation.4. valproic acid oral solution 250 mg/5 mL - give 2.5 mL via gastrostomy tube two times a day for tremors. Record review of Resident #2's MAR, reflected the following:1. apixaban 2.5 mg - give 1 tablet via gastrostomy tube every morning and at bedtime for atrial fibrillation was scheduled for 8 AM.2. ferrous sulfate oral solution 5 mg /20 mL - give 30 mL via gastrostomy tube two times a day for supplement was scheduled for 8 AM.3. furosemide 40 mg - give 1 tablet via gastrostomy tube two times a day for edema and atrial fibrillation was scheduled for 8 AM.4. valproic acid oral solution 250 mg/ 5 mL - give 2.5 mL via gastrostomy tube two times a day for tremors was scheduled for 8 AM. During an interview on 08/26/25 beginning at 6:45 AM, the Regional Nurse Consultant stated LVN C had already given Resident #1 and Resident #2 all the scheduled morning medications through the gastrostomy tube. The Regional Nurse Consultant stated the next medications due were at noon. During an interview on 08/27/25 beginning at 10:16 AM, LVN C stated she normally started her morning medication pass at around 6 AM. LVN C stated medications could have been given one hour before the scheduled time and one hour after the scheduled time. LVN C stated all medications should have been scheduled for the same time if possible. LVN C stated preferences should be considered within the timeframes for each resident. LVN C stated the charge nurses were responsible for putting orders into the computer and ADON D followed up to ensure the accuracy of the orders. LVN C stated Resident #1 and Resident #2's medications were usually given at the same time. LVN C stated it was important to ensure medications were given at the appropriate timeframes to prevent toxicity or drug interactions. LVN C stated some medications need to be given at certain times and could affect the absorption of the medication. During an interview on 08/27/25 beginning at 10:25 AM, ADON D stated ensuring medications were grouped together at the same time was a group effort. ADON D stated the nurse was responsible for putting the orders into the computer system. ADON D stated the nurse was responsible for administering the medication within the appropriate timeframes. ADON D stated medications should have been administered between one hour before the scheduled time or one hour after the scheduled time. ADON D stated Resident #1 and Resident #2's medications should have been scheduled at the time as possible. ADON D stated it was important to ensure medications were given within the appropriate timeframes to prevent drug interactions or overdose. During an interview on 08/27/25 beginning at 10:29 AM, the DON stated medications should have been given between one hour before or one hour after the scheduled time. The DON stated the nursing staff tried to group medications at the same time as possible. The DON stated she expected the nurse to explain or communicate any issues with medication administration to the management staff, such as inability to administer medications within the required timeframes. The DON stated nursing management could have consulted with the pharmacist and physician to ensure medications could have been given together during the same time. The DON stated it was important to ensure medications were given within the scheduled timeframes to ensure the best interest of the residents. During an interview on 08/27/25 beginning at 12:33 PM, the Administrator stated she expected the nurses to ensure medications were given according to the appropriate standards of practice and within the required timeframes. The Administrator stated nursing management was responsible for monitoring to ensure medications were given within the required timeframes. The Administrator stated it was important to ensure medications were given within the scheduled timeframes to prevent adverse drug side effects. Record review of the General Guidelines for Medication Administration policy, revised 08/2020, reflected .at a minimum, the 5 rights - .right time. - should be applied to all medication administration and reviewed at three steps in the process of preparation. medications are administered within 60 minutes of the scheduled administration time.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 4 of 7 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for quality of care. The facility failed to ensure Resident #1's had a skin assessment performed weekly on 8/9/24 and 8/16/24 per facility policy. The facility failed to ensure Resident #2, Resident #3, and Resident #4 had skin assessment performed weekly on 8/16/24 per facility policy. These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 8/28/24 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, hypertension (elevated blood pressure), muscle weakness, and depression. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #1 was at risk for developing pressure ulcers. Record review of the care plan revised 7/5/24 indicated Resident #1 was at moderate risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #1 had a skin assessment on 8/2/24 and 8/23/24. The weekly skin assessments indicated Resident #1 did not have a skin assessment on 8/9/24 or 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #1 did not have any skin impairment. 2. Record review of the face sheet dated 8/28/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, diabetes, psychosis (a mental disorder characterized by a disconnection from reality), and hypertension. Record review of the MDS dated [DATE] indicated Resident #2 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #2 had a BIMS of 08 and was moderately cognitively impaired. The MDS indicated Resident #2 was at risk for developing pressure ulcers Record review of the care plan revised 6/3/2024 indicated Resident #2 was at minimum risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #2 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #2 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 had redness under her right breast. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 redness/moisture under her left and right breasts. Record review of the weekly skin assessment dated [DATE] indicated Resident #2 had yeast rash/redness under her left and right breasts with a treatment in place. 3. Record review of the face sheet dated 8/28/24 indicated Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #3 usually understood others and was usually understood by others. The MDS indicated Resident #3 had a BIMS of 06 and was severely cognitively impaired. The MDS indicated Resident #3 was at risk for developing pressure ulcers. Record review of the care plan revised 4/14/24 indicated Resident #3 had an ADL self-care deficit. Record review of the weekly skin assessment for August 2024 indicated Resident #3 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #3 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #3 did not have any skin impairment. 4. Record review of the face sheet dated 8/28/24 indicated Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, diabetes, hypertension, and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the MDS dated [DATE] indicated Resident #4 usually understood others and was usually understood by others. The MDS indicated Resident #4 had a BIMS of 09 and was moderately cognitively impaired. The MDS indicated Resident #4 was not at risk for developing pressure ulcers. Record review of the care plan revised 6/4/24 indicated Resident #4 was at minimum risk for impaired skin integrity with interventions including licensed nurse would assess skin and document assessment weekly. Record review of the weekly skin assessment for August 2024 indicated Resident #4 had a skin assessment on 8/2/24, 8/9/24 and 8/23/24. The weekly skin assessments indicated Resident #4 did not have a skin assessment on 8/16/24. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 did not have any skin impairment. Record review of the weekly skin assessment dated [DATE] indicated Resident #4 had yeast rash/redness to her left and right breasts. During an interview on 8/28/24 at 2:13 p.m. the Treatment Nurse said she had been the Treatment Nurse for approximately 2.5 years. The Treatment Nurse said skin assessments should be performed weekly. The Treatment Nurse said skin assessments were documented in the residents' EMR. The Treatment Nurse said the importance of weekly skin assessments was to observe each resident's skin and catch any skin issues early. The Treatment Nurse said the reason she did not perform skin assessments on Resident #1, Resident #2, Resident #3, and Resident #4 the week of 8/12/24 through 8/16/24 was because she was off work on 8/14/24, 8/15/24, and 8/16/24. The Treatment Nurse said she did not know who was responsible for completing skin assessments while she was off. The Treatment Nurse said the DON would had to have assigned the skin assessments to someone. The Treatment Nurse said Resident #1 not having a skin assessment documented for 8/9/24 was an oversight on her part. The Treatment Nurse said she knows she did a skin assessment on Resident #1 that day, but it could not be proven she had performed a skin assessment or if the resident had any issues if it was not documented. The Treatment nurse said a yeast rash could worsen in a week's time. During an interview on 8/28/24 at 2:46 p.m. the DON said skin assessments should be performed weekly and as needed. The DON said the Treatment Nurse was responsible for performing weekly scheduled skin assessments. The DON said if the Treatment Nurse was off then either the charge nurse or another designated nurse was responsible for weekly scheduled skin assessments. The DON said she and the ADON would verbally tell the nurses and hang notes at each nursing station to let them know when they were responsible for the weekly scheduled skin assessments. The DON said the importance of weekly skin assessments was to inspect the skin for any rashes, wound, skin tears, bruising, etc. and monitor existing skin issues. The DON said on 8/14/24, 8/15/24, and 8/16/24 the charge nurses would have been responsible for completing the weekly skin assessments due to the Treatment Nurse being off. The DON said she would have expected the weekly skin assessment that were due to have been performed on 8/2/24 and 8/9/24. The DON said it was possible for skin issues to worsen in a week's time. During an interview on 8/28/24 at 3:27 p.m. the Administrator said she expected skin assessments to be performed weekly and on admission. The Administrator said the Treatment Nurse was responsible for weekly skin assessments and the admitting nurse was responsible for the skin assessment on admission. The Administrator said July 1, 2024, the facility got a new EMR system. The Administrator said with the new EMR system the skin assessments populate automatically to let the Treatment Nurse or charge nurse know a skin assessment was due. The Administrator said if the Treatment Nurse was off work, it was the responsibility of the charge nurses to complete the skin assessments. The Administrator said the importance of weekly skin assessments was to inspect for skin issues and ensure skin issues are not deteriorating. The Administrator said skin issues could happen quickly and deteriorate quickly sometimes in as little as 2 hours. Record review of the facility's Wound Management policy revised June 2020 indicated, To provide a system for the treatment and management of residents with wounds including pressure and non-pressure .A Licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident .

Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 19 of 74 residents (Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60, Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110) reviewed for immunizations. The facility failed to offer and administer the influenza and pneumococcal vaccination to Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60. The facility failed to offer and administer the pneumococcal vaccination to Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110. The facility failed to offer and administer the influenza vaccination to Resident #67, Resident #68, Resident #60. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings included: Record review of a facility's Influenza and Pneumonia Vaccines list run date 05/30/34 was provided on 07/16/24. The list indicated Residents #39, Resident #38, Resident #7, Resident #53, Resident #33, Resident #58, Resident #56, Resident #54, Resident #2, Resident #67, Resident #68, Resident #60 had not received or refused influenza or pneumococcal vaccinations. The list indicated Resident# 107, Resident #51, Resident #72, Resident #108, Resident #44, Resident# 109, and Resident #110 had not received or refused pneumococcal vaccinations. The list indicated Resident #67, Resident #68, Resident #60 had not received or refused influenza vaccination and was not admitted out of influenza season. During an interview on 07/17/24 at 5:07 p.m., the DON said the ADON was responsible for ensuring residents were offered and received vaccinations. She said the DON should be ensuring the ADON kept an accurate record of resident's vaccination status and administered vaccinations. She said she was not aware 19 out of 74 residents had not received the influenza and/or pneumonia vaccine. She said vaccination was important for prevention. She said vaccinations helped prevent the resident from getting sick and reduced the resident's symptoms if the virus was contracted. She said residents not receiving vaccinations place residents at risk for contracting the virus and spreading the virus. During an interview on 07/17/24 at 6:00 p.m., the ADM said the DON was responsible in ensuring the resident were offered and received the flu and pneumonia vaccine. She said being vaccinated helped the resident, if contracted the virus, decreased the severity of the illness. She said vaccinations were a protection against viruses. During an interview on 07/22/24 at 2:28 p.m., the ADON said vaccines were offered to all residents during the admission process. He said he often had to reach out to families/PCPs to obtain prior vaccine information for residents. He said vaccines were an important prevention tool the facility used to decrease the risk of preventable infection for the resident. Record review of a facility's Influenza Prevention and Control policy revised 06/2020, indicated .to ensure that the Facility prevents and controls the spread of influenza in the Facility .influenza vaccinations of residents .residents are offered an influenza immunization during flu season annually, unless the immunization is medically contraindicated .the resident's medical record includes documentation that indicates, at a minimum .that the resident either received the influenza immunization or did not receive . Record review of a facility's Pneumococcal Disease Prevention policy revised 06/2020, indicated .to ensure that the Facility prevents and controls the spread of pneumococcal disease in the facility .the pneumococcal polysaccharide vaccine is recommended for the following .residents of nursing homes or long term care facilities . the resident's medical record includes documentation that indicates, at a minimum .that the resident either received the pneumococcal polysaccharide vaccine or did not receive .

Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 33, Resident #35, Resident #54, Resident #69) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #33 had side effect monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Seroquel ((is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)), Buspirone (antianxiety; is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety, and Venlafaxine (antidepressant; is used to treat depression) and Remeron ((is an atypical antidepressant (are prescription medicines to treat depression)) for July 2024. 2. The facility failed to ensure Resident #35 had behavior monitoring (monitor activities and mood) for her prescribed Paroxetine ((antidepressant; is used treat depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest)) and Lorazepam (antianxiety; is used to treat anxiety) for July 2024. 3. The facility failed to ensure Resident #35 had side effect monitoring for her prescribed antidepressant and antianxiety for July 2024. 4. The facility failed to ensure Resident #54 had side effect monitoring for her prescribed Depakote (anticonvulsant; is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) used to treat a mood disorder for July 2024. 5. The facility failed to ensure Resident #69 had an appropriate diagnosis for her prescribed Seroquel and Hydroxyzine (Antihistamines (medicines often used to relieve symptoms of allergies,), Miscellaneous anxiolytics (are medications that can treat anxiety and related conditions), sedatives, and hypnotics (used to reduce tension and anxiety and induce calm (sedative effect) or to induce sleep (hypnotic effect)); is used to treat anxiety disorders and allergic conditions, especially those that involve the skin). 6. The facility failed to ensure Resident #69 had behavior monitoring for her prescribed Seroquel and Hydroxyzine for July 2024. 7. The facility failed to ensure Resident #69 had side effect monitoring for her prescribed Seroquel and Mirtazapine (Remeron) for July 2024. These failures could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and bipolar disorder. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #31 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. Record review of Resident #33's order summary dated 07/17/24, indicated: *Buspirone tablet 5 mg, give 1 tablet by mouth two times a day related to depression. Started date 11/20/23. *Venlafaxine Oral Tablet 37.5 mg, give 1 tablet by mouth one time a day related to depression. Started date 11/20/23. *Remeron Oral Tablet 15 mg (Mirtazapine), give 1 tablet by mouth at bedtime related to depression. Started date 05/15/24. *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Started date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Started date 05/14/24. Further review revealed there was no order for side effect monitoring noted for AP, AA, and AD. Record review of Resident #33's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AP, AA, and AD. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Only received behavior monitoring flowsheet for AP, AA, and AD for Resident #33. 2. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #35 received an antianxiety and antidepressant during the last 7 days of the assessment period. Record review of Resident #35's care plan dated 04/16/24 indicated Resident #35 had potential for drug related complications related to antidepressant medications. Intervention included monitor side effects. Record review of Resident #35's order summary dated 07/16/24, indicated: *Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Started date 07/02/24. *Ativan Oral Tablet 1 mg (Lorazepam), give 1 tablet by mouth in the morning related to anxiety disorder. Started date 07/03/24. *Ativan Oral Tablet 0.5 mg (Lorazepam), give 1 tablet by mouth every 4 hours as needed for anxiety related to anxiety disorder. Started date 07/02/24. Further review revealed there was no order for behavior or side effect monitoring noted for AD and AA. Record review of Resident #35's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AD and AA. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received June 2024 behavior and side effect monitoring flowsheet for AD and AA for Resident #35. 3. Record review of Resident #54's face sheet dated 07/15/24 indicated Resident #54 was a [AGE] year-old, female admitted on [DATE] with diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression, and mood affective disorder (is a mental health condition that primarily affects your emotional state). Record review of Resident #54's quarterly MDS assessment dated [DATE], indicated Resident #54 was usually understood and sometimes understood others. Resident #54 had a BIMS of 00 which indicated severe cognitive impairment. The MDS indicated Resident #54 had received an antianxiety and antidepressant during the last 7 days of the assessment period. The MDS did not indicate Resident #54 had diagnosis including depression. Record review of Resident #54's care plan dated 03/14/24, edited on 06/07/24, indicated Resident #54 had depression as evidence by diagnosis/history of depression and mood disorder, and wandering. Intervention included administer anti-depressant medication as ordered by MD. Record review of Resident #54's order summary dated 07/17/24, indicated: *Depakote Extended-Release Oral Tablet 24-hour 250 mg, give 1 tablet by mouth one time a day for mood disorder. Started date 02/26/24. *Depakote Delayed Release Oral 500 mg, give 1 tablet by mouth at bedtime for mood disorder. Started date 03/02/24. Further review revealed there was no order for side effect monitoring noted for an AC. Record review of Resident #54's MAR dated 07/01/24-07/31/24, indicated there was no documentation of behavior or side effect monitoring noted for AC: On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received side effect and behavior monitoring for AD and AA for Resident #54. 4. Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. No diagnosis of anxiety noted. No appropriate diagnosis for AP noted. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. The MDS indicated Resident #69 received an antianxiety and antipsychotic during the last 7 days of the assessment period. Record review of Resident #69's care plan dated 07/03/24, indicated: *Resident #69 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. *Resident #69 had potential drug related complication to antipsychotic medication. Intervention included monitor for side effects of antipsychotic medication every shift. Record review of Resident #69's order summary dated 07/17/24 indicated: *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth at bedtime for antipsychotic. Started date 06/22/24. *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Start date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Start dated 07/15/24. Further review revealed there was no order for behavior and side effect monitoring for AP ,hypnotic , and AD noted. Record review of Resident #69's MAR dated 07/01/24-07/31/24 indicated there was no documentation of behavior or side effect monitoring noted for AP, hypnotic, and AD. On 07/17/24 at 2:37 p.m., requested behavior and side effect monitoring for July 2024 from the ADM and Regional DOO by email. Received side effect monitoring for hypnotic only for Resident #69. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said medical records put diagnoses in the electronic computer system. She said active resident's diagnoses were obtained from physician notes and the diagnoses list. During an interview on 07/17/24 at 4:10 p.m., LPN M said behavior and side effect monitoring was done every shift by the nurse. She said when the psychotropic medication was ordered, the nurse should also add behavior and side effect monitoring that correlated with the medication. She said it was important to assess behaviors and potential side effects to understand why the medication was prescribed and treating and to know if the medication was helping with the resident's behaviors. She said if the side effect were not being monitored, side effect to the medication could be missed. She said the orders for behavior and side effect monitoring noted behaviors and side effects to look for, which helped staff know what side effects and behaviors to look for. She said she did not know who was responsible for resident's having appropriate diagnoses for antipsychotic medications. During an interview on 07/17/24 at 5:07 p.m., the DON said the nurse on admission and/or the nurse who took the psychotropic medication order was responsible for ordering behavior and side effect monitoring for each type of medication ordered. She said the ADON and DON should be ensuring psychotropic medication had side effect and behavior monitoring. She said the ADON reviewed new medication orders and should at that time ensure monitoring was ordered. She said behavioral monitor let you know if the medication was effective treating the diagnosis or behavior. She said the behavior monitoring could also show if the medication was too effective. She said if monitoring was not done, staff did not know if the medication was helping or not and if the resident was experiencing adverse side effects. She said the MDS coordinator and nurses were responsible in ensuring residents had an appropriate diagnosis for medications. She said antipsychotic on Resident #69's order as being the diagnosis, was not an appropriate diagnosis for Seroquel use. She said the facility should have contacted Resident #69's previous admitting facility to get appropriate diagnosis for Seroquel and Lorazepam or contact the transferring hospital. She said the facility could have also contacted her physician about her diagnoses. She said appropriate diagnoses for psychotropic medications were important to make sure residents were not being treated with the wrong medication, helped prevent oversedation, and helped them not receive a medication not needed. She said the ADON reviewed admission orders and should be noticing inappropriate diagnoses for medication. She said another way to ensure psychotropic medication had an appropriate diagnosis was the facility should request medical records from the admitting facility on admission to get or add the appropriate diagnosis from the documentation received. During an interview on 07/17/24 at 6:00 p.m., the ADM said the DON and ADON should ensure residents had appropriate diagnoses for psychotropic medications. She said the DON should be monitoring the process to ensure it was being done. She said appropriate diagnoses were important to ensure the diagnosis fit the medication ordered. She said there were medications that were approved for off labeled use so making sure there was an appropriate diagnosis was important. She said the diagnosis needed to fit what it was manufactured for. Record review of a facility's Psychotherapeutic Drug Management policy revised 10/24/22, indicated .to ensure the resident receives only those medications, in dose and for duration clinically indicated to treat the resident's assessed condition(s) .to ensure that any potential contributions the medication regimen has to an unanticipated decline or newly emerging or worsening symptoms is recognized and evaluated .the Facility will make every effort to comply with state and federal regulations .side effects .psychotropic medications .are drugs that affect brain activities associated with mental processes and behavior .categories of medications which affect brain activity include antihistamines .and central nervous system agents used to treat conditions such as seizures, mood disorders, pseudobulbar affect .the requirement pertaining to psychotropic medications apply to these types of medications when their documented use appears to be substitution for another psychotropic medication rather than the original or approved indication .attending medical practitioner responsibility .the psychotherapeutic medication order will include the following .diagnosis for the medication .indications and manifestations of the disorder treated .nursing responsibilities .will monitor psychotropic drug use daily noting any adverse effects .monitoring should also include evaluation of the effectiveness of non-pharmacological approaches .will monitor the presences of target behaviors on a daily basis charting by exception .

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 10 resident reviewed for assessments. (Resident #31, Resident #33, and Resident #54) The facility failed to ensure Resident #31's diagnoses of anxiety (persistent and excessive worry that interferes with daily activities) and depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest) was coded on her MDS. The facility failed to ensure Resident #33's diagnoses of bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depression was coded on her MDS. The facility failed to ensure Resident #54's diagnosis depression was coded on her MDS. These failures could place residents at risk of not having individual needs met. Findings included: 1. Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including depression and anxiety disorder. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 was prescribed an antianxiety during the last 7 days of the assessment period. The MDS did not indicate Resident #31 had diagnoses including anxiety and depression. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated Resident #31 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. 2. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression and bipolar disorder. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. The MDS did not indicate Resident #33 had diagnoses including bipolar and depression. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #31 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. 3. Record review of Resident #54's face sheet dated 07/15/24 indicated Resident #54 was a [AGE] year-old, female admitted on [DATE] with a diagnosis of depression . Record review of Resident #54's quarterly MDS assessment dated [DATE], indicated Resident #54 was usually understood and sometimes understood others. Resident #54 had a BIMS of 00 which indicated severe cognitive impairment. The MDS indicated Resident #54 had received an antianxiety and antidepressant during the last 7 days of the assessment period. The MDS did not indicate Resident #54 had diagnosis including depression. Record review of Resident #54's care plan dated 03/14/24, edited on 06/07/24, indicated Resident #54 had depression as evidence by diagnosis/history of depression and mood disorder, and wandering. Intervention included administer anti-depressant medication as ordered by MD. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said she was responsible for resident's MDSs. She said medical records put diagnoses in the electronic computer system. She said active resident's diagnoses were obtained from physician notes and the diagnoses list. She said some of the resident's diagnoses may not be added because another staff member in training completed their MDS. She said RUGS, during their yearly review, recommended MDSs have active diagnoses only which are obtained from the most recent physician's progress notes. She said the other staff member in training probably followed those recommendations when she completed Residents #31, #33, and #54's MDS. She said she did not check over every MDS the staff member in training completed independently to make sure they were correct. She said all of Resident #31, #33, and #54's mental health diagnoses should be coded on their MDSs. She said she did check the progress notes for active diagnoses but if the resident was on a medication to treat a diagnosis not listed, she coded it on the MDS anyway. She said it was important for MDSs to be accurate so it could be reflected on the resident's care plan. During an interview on 07/17/24 at 5:07 p.m., the DON said the MDS coordinator was responsible for coding resident diagnoses. She said resident's psychiatric diagnoses should be coded on their MDSs. She resident's MDS should reflect the condition of the resident. She said the new company's regional MDS coordinator was the one who provided oversight and monitored the MDS coordinator. She said inaccurate MDSs affected the resident's plan of care and the facility's billing. During an interview on 07/17/24 at 6:00 p.m., the ADM said the RN who reviewed the MDS before submission was responsible for the MDS accuracy. She said she expected resident's mental illnesses to be coded on their MDS. She said MDSs should be accurate because it ensured care of the resident and proper medication and treatment. She said the RN coordinator or MDS coordinator should monitor the submitted MDSs for accuracy. Requested an accuracy of assessment policy from the ADM. Record review of a facility's Documentation-Nursing policy revised 06/2020, indicated .minimum data set (MDS) completion per CMS and Medicare guidelines .

Based on interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 5 of 21 residents reviewed for the right to be informed. (Resident's #21, #31, #33, #35, and #69) 1. The facility failed to ensure Resident #21 had a signed psychotropic consent form for Duloxetine (antidepressant medication) or Haloperidol (antipsychotic medication). 2. The facility failed to ensure Resident #31's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consent was completed for Depakote (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches). 3. The facility failed to ensure Resident #33's psychoactive medication therapy consent was completed for Seroquel (is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs)). 4. The facility failed to ensure Resident #35's psychoactive medication therapy consent was completed for Paroxetine (is used treat depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), obsessive-compulsive disorder (is a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both) and anxiety disorders (persistent and excessive worry that interferes with daily activities)). 5. The facility failed to ensure Resident #69's psychoactive medication therapy consent was completed for Hydroxyzine (is used to treat anxiety disorders and allergic conditions, especially those that involve the skin) and Mirtazapine (is an atypical antidepressant (are prescription medicines to treat depression) and is used primarily for the treatment of a major depressive disorder (is a mood disorder that interferes with daily life)). These failures could place residents at risk for treatment or services provided without their informed consent. Findings included: 1 .Record review of the undated face sheet revealed Resident #21 originally admitted [DATE] and readmitted [DATE]. She was an [AGE] year-old female. Record review of the quarterly MDS dated [DATE] revealed Resident #21 understood others and was understood by others. She had a BIMS of 14 indicating her cognition was intact. The MDS revealed she had disorganized thinking that fluctuated in severity. She had a diagnosis of Schizophrenia. The MDS indicated she was taking an antipsychotic and antidepressant. Record review of the care plan dated 1/30/24 indicated Resident #21 had a potential for complications related to antipsychotic medication with a goal of stabilizing major psychiatric diagnosis, minimize agitated behaviors, and would not have side effects. Resident #21 had an alteration in thought process, memory impairment and confusion related to dementia .with paranoia/delusions (frequently speaks of her husband as having an affair, will say it is staff members at times,) history of behaviors, verbal and physical aggression, anger and wandering. She had a potential for psychotic behavior with a diagnosis of psychosis related to Schizophrenia. Record review of the physician's orders dated 7/17/24 revealed Resident #21 had diagnoses that included: dementia with behavioral disturbance (loss of cognitive functioning, including restlessness and accusatory behaviors), Parkinsonism (brain conditions that cause slowed movements, rigidity and tremors), and schizoaffective disorder (hearing voices, unusual beliefs, depression or mania). Further review of the orders included the following medications: *7/8/24 Duloxetine HCL Oral Capsule Delayed Release, give 1 capsule by mouth two times a day related to unspecified dementia, moderate, with other behavioral disturbance. *7/8/24 Haloperidol oral tablet 0.5 mg by mouth at bedtime related to unspecified dementia, moderate, with other behavioral disturbance. Give with 1 mg tablet for a total of 1.5 mg. *7/8/24 Haloperidol oral tablet 1 mg by mouth at bedtime related to unspecified dementia, moderate, with other behavioral disturbance. Give with 0.5 mg tablet for a total of 1.5 mg. During an interview on 07/17/24 at 2:26 PM, the DOO said they could not find the consents for Resident #21's Duloxetine or her Haloperidol. He said there was a problem with consents, and they were currently doing an audit. 44933 2. Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including pseudobulbar affect (is a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), depression, anxiety disorder, and mood affective disorder (is a mental health condition that primarily affects your emotional state). The face sheet indicated Resident #31 family members were her responsible party. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 was prescribed an antianxiety during the last 7 days of the assessment period. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated Resident #31 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. Record Review of Resident #31's order summary report dated 07/16/24 indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for anxiety/agitation. Start date 07/05/24. Record review of Resident #31 MAR dated 07/01/24-07/31/24 indicated Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg, give 1 capsule by mouth two times a day for anxiety/agitation. Order date 07/05/24. On 07/17/24 at 12:57 p.m., requested Resident #31's Depakote consent from ADM and Regional DOO by email. Resident #31's consent was not received prior or after exit. 3. Record review of Resident #33's face sheet dated 07/16/24, indicated Resident #33 was a [AGE] year-old female admitted on [DATE] with diagnoses including depression, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and bipolar disorder. Resident #33's face sheet indicated a family member was her responsible party. Record review of Resident #33's quarterly MDS assessment dated [DATE], indicate Resident #33 was usually understood and sometimes had the ability to understand others. Resident #33's BIMS score was 09 which indicated moderately impaired cognition. Resident #33's MDS indicated she had been prescribed an antipsychotic, antianxiety, and antidepression during the last 7 days of the assessment period. Record review of Resident #33's care plan dated 12/01/23, edited on 06/04/24 indicated Resident #33 had potential for drug related complication related to psychotropic drug use related to medical diagnoses of depression, bipolar, and insomnia. Resident #33 received antianxiety medication, antidepressant medication, and antipsychotic medication. Intervention included obtain consent for psychotropic drug use. Record review of Resident #33's order summary dated 07/17/24, indicated the following medications : *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Start date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Start date 05/14/24. Record review of Resident #33's MAR dated 07/01/24-07/31/24 indicated: *Seroquel Oral Tablet 25 mg, give 1 tablet by mouth one a day related to bipolar disorder. Order date 05/14/24. *Seroquel Oral Tablet 50 mg, give 1 tablet by mouth at bedtime related to depression. Order date 05/14/24. On 07/17/24 at 8:34 a.m., requested Resident #33's Seroquel consent from ADM and Regional DOO by email. Resident #33's consent was not received prior or after exit. 4. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. The face sheet indicated Resident #35 family member were her responsible party. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #35 received an antianxiety and antidepressant during the last 7 days of the assessment period. Record review of Resident #35's care plan dated 04/16/24 indicated Resident #35 had potential for drug related complications related to antidepressant medications. Intervention included monitor side effects. Record review of Resident #35's order summary dated 07/16/24, indicated Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Start date 07/02/24. Record review of Resident #35's MAR dated 07/01/24-07/31/24 indicated Paroxetine Oral Tablet 20 mg, give 1 tablet by mouth at bedtime for mood. Order date 07/02/24. On 07/17/24 at 10:16 a.m., requested Resident #35's Paroxetine consent from ADM and Regional DOO by email. Resident #35's consent was not received prior or after exit. 5. Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. The face sheet indicated Resident #69 family member was her responsible party. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. The MDS indicated Resident #69 received an antianxiety and antipsychotic during the last 7 days of the assessment period. Record review of Resident #69's care plan dated 07/03/24, indicated Resident #69 had potential for drug related complication related to anxiolytic /sedative medications. Intervention included monitor side effects. Record review of Resident #69's order summary dated 07/17/24 indicated the following medications: *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Start date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Start dated 07/15/24. Record review of Resident #69's MAR dated 07/01/24-07/31/24 indicated: *Hydroxyzine Oral Tablet 25 mg, give 1 tablet orally every 8 hours as needed for anxiety. Order date 06/22/24. *Mitrazapine Oral Tablet 7.5 mg, give 1 tablet by mouth at bedtime for appetite stimulation. Order dated 07/15/24. On 07/16/24 at 2:07 p.m., called Resident #69's RP to discuss psychotropic consents. Resident #69's RP did not answer, and voicemail left with call back number. Call back was not received prior or after exit. On 07/17/24 at 10:16 a.m., requested Resident #69's Hydroxyzine and Mitrazapine consent from ADM and Regional DOO by email. Resident #69's consent was not received prior or after exit. During an interview on 07/17/24 at 4:10 p.m., LPN M said the nurses were responsible for obtaining consent for psychotropic medications. She said consent should be obtained before the medication was given. She said the power of attorney or resident should give consent for the psychotropic medication, verbally or in person. She said it was important to get consent for psychotropic medications to make sure the resident was not allergic to the medication and able to take the medication. She said if consent was not given, the resident or power of attorney may not be aware of the risk and benefits of the medication. During an interview on 07/17/24 at 5:07 p.m., the DON said the nurses were responsible for obtaining consent for psychotropic medications. She said consent should be obtained from the RP. She said consent should be done on admission and when the medication was ordered. She said the ADON was responsible for ensuring the nurses obtaining consent for psychotropic medications. She said she did not know the ADON's process in monitoring psychotropic consents being obtained by the nurses. She said it was important to obtain consent, so the facility was not medicating a resident without consent. She said it was important to obtain consent, so the RP and resident knew the risk and benefits and to decide if they want to take it. She said she did not know why Residents #21, #31, #33, #35, and #69 did not have consent for their psychotropic medications. She said the ADON was at home with a family situation. During an interview on 07/17/24 at 6:00 p.m., the ADM said the admitting nurse should get the psychotropic consents signed by the RP or resident on admission. She said verbal consent could be obtained and signed eventually when the family visited. She consents should be obtained prior to the medication being administered. She said getting consent was important so the RP and resident could make an informed decision and be clear on what the medication was treating. She said the DON should be monitoring resident's psychotropic consents. Record review of a facility's Psychotherapeutic Drug Management policy revised 10/24/22, indicated .attending medical practitioner responsibility .the psychotherapeutic medication order will include the following information .informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage .nursing responsibilities .the licensed nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the attending physician from the resident and/or surrogate decision maker, unless it is an emergency situation .

ased on interview and record review the facility failed to complete a performance review of each Certified Nurse Assistant (CNA) at least once every 12 months, for 5 of 5 (CNA J, CNA F, CNA H, CNA K, and CNA G) reviewed for annual competency evaluations. The facility failed to complete annual CNA competency evaluations for CNA J, CNA F, CNA H, CNA K and CNA G based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have a competency evaluation on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 5:07 p.m., the DON said the staffing coordinator was responsible for the CNA trainings and competency evaluations. She said CNAs evaluation were supposed to be done annually. She said when trainings and evaluations were not done, CNAs were working but not trained correctly. She said this risked the residents not getting the care they needed, and it being done incorrectly. During an interview on 07/17/24 at 6:00 p.m., the ADM said if CNAs were not trained properly or evaluated, CNAs may not be aware of changes, informed of new processes, and new information the facility wanted them to know. She said staff would be working with a lack of knowledge which placed residents at risk. A policy regarding staff development and training was requested at this time. On 07/18/24 at 4:29 p.m., the ADM sent an email stating the facility did not have a policy for staff development and training. The employee handbook was requested at this time. Record review of the facility's 2024 Employee Handbook dated 11/2020, indicated .the purpose of a performance review is to evaluate your past performance and to guide you to maintain and/or improve your future job performance .generally, your job performance may be reviewed 90 days after hire, transfer or promotion, and annually thereafter .all performance reviews become part of your personnel file .

ased on interview and record review, the facility failed to maintain ensure the required in-service trainings were sufficient for the continuing competencies of nurse aides but must be no less than 12 hours per year for 5 of 5 staff, (CNA F, CNA G, CNA H, CNA J, and CNA K) records reviewed for staff training. The facility failed to provide CNA F, CNA G, CNA H, CNA J, and CNA K 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff. Findings included: Record review of the Personnel File Review completed on 07/16/24, indicated CNA J, CNA F, CNA H, CNA K, and CNA G did not have 12 hours of training per year on file. The Personnel File Review indicated CNA J's date of hire was 03/07/17, CNA F 04/27/10, CNA H 01/22/02, CNA K 06/17/02, and CNA G 08/06/13. During an interview on 07/17/24 at 4:59 p.m., the HR Payroll said she had been at the facility for 4 months. She said she was responsible for training records, background checks, EMR and OIG results. She said she was responsible to notify the DON about training that needed to be completed. She said if trainings were not done, staff would not know the facility's protocols and procedures. During an interview on 07/17/24 at 5:07 p.m., the DON said she did not know the process or who was responsible for ensuring employees files were up to date. She said the staffing coordinator was responsible for the CNA trainings and competency evaluations. She said CNAs evaluation were supposed to be done annually. She said when trainings and evaluations were not done, CNAs were working but not trained correctly. She said this risked the residents not getting the care they needed, and it being done incorrectly. During an interview on 07/17/24 at 6:00 p.m., the ADM said HR was responsible for personnel files. She said records should be kept on want was completed upon hire and annually. She said if CNAs were not trained properly or evaluated, CNAs may not be aware of changes, informed of new processes, and new information the facility wanted them to know. She said staff would be working with a lack of knowledge which placed residents at risk. A policy regarding staff development and training was requested at this time. On 07/18/24 at 4:29 p.m., the ADM sent an email stating the facility did not have a policy for staff development and training to this surveyor. The employee handbook was requested at this time. Record review of the facility's 2024 Employee Handbook dated 11/2020, indicated .orientation& in-service training .ongoing training is necessary to provide the highest level of quality care to our resident/patients .you will be responsible for participating in orientation and training related to your position .your supervisor and/or Human Resources will communicate those requirements to you .

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 4 of 6 staff (CNA F, CNA H, CNA G, the DOR) reviewed for abuse policy. 1. The facility failed to ensure CNA F, CNA G, and DOR had criminal history background checks in their personnel file. 2. The facility failed to ensure CNA H had EMR in the personnel file. These failures could place residents at risk for unsafe environment and abuse. Findings included: Record review of a facility's Abuse Prevention and Prohibition Program policy revised 10/24/22, indicated .to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse .the administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems .screening .the facility does not knowingly employee anyone who has disciplinary action .a finding entered into the state nurse aide registry related to abuse .reporting/response .the facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin .immediately, but no later than 2 hours after forming suspicion . 1. Record review of the Personnel File Review completed on 07/16/24, indicated CNA F, CNA G, and DOR did not have a criminal history on file. The personnel file review indicated CNA H did not have a EMR report on file. The personnel file review indicated the DOH (date of hire) for CNA F was 04/27/2010, CNA G 08/06/2013, DOR 11/02/2020, and CNA H 01/22/2002. During an interview on 07/17/24 at 4:59 p.m., the HR Payroll said she had been at the facility for 4 months. She said she was responsible for background checks and running EMR reports. She said the previous HR Payroll did not tell her how often she was supposed to do background checks and EMR reports. She said with the new company, which took over at the beginning of the month (July 2024), their policy was to do it on hire and yearly. She said if the background checks or EMR report were not done, resident were at risk for abuse and facility hiring sex offenders. During an interview on 07/17/24 at 5:07 p.m., the DON said HR was responsible for running background checks and EMR on employees. She said not doing background checks and EMR reports risked the facility employing someone with a criminal history or misconduct on their license. During an interview on 07/17/24 at 6:00 p.m., the ADM said HR was responsible for performing background checks and EMR reports upon hire and annual. She said HR was responsible for the information being on the employee's file. She said when background checks and EMR reports were not done it risked sex offender being employed and employing someone with a conviction on the barred from hiring list. Record review of the facility's 2024 Employee Handbook dated 11/2020 indicated .criminal and other background checks .at the company, we pride ourselves on providing the highest level of quality care .one of the best ways to give our residents/patients and their families peace of mind that we have a safe and secure environment is to ensure we hire and maintain a workforce of high integrity .we therefore conduct reference checks, criminal background checks, and other background checks on hire and as required or appropriate at other times, to the extent permitted by law .

ased on interview and record review the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 18 residents reviewed for resident rights. (Resident #178) The facility failed to treat Resident #178 with respect and dignity when staff told her to urinate in her brief. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Record review of the face sheet dated 07/17/24 revealed Resident #178 was [AGE] years old female and admitted on [DATE] with diagnoses including Unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), insomnia (persistent problems falling and staying asleep) and Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors). Record review of the MDS dated [DATE] revealed Resident #178 BIMS was not performed and required maximal assistance for toilet use and moderate assistance for transfers, dressing, personal hygiene, and bathing. Record review of the care plan dated 04/04/24 revealed Resident #178 was at risk for skin breakdown/pressure injury related to decreased mobility and incontinence. Interventions included: Complete Braden assessment for early identification of risk factors and interventions. Nursing assistants to examine resident's skin daily for signs of redness or discoloration especially areas prone to breakdown such as boney prominences. Provide peri-care after each incontinent episode. Monitor labs per physician orders. (Especially albumin and pre-albumin) Provide nutritional assessment per RD and administer vitamins/supplements/medications as ordered by MD. Licensed Nurse to complete skin checks weekly. During an interview on 07/15/24 at 6:48 PM, Family Member #1 of Resident #178 said she was on the phone with Resident #178 when she heard a staff member told her to urinate on herself. Family Member #1 said she called the nursing station to get Resident #178 assistance to the bathroom when staff would not answer Resident #178's call light. Family Member #1 said Resident #178's roommate heard the staff tell her to urinate in her brief. Family Member #1 said she took Resident #178 home that night from the facility. During an interview on 07/16/24 1:45 PM, Resident #13 said she remembered Resident #178. Resident #13 said staff always tried to help her, but she refused their help. It depends on which time of day it waws with the accuracy of how long it would take for someone to come help her. Resident #13 said when Resident #178 told staff she had to use the bathroom, the staff would take her and she would not be able to urinate for about 30-45 minutes with staff waiting, so staff told her to go in her brief and they would change her. Resident #13 said one night Resident #178 called Family Member #1 and she came to get her, then took her home. Resident #13 said she thought the facility took care of Resident #178 while she was in the facility, but she was very difficult to take care of. During an interview on 07/16/24 at 1:59 PM, Family member #2 said Resident #178 called Family Member #1, because she had called for staff to assist her to the bathroom, but no one came. Family Member #2 said Family Member #1 told her that a staff member told Resident #178 to urinate in her brief. Family Member #2 stated she assisted Family Member #1 with transferring Resident #178 to the car, to go home. Family member #2 said Resident #178 cried when she got in the car, because she said the staff member told her to urinate in her brief. During an interview on 7/17/24 at 9:06 AM, RN L said he remembered Resident #178 leaving the facility. RN L said there was nothing the staff or the facility could do was satisfactory to the resident or the family. RN L said at night Resident #178 was on the call light nonstop, calling for items she could do on her own, like turn the light on and turn the light off. RN L said Family Member #1 told him she was taking Resident #178 home, because we could not provide adequate care for her at the facility. RN L said he remembered if she needed to go to the restroom the staff would take her. RN L said he does not recall telling Resident #178 to urinate in her brief. RN L said he did remember telling Resident #178 if she did wet her brief, he would change her brief. RN L said he remembered a couple times taking Resident #178 to the bathroom and she was very weak, so changing her brief was probably a safety precaution. During an interview on 7/17/24 at 2:57 PM, the DON said a staff member should never encourage a resident to urinate in their brief if they were aware of when they need to go to the bathroom. The DON said if a staff member told a resident to urinate on themselves, that was a dignity issue and potential for skin breakdown. During an interview on 7/17/24 at 3:15 PM, ADM said it is not ok for a staff member to tell a resident to urinate in their brief. We want the residents to stay independent as long as possible. If it were me, I would feel like they would not want to help me. I feel I am an adult, and it is a huge blow to your dignity, and it would make me feel like staff did not have time for me. Record review of a facility resident admission agreement dated 12/1/23 revealed . the facility shall offer personal care . the facility will also offer nursing care, activities, restorative and rehabilitative services and psychosocial care as identified by the Resident's Plan of Care established by the Facility Standards and in accordance with the policies of the facility.

Based on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 5 residents (Resident #31) reviewed for a homelike environment. The facility failed to ensure Resident #31's wheelchair was clean. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Record review of Resident #31's face sheet dated 07/16/24, indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), muscle weakness, and abnormalities of gait and mobility. Record review of Resident #31's quarterly MDS assessment dated [DATE], indicated Resident #31 was sometimes understood and sometimes had the ability to understand others. Resident #31 was unable to complete the BIMS assessment. Resident #31 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #31 used a wheelchair as a mobility device. Resident #31 required supervision for oral hygiene, maximal assistance for personal hygiene and putting on/taking off footwear, and dependence for toileting hygiene and dressing. Record review of Resident #31's care plan dated 12/28/23, edited on 06/19/24, indicated: *Resident #31 had ADL functional status/rehabilitation potential and self-care deficit with oral care, dressing, eating, bathing, grooming, and resistive to ADL assistance at times. Intervention included able to feed self after tray set-up. *Resident #31 had falls and was high risk related to cognitive deficits with poor safety awareness. Intervention included lock all moveable equipment before transferring residents. During an observation on 07/15/24 at 11:30 a.m., Resident #31 was a dining room table in her wheelchair. Resident #31 made constant noise, humming, or counting out load. Resident #31 was un-interviewable. Resident #31's wheelchair wheels had moderate amount of dried substance splattered throughout both wheels. Resident #31's wheelchair had a moderate amount of hair tangled where the wheels and the frame connected. During an observation on 07/16/24 at 9:00 a.m., Resident #31 was self-propelling herself aimlessly up and down the secured unit hallway. Resident #31's wheelchair wheels had moderate amount of dried substance splattered throughout both wheels. Resident #31's wheelchair had a moderate amount of hair tangled where the wheels and the frame connected. During an interview and observation on 07/17/24 at 3:48 p.m., CNA J said Resident #31 used her wheelchair to get around. She said maintenance was responsible for the upkeep of resident's wheelchairs. She said the CNAs were responsible for wiping down the wheelchairs. CNA J entered Resident #31's room and inspected her wheelchair. She said the wheelchair was dirty, but the CNAs normally cleaned the seat area not the wheels. She said maintenance would be able to take the wheels off and clean them better than the CNAs. She said residents should not have dirty wheelchair because of infection control. She said the dried food could attract pest and the dementia residents could eat the food particle from the wheelchair not knowing it was dirty. CNA J said she would take the wheelchair out of Resident #31's room so maintenance could look at it. CNA J left the secured unit to locate the maintenance supervisor. During an interview and observation on 07/17/24 at 4:07 p.m., the maintenance supervisor arrived on the secured unit and inspected Resident #31's wheelchair. He said Resident #31's wheelchair needed cleaning. He said the CNAs and maintenance was responsible for cleaning resident's wheelchairs. He said residents should not have dirty wheelchairs because of infection control. During an interview on 07/17/24 at 4:10 p.m., LPN M said the night shift CNAs were probably responsible for cleaning the resident's wheelchairs. She said that would be the best time since the residents would be asleep. She said but anyone who noticed a dirty wheelchair should clean it. She said a dirty wheelchair was unsanitary and staff who put the resident it the wheelchairs should be inspecting them for cleanliness all the time. During an interview on 07/17/24 at 5:07 p.m., the DON said anyone could clean resident's wheelchairs. She said maintenance was responsible for the upkeep of resident's wheelchairs, but staff had to inform him of the issue. She said it was an infection control issue if a resident was using a dirty wheelchair. During an interview on 07/17/24 at 6:00 p.m., the ADM said CNAs were responsible for cleaning resident's wheelchairs. She said it was important for residents to not have dirty wheelchairs because of esthetic and infection control. She said ultimately it was maintenance responsibility to maintain resident's wheelchairs. Record review of a facility's Cleaning and Disinfection of Environmental Surfaces and Equipment policy revised 06/2020 indicated .to ensure that the cleaning and disinfection of environmental surfaces is in accordance with Centers for Disease Control and Prevention (CDC) and Occupational Safety and Health Administration (OSHA) guidelines .non-critical items are those that come in contact with intact skin but not mucous membrane .most non-critical items can be decontaminated where they are used .

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 18 residents (Resident #35) reviewed for abuse and neglect. The facility failed to report Resident #35's injury of unknown origin to her face, within 24 hours to the state agency. This failure could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely. Findings included: Record review of a facility's Abuse Prevention and Prohibition Program policy revised 10/24/22, indicated .to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse .the administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems .reporting/response .the facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin .immediately, but no later than 2 hours after forming suspicion. Record review of Resident #35's face sheet fated 07/16/24, indicated Resident #35 was a [AGE] year-old female admitted on [DATE] and 04/17/24 with diagnoses including anxiety disorder and dementia. Record review of Resident #35's significant change in status MDS assessment dated [DATE], indicated resident #35 usually understood and sometimes had the ability to understand others. Resident #35 was unable to complete the BIMS assessment. Resident #35 had short-and-long term memory recall problem and moderately impaired cognitive skills for daily decision making. Resident #35 had other behavioral symptoms not directed toward others and daily behavior of rejection of care. The MDS indicated her current behavior status have worsen compared to prior assessment. Resident #35 required moderate assistance for toileting and personal hygiene, dressing, putting on/taking off footwear and dependent for shower/bathe self. Record review of Resident #35's care plan dated 04/16/24, indicated Resident #35 had an alteration in thought process related to dementia with memory deficits, impaired decision making, confusion/disorientation, making self-understood: impaired, and understanding others: impaired. Intervention included always approach in a calm nurturing manner. Record review of Resident #35's care plan dated 05/02/24, indicated Resident #35 had a risk for bruises/discoloration related to fragile skin, restless movements, repeated falls, aspirin use. Intervention included monitor arms and legs during transfer and ADL care. Record review of Resident #35's weekly skin check dated 07/01/24 indicated no skin impairments found. Record review of Resident #35's accident/incident report dated 07/01/24, indicated .Resident #35 .resident's room .incident time: 6:30 p.m.reported by: family member (present in room) .reported to: LVN N .family member in room alerted nurse small bruise noted to Resident's [#35] right jaw .dime size bruise black/blue in color .no indication of pain .no pain voiced .level of consciousness: alert and oriented x1 .injury: bruise . Record review of Resident #35's accident/incident final disposition report completed by LVN N on 07/01/24, indicated .Resident #35 .date of incident: 07/01/24 .type: bruise/right jaw .outcome of interview with staff: spoke with all nurses, cnas, and hospice staff regarding bruise, upon interviewing it was discovered that resident sleeps with bed controller close to face and occasionally wakes up with remote under head/face also sleeps with a baby doll in bed that stays by her face/head and has hard hands and feet .state cause: unknown .did occurrence require notification of state agency .no .was equipment involved .unknown .LVN N .DON .ADM . Record review of Resident #35's hospice coordination notes report dated 07/02/24 indicated .call center-general .time of call:0756 .caller: ADON .the HHA gave the patient a bath last evening and the facility staff noted a bruise to the patient's jawline shortly after .the caller reports that because it is a suspicious bruise, they are conducting an investigation .they would like to know if the patient had been combative or if this bruise was noticed by the HHA during the shower .the patient has a history of being combative during care . During an interview on 07/17/24 at 3:29 p.m., the ADM said she was the abuse coordinator. She said Resident #35 had a history of sleeping with a baby doll and the bed controller remote. She said Resident #35 could not tell how she got the bruise to her jaw. She said after her, ADON, and DON talked about the incident, they did not think it was an injury of unknown origin due to history of sleeping with a baby doll and remote near her face. She said she did not know Resident #35 had a history of being resistive to cares and agitation. She said injury of unknown origin was supposed to be reported to HHSC. She said she was responsible for investigating and reporting. She said when injury of unknown origin was not reported the resident could get injured. She said it was important to report because better safe than sorry. During an interview on 07/17/24 at 5:07 p.m., the DON said Resident #35's family member was visiting on 07/01/24 and noticed the bruise on her jawline. She said Resident #35's bruise was dime sized. She said nurses reported they sometimes find Resident #35 laying on her remote and she slept with a baby doll too. She said we attributed the bruise to her bed remote or baby doll. She said Resident #35 was confused and could be confused about what staff are doing to her. She said after the incident, staff were supposed to ensure Resident #35 was not laying on the remote or baby doll. She said HHA R bathed Resident #35 the morning of or within a 24-hour period of when the bruise being found. She said she did not think it was an injury of unknown origin. She said Resident #35 could not say what happened. She said the ADM was the abuse coordinator. She said the ADM was responsible for investigating and reporting to HHSC within 2 hours for allegation of abuse. She said not reporting to HHSC placed resident at risk for harm if abuse or neglect was suspected. She said the facility had implemented a new abuse policy on July 1st, 2024.

Based on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions. (Resident #69) The facility failed to complete a baseline care plan for Resident #69 within 48 hours of admission. The facility failed to provide Resident #69's RP, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #69's face sheet dated 07/16/24, indicated Resident #69 was an [AGE] year-old female admitted on [DATE] with diagnosis including dementia with other behavioral disturbance. The face sheet indicated Resident #69 family member were her responsible party. Record review of Resident #69's admission MDS assessment dated [DATE] indicated Resident #69 was usually understood and usually understood others. Resident #69's BIMS score was 08 which indicated moderately impaired cognition. Resident #69 required supervision for eating, maximal assistance for oral hygiene, shower/bathe self, dressing and personal hygiene and dependent for toileting hygiene. During an interview on 07/15/24 at 4:53 p.m., the responsible party for Resident #69 said Resident #69 was admitted to the facility for rehabilitation. She said she had not been involved in a care plan meeting to develop a baseline care plan and had not received a copy of a baseline care plan. She said she visited a lot and spoke to the rehab department about her family member's progress. She said a baseline care plan would have been nice to have. During an interview on 07/16/24 at 3:15 p.m., the MDS coordinator said she was not responsible for baseline care plans. She said the DON was responsible for initiating baseline care plan. She said that was the way with the old company but did not know how the new company was going to do it. During an interview on 07/16/24 at 3:20 p.m., the DON said she did not know she was responsible for initiating baseline care plans. She said she thought the MDS coordinator was responsible for baseline care plans. Requested copy of Resident #69's baseline care plan from the DON. Resident #69's baseline care plan was not received prior or after exit. During an interview on 07/17/24 at 3:10 p.m., the MDS Coordinator said before the current DON started in April (2024), the DON or a RN initiated the baseline care plans. She said after the DON or RN initiated the baseline care. The nurses completed it within 48 hours of admission. She said she was not responsible for the baseline care plans. During an interview on 07/17/24 at 4:10 p.m., LPN M said she had not done a lot of admission at the facility. She said she assumed the admission nurse started the baseline care plan. She said she assumed the ADON or DON ensured it was completed within 24-48 hours of admission. She said the care plan helped you know how to take care of the resident. During an interview on 07/17/24 at 5:07 p.m., the DON said the LVN on admission was responsible for resident's baseline care plans. She said baseline care plan needed to be completed within 24 hours of admission. She said the ADON or DON should ensure resident's baseline care plan were completed within 24 hours of admission. She said new admission were talked about in morning meeting and that where we should be making sure baseline care plans were completed. She said if baseline care plan were not done, it did not alert staff what patient care should be provided. She said without a baseline care plan, a standard of care was not established, and the facility would not know of the resident was progressing or if something needed to be changed. During an interview on 07/17/24 at 6:00 p.m., the ADM said the admitting nurse started the baseline care plan and the DON finished it within 48 hours of admission. She said all facility departments had input on the baseline care plan. She said the DON was responsible for ensuring the baseline care plan were completed timely. She said if baseline care were not done, staff may not know how to properly care for the resident. Record review of a facility's Care Planning policy revised 10/24/22, indicated .the Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines .the care plan serves as a course of action where the resident, resident's attending physician, and IDT work to help the resident move towards resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs .a licensed nurse will initiate the Care Plan, and will be finalized in accordance with OBRA/MDS guidelines .the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .once the baseline Care Plan is completed, the Facility must provide the resident and/or resident's representative with a written summary of the Baseline Care Plan .

Based on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 18 residents (Resident #17 and Resident #68) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan for Resident #17's positioning rail. 2. The facility failed to ensure Resident #68 was care planned as smoker. 3. The facility failed to perform quarterly smoking assessments for Resident #68. 4. The facility failed to perform Resident #68's quarterly elopement risk assessments. These failures could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included: 1. Record review of Resident #17's face sheet dated 7/17/24 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #17 had diagnoses of a cerebral infarction (stroke-occurs when there is a lack of oxygen to the brain and brain cells die), hemiplegia and hemiparesis of left side (muscle weakness or partial paralysis (not able to move) on one side of the body that affects arms, legs, and/or facial muscles) following a brain bleed, and weakness. Record review of Resident #17's annual MDS assessment dated [DATE] revealed he was understood and understood others. Resident #17 had a BIMS of 14, which indicated he was cognitively intact. The MDS indicated Resident #17 required total to maximum assistance for most ADLs. The MDS did not indicate the use of bed rail. Record review of Resident #17's undated Physician Orders revealed there were no orders for his positioning rail on his bed. Record review of Resident #17's undated care plan revealed he had a history of cerebral infarction and was at risk of complications r/t left sided hemiplegia with goals to maintain or improve current levels of ADLs and not have another cerebral infarction over the next 90 days. He had pain with interventions to assist with turning and repositioning to find a comfortable position. He had a history of falls. The care plan did not address Resident #17's use of a bed rail for positioning. Record review of Resident #17's therapy screening dated 7/15/24 revealed he was screened for the use of assist bar and was appropriate for assist bar to left side to facilitate mobility. During an observation and interview on 7/15/24 at 10:39 AM, Resident #17 said things were going pretty good. Resident #17 said he had a positioning bed rail on his left side of his bed, but he also needed one on his right side to assist with turning and it would make him feel safer when being turned to the right side during his incontinent care. Resident #17 had a positioning bed rail on his left side of the bed. During an interview on 7/17/24 at 1:45 PM, Resident #17 said he wanted a positioning bed rail on his right side to help with turning himself. Resident #17 said he was not able to use his left arm or leg. Resident #17 said he received his current bed three or four weeks ago and it came with the one positioning bed rail on his left side. Resident #17 said the bed he had prior to his current one had positioning bed rails on both sides. During an interview on 7/17/24 at 1:30 PM, CNA D said she had worked at the facility for five years and usually worked on the day shift. CNA D said she thought Resident #17 had his positioning bed rails since he had been in his room for some time. During an interview on 7/17/24 at 1:54 PM, the Regional Director of Therapy said she had screened Resident #17 on 7/15/24 because they were a new company for the facility as of 7/1/24 and their policy was to screen everyone and look at everyone to see if they were appropriate to use positioning rails, wheelchairs, etc. She said they had already scheduled to come to the facility that week to screen all the residents. She said she did not know what the previous company's policy was, but they required residents to be screened for positioning bed rails and to be care planned, and to have an order. During an interview on 7/17/24 at 1:57 PM, the Director of Therapy said previously, if nursing felt like a resident needed positioning bed rails, nursing would tell the Maintenance Supervisor and he would install the positioning bed rails on the bed. She said if therapy felt a resident needed the positioning bed rails, therapy would tell the nursing staff and the nursing staff would tell the Maintenance Supervision and he would put them on. She said therapy did not do screenings or evaluate residents for the use of positioning bed rails. During an interview on 7/17/24 at 2:05 PM, LVN B said she had worked at the facility for fourteen years. LVN B said if a resident needed positioning bed rails, they just called the Maintenance Supervisor, and he would put the positioning bed rails. LVN B said therapy would also tell them if a resident needed positioning bed rails and then nursing would notify the Maintenance Supervisor and he would install them. LVN B said they did not put orders in for the positioning bars with the previous company or do consents. LVN B said she did not know what the new company would require. LVN B said the MDS coordinator was responsible for doing any care plans and/or changes in the morning meetings. LVN B said the care plan was to go over expectations for staff to take care of the resident related to all aspects of life. LVN B said positioning bed rails should be care planned to monitor the resident for safety of the bars to help the resident turn and not get tangled up in them or anything that would negatively affect the resident. LVN B said she did not know how long Resident #17 had been using the positioning bed rail, but it had been over a year. During an interview on 7/17/24 at 2:15 PM, the MDS coordinator said she had worked at the facility for [AGE] years. She said she was responsible for the admission, quarterly, annual, and significant change MDSs and implementing/updating the care plans with each MDS schedule. She said she reviewed everything during the MDS assessment and updated the care plan as indicated and if she was asked to update a care plan she would, but she was not responsible for the acute care plan changes/updating. She said she believed nursing was responsible for the acute care plan changes/updates. She said she would update the care plan to include positioning bed rails and interventions for assessments and monitoring, if she knew a resident had the positioning bed rails. She said she would have to see documentation, such as an order, nurse's note, or have someone tell her if a resident had positioning bed rails to know to update the care plan. She said she did not know Resident #17 had positioning bed rails. She said the purpose of the care plan was so residents received the care needed and it was a guide to staff of what care the resident needed. She said the resident should be assessed to ensure they know how to use the positioning bed rails and were using them appropriately. She said the negative affect to the resident of not having something care planned would depend on what was not care planned. During an interview on 7/17/24 02:27 PM, LVN C said the MDS Coordinator, and the RNs were responsible for updating the care plans. LVN C said as an LVN, she was not allowed to do care plans. LVN C said she could update orders. LVN C said an order was needed for a resident to have positioning bed rails. LVN C said if a resident needed positioning bed rails, she would let therapy know and then tell the Maintenance Supervisor to install them. LVN C said positioning bed rails should be included on the care plan. LVN C said the purpose of the care plan was to guide the resident's care and if something was not care planned, then the resident may not receive the care they needed. During an interview on 7/17/24 at 3:44 PM, the DON said therapy should evaluate the resident to see if they could use positioning bed rails correctly and the Maintenance Supervisor installed the positioning bed rails on the resident beds. The DON said the positioning bed rails should be on the care plan to include assessments and monitoring for safety. The DON said the nurses initiated the base line care plan and the MDS Coordinator was responsible for the comprehensive care plan and for revising the care plans. The DON said the nurses and/or herself were responsible for revising the acute care plans with changes. The DON said the LVNs, and RNs could update/revise the care plans, but mainly the nurse managers did it. The DON said the positioning bed rails should have an order, consents signed, and be care planned, per their new company's policy, but she said she did not know what the old company required. The DON said once they get completely switched over to the new software system, when the nurses did their assessments, the system would automatically update the care plans. The DON said the purpose of the care plan was so everyone to be updated and everyone to be on the same page in what care the resident needed or required. The DON said if the positioning bed rails were not care planned, the rails could serve as a restraint, or the resident could injure themselves if not being assessed for safety and appropriate use. During an interview on 7/17/24 at 4:01 PM the ADM said the MDS nurse was responsible for the development and revising of the care plans. The ADM said the admitting nurse initiated the baseline care plans and the DON reviewed and signed off on it. The ADM said the DON also signed off on the comprehensive care plan when it was completed. The ADM said the care plan was the recipe to care for each resident and should be very specific to that resident on how to care for them and it was the prescription for the resident's care. The ADM said she would expect the positioning bed rails to be care planned with interventions to ensure the residents safety. The ADM said if not care planned the resident may not receive the care they needed. 2. Record review of Resident #68's face sheet dated 07/16/24, indicated Resident #68 was an [AGE] year-old, female admitted on [DATE] with diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), nicotine dependence, and tremors. Record review of Resident #68's admission MDS assessment dated [DATE], indicated Resident #68 was usually understood and usually understood others. Resident #68's BIMS score was 15 which indicated intact cognition. The MDS indicated Resident #68 did not wander or reject care. The MDS indicated Resident #68 was a current tobacco user. Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 was understood and understood others. Resident #68's BIMS score was 14 which indicated intact cognition. The MDS indicated Resident #68 did not wander but rejected care. Record review of Resident #68's care plan dated 11/08/23, edited 04/29/24 indicated Resident #68 was at risk for elopement due to cognitive deficits, history of wandering behavior, and history of exit seeking. Resident #68 resided in secured unit of facility. Intervention included reassess secured unit placement quarterly and as needed with significant change. Resident #68's care plan did not indicate she was a smoker and to complete quarterly smoking assessments. Record review of Resident #68's elopement risk dated: *01/22/24 *07/16/24 Resident #68 did not have quarterly elopement assessment performed. Record review of Resident #68's smoking safety risk assessment dated [DATE], indicated Resident #68 used cigarettes and was a modified independent smoker. Resident #68 did not have quarterly smoking assessment. Record review of a Smokers list provided by the ADM on 07/15/24, indicated Resident #68 was a smoker on the secured unit. During an observation on 07/16/24 at 8:41 p.m., Resident #68 headed outside with a staff member to smoke. During an interview on 07/17/24 at 3:10 p.m., the MDS coordinator said she did resident's care plans. She said the resident's MDS coded for smoking should prompt staff to develop a smoking care plan. She said Resident #68 having a smoking care plan was important to know what care or supervision she required. She said without a smoking care plan, Resident #68 could not get the supervision she needed, and injury could happen. She said she did not know why Resident #68 did not have a smoking care plan. She said the ADON completed smoking assessments. She said nurses completed elopement risk assessments. During an interview on 07/17/24 at 4:10 p.m., LPN M said Resident #68 should have smoking on her care plan. She said the care plan let staff know about smoke breaks and what accommodations was needed. She said the care plan helped you know how to care for the resident. She said if the wrong accommodations were given to Resident #68 during smoking, injury could happen or if not taken when scheduled, Resident #68 could become combative. She said smoking and elopement risk assessments should be completed on schedule. She said the assessment were completed quarterly by the DON. During an interview on 07/17/24 at 5:07 p.m., the DON said nurses completed the smoking and elopement risk assessments. She said but anyone could complete the assessments if needed. She said elopement risk assessment should be completed quarterly and smoking assessments should be done on admission and quarterly. She said the ADON should be monitoring the completion of smoking and elopement risk assessments. She said the chart system also triggered when the resident's assessments are due. She said Resident #68's care plan should have smoking as a care area. She said the MDS coordinator or nurses were responsible for care planning smoking on resident's care plans. She said when smoking was not care planned, residents could be injured because they could be not safe smoking. She said when elopement risk assessments were not done, it placed resident at risk for elopement and being inappropriate placed on the secure unit. During an interview on 07/17/24 at 6:00 p.m., the ADM said each disciplinary made sure resident's intervention addressed the care area. She said the DON was responsible for reviewing the comprehensive care plan to ensure all care areas were addressed. She said smoking should be care planned for a resident who smoked. She said the MDS coordinator was responsible for care plan with the old company. She said smoking needed to be on the resident's care plan to know how to care and special needs of the resident. She said nurses were responsible for elopement risk assessments and safe smoking assessments. She said assessments were done on admission, quarterly, and as needed. She said when elopement risk assessment was not performed, staff could not be in tuned with residents attempts to elope. She said staff members could not pay close attention to the resident and the resident could elope. She said if smoking assessments were not done, then may not know if a resident is a safe smoker. She said staff may not know how to safely smoke the resident and injury can happen. She said the DON and MDS coordinator should ensure care plan are comprehensive. Record review of the facility's policy titled Care Planning dated revised October 24, 2022, revealed . the purpose of care planning was . to ensure that a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs . the care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's attending physician, and interdisciplinary team work to help the resident move toward resident specific goals that address the resident's medical, nursing, mental and psychosocial needs . a licensed nurse would initiate the care plan, and the plan would be finalized in accordance with . guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed bases . each resident's comprehensive care plan would describe the following . services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Record review of the facility's policy titled Bed Rails dated revised 06/2020, revealed . the purpose was to determine the appropriateness of bed rail use for individual residents . decisions to use or to discontinue the use of a bed rail would be made in the context of an individualized resident assessment using an Interdisciplinary Team and would take into account the resident's medical needs, comfort, and freedom of movement . the resident's plan of care would be updated to reflect the use of bed rails . the plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs would be met during the use of bed rails ( such as repositioning, hydration, etc.) . Record review of a facility's Smoking by Residents policy revised 06/2020, indicated .to respect resident choice to smoke and to maintain a safe healthy environment for both smokers and non-smokers .residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke in these areas .a licensed nurse will complete a Safe Smoking Assessment for residents who wish to smoke .all smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA assessment timeframe .the IDT shall create a Smoking Care Plan for the resident . Record review of a facility's Secure Care Neighborhood policy revised 08/2020, indicated .the secure care neighborhood may be used to keep residents who are a high risk for elopement safe from exiting the facility .the resident should have an Elopement Risk Assessment completed with a physician order completed . 44933

Based on interview and record review, the facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents who were reviewed for quality of care. (Resident #279) 1. The facility failed to ensure Resident #279 had orders for the size and amount of fluid in the bulb of her indwelling urinary catheter (tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident# 279 had orders catheter care with an indwelling urinary catheter. The failures could place residents at risk for indwelling urinary catheter pain, urinary tract infections, and not receiving needed care. Findings included: 1. Record review of Resident #279's face sheet dated 7/17/24 indicated Resident #279 was a [AGE] year old female and admitted to the facility initially on 7/13/24 with diagnosis chronic kidney disease stage 3 unspecified (when the kidneys have mild to moderate damage and less able to filter waste and fluid out of your blood). Record review of Resident #279's quarterly MDS assessment dated [DATE] indicated Resident #279 was usually understood and understood others. The MDS indicated Resident #279 had no BIMs conducted. Resident #279 was maximal assistance on staff for toileting hygiene. The MDS indicated Resident #279 had an indwelling catheter (urinary catheter) and was always incontinent of bowel. Record review of Resident #279's baseline care plan dated 7/13/2024 indicated she was cognitively intact. She was always incontinent to urine. She had a wound to sacral area. She was on enhanced barrier precautions with interventions of gloves and gown should be donned (put on) if any of the following activities occurred: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bathing, or other high contact activity. Record review of Resident #279's Order Summary Report dated 7/16/24 revealed there was no order noted related to Resident #279's urinary Foley catheter size, amount of fluid in the bulb and no catheter care. During an interview on 7/17/24 at 9:30 AM the DON stated Resident #279's urinary catheter size, bulb and catheter care orders were not in the resident's chart, but she had updated the resident's chart and put the orders in after made aware by surveyor. During an interview on 7/17/2024 at 10:15 AM the Director of Operations voiced Resident #279's foley catheter orders were not in the system, but after notified by surveyor orders had been added to system. During an interview on 7/17/24 at 2:12 PM, revealed LVN C said the nurses had the residents' orders on the paper MAR and in electronic record. She said the orders should show the catheter size, how much fluid should be in the bulb and catheter care each shift or as needed. She said she could not find Resident #279's catheter orders on the medication administration report. During an interview on 7/17/24 at 2:37 PM, LVN P said normally the residents came to the facility with a catheter order on admission and the nurses should know to performed standard care with the catheter. She said if she could not find the resident's catheter orders she would call the physician to get orders. She said not performing catheter care could cause the resident discomfort or pain, it could have an effect on their vital signs and cause sepsis. During an interview on 7/17/24 at 2:57 PM, the DON said the foley catheter orders should be put in the system on resident's admission. She said the orders for an indwelling catheter should include a secured to leg device, check urine in bag and ensure proper placement. She said the order should had the size of the catheter, the amount of fluid in the bulb and when to change the catheter. The DON said the foley catheter on admission order was probably missed due to the facility changed to a new charting system and their nurse has not been trained on the system yet. The DON said the negative effects of catheter orders not available for nurses could cause urinary tract infections and sepsis for residents with catheters. She said if the catheter orders were not on the medication administration report it was not monitored. She said if a nurse could not find the catheter orders they should ask her or a co-worker with point click care knowledge or notify the physician that foley catheter orders were needed for a resident. During an interview on 7/17/24 at 3:15 PM, the ADM said there should be an order for an indwelling catheter. The ADM said when applying a catheter, the nurse should be following the physicians' orders. The ADM said the nurse should always make sure they have a supporting diagnosis for a catheter, if not call the physician get an order or to discontinue the order for the foley catheter. The nurse should follow their facility policy in taking care of a catheter. Our nursing staff had not been taught how to add orders to this new point click care system. We are in orientation on how to use this system. If Resident #279 had a catheter her orders should have been put in the system. The ADM said if a foley catheter was not cleaned properly, that could lead to urinary tract infection or sepsis. Review of a Catheter- Care of, Urinary Policy dated revised 6/2022 revealed .the purpose of this procedure is to prevent urinary catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. Documentation of catheter care will be maintained in the resident's medical record. Review of Physician Orders Policy dated revised 6/2020 revealed .This will ensure that all physician orders are complete and accurate. The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary. Orders will include a description complete enough to ensure clarity of the physician's plan of care. Whenever possible, the Licensed Nurse receiving the order will be responsible for documenting and implementing the order. Medication/treatment orders will be transcribed onto the appropriate resident administration record. Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR.

Based on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 3 of 20 residents reviewed for accidents hazards. (Resident's #45, #34, and #53) The facility failed to provide adequate supervision to prevent Resident #45 from falling where he sustained a fractured right elbow and torn tendons requiring a surgical procedure. The facility failed to ensure Resident #34 and #53 mechanic lift pad was in good repair. These failures could place residents at risk to have falls and falls with serious injury. Findings included : 1.Record review of an undated face sheet indicated Resident #45 was a [AGE] year-old male, admitted on [DATE] with a diagnoses of Dementia with Lewy bodies (deposits in the brain causing problems with thinking, movement, behavior, and mood), and [CONDITION(S)] (disease affecting movement often shaking ). Record review of an admission MDS dated [DATE] indicated Resident #45 was sometimes understood and sometimes understands. Resident #45's BIMS score (cognitive scoring) 8 indicated he had moderately impaired cognition. The MDS indicated Resident #45 required extensive assistance with bed mobility, transfers, toileting, and dressing of one staff. He required limited assistance of one staff with locomotion, and total assistance of one staff with bathing. He was frequently incontinent of bowel and bladder. The MDS indicated Resident #45 had falls in the last month prior to admission, the previous 2-6 months and one with an injury. Record review of a fall risk assessment dated [DATE] the DON indicated Resident #45 was a high risk for falls due to impulsive behavior, forgetfulness of his limitations. The DON indicated the interventions were the bed to be in low position, fall mat and increase visual checks. Record review of an accident report dated 2/02/2022 indicated Resident #45 was found on the floor and had a skin tear to his right elbow. The prevention measures were to monitor the resident and provide a fall mat. Record review of an accident report dated 2/03/2022 indicated Resident #45 attempted to get up from wheelchair, slid to his knees on the fall mat. The report indicated no injuries. Record review of an accident report dated 2/11/2022 indicated Resident #45 had a witnessed fall. The accident report indicated another resident witnessed the fall. The prevention measures were to notify the hospice service, hospice to review medications, fall mat and bed low. Record review of an accident report dated 2/14/2022 indicated Resident #45 had an unwitnessed fall and sustained an abrasion on his back. The prevention measures included hospice notified, hospice to review medications, and increase visuals and redirection. Record review of an accident report dated 2/18/2022 indicated Resident #45 was found on the floor next to the roommates dresser. The prevention measures included follow labs, therapy notified, and continue frequent visual monitoring. Record review of a physician's order dated 2/23/2022 indicated Resident #45 was sent to the hospital by the facility transportation for evaluation and treatment. Record review of a comprehensive care plan dated 2/04/2022 indicated Resident #45 was a high fall risk related to cognitive deficits, unaware of environmental obstacles, loss of balance, inability to use call light, decline in medical condition of [CONDITION(S)], attempts to transfer, stand, and ambulate. The care plan indicated Resident #45 had a history of falls. Interventions implemented on 2/04/2022 listed on the care plan indicated Resident #45 wound have increased visial checks while resident was in his room, encourage/assist with rest periods during the day, instruct to change positions slowly to avoid dizziness, keep bed in low position when resident was in bed, use non-skid shoes or treaded socks during transfers, place all articles needed within reach, provide adequate lighing and keep the room free of unnecessary obstacles, request a medication review from the pharmacy, transfer with assistance of 1-2 staff, and a fall mat at bedside. The care plan indicated on 2/15/2022 the interventions implemented included encouraged/assisted in group activities during the day to increase visual observation/supervision, and encourage use of assistvie devices with mobility. An intervention dated 2/15/2022 implemented on the care plan indicated to bring Resident #45 to the nurses station when awake for increased supervision. Record review of an accident report dated 2/22/2022 indicated Resident #45 had an unwitnessed fall in his room. The accident report indicated Resident #45 was in the dining room in activities but had become frustrated and attempting to stand numerous times. Resident #45 left activities and went to his room in his wheelchair. The report indicated at 11:00 a.m., Resident #45 was found sitting on the floor next to his bed. The accident report indicated Resident #45 was barefoot. The accident report in the final disposition area indicated Resident #45 was sent to the ER for symptoms of infection on 2/23/2022. The report indicated the spouse notified the facility Resident #45 was being admitted for an infection and with a possible fractured elbow. Record review of a nurse's note dated 2/22/2022 indicated Resident #45 was at the nurse's station most of the morning for staff monitoring. He was taken into activities around 10:30 a.m. The note indicated Resident #45 attempted to stand up numerous times while in activities and was getting frustrated. The nurse's note indicated Resident #45 made his way back to his room and at 11:00 a.m. and was found sitting on the fall mat next to his bed. Record review of an all-staff in-service training record dated 2/22/2022 indicated Resident #45 would be within sight of staff for monitoring due to increased fall risk . Resident #45 would be in activities, at the nurse's station or in the dining room, and he was not to be in his room by himself. The in-service had 17 employee signatures. Record review of a nurse's note dated 2/23/2022 at 1:50 p.m., indicated Resident #45's right elbow noted to be more swollen this morning. Resident #45's spouse called the hospice provider and indicated Resident #45 should be sent to the local emergency room for evaluation and treatment. Record review of a hospital consult report dated 2/23/2022 indicated the patient stated to have multiple falls about 10 times this month and was stated every time the patient fell , he fell on his right elbow. The x-ray of the right elbow revealed acute enthesophyte evaluation along the triceps insertion. The report indicated there were no other elbow fracture, dislocation or joint effusion seen. The report indicated Resident #45 had a right elbow triceps tendon repair and right elbow debridement from skin to bone. The report indicated the right elbow wound grew [CONDITION(S)]-resistant Staphylococcus aureus. Record review of a three-view x-ray of the right elbow on 2/23/2022 indicated Resident #45 had an acute enthesophyte avulsion along the triceps insertion (a failure of bone in which a bone fragment was pulled away by soft tissue resulting from an acute event) with no additional elbow fracture, dislocation or joint effusion seen. Record review of an operative report dated 2/25/2022 indicated the pre-operation diagnosis was a right elbow enthesophyte fracture chronic laceration posterior elbow and post operation diagnosis was right elbow enthesophyte fracture with partial triceps rupture. The operative report indicated the procedures performed were right elbow triceps tendon repair and right elbow debridement skin subcutaneous tissue, tendon, bone and muscle. Record review of a physician's order dated 3/01/2022 indicated Resident #45 admitted to SNF (skilled nursing facility) for skilled observations and assessment under Medicare Part A services for a diagnosis of closed fracture to right elbow, antibiotic therapy for [CONDITION(S)] ([CONDITION(S)]. The order indicated Resident #45 was ordered [MEDICATION(S)] 750 milligrams every 12 hours until 4/07/2022. Record review of a significant change MDS dated [DATE] indicated Resident #45 was sometimes understood and sometimes understands. Resident #45's BIMS score (cognitive scoring) 7 indicated he had severely impaired cognition. The MDS indicated Resident #45 required extensive assistance of two staff with bed mobility and transfers. He required extensive assistance of one staff with locomotion. The MDS indicated Resident #45 required total assistance of one staff with dressing, toileting, personal hygiene, and bathing. He was always incontinent of bowel and bladder. The MDS under section I indicated Resident #45's active diagnosis included fractures and other multiple trauma and additional diagnoses of displaced fracture of olecranon process without intraarticular extension of right ulna and [CONDITION(S)] infection. The MDS indicated Resident #45 was experiencing moderate pain in the 3-4 days of the 5 days evaluated. In section J the MDS indicated Resident #45 had a fall with major injury. Record review of an accident report dated 4/05/2022 at 6:08 a.m ., indicated Resident #45 had an unwitnessed fall and was found on the floor in his room. Resident #45 had a skin tear to right elbow. A progress note written by the DON attached to the incident report indicated Resident #45's fall interventions included notification of therapy, the interventions currently in place were effective in the prevention of major/serious injury, continue with frequent monitoring and redirection. Record review of a nurse's note, dated 4/05/2022 at 8:04 a.m., indicated Resident #45 was noted on the floor in his room, sitting on the fall mat at 6:08 a.m. Resident #45 had a skin tear/small incision dehiscence (partial or total separation of a previously approximated wound edges) noted of his right elbow. During an observation on 5/02/2022 at 9:22 a.m., Resident #45 was up in his wheelchair in his room. His call light was not within reach. During an interview on 5/02/2022 at 12:30 p.m., Resident #45's spouse indicated he had numerous falls since his admission. She indicated on the day of his last fall the orthopedic surgeon indicated even if his arm was re-injured, he could not take Resident #45 back into surgery. During an observation on 5/03/2022 at 8:26 a.m., Resident #45 was in his sitting in his wheelchair room. A staff member delivered a newspaper to the room and left. Resident #45's call light string was in the recliner seat. During an interview on 5/03/2022 at 1:45 p.m., the DON indicated Resident #45's elbow was not fractured when he fell on [DATE] he had [CONDITION(S)] (a bone infection ). During an observation on 5/03/2022 at 4:02 p.m., Resident #45 was awake lying in his bed. Resident #45's call light string was lying in his recliner and his bed was not in the lowest position. The bed was approximately thigh high. During an interview on 5/03/2022 at 4:05 p.m., the Activity Director indicated she did not recall Resident #45 having a fall after leaving an activity. The Activity Director indicated she did remember a time when Resident #45 had increased confusion he had to be at the nurse's station. During an observation and interview on 5/03/2022 at 4:08 p.m., Resident #45 was awake in his bed, the bed was not in the lowest position (approximately thigh high), and his call light was in the seat of the recliner. RN A lowered the bed and placed the call light within reach of Resident #45 after surveyor intervention. RN A indicated Resident #45 had been resting and she was aware the care plan indicated Resident #45 should not be in the room alone. RN A indicated she was responsible for Resident #45's fall prevention interventions. During an interview on 5/03/2022 at 4:45 p.m., CNA C indicated she was not sure why Resident #45's bed was not lowered or why his call light was in the recliner. CNA C indicated she was assigned to Resident #45. CNA C indicated she had worked with Resident #45 4-5 months. CNA C indicated Resident #45 was at risk to fall. CNA C indicated she had not seen Resident #45's care plan. During an interview on 5/04/2022 at 7:05 a.m., RN B indicated Resident #45 was at risk to fall and she tries to keep him out of his room. RN B said there was an in-service on Resident #45's fall precautions in the employee sign in book. RN B indicated the nurse aides do not have access to the care plan. During an interview on 5/04/2022 at 7:15 a.m., CNA D indicated Resident #45 was at risk to fall. CNA D indicated she had not bed told Resident #45 had to be up at the nurse's station. CNA D said she does not have access to care plans . CNA D said she was assigned to Resident #45 and she had been employed by the facility for [AGE] years. During an interview on 5/04/2022 at 7:19 a.m., CNA E was unable to answer fall prevention questions regarding Resident #45. CNA E said she was unaware of Resident #45 needing to be at the nurse's station. She said she was unable to view care plans. During an interview on 5/04/2022 at 7:56 a.m., the DON indicated Resident #45 was a high fall risk related to his Lewy Body Dementia, and [CONDITION(S)]. The DON said Resident #45's fall preventions were his bed low, fall mat down, encourage activities, be out in the public, redirection, encourage assistance, and his wife visits every day and that is a benefit. The DON indicated Resident #45 had the right to fall . The DON indicated all staff were responsible for fall preventions and this was monitored with daily rounds by all staff. The DON said Resident #45's arm was not fractured. The DON said she was could not remember reading the hospital paperwork. During an interview on 5/04/2022 at 8:17 a.m., the ADON indicated Resident #45 was a great fall risk. The ADON indicated Resident #45's x-ray had no indication of a fracture. The ADON indicated he had not read the hospital reports for Resident #45 . The ADON indicated he would have to cross reference Resident #45's care plan for his interventions. The ADON said the DON reviews the incident reports during morning meetings, and identifies the interventions needed. During an interview on 5/04/2022 at 9:00 a.m., the MDS nurse indicated Resident #45 had a fractured elbow . She indicated the DON and ADON were responsible for initiation of acute care plans for falls. During an interview on 5/04/2022 at 9:37 a.m., the DON indicated she was aware an avulsion was a tearing of tendon or muscle away from a bone. The DON indicated when she was unfamiliar with a diagnosis she would goggle or look it up. The DON indicated she would advise the nursing staff when needing knowledge of a diagnosis she would inform them of her knowledge and encourage them to look it up as well. The DON indicated the staff were made aware of fall precautions by word-of-mouth communication. She indicated the new staff members were trained by seasoned staff and they too would be told by word of mouth of the fall precautions. The DON indicated the CNAs do not have access to the care plans and interventions to prevent falls. The DON said CNA F was the lead CNA and she would know if the CNAs had fall prevention interventions on their electronic documentation system. During an interview on 5/04/2022 at 9:46 a.m., CNA F indicated the kiosk charting system for the CNAs had no entries or way to enter fall precaution interventions for the residents. CNA F indicated the nurse aides have no way to access the care plans for the residents. CNA F said the nurse aides learn of the fall interventions by word of mouth . During an interview on 5/04/2022 at 11:38 a.m., the Administrator indicated any time there were falls she was looking for areas of abuse and neglect. The Administrator indicated some of the areas she would review were fall interventions not in place, and injuries of unknown origin. The Administrator indicated if a fall was witnessed, or she could look at the cameras these aides her determination of a reportable incident. The administrator indicated she learns of falls during morning meetings and throughout the day . She said the fall care plans were updated with interventions in the morning meetings. The Administrator indicated the falls were again reviewed in QAPI (quality assurance performance improvement) meetings which were held quarterly but was trying to hold the meeting monthly. The Administrator indicated the care plan was made available for everyone to view. The Administrator indicated Resident #45 was a high fall risk. The Administrator indicated she was unsure how the fall interventions were communicated to the staff. Record review of Falls and Injuries policy, dated August 2018, reflected the following: The facility strives to reduce the risk of falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. The procedure included assess and review risk factors for falls and injuries, review other interdisciplinary assessment, explore underlying medical or environmental conditions, discuss goals and interventions, schedule a plan of care meeting, initiate or revise the plan of care based on the individuals needs or risks, communicate interventions during shift report and clinical rounds to the care giving team, provided training to the staff, and educate the patient and family. 2. Record review of Resident #34's undated face sheet indicated Resident #34 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of [CONDITION(S)], muscle weakness, lack of coordination, repeated falls, and vascular dementia. Record review of Resident #34's a significant change MDS, dated [DATE], indicated Resident #34 was sometimes understood by others and was sometimes understood others. The MDS indicated Resident #34 had a BIMs score was a 5 indicating severe cognitive impairment. The MDS indicated Resident #34 required extensive assistance of one staff for bed mobility, transfers, locomotion, dressing, and eating. She required total assistance with toileting and personal hygiene. Record review of Resident #34's comprehensive care plan, dated 3/10/202,2 indicated Resident #34 was at risk to fall and the goal would be to minimize the risk of falls during her stay. The care plan did not address Resident #34's transfer needs . During an observation on 5/02/2022 at 10:26 a.m., Resident #34 was sitting in a Geri chair with a mechanic lift pad with tattered and torn edges underneath her. The bordered edges were no longer on the entire lift pad. 3. Record review of Resident #53's undated face sheet indicated Resident #53 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of peripheral vascular disease (narrowing blood vessels reducing blood flow), depression, diabetes, high blood pressure, weakness, and lack of coordination. Record review of Resident #53 's most recent quarterly MDS dated [DATE] indicated Resident #53 was understood by others and could understand others. Resident #53's BIMs score was 15 indicating he had no cognitive deficits. The MDS indicated Resident #53 required total assistance of two staff for transfers. Record review of Resident #53's comprehensive care plan, dated 12/09/2021, indicated Resident #53 was at high risk to fall due to limited/no weight bearing with the intervention of a mechanical lift. During an observation and interviews on 5/02/2022 at 9:45 a.m. revealed, Resident #53 was transferred using the mechanical lift. Resident #53 was being transferred with a mesh lift pad with the border missing around the opening for the buttocks rest for toileting purposes. CNA X said they mechanical lift pad was already in the room and she said the bordered edge was missing. CNA X said the lift pad could tear and Resident #53 could slip through the opening. CNA Y said the mechanical lift pad was supposed to have a bordered edge around the opening. CNA Y said the lift pad could tear and the pad was not safe . During an observation and interview on 5/02/2022 at 11:48 a.m. revealed, the clean laundry holding area had two more mechanical lift pads with the borders torn away and the material tattered. The Maintenance/Laundry Supervisor said there was not a system in place to monitor the mechanical lift pads for wear. He said the torn pads could rip and the resident could fall from the mechanical lift machine. After surveyor intervention the Maintenance Supervisor removed the torn mechanical lift pads and replaced them with a new one . During an interview on 5/05/2022 at 2:16 p.m., the DON indicated she expected the torn mechanical lift pads not to be sent in from the laundry for use. The DON said the CNAs could bring the mechanical lift pads for replacement. The DON indicated the laundry was responsible for ensuring the mechanical lift pads were safe to use. During an interview on 5/05/2022 at 2:30 p.m., the Administrator indicated she expected the mechanical lift pads not to have holes and be in good repair for use. She indicated laundry should wash them, inspect them and then the CNAs should inspect them before use. The Administrator indicated a torn mechanical lift pad could result in an injury. Record review of a policy titled Transfer Techniques- Mechanical Lift, dated March 2019, revealed to iInspect the mechanical lift and sling to make sure it was clean and in good working order.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed for accidents. (Resident #2) The facility did not implement adequate supervision and assistive devices to prevent Resident #2 from falling out of the bed. Resident #2 was totally dependent on staff for bed mobility and was identified to be at risk for falls. The resident's bed was not placed in the lowest position and the Resident fell out of bed. Resident #2 was found on the floor with laceration to her forehead which required stitches. This failure could place 3 residents who were in bed most of the time at risk for injury. Findings included: Physician orders [REDACTED].#2 was an [AGE] years, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #2 was totally dependent on two staff for transfers and one staff for bed mobility and toileting. She was totally incontinent of bowel and bladder. She had impairment on one side of upper and lower extremity. She had not had any falls since admission. A care plan dated 11/06/17 indicated Resident #2 had a history of [REDACTED]. The plan indicated the resident had a decline in medical condition related to a stroke with left [MEDICAL CONDITION]. Interventions included to provide Resident #2 with 2 staff during transfers, the resident should wear non-skid shoes or treaded socks during transfers/ambulation, and to keep the resident's bed in a low position while the resident was in bed. An Interdisciplinary Plan of Care Summary dated 12/15/17 indicated Resident #2 was at risk for falls and injury. An incident report dated 04/03/18 at 8:55 a.m. indicated Resident #2 had an unwitnessed fall and was found by CNA H lying face up on the floor at her bedside. The resident had a laceration on her left forehead, noted by the assessing nurse. During an interview on 04/04/18 at 2:17 p.m. CNA H said she went to provide Resident #2 incontinent care on 04/03/18. She said after entering the room she remembered she did not have all the supplies and she left the room to go get [MEDICATION NAME] cream. She said when she left the room, the resident was lying on her back, and the bed was in a medium position, not in the lowest position. She said when she returned she found the resident of the floor facing up and bleeding from her face. She said she notified the nurse and the resident was sent to hospital. CNA H said the resident did not have a floor mat before the fall. She said after this incident, Resident #2 was placed on a different mattress and a floor mat was put in place. During an interview on 04/04/18 at 1:20 p.m., LVN A said Resident #2 was found on the floor face up on 04/03/18. She said the resident was on a regular mattress and she rolled out of bed using her left stronger side of extremity. She said the resident previously attempted to put her legs out of bed and pull on the feeding pole. She said CNA H notified her Resident #2 fell out of bed on 04/03/18 and she assessed the resident. LVN A said she applied pressure then sent her to the hospital with emergency responders for an evaluation. She said there was no floor mat beside the bed at the time of the fall, but one was put in place after the fall. She said Resident #2 did not have a previous history of falls in the facility. A nursing note dated 12/9/2017 reflected Resident #2 noted grabbing feeding pump pole and attempting to pull towards self; Resident throwing legs over side of bed; Resident becoming combative when redirected; Feeding pole moved out of reach and legs placed in bed; Monitoring closely. The Emergency Department Physician Documentation dated 04/03/2018 reflected Resident #2 had the following Diagnoses: [REDACTED]. A facility Skin Grid - Other Skin Problems dated 4/4/18 indicated on 4/4/18 Resident #2 had an area to the left forehead that measured 3.2 cm x 0.1 cm with the depth being unable to be determined. The area had 9 sutures. A facility Skin Grid - Other Skin Problems dated 4/4/18 indicated Resident #2 had a bruise to face around the left and right eye and forehead. The area was 10 cm x 11 cm with a blue color. During an observation on 04/04/17 at 12:30 p.m., Resident #2 was in her room, lying in bed on her left side with a feeding pump running. The resident had a laceration with stitches noted on the left side of her face, with swelling and bruise around it. The resident's mattress was winged on the sides and the bed was in a lower position and a floor mat was in place at bedside. The feeding pump pole frame was padded. The CMS 672 dated 04/04/18 indicated 3 residents were in the bed most of the time.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing for 1 of 5 residents reviewed for pressure injuries. (Resident #60) The facility did not provide Resident #60 repositioning and offloading to prevent the development or worsening of a facility acquired stage 2 pressure injury to the ankle. The resident's left ankle pressure injury worsened to an unstageable with slough. Resident #60's mattress was not functioning properly. The facility did not provide adequate monitoring of Resident #60's low air loss mattress. This failure could place 13 residents who were receiving preventive skin care and 7 residents with pressure injuries at risk of developing avoidable pressure injuries and the worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#60 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #60 was totally dependent on two staff for bed mobility and transfers, one staff for toileting, was totally incontinent of bowel and bladder. She had limited range of motion of both arms and legs. She had a history of [REDACTED]. A MDS dated [DATE] indicated Resident #60 was unable to speak, and was rarely or never understood, and had severe cognitive impairment. She was totally incontinent of bowel and bladder and totally dependent on two staff for bed mobility, transfers and hygiene. She had impaired range of motion of both arms and legs. She was at risk for the development of pressure injuries with no current pressure injuries identified as present or healed. There were no other injuries, wounds and skin problems identified. A Braden Risk Assessment Scale dated 12/16/17 indicated Resident #60 was at high risk for the development of pressure injuries, specifically she had limited sensory perception, skin was often moist, she was confined to bed, and completely immobile, A treatment sheet, initiated on 2/12/18, indicated Resident #60 received treatment of [REDACTED]. A Skin Grid-Other Skin Problems for Resident #60 indicated the following: Shear to her coccyx identified on 2/12/18. * 2/12/18 - measured 5.0 x 6.0 x 0.2 centimeters with serous drainage, red wound bed, located over an old scar. *2/21/18 measured 0.7 x 1.5 cm x <0.1 centimeters, serous drainage and pink wound bed. A nursing note dated 2/14/18 at 10:00 a.m. indicated a stage 2 pressure injury on Resident #60's right foot was identified and measured 8.0 x 5.0 centimeters intact blister. New orders received to apply skin prep to blister every shift and apply low air loss mattress. A nursing note dated 2/16/18 at 10:30 a.m. indicated a CNA reported an open pressure area on Resident #60's left lateral ankle that measured 0.5 cm x 1.3 cm x 0.1 cm. New orders received to cleanse with normal saline, apply Manuka honey, and cover with a silicone dressing every day and as needed. A care plan dated 2/17/18 indicated Resident #60 had a pressure injury related to immobility, incontinence, nutritional deficits, history of healed pressure injury, and [DIAGNOSES REDACTED]. Interventions included: Do not position on pressure injury of left ankle, turn every 2 hours, and provide treatment as ordered. A Skin Grid-Pressure Only for Resident #60 indicated the following: Pressure injury on her left lateral ankle identified on 2/16/18. *2/19/18 - Stage 2 measured 0.5 x 1.3 x 0.1 centimeters, wound bed pink/red. *2/20/18 - Unstageable pressure injury measured 0.5 x 1.3 x (unable to determine) covered with 50-75% necrotic tissue. A nursing note dated 2/20/18 at 10:30 a.m. indicated Resident #60's pressure injury on the left lateral ankle now had slough and eschar and increased in size, the physician was notified and the wound care nurse was awaiting new orders. During an observation on 02/20/18 at 02:32 p.m., Resident #60 was positioned on a low air loss mattress on her left side, with the head of bed elevated 30 degrees. A pillow was between her knees, her left ankle lying on the bed, not off-loaded. During an interview on 02/20/18 at 02:39 p.m., the wound care nurse said Resident #60 developed a facility acquired pressure injury to her left ankle, and a shear on her coccyx. She said Resident #60's feet were always off-loaded and she did not believe the injury on the left lateral ankle was pressure related. She said the area of the coccyx was a shear injury and occurred over old scar tissue of a healed pressure injury. She said she did not stage as a pressure injury because the shear area occurred when facility staff provided Resident #60's shower and the shower chair caused the injury to the coccyx. During an observation and interview on 02/21/18 08:15 a.m., Resident #60 was positioned on her right side. CNA E said she did not usually work with Resident #60 and could not give a history of pressure injuries. A dressing was covering the resident's left lateral ankle. LVN C said Resident #60 was identified with a stage 2 pressure injury on her coccyx a week ago, and the wound care nurse provided wound care treatments. During an observation and interview on 02/21/18 at 08:23 a.m., Resident #60 was positioned on her back with the head of the bed elevated, the wound care nurse cleansed Resident #60's left lateral ankle pressure injury was cleansed with normal saline, and measured 0.5 x 1.3 x (unable to determine) the margins of the injury were distinct with a deeper area over 50 percent of the center. 75% of the wound bed had yellow slough and a black necrotic. Manuka honey and a silicone dressing was applied to the injury. The wound care nurse said the area had worsened and was now unstageable since her last assessment of 2/19/18 During an observation on 2/23/18 at 8:20 a.m., Resident #60 was lying on her left side with head of bed elevated 30 degrees. The low air loss mattress under her left hip and buttocks was flat- resting on the bed frame. Her left ankle was not off-loaded and was lying on mattress. During an observation and interview on at 02/23/18 at 08:50 a.m., Resident #60 was lying on her left side. The wound care nurse said the pressure injury on the left ankle was in contact with the surface of the bed and there was no device for offloading under it. The wound care nurse said they had not tried other measures to off load Resident #60's feet, only pillows. The wound care nurse was alerted by surveyor that the low air loss mattress was bottomed out and she said she would call the mattress company. During an observation and interview on 02/23/18 at 09:05 a.m., CNA G said the bed had lost air and metal frame could be felt between the Resident's bottom and mattress. During an observation and interview 2/23/18 at 1:30 p.m., Resident #60 was in the Geri chair, and the mattress representative was examining the low air loss mattress. He said the bed should have never been delivered because the center baffles were flat due to a missing cover that holds them in place. He said this would cause the resident's buttocks to bottom out on the bed frame. He said the mattress needed to be replaced. During an observation and interview on 02/23/18 02:27 p.m., Resident #60 was positioned on her right side with a pillow under her right lower leg and between her legs; however, her feet were not off-loaded. LVN H said the resident's feet were not off-loaded and readjusted the pillow. During an interview on 2/22/18 at 09:30 a.m., the ADON said he expected staff to provide off-loading of pressure injuries to prevent further injury or the development of new pressure injuries. A Wound Prevention and Management policy and procedure dated (MONTH) 2012 indicated the following: The facility strives to ensure that a resident/patient entering the facility without a pressure injury does no develop pressure injuries unless the individual's clinical condition demonstrates that they are unavoidable. The facility will implement the following interventions to prevent the development of pressure injuries: Identify at risk residents ., and implement appropriate preventive interventions. Reduce occurrence of pressure over boney prominences to minimize injury. Protect against the adverse effects of external mechanical forces (pressure, fiction, and shear). Increase the awareness of pressure injury prevention through education programs .the facility follows the National Pressure Ulcer Advisory Panel (NPAUP) for staging pressure ulcers . The National Pressure Ulcer Advisory Panel website accessed 2/26/18 indicated the following: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. * Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. *Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The CMS 672 dated 2/20/18 indicated 13 residents received preventive skin care and 7 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 10 residents reviewed for accidents. (Residents # 60) The facility did not implement adequate supervision and assistive devices timely or consistently to prevent Resident #60 from falling out of the bed. Resident #60 was totally dependent on staff for bed mobility. The resident fell out of bed and lacerated her forehead which required stitches. Resident #60 was to have bed bolsters to prevent falls. The bed bolsters were not functioning properly. This failure could place 10 residents who had falls at risk for injury. Findings included: Physician orders [REDACTED].#60 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. Consolidated physician orders [REDACTED].#60 should have sutures from forehead removed on 1/3/18. A MDS dated [DATE] indicated Resident #60 was totally dependent on two staff for bed mobility, transfers, one staff for toileting and was totally incontinent of bowel and bladder. She had limited range of motion of both arms and legs. She had not had any falls since admission. The Care Area Assessment Summary dated 10/2/17 did not trigger falls. A care plan dated 10/13/16 indicated Resident #60 had alteration in mobility, was bedfast with contractures and was unable to turn or reposition herself. Interventions included provide 2 staff for turning and repositioning in bed and 2 staff for transfer with lift. The care plan indicated a risk of falls related to use of mechanical lift. There were no other fall prevention measures in place. An incident reports dated 12/9/17 at 9:15 PM indicated Resident #60 had an unwitnessed fall and was found by CNA L lying face down on the floor at bedside. No injuries were noted by the assessing nurse. A follow up by the DON dated 12/11/17 indicated the low air loss mattress had developed a hole and lost pressure and would be replaced. A nursing note dated 12/9/17 at 9:15 PM indicated Resident #60 was found lying on floor face down beside the bed. The resident was lifted back to bed via Hoyer lift. No injury was noted. During an interview on 02/21/18 at 09:20 a.m., RN B said Resident #60 was found on the floor she believed face down on 12/9/18, she was on a low air loss mattress and she believed her positioning in the bed affected her because she was top heavy. She may move a small amount, never saw her make any purposeful/unpurposeful forward motion that would cause her to turn over. She is unable to move her arms or legs but might twitch them a little. She said the CNA notified her Resident #60 had fallen out of bed and she assisted to transfer back to bed with a Hoyer lift. She did not see injury related to this fall. She could not recall if there was a mat beside the bed, she said Resident #60 did not have a previous history of falls. There were no bolsters on the bed. An incident reports dated 12/24/27 at 7:00 PM indicated CNA D reported Resident #60 rolled out of bed after incontinent care, face down resulting in a laceration to her forehead. Vital signs were not obtained and the nurse indicated unable to obtain. Injury location was marked over the front of the forehand and of the nose and area of face around the nose. Resident #60 was transferred to the hospital at 7:09 PM by ambulance. A follow up by the DON dated 12/25/17 indicated the following measures would be put in place: Check on bed bolster to prevent rolling off bed and also now a 2 person assist for all ADLs. During an interview on 02/21/18 at 03:17 p.m., CNA D said she provided Resident # 60 incontinent care on 12/24/17 and turned her toward the window on her right side. She said she completed her task and turned away from Resident #60 because her roommate had knocked personal items off the bedside table and was attempting to get out of bed. She said Resident #60 was a 1-2 person total assist for turning, but only 1 assist for incontinent care. She said she performed incontinent care and turning and positioning by herself and believed at the time of the incident Resident #60's care plan indicated only one person to assist in incontinent care and 1 or 2 to assist with turning. CNA D said she could not perform incontinent care without turning and repositioning Resident #60. CNA D said Resident #60 required 2 staff assist with transfers using a Hoyer lift on Monday and Fridays, when she received a shower. CNA D said she was told to take 2 staff for incontinent care after the incident of 12/24/17. CNA D said Resident #60 was on a low air loss mattress, and had a previous fall from the same type of mattress. She said after the earlier fall on 12/8/17 they placed a fall mat by her bed and changed out the air mattress. She did not have bolsters on either air mattress. After this incident she was placed on a different mattress and the care plan was changed to 2 person assist for incontinent care. After the incident she was told 2 staff was required for turning and repositioning. During an interview on 02/21/18 at 09:20 a.m., RN B said on 12/24/17, CNA D notified her that while she provided incontinent care for Resident #60, she turned to care for Resident #60's roommate and Resident #60 fell out of the bed face down. She said she believed there was a fall mat, but the resident's face hit the feeding pole. RN B said the resident did not have bolsters on her bed at that time. She said at that time she was a one person assist for turning and incontinent care, since then they made her a 2 person assist. A nursing note dated 12/24/17 at 7:00 PM indicated the nurse was notified by a CNA Resident #60 was on the floor. The nurse indicated Resident #60 was face down and a large amount of blood was around her head. She indicated a laceration was noted in the center of Resident #60's forehead and her nose was bleeding. The nurse held pressure until the ambulance arrived. She indicated Resident #60 was crying and moaning, she had a skin tear to her right knee and blood coming out of her mouth. The notes indicated Resident #60 was attended by ambulance attendants at 7:05 PM and believed Resident #60 could have a fractured nose. A Department of Medical Image CT report dated 12/24/17 indicated Resident #60 was evaluated for facial injuries. The findings indicated: no acute fracture or subluxation seen . Small soft tissue contusion is seen along the midline frontal scalp. A nursing note dated 12/25/17 at 12:50 a.m. indicated Resident #60 was returned to the facility by an ambulance with 7 sutures in her forehead. A care plan initiated 2/20/18 indicated Resident #60 was at risk of injury related to falls. Interventions that were added as a look back included to provide care with assist of 2 staff (12/24/17), to place fall mats on floor at bedside, visual checks every hour, and to position resident in the center of bed, if turning to side use pillows to keep from the edge of the bed (12/24/17). The care plan indicated on 12/24/17 bolsters were to be placed on the bed when available. A nursing note dated 12/25/17, 12/26/17, 12/27/17, and 12/28/17 indicated Resident #60 had swelling over the bridge of the nose and facial [MEDICAL CONDITION]. A MDS dated [DATE] indicated Resident #60 was unable to speak, and was rarely or never understood, and had severe cognitive impairment. She was totally incontinent of bowel and bladder and totally dependent on two staff for bed mobility, transfers and hygiene. She had impaired range of motion of both arms and legs. The MDS identified a fall in the past month with no injuries identified. An incident reports dated 1/8/18 indicated at 5:00 PM Resident #60 had an unwitnessed fall. LVN H found Resident #60 lying on the floor mat at bedside. No injuries were noted. A follow up by the DON dated 1/9/18 indicated the air mattress was replaced by a scoop mattress. A nursing notes dated 1/8/18 at 9:00 AM indicated Resident #60's sutures were removed from her forehead. At 5:00 PM Resident #60 was found on the floor lying on floor mat. Low air loss mattress was replaced with scoop mattress. During an interview on 02/21/18 03:05 p.m., LVN H said she was making rounds on 1/8/18 around 5:00 PM and found Resident #60 lying on the floor at her bedside. She said she believed Resident #60 was lying on her right side on the floor mat. LVN H said she believed the low air loss mattress was throwing Resident #60 out of the bed. She said there were no bolsters on the air mattress at the time of the incident. LVN H said Resident #60's low air loss mattress now had bolsters- they were added about 2 weeks ago. She said Resident #60 had always required 2 staff for turning and repositioning. The care plan dated 2/20/18 indicated on 1/8/17 after the third fall, Resident #60 was placed on a scoop mattress. During an observation on 02/20/18 at 02:37 p.m., Resident #60 was lying in bed with a fall mat at the bedside, bolsters on the bed, bed in low position, and padding on the wall. During an interview on 2/22/18 at 9:30 a.m., the ADON said they reviewed falls in their falls committee meeting. He said he was pretty sure the low air loss mattress had a hole in it related to the fall of 12/9/17 so they replaced it with another air mattress. He said the low air loss mattress that was place did not have bolsters. He said they eventually placed a scoop mattress after the fall with injury on 12/24/17, but since then Resident #60 developed a pressure ulcer of the left ankle and they special ordered a new low air loss mattress with bolsters. The ADON could not provide a reason for 1 person assist with incontinent care for a resident who required 2 person assist with bed mobility. During an interview on 2/22/18 at 10:15 a.m., the administrator said he did not believe a Resident who required 2 person assist with bed mobility would require 2 person assist with incontinent care. He said Resident #60 was placed on 2 person assist for incontinent care after she fell out of the bed on 12/24/17. He said after the fall on 12/9/17 they changed the low air loss mattress and placed another one, but they did not place bolsters at that time, they were unable to find a suitable bolster to fit the low air loss mattress. He said after the fall on 1/8/18 they placed Resident #60 on a scoop mattress and she developed shear injury and they special ordered a low air loss mattress with wings on it about 2 weeks ago. He said he did not report to the state agency the fall with injury on 12/24/17 because it was witnessed by CNA D. During an interview on 2/22/18 at 10:26 a.m., the maintenance supervisor said Resident #60's low air loss mattress was changed on the same day of the incident of 12/9/17, but he did not apply bolsters, he said after the incident of 12/24/17 there was no suitable bolsters to place on the bed, and on 01/8/18 the low air loss mattress was replaced with a scoop mattress, he said he then special ordered a low air loss mattress and it was placed on the bed on 2/14/18 and the bolsters were placed on the bed on 2/15/18. During observations on 2/22/18 at 08:25 a.m., Resident #60 was lying in bed with the head of the bed elevated 30 degrees. The low air loss mattress was in place but the air bolster on the right side of the bed was depressed to the level of the mattress, and was not providing protection to prevent rolling out of the bed. This surveyor notified the administrator. During an observation and interview on 2/23/18 at 8:50 a.m., Resident #60's was lying on her back in bed with her buttocks sitting below the level of the foot of the bed and sunk into the low air loss mattress. Surveyor informed the wound care nurse and she said it looked like there was no air in the mattress at the level of the buttocks. She said she would notify the low air loss mattress representative. During an observation and interview on 2/23/18 at 1:30 p.m., the representative for the low air loss mattress said the baffles were not positioned properly so they did not properly fill with air, he said the mattress baffles were not covered with a liner to hold them in place and the mattress should have never been put into service. He said he would replace the mattress today and assure it was put together properly A policy and procedure for Accidents and Incidents: Report, Investigation, Follow-up, and Disposition indicated the following: The facility strives to ensure that resident/patients, visitors, and/or volunteers will not experience undue discomfort and/or have their health and safety placed in jeopardy due to an unusual occurrence (accident/incident). The facility defines and accident/incident as an event, occurrence, or happening that may produce an actual or potential undesirable outcome. The event may be am accident or a situation that could result in an accident. Accidents/incidents may include, but are not limited to, the following: Fall/suspected falls .Should an accident/incident occur, the facility strives to prevent such an occurrence from happening again. A thorough investigation and follow-up will be completed within five working days. All occurrences will be reviewed by the Administrator, Director of Nursing, Medical Director and QAPI Committee. A final disposition of the accident/incident will be documented . The Facility Matrix indicated 10 residents had falls.

Based on observation, interview, and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for 1 of 2 residents reviewed for assessments. (Resident # 1) Resident #1 had a [DIAGNOSES REDACTED]. The facility did not assess and provide interventions for Resident #1's left foot. Resident #1 developed gangrene (tissue death with infection) of the left foot. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and complete skin rounds for all residents. This failure could place 37 residents who received preventive skin care at risk for skin breakdown, wound infections, or gangrene. Findings included: Physicians orders dated [DATE] indicated Resident #1 was an [AGE] year old female, admitted on [DATE], with [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #1 was independent for walking and locomotion. Resident #1 required 1- person assistance with dressing and bathing and was total dependent with bathing. She was severely cognitively impaired. The resident did not have any identified skin issues. A Doppler evaluation (ultrasound) completed on [DATE] for [MEDICAL CONDITION] and claudication (pain or cramping caused by poor circulation due to blockage of the arteries of the lower extremity) indicated no sonographic or Doppler evidence of high-grade stenosis within the bilateral lower extremity arterial vessels. Progress Notes dated [DATE] from the physician assistant indicated Resident #1 was last seen on [DATE]. It did not address the resident's feet. A routine foot care exam by a podiatrist dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The progress note indicated the resident received routine foot care. The resident did not have a pedal pulse in the left foot, left ankle, or the right ankle. The resident had skin discolorations to the left and right foot. The note did not document any recommendations. There was not a nursing note dated [DATE] to address the podiatrist's findings. The Braden Risk Assessment Scale dated [DATE] indicated Resident #1 was at minimal risk for skin breakdown. The nursing notes from [DATE] through [DATE] and [DATE] - [DATE] do not contain any evidence that lower extremity assessments were done including, pulses, temperatures, or color gradations. The nursing notes dated [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 had weakness in both of her legs and was non-weight bearing. The Nursing notes did not address any skin issues or discoloration of Resident #1's feet or pulses. There were no changes in behavior noted. A care plan dated [DATE] indicated Resident #1 used a wheelchair for mobility. The care plan indicated the resident received occupational and physical therapy due to weakness of the lower extremities. The care plan did not address skin issues. The care plan did not address checking the resident's ankles or feet. A Physical Therapy Evaluation and Plan of Treatment dated [DATE] indicated Resident #1 was referred to physical therapy due to a decrease in strength, functional mobility, ability to transfer, and walk safely. The evaluation indicated the resident required minimal assistance with bed mobility, moderate assistance with transfers. The evaluation indicated her ability to walk was not applicable at this time . The evaluation indicated the resident would receive gait training therapy. A physical therapy progress report dated [DATE] indicated Resident #1 ' s baseline for standing balance was poor and on [DATE] her standing balance was fair. The report indicated the resident was discharged from therapy on [DATE] due to being discharged to the hospital. An Occupational Therapy Evaluation & Plan of Treatment dated [DATE] indicated Resident #1 was referred to occupational therapy due to new onset of decrease strength, increased need for assistance from others, reduced balance and decrease in functional mobility. The evaluation indicated the clinical impressions included the resident had severe upper and lower extremity weakness, reduced functional balance and safety awareness and a significant decline in self-care and functional mobility. During a telephone interview on [DATE] at 1:54 p.m., LVN D said Resident #1 had no discoloration and no open wounds on her feet. She said she did the best she could to cut her toenails because they were too thick. She said every Wednesday she did a head to toe assessment and took the resident's shoes off to assess. LVN D said Resident #1 had perfect feet with no skin discoloration. She said she needed to see a podiatrist for the thick toenails and made a note to herself for Resident #1 to see the podiatrist however, the resident was sent out before the podiatrist came. She said she did not document the information. LVN D said Resident #1's feet had no discoloration or maceration in the toes. She did not state that she checked pulses. The weekly skin assessments completed by LVN D dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] indicated Resident #1 did not have any skin concerns. The assessments did not address pedal pulses. During an interview on [DATE] at 3:00 p.m., CNA C said Resident #1's feet were bluish in color on the top and the toes nail bed was yellow. She said it looked normal to her because she thought it was just a skin pigmentation issue. She said there were no blisters. CNA C said she did not report this to anyone because she thought it was just a skin pigmentation issue. She said one part of the resident's leg was lighter in color than her feet. She said Resident #1 would sleep in her shoes because she said her feet were cold. CNA C said she gave Resident #1 her showers and would remove her shoes and socks. During an interview on [DATE] at 2:00 p.m., CNA B said Resident #1 walked around the facility before she became wheelchair bound. CNA B said she did not know why Resident #1 could no longer walk or how long she had been using a wheelchair. During a telephone interview on [DATE] at 1:58 p.m., CNA G said he assisted Resident #1 with her showers. He said he could not remember what her feet looked like. He said she wore socks all the time, but he took them off when he gave her a shower. CNA G said Resident #1 walked with a limp 2 or 3 months before she could no longer walk. He said he did not know why she could not walk any longer and thought it was because of her legs. During an interview on [DATE] at 11:32 a.m., CNA A said on [DATE], Resident #1 was shaking really badly in bed when she went to check on her during rounds. CNA A said Resident #1 had started to decline. She said Resident #1 used to walk, but now had become wheelchair bound. She said she did not know the date she the resident started using a wheelchair. She said she assisted Resident #1 up in the mornings and dressed her. A nursing note dated [DATE] at 6:15 a.m. indicated Resident #1 was not responsive to verbal or physical stimuli. The note indicated Resident #1 had twisted motions and was making grunting noises. The local emergency service was called and Resident #1 was transported to the local hospital. During an interview on [DATE] at 2:30 p.m. the administrator said Resident #1 started therapy prior to going to the local hospital on [DATE]. He said Resident #1 had no problems with her feet or her skin and if she did it would have been noted. The administrator said there was absolutely nothing wrong with Resident #1's feet. He said there no was no skin assessment done prior to transfer. During an interview on [DATE] at 3:04 p.m., the administrator said Resident #1 was walking on [DATE] the day she went to the local hospital. He said she had a pretty good gait and was participating in occupational and physical therapy. A hospital nursing note dated [DATE] indicated Resident #1 was admitted to the hospital at 6:52 p.m. on [DATE]. The hospital progress notes dated [DATE] indicated Resident #1 was admitted on [DATE]. Resident #1 was brought to the emergency department from the nursing home with complaints of possible [MEDICAL CONDITION]. She had some jerking of her right upper and lower extremity, but no movement on the left. This was resolved after she was given [MEDICATION NAME] and then she was in a postictal (altered state of consciousness after an epileptic [MEDICAL CONDITION]) state. She was admitted to the hospital for further observation and management. Physical examination of Resident #1's lower extremity revealed she had hyperpigmentation (darkening of an area of skin) of her left foot and some desiccation (extreme dryness). Resident #1's left extremity was significantly cooler than the right. There was no palpable pulse and there was a large bullous (blister) to the dorsal aspect (top) of her left foot. Resident #1 had maceration (softening and breaking down of skin) between her toes on the left side. The assessments revealed ischemia (inadequate blood supply) of the resident's left lower extremity. A hospital assessment dated [DATE] at 8:00 p.m. indicated Resident #1's left foot was cool to touch with flaky skin, blisters, discoloration, and wrinkles. Redness was noted to the resident's left leg and her left foot was dusky and cold with blister noted on the top of her foot. The resident's toes were stuck together and no pulse present. A hospital quick note dated [DATE] indicated Resident #1 had [MEDICAL CONDITION] with left foot gangrene. The duration of changes was noted to be unclear with amputation of the left foot required. A consultation report dictated by Physician D on [DATE] indicated the reason for the consultation was gangrene of Resident #1's left foot. Resident #1 had gangrenous changes involving all toes on her left foot. There were blisters present. The upper leg was warm. During a telephone interview on [DATE] at 4:37 p.m., the admitting physician from the local hospital said she diagnosed Resident #1 with ischemia of the left foot. The physician said gangrene usually occurs over days. A Discharge summary from the local hospital indicated Resident #1 was admitted on [DATE] and discharged [DATE] to hospice with a [DIAGNOSES REDACTED]. A clinical documentation report from the local hospital dated [DATE] indicated Resident #1 expired on [DATE]. The cause of death was not indicated. A guideline revised [DATE] and on [DATE] titled Admission/Weekly Skin Assessments indicated .to document skin condition upon admission, to document the presence of new skin impairment, and place an X on the anatomical figure at the site of skin impairment . The administrator, DON, and ADON were notified on [DATE] at 3:53 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 8:37 p.m. and included: 1. All Nursing Assistants will be in-serviced concerning the STOP and WATCH program to identify and report any changes in a resident condition. This includes subtle changes such as a minor change in level of consciousness changes in appetite changes in a resident's mobility changes in skin color/integrity, etc., This, in-service will include the procedure to complete the STOP and WATCH form and turn it into the Charge Nurse. In-service will begin tonight for the 2 to 10shift and will continue through future shifts until all nursing staff are in-serviced. Complete skin rounds of all residents will be completed to ensure that all Changes in skin integrity have been identified and are being treated. Special focus of lower extremities/feet will be completed to ensure no changes in LE circulation ie. Warmth, color, pallor, texture, etc. is present. Initial skin rounds for all residents will be completed by 5:00pm on ,[DATE], 2016. 2. DON/ ADON will review all STOP and WATCH forms in addition to 24-hour report daily. Any resident identified on the STOP and WATCH form will receive additional assessment by the DON/ADON to ensure, that the clinical documentation/assessment of the resident has been accurately assessed and documented. These reviews will begin immediately and continue daily for at least two weeks, then Six week thereafter. Initiation Date: [DATE] 3. All nurses will be in-serviced on their responsibility to assess each resident in their care for signs and symptoms of breakdown on each shift. Skin assessments will occur three times per-day. A check off box will be placed on the MARS where the nurse can initial indicating they have completed skin assessment. In-service will begin tonight for the 2 to 10shift and will continue through all future shifts until all nurses are in-serviced. 4. In-service on Anatomical Skin Shower Grid to all Nursing staff. All CNAs will complete a skin grid and document any unusual abnormal or discolored areas on the grid. Grid will then be given to the Charge Nurse for him/her to review and assess areas of concern and document findings. Charge Nurse will pass information on to Treatment Nurse for him/her to review and assess area of concern and document finding. Treatment nurse will then present findings to Administration. Administration will act accordingly. In¿ service began today on the 2 to 10shift and will continue through all future shifts until all nursing staff are, in-serviced. 5. All facility staff was in-serviced on Elder Abuse and Neglect on [DATE]. Investigation process and the importance of reporting to DADS were presented. 6. In-service to all Nursing staff on the importance and requirement to report skin abnormalities, open areas, skin tears and anything unusual or new to the, Charge Nurse. Charge Nurse to assess and report findings to Treatment Nurse. Treatment Nurse to present findings to Administration. In-service began today for the 2 to 10shift and will continue on future shifts until all nursing staff are in-serviced. 7. In-service to all Nurses regarding, proper skin assessments- procedure and documentation. Head to toe skin assessments are to be done weekly. Findings are to be documented on the correct skin grid. Findings will also be documented on the weekly skin assessment. In-service began today for the 2 to 10 shift and will continue on future shifts until all Nurses are in-serviced. Note: All staff who, are on vacation, sick/medical leave or on their days off will be in-serviced upon their return. On [DATE] the surveyor confirmed the facility implemented their plan of removal to sufficiently remove the Immediate Jeopardy by: *During an interview on [DATE] at 2:55p.m., the administrator said all nurse aides were in-serviced except for 3 who would be in-serviced on the weekend and 2 nurse aides on medical leave, who would be in-serviced prior to returning on the floor. He said 60 percent of residents were assessed for skin integrity and the remainder would be completed by 5:00 p.m. that day. The administrator said Stop and Watch forms would be reviewed daily. He said all nurses were in-serviced on their responsibility to assess each resident for signs and symptoms of breakdown along with the anatomical skin shower grid on each shift, the importance and requirement to report skin abnormalities, and proper skin assessments. He said the CNAs were currently being in-serviced with it continuing onto future shifts. *Six (6) LVNs and 5 CNAs said they were in-serviced regarding skin assessments, the Stop and Watch program, skin assessments, skin grid, and their responsibility to assess and report abnormalities. *The In-service log provided on [DATE] included the Stop and Watch program, assessing skin breakdown, shower skin grids, and elder abuse and neglect reporting. On [DATE] at 4:07 p.m., the administrator was informed Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated 37 residents were receiving preventive skin care.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 2 of 17 residents reviewed for falls (Resident #s 2 and 9) The facility failed to provide interventions to prevent Resident # 2 from having repeated falls which resulted in injuries. This failure contributed to Resident #2 receiving a fracture in the long bone in the arm and a closed head injury. Resident #9 had a history of [REDACTED]. This failure could place 66 residents who were dependent or required the assistance of one or two staff for transfers at risk for discomfort, injury, neglect and abuse. Findings included: 1. The consolidated physician orders [REDACTED].#2 was an [AGE] year old female admitted [DATE] with [DIAGNOSES REDACTED]. Resident #2 was placed on Fall Risk Precautions on 06/03/14. Resident #2 had an order for [REDACTED]. An admission MDS dated [DATE] indicated Resident #2's cognition was intact. She exhibited no delirium but did reject care on occasions. Resident #2 required limited assistance with the support of one staff for transfers, dressing, toilet use, and personal hygiene. She used a wheelchair for mobility. She had falls identified prior to admission which resulted in a fracture. Resident #2 received occupational and physical therapy. A significant change MDS dated [DATE] indicated Resident #2's cognition was severely impaired. She exhibited inattention and disorganized thinking on occasions but no behaviors were identified. Resident #2 required extensive assistance with the support of two or more staff for transfers, bed mobility, and toilet use. She used a wheelchair for mobility. Resident #2 had one fall which resulted in a major injury. She received occupational and physical therapy. The most recent quarterly MDS dated [DATE] indicated Resident #2's cognition was moderately impaired. She exhibited inattention and disorganized thinking occasionally but no behaviors were identified. Resident #2 required supervision with transfers. She required extensive assistance with the support of one staff for toileting and dressing. She used a wheelchair for mobility. The assessment indicated Resident #2 had one fall with a minor injury. Physical and occupational therapy were not indicated. A care plan dated 12/12/14 indicated Resident #2 was able to make her needs known and required minimal assistance with ADLs. Resident #2 was at risk for falls and injuries and had fallen and/or sustained injury since the last care plan meeting. Neither restorative nursing nor therapy was indicated. Resident #2 required assistance of one staff for bathing and dressing. The care plan indicated she sustained a left trochanter fracture on 6/5/14. Resident #2 was at risk for falls due to unsteady gait, previous attempts to stand unassisted, history of previous falls, and use of psychoactive medications. Interventions included wearing non-skid shoes or treaded socks during transfers/ambulation, utilizing bed alarms when in bed and responding promptly if alarm sounded, utilizing wheelchair alarm and responding promptly if alarm sounded, and occupational and physical therapy. Resident #2 had potential for injury related to Coumadin use. An Accident/Incident Report dated 12/29/14 indicated Resident #2 had extensive bruising to left scalp and left arm. Resident #2 stated, "I fell into bed last night." Immediate action included assessment, monitor of vital signs, and neurologic checks. There were no measures or systematic changes documented. There was no in-service to staff. Witness statement by ADON documented Resident #2 "stated she fell last night returning from the bathroom, got herself up, got in bed. I asked if she told anyone. She informed me that she did not. Saying she thought it was no big deal. " An Accident/Incident Report dated 01/15/15 indicated Resident #2 slid off the bed while trying to pick something up off the floor. Resident #2 had two skin tears from the fall. Report indicated the housekeeper heard resident yell and saw her on the floor. Immediate action documented assessing for injury and helping resident off the floor. There were no measures or systematic changes documented. There was no in-service to staff. Nursing notes dated 01/15/15 documented housekeeper notified the nurse that Resident #2 slid off her bed and was on the floor. Resident #2 sustained a skin tear to right forearm and right lower leg. Nursing notes dated 01/31/15 indicated nurse sitting at the nursing station observed Resident #2 fell backwards as she was backing out of her room and hit her head on the wheelchair. Resident #2 sustained a laceration to the back of her head. Emergency Medical Services (EMS) was called and Resident #2 was transported to the emergency room . Nursing note dated 02/01/15 indicated Resident #2 returned with a splint and sling in place to her right arm and staples to the laceration on the back of her head. Nursing note dated 02/02/15, documented day two follow up from fall and humerus (long bone in the arm)fracture and closed head injury with staples. Nursing notes for Resident #2 indicated the following: *On 11/01/14, Resident #2 was found on her knees on the floor on the side of her bed. She hit her head on the right side on the handle of her bedside table. Resident #2 sustained a " small cut " to the right side of her head and one on her right ear. A cut was observed on her scalp after the blood was cleaned off. *On 11/27/14, Resident #2 informed the nurse she had fallen onto the floor from her bed while reaching for something on her bedside table. Resident #2 sustained a bruise to the right side of her forearm and a skin tear to right shin. *On 12/29/14, Resident #2 fell into her bed the previous night causing bruise to left side of her scalp and left arm. Fall Risk Assessment documented the following for Resident #2: *On 02/23/14, Resident #2 was documented as being at moderate risk for falls with reference to care plan for intervention. *On 05/28/14 and 12/01/14, Resident #2 was documented as being at high risk for falls with reference to care plan for interventions. Hospital records dated 06/01/14 indicated Resident #2 sustained a distal radius fracture and greater trochanter fracture. Nurse Aide Care Plan dated 02/23/14 indicated Resident #2 required the assistance of one staff to transfer. She was identified as Risk of Falling due to unsteady at times. During the following observations, no alarms were observed on Resident #2's wheelchair or bed, scoop mattress was not on her bed, and there was no fall mat on the floor: *On 02/09/15 at 12:00 p.m. *On 02/09/15 at 4:00 p.m. *On 02/10/15 at 8:20 a.m. *On 02/11/15 at 8:45 a.m. During an interview on 02/09/15 at 3:00 p.m., Resident #2's granddaughter indicated no interventions for prevention of falls or injuries resulting from falls were put in place until Resident #2 sustained two falls. The granddaughter said "In my personal opinion, she should have had an alarm when she moved in." She indicated Resident #2 had a bed alarm at one time but she figured out how to turn off the bed alarm. Resident #2's granddaughter stated, "I just want her to be safe and have no further broken bones." During an interview on 02/09/15 at 3:30 p.m., CNA B (aide for Resident #2) indicated she was not aware if Resident #2 was at risk for falls. CNA B said Resident #2 was " fairly independent " and would use her call light if she needed help. During an interview on 02/10/15 at 8:20 a.m., Resident #2 indicated she did not have an alarm on her wheelchair or bed. She said she was able to go to the bathroom by herself. During an interview on 02/10/15 at 9:35 a.m., LVN A (charge nurse for Resident #2) indicated Resident #2 had a history of [REDACTED]. LVN A said Resident #2 could walk in her room. She indicated staff checked on her frequently and reminded her to use her call light. LVN A said they also encouraged Resident #2 to not walk around in her socks. She indicated most of Resident #2's falls occurred in her room. LVN A said Resident #2 did not have a wheelchair alarm but was unsure if she had a bed alarm. She was unable to identify any interventions in place to prevent falls for Resident #2. During an interview on 02/10/15 at 9:45 a.m., CNA E indicated Resident #2 experienced falls, " more than once a week. " CNA E said Resident #2 did not attend therapy, and did not have a wheelchair or bed alarm. She indicated interventions to prevent falls were to "watch her when she's up." During an interview on 02/10/15 at 10:50 a.m., Resident #2's daughter indicated she had a bed alarm at one time but would place items on it so it would not alarm if she got out of bed. Resident #2's daughter indicated she never had a wheelchair alarm. She said Resident #2 would not use her call light if she needed help. During an interview on 02/10/15 at 11:10 a.m., CNA F indicated common interventions used to prevent falls or protect from injury included fall mats and low beds. During an interview on 02/10/15 at 2:35 p.m., housekeeper H indicated she was aware Resident #2 had a history of [REDACTED].#2 falls out of her wheelchair onto the floor because of a dizzy spell. During an interview on 02/10/15 at 2:40 p.m., LVN C (charge nurse for Resident #2) indicated Resident #2 had a history of [REDACTED].#2 " is pretty much with it. " She indicated on some days she was steady and other days not. LVN C indicated she was unaware if Resident #2 had a bed or wheelchair alarm or any other interventions to prevent falls. During an interview on 02/10/15 at 2:50 p.m., CNA D (aide for Resident #2) indicated Resident #2 had a history of [REDACTED]. She indicated to prevent falls for Resident #2 she did routine checks every hour. CNA D said Resident #2 did not have a bed or wheelchair alarm. During an interview on 02/10/15 at 3:10 p.m., the DON indicated Resident #2 ' s falls were usually because she was trying to pick up things off the floor or due to change in cognition secondary to a urinary tract infection (UTI). She said Resident #2 had a scoop mattress and fall mat. She indicated residents received interventions such as fall mats, scoop mattresses, or wheelchair alarms as result of a fall. The DON said they also would get a therapy referral. During an interview on 02/10/15 at 3:15 p.m., the administrator indicated facility still used alarms for beds and wheelchairs. He stated, " Some people are prone to fall, and we can ' t watch them at all times. " During an interview on 02/11/15 at 10:00 a.m., Lead CNA G indicated interventions for protection from falls included using low beds and alarms. She said Resident #2 had several falls, but she was independent and ambulatory. Lead CNA G indicated she was unaware what interventions were put in place to prevent Resident #2 from falls or from sustaining injuries from falls. 2. Physician orders [REDACTED].#9 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] for Resident #9 indicated she had moderate cognitive impairment. She required two person assistance with transfers and most ADL care. The MDS indicated no falls. A care plan dated 8/12/14 indicated Resident #9 had a problem with falls. The care plan noted the staff were to "remind/encourage to use call light for assistance." Accident/Incident reports for Resident #9 indicated the following: 11/11/14- got up from wheelchair and fell into floor. No injuries noted. The Final Disposition Report section, "What Measures were put in Place or What Systemic Changes were Made?" was left blank. 12/29/14- resident noted on floor. No injuries noted. The Final Disposition Report section, "What Measures were put in Place or What Systemic Changes were Made?" was left blank. During an interview on 2/10/15 at 3:32 p.m., Resident # 9 was lying in bed. She said she had fallen a couple times while attempting to transfer without assistance. She said she used to have wheelchair alarm but did not have it anymore. Resident # 9 said she did not remember a bruise to her thigh. During an interview on 2/10/15 at 8:58 a.m., LVN O said nursing completed The Final Disposition Report section, "What Measures were put in Place or What Systemic Changes portion of incident/accident reports. She said measures were to be implemented to prevent future incidents. During an interview on 2/10/15 at 2:25 p.m., LVN P said nursing completed The Final Disposition Report section, "What Measures were put in Place or What Systemic Changes portion of incident/accident reports. She said measures were to be implemented to prevent future incidents. During an interview on 2/10/15 at 9:04 a.m., the DON said nursing completed The Final Disposition Report section, "What Measures were put in Place or What Systemic Changes portion of incident/accident reports. She said measures should be implemented to prevent future incidents. During an interview on 2/10/15 at 9:04 a.m., the DON and ADON said after Resident #9 had her first fall a wheelchair alarm should have been implemented. The facility's policy and procedure for Accidents and Incidents: Report, Investigation, Follow-up, and Disposition dated April 2012 indicated "...2. Protect resident/ patient from further immediate harm or potential harm..." Policy for Falls and Injuries dated July 2000 indicated, " The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence ... " Policy for Fall/Injury Management dated July 2000 indicated, " 1. Assess the resident/patient and implement appropriate measures to provide immediate care. 2. Initiate and complete the Accidents/Incidents Process ... 3. Review Fall Risk Data Collection and Assessment for any changes in fall risk. 4. Review the Plan of Care-Fall Risk Reduction 5. Discuss findings and interventions with the resident/patient/family for inclusion in the Interdisciplinary Plan of Care 6. Adjust/add interventions on the Plan of Care-Fall Risk Reduction 7. Present resident/patient at the next scheduled Interdisciplinary Plan of Care meeting...8. Review and revise Interdisciplinary Plan of Care 9. Update and communicate interventions on Individual Resident Care Plan 10. Provide staff training as needed 11. Educate resident/patient family, as appropriate 12. Verify completion of the Accident/Incident Process. " Policy for Fall Risk Care Plan Development dated July 2000 indicated, " Identify interventions to reduce the risk of falls. 1. Review the Fall Risk Data Collection and Assessment 2. Utilize the Plan of Care-Fall Risk Reduction to assist in developing an individualized plan of care. 3. Determine appropriate interventions for identified risk factors. Interventions included, but are not limited to: * ...anticipate needs, utilize bed/chair alarms, frequently orient to call bell, as appropriate ... " The facility's Abuse/Neglect Prohibition Policy dated April 2012 indicated, " The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. " The CMS 672 dated 02/09/15 indicated 37 residents needed assistance of one or two staff for transfers and 29 residents were dependent on staff for transfers (total 66).