Every finding on record at The Waters of Gallatin

Based on policy review, facility Infection Control Program document review, observation, and interview, the facility failed to ensure the prevention and spread of infections for 1 of 1 (Resident #97) when reusable medical equipment was not properly cleaned, and failed to establish and implement an infection control program to identify, report, investigate, and control infections and communicable diseases when the facility failed to ensure the tracking and trending of infections were conducted monthly for 1 of 3 months (February 2026) reviewed. This facility's failure to ensure tracking and trending of infections were conducted had the potential to affect 86 of the 86 residents residing in the facility.The findings include: 1. Review of the facility policy titled, Nebulizer Therapy, dated 4/1/2026, revealed .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Observe resident during the procedure for any change in condition .Clean after each use .Disassemble parts after every treatment .Rinse the nebulizer cup and mouthpiece with sterile or distilled water .Shake off excess water . Air dry on an absorbent towel . Review of the undated facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed Resident-care equipment can be a source of indirect transmission of pathogens .Reusable single-resident items are items that may be used multiple times, but for one resident only .Direct care staff are responsible for cleaning single-resident equipment . Review of the facility policy titled, Infection Surveillance and Tracking, dated 4/1/2026, revealed A system of infection surveillance serves as a core activity of the facility's infection control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.Monthly time periods will be used for capturing and reporting data.All residents and infections will be tracked.All resident and infections will be tracked . 2. Review of the medical record revealed Resident #97 was admitted to the facility 8/26/2025, with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #97 scored a 15 on the Brief Interview for Mental Status assessment, which revealed he was cognitively intact. Review of the Physician's Order dated 1/29/2026, revealed .Ipratropium-Albuterol Inhalation Solution [a combination of bronchodilators (medications used to open the lungs for better breathing ) used to treat and prevent symptoms of wheezing and shortness of breath that is caused by ongoing lung disease] 0.5-2.5 (3) MG[milligram]/3ML[milliliter] .1 vial inhale orally every 4 hours for SOB [Shortness of Breath] . Observation at Resident #97's doorway on 4/6/2026 at 2:33 PM, revealed Licensed Practical Nurse (LPN) E, with gloved hands, removed the nebulizer treatment mouthpiece from the resident's mouth and disconnected the tubing from the breathing treatment machine. LPN E used a brown paper towel to wipe off the mouthpiece and placed the mouthpiece, with the nebulizer medication cup still connected, in a plastic bag. LPN E failed to separate and rinse the mouthpiece and the nebulizer medication cup off and allow them to air dry on a barrier before placing them into the plastic bag for storage. During an interview on 4/6/2026 at 2:40 PM, the Director of Nursing (DON) was asked after a breathing treatment what should nursing staff do with mouthpiece and nebulizer medication cup that the medication is poured into. The DON stated, The mouthpiece and casing [round plastic piece that the medication is poured into] should be separated, rinsed, and allowed to dry .turning the pieces upside down on a barrier, then in a plastic bag for storage. The DON was asked to explain the purpose of rinsing and allowing to dry. The DON stated. For infection control, to prevent buildup of bacteria from forming in the chamber. The DON was asked to explain what the chamber is. The DON stated, The chamber is the part of the mouthpiece where you pour the solution. During an interview on 4/6/2026 at 2:43 PM, LPN E was asked about what she did with the resident's mouthpiece and the nebulizer medication cup that held the resident nebulizer treatment after the resident had finished his nebulizer treatment. LPN E stated, I wiped it out with the paper towel and put it in the bag. LPN E failed to clean the resident's mouth piece and nebulizer cup in accordance with the facility policy. 3. Review of the facility's infection tracking and trending reports revealed the facility had no tracking and trending of infections report for 2/2026. During an interview on 4/8/2026 at 11:32 AM, the Infection Control Preventionist (ICP) was asked to see the last 3 months of tracking and trending for infections. The ICP confirmed the facility had tracking and trending for December 2025 and January 2026 but did not have tracking and trending of infections for February 2026. During an interview on 4/8/2026 at 1:52 PM. The ICP was asked should the facility have the tracking and trending for infections for February 2026. The ICP stated, Yes.

Based on facility policy review, Certified Nursing Assistant (CNA) in-service review, and interview, the facility failed to ensure 4 of 11 CNA's (CNA A, B, C, and D) received at least 12 hours of required in-service training annually. The findings include: 1. Review of the facility policy titled, Nurse Aide Training Program, with a revision date of 4/1/2026 revealed . Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year.The Staff Development Coordinator shall maintain documentation of training in his/her office during the current training year, and shall forward to the HR [Human Resources] Director at the completion of the training year to be maintained in the employee's personnel file. 2. Review of the CNA in-service training revealed the following: CNA A was hired on 1/31/2002 and only completed 8 hours of education from 1/31/2025 to 1/31/2026. CNA B was hired on 10/7/2021 and only completed 7 hours of education from 10/7/2024 to 10/7/2025. CNA C was hired on 12/27/2024 and only completed 6 hours of education from 12/27/2024 to 12/27/2025. CNA D was hired on 6/6/2022 and only completed 7 hours of education from 6/6/2024 to 6/6/2025. During an interview on 4/8/2026 at 2:56 PM, the Director of Nursing (DON) was asked if a CNA should have 12 in-service hours during a 12-month period beginning on his/her hire date annually. The DON replied, Yes, annually. During an interview on 4/8/2026 at 2:58 PM, the Staffing Coordinator was asked if a CNA should have 12 in-service hours during a 12-month period beginning on his/her hire date annually. The Staffing Coordinator replied, Yes.

Based on facility policy review, Patient & Family Fridge Notice review, Bistro Fridge Notice review, observation, and interview, the facility failed to properly store resident food when 2 of 2 (Patient & Family and Bistro) refrigerators contained unlabeled, undated, and uncovered food items. The findings include: 1. Review of the facility policy titled, Use and Storage of Food Brought in by Family or Visitors, dated 4/1/2026, revealed .It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident.All food items that are already prepared by the family or brought in must be labeled with content and dated.The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.The prepared food must be consumed by the resident within 3 days.If not consumed within 3 days, food will be thrown away by facility staff. Review of the undated facility policy titled Food Safety Requirements, revealed .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will so be stored, prepared, distributed and served in accordance with professional standards for food service safety.Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon deliver/receipt and ensure timely and proper storage.Practices to maintain safe refrigerated storage include.Labeling, dating, and monitoring refrigerated food.Keeping foods covered or in tight containers. 2. Review of the undated Patient & Family Fridge Notice, revealed .This refrigerator is available for food items provided by patients and their families. To ensure food safety and compliance with Tennessee health code guidelines, please follow the expectations below.All items must be clearly labeled with the patient's name and date.Items may be stored for a maximum of 3 days only.Unlabeled or expired items will be removed during routine checks. 3. Review of the undated Bistro Fridge Notice, revealed .This refrigerator is designated for snacks provided by the Dietary Department for patients only. To ensure food safety and compliance with Tennessee health code guidelines, please follow the expectations below.All items placed in this fridge must be properly labeled with a date. 4. During an observation of the Patient & Family Fridge in the nourishment room on 4/8/2026 at 10:36 AM, revealed the following items: a. One (1) 12 ounce (oz) opened can of lemonade undated, unlabeled, and uncovered with a straw inside the can opening b. Two (2) 8 oz bottles of nutritional supplement with a use by date of 1/19/2026 c. 1 undated small Styrofoam container of salad d. 2 undated to go containers full of unknown food items e. 1 clear plastic container containing a chicken salad sandwich and potato salad with sell by date of 3/23/2026 f. 1 small undated box of pizza g. A 32 oz tub full of Greek vanilla yogurt with a use by date of 3/26/2026 h. A 32 oz tub full of Greek strawberry yogurt with a use by date of 3/29/2026 i. 1 unlabeled and undated paper plate with hotdogs and baked beans loosely covered with foil j. 1 unlabeled and undated cheeseburger loosely wrapped in foil k. 1undated large to go bowl full of chili l. 1 undated small to go bowl full of an unknown food item m. 1 undated large cup with opening in lid full of chocolate ice cream 5. During an observation of the Bistro Fridge in the nourishment room on 4/8/2026 at 10:50AM, revealed 5 undated roast beef and cheese sandwiches wrapped in plastic. During an interview on 4/8/2026 at 10:53 AM, LPN F was asked should unlabeled, undated, expired, or uncovered food items be in the Patient & Family or Bistro refrigerators. LPN F stated, No. During an interview on 4/8/2026 at 1:43 PM, the Certified Dietary Manager (CDM) was asked if items in the Patient & Family refrigerator should be dated. The CDM stated, It should be labeled with resident name and dated. The CDM was asked if expired items should be in the Patient & Family refrigerator. The CDM stated, No. The CDM was asked if opened and uncovered items should be in the Patient & Family refrigerator. The CDM stated, No. The CDM was asked if sandwiches should be in the Bistro refrigerator without a date. The CDM stated, No.

Based on facility policy review, medical record review, and interview, the facility failed to reimburse funds within 30 days to 1 of 1 (Resident #101) sampled residents reviewed for personal fund accounts. The findings include: 1. Review of the undated policy titled, Conveyance of Resident Funds Upon Death, revealed .Upon the death of a resident with a personal fund deposited with the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate, in accordance with State law 2. Review of the medical record revealed Resident #101 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Adult Failure to Thrive. Review of the medical record revealed Resident #101 was deceased on [DATE]. Review of Resident #101's Resident Trust Fund Account revealed, a returned check dated [DATE] was issued for the account balance of $1,285.81, 33 days passed the allotted 30 day time period. The facility failed to refund the remaining balance to Resident #101's estate within 30 days of death. During an interview on [DATE] at 9:18 AM, the Business Office Manager (BOM) was asked when resident trust fund balances should be refunded. The BOM stated .I did not make the 30-day timeframe.I just overlooked it. During an interview on [DATE] at 1:42 PM, the Administrator was asked when resident funds should have been sent. The Administrator stated, 30 days. The Administrator was asked if it should be completed in those 30 days. The Administrator stated, Yes, it should have.

Based on facility policy review, medical record review, observation, and interview, the facility failed to store medications in accordance with facility policy when medications were found unsecured and unattended at the resident's bedside and failed to ensure equipment was properly cleaned after use for 1 of 1 (Resident #97) residents. The findings include: Review of the facility policy titled, Nebulizer Therapy, dated 4/1/2026, revealed .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .Observe resident during the procedure for any change in condition .Clean after each use .Disassemble parts after every treatment .Rinse the nebulizer cup and mouthpiece with sterile or distilled water .Shake off excess water . Air dry on an absorbent towel . Review of the facility policy titled, Medication Storage, dated 4/1/2026, revealed .During a medication pass, medications must be under the direct observation of the person administering medications . Review of the undated facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed Resident-care equipment can be a source of indirect transmission of pathogens .Reusable single-resident items are items that may be used multiple times, but for one resident only .Direct care staff are responsible for cleaning single-resident equipment . 2. Review of the medical record revealed Resident #97 was admitted to the facility 8/26/2025, with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed Resident #97 scored a 15 on the Brief Interview for Mental Status assessment, which revealed he was cognitively intact. Review of the Physician's Order dated 1/29/2026, revealed .Ipratropium-Albuterol Inhalation Solution [DuoNeb is a combination of bronchodilators (ipratropium bromide and albuterol sulfate) used to treat and prevent symptoms of wheezing and shortness of breath that is caused by ongoing lung disease] 0.5-2.5 (3) MG[milligram]/3ML[milliliter] .1 vial inhale orally every 4 hours for SOB [Shortness of Breath] . A random observation at Resident #97's doorway on 4/6/2026 at 2:12 PM, revealed Resident #97 was holding his nebulizer treatment mouthpiece in his mouth as he was getting the nebulizer treatment. There was no nurse in the room during Resident #97's nebulizer treatment. During an observation and interview at Resident #97's doorway on 4/6/2026 at 2:14 PM, the Director of Nursing (DON) was asked about Resident #97 self-administering the breathing treatment. The DON stated, The nurse should be with the resident during the breathing treatment the entire time. [Named Resident #97] has not been assessed to self-administer his medications. The DON summoned for Licensed Practical Nurse (LPN) E to come to the resident's doorway. The DON stated to LPN E, Anytime Resident #97 is getting a breathing treatment you [LPN E] should be there the entire time because he [named Resident #97] has not been assessed to self-administer medications. Observation at Resident #97's doorway on 4/6/2026 at 2:33 PM, revealed LPN E with gloved hands removed the nebulizer treatment mouthpiece from the resident's mouth and disconnected the tubing from the breathing treatment machine. LPN E used a brown paper towel to wipe off the mouthpiece and placed the mouthpiece, with the nebulizer cup still connected, in a plastic bag. LPN E failed to separate the mouthpiece from the nebulizer cup and failed to rinse them off and place them on a barrier to dry before placing them into the plastic bag for storage. During an interview on 4/6/2026 at 2:35 PM, LPN E was asked the name of medication during Resident #97's nebulizer treatment. LPN E stated DuoNeb. During an interview on 4/6/2026 at 2:40 PM, the DON was asked after a breathing treatment what should nursing staff do with mouthpiece and round plastic piece that the medication is poured into. The DON stated, The mouthpiece and casing [round plastic piece that the medication is poured into] should be separated, rinsed, and allowed to dry .turning the pieces upside down on a barrier, then in a plastic bag for storage. The DON was asked to explain the purpose of rinsing and allowing to dry. The DON stated. For infection control, to prevent buildup of bacteria from forming in the chamber. The DON was asked to explain what the chamber is. The DON stated, The chamber is the part of the mouthpiece where you pour the solution. During an interview on 4/6/2026 at 2:43 PM, LPN E was asked about what she did with the resident's mouthpiece and the round plastic piece (chamber) that held the resident nebulizer treatment after the resident had finished his nebulizer treatment. LPN E stated, I wiped it out with the paper towel and put it in the bag.

Based on facility policy review, Certified Nursing Assistant (CNA) in-service review, and interview, the facility failed to ensure 4 of 11 CNA's (CNA A, B, C, and D) received at least 12 hours of required in-service training annually. The findings include: 1. Review of the facility policy titled, Nurse Aide Training Program, with a revision date of 4/1/2026 revealed . Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year.The Staff Development Coordinator shall maintain documentation of training in his/her office during the current training year, and shall forward to the HR [Human Resources] Director at the completion of the training year to be maintained in the employee's personnel file. 2. Review of the CNA in-service training revealed the following: a. CNA A was hired on 1/31/2002 and only completed 8 hours of education from 1/31/2025 to 1/31/2026. b. CNA B was hired on 10/7/2021 and only completed 7 hours of education from 10/7/2024 to 10/7/2025. c.CNA C was hired on 12/27/2024 and only completed 6 hours of education from 12/27/2024 to 12/27/2025. d. CNA D was hired on 6/6/2022 and only completed 7 hours of education from 6/6/2024 to 6/6/2025. During an interview on 4/8/2026 at 2:56 PM, the Director of Nursing (DON) was asked if a CNA should have 12 in-service hours during a 12-month period beginning on his/her hire date annually. The DON replied, Yes, annually. During an interview on 4/8/2026 at 2:58 PM, the Staffing Coordinator was asked if a CNA should have 12 in-service hours during a 12-month period beginning on his/her hire date annually. The Staffing Coordinator replied, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to initiate an investigation related to allegations of sexual abuse for 1 (Resident #6) of 3 sampled residents. The findings include: 1. Review of the facility policy titled, ABUSE PREVENTION PROGRAM, dated 10/22/2022, revealed, .It is the policy of this facility to prevent resident abuse .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect or a resident by a 3rd [third] party [a party not primarily involved in a situation] .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .All personnel must promptly report any incident or suspected incident of resident abuse .Any alleged violations involving mistreatment, abuse .MUST be reported to the Administrator . 2. Review of the medical records revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction, Major Depressive Disorder, and Need for Assistance with Personal Care. Review of the Progress Notes for Resident #6 dated 12/2/2024 revealed, .Reported by two staff members suicidal ideation expressed .order from facility provider to send to ER [emergency room ] for psych [mental health] eval [evaluation] . Review of the Hospital Transfer Form dated 12/2/2024 revealed Resident #6 was transferred to Hospital #1 on 12/2/2024 at 6:00 PM for suicidal ideations/statements. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 required maximal assistance with Self-Care for toileting hygiene, bathing, and Personal hygiene. Behavior was coded for no Hallucinations, Delusions, Physical, Verbal and Other behavioral symptoms. During a telephone interview on 1/8/2025 at 12:37 PM, Adult Protective Services (APS) Q stated the Hospital #1 had reported Resident #6 was admitted to the geriatric psychiatric unit for evaluation on 12/2/2024 and had alleged an incident of sexual abuse by staff at the facility where she resided. APS Q stated, .On 12/4/2024 at 12:30 PM, I spoke with [Named Social Services Director-SSD] about the allegations [Named Resident #6] had made when she was admitted to [Named Hospital #1] .[SSD] said they were looking into it and that [Named Resident #6] was on the memory care unit, could be hallucinating . When asked if she had told the SSD about the specific allegations of sexual abuse, APS Q replied, Yes, she understood [Named Resident #6] had reported the allegations to staff at [Named Hospital #1] . During an interview on 1/14/2025 at 12:26 PM, the SSD stated she had been employed by Facility #1 for 3 years and had received abuse training multiple times. The SSD defined sexual abuse as any type of sexual contact without consent. When asked if APS Q had notified the facility regarding allegations of sexual abuse made by Resident #6, the SSD replied, .Yes, [Named Resident #6] was not cognitively intact, she was on the memory care unit .she was only here for a couple of days .I spoke with [Named Administrator] after [Named APS Q] left .he [Administrator] told me he was already looking into it [Resident #6's allegations] . When asked, if she participated in the facility abuse investigations, the SSD stated she conducts interviews with residents. When asked if she had a role in the investigation related to Resident #6's allegations of sexual abuse, the SSD replied, I am sure that I did. During an interview on 1/14/2025 at 1:10 PM, The Administrator was asked for copies of the investigation related to allegations of sexual abuse reported by Resident #6 on 12/2/2024. The Administrator stated he was not aware of any allegations of sexual abuse made by Resident #6. The Administrator was asked if the SSD had notified him related to the allegations of sexual abuse made by Resident #6 when she had been transferred to Hospital #1 for evaluation. The Administrator stated no one had reported the allegations of sexual abuse made by Resident #6 to him and confirmed the facility had not investigated the alleged sexual abuse. The Administrator affirmed he expected all staff to report allegations of abuse immediately to him, the Abuse Coordinator. The Administrator confirmed all allegations of sexual abuse should be reported and investigated thoroughly. During a telephone interview on 1/15/2025 at 9:45 AM, the Social Worker at Hospital #1 stated Resident #6 was admitted to the facility on [DATE] for psychiatric evaluation following suicidal ideations reported by staff at Facility #1. The Social Worker stated the hospital physician documented bruising on Resident #6's arms and under her chin. The Social Worker stated, .The M.D. [Medical Doctor] reported that [Named Resident #6] had made allegations of sexual assault by two white women, nurses who had both put their fingers in her vagina .[Named Resident #6] alleged she had told the women to stop and they would not .[Named Resident #6] stated she did not really have suicidal thoughts, she just wanted to get out of the facility because she was scared . The Social Worker stated she had reported the allegation to Adult Protective Services (APS) and to the local police department.

Based on facility policy review, video footage review, medical record review, facility document review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control for 1 of 3 (Resident #10) sampled residents reviewed for falls. The findings include: 1. Review of the facility policy titled, GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 6/30/2023, revealed, .If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by a nurse .Whether or not the resident can be moved or repositioned will be determined by the assessing nurse . 2. Review of video footage dated 1/3/2025 at 11:34 AM, revealed Resident #10 telling staff she was sliding out of the chair. Certified Nursing Assistant (CNA) K then told CNA L to go get the mechanical lift and the bigger chair. CNA K was standing in front of Resident #10 and CNA M was standing behind the resident. Resident #10 was in the transport chair facing the 600 Hall entrance. CNA K attempted to adjust the sling under Resident #10's legs. Resident #10 was leaning over the right chair arm with her feet on the floor. Resident #10 stated, .I am falling out of this thing [transport chair]. CNA M told Resident #10 to lean back, twice, then Resident #10 stated, .I can only lean back so far . CNA K attempted to adjust Resident #10's legs and Resident #10 stated, .I feel like my leg is falling .I am going to be on the floor in a minute . CNA M called Resident #10 by her first name in a loud voice and proceeded to pull the resident backwards with Resident #10's feet both on the floor. Resident #10 yelled out and stated, .I'm not kidding .I am just on the edge of this chair . CNA M stopped pulling the chair, looked at CNA K and stated, .I am losing my patience .I didn't want to get her up in the first place . Resident #10 stated, .I can't I am going to hit the floor in a second . CNA K disagreed with Resident #10 and Resident #10 screams, .Yes I am . as CNA M pulls the chair again. Resident #10 slid out of the chair on to the foot rest and stated, .I tried to tell you . CNA L attempted to support Resident #10 and CNA K covered Resident #10's exposed lower body with a sheet/blanket. CNA M turned her head to the side, raised her hand in the air and states, .I am just to the point of like, so I'm going to get arrested . and myself at risk, no . CNA K states, .This chair don't need to go in her room no more . CNA L states, .We can lift her up with the lift .we can go get the chair she is supposed to have . CNA L and CNA K attempted to move Resident #10 off of the foot rest. CNA M continued to stand behind the transport chair and raises both hands in the air and declares, .I'm going to go get help . Further review of the video footage revealed Licensed Practical Nurse (LPN) E arrived to the area and assured Resident #10 staff would help lift her. Physical Therapy (PT) arrived shortly after LPN E, and assisted with positioning the sling under Resident #10. Staff raised Resident #10 off of the floor on both sides and raised both legs in order to place the sling. Resident #10 cried out during movement. The video footage revealed no one physically touched the resident to assess for injury. Registered Nurse (RN) C was not in the video footage at any time. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Generalized Anxiety Disorder, and history of Age-Related Osteoporosis with Current Pathological Fracture. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #10 was coded for total dependence with all mobility and locomotion in wheelchair. Review of the care plan for Resident #10 dated 7/3/2024 revealed, .7/3/2024 .Pain/Comfort .ROM [Range of Motion] .7/19/2024 .[Named Resident #10] has a 'Self Care Deficit' .Ensure proper positioning while in bed and/or chair .Fall: [Named Resident #10] has the potential for serious injury/fall .1/3/25 [2025] Bariatric Wheelchair .Remind resident of safety awareness .OSTEOPOROSIS: [Named Resident #10] is at risk for Fracture R/T [Related/To] dx: [diagnosis] osteoporosis .Avoid exercises that may increase risk for fractures . Review of the facility incident report dated 1/3/2025 revealed, .[Resident #10] slid from wheelchair on to floor in hallway .Predisposing Physiological Factors . Agitated/Anxious .Decreased safety awareness . Review of the Incident Report Checklist for Resident #10 dated 1/3/2025 revealed a statement from CNA K indicating Resident #10 slowly slid out of her chair and was easily guided to the floor. A statement from CNA L indicated Resident #10 had to be pulled backwards in the chair because her feet would not fit on the foot rest of the transport chair. CNA L's statement revealed Resident #10 was slipping out of an inappropriate chair which required the CNAs to ease her to the floor onto blankets and pillows. A statement from CNA M alleged Resident #10 began to slide out of her wheelchair and CNA grabbed the sling that was underneath the resident and gently slid her to the ground. Review of the Multidisciplinary Incident Report Meeting Minutes dated 1/3/2025 at 11:35 AM, revealed a signature page which included a signature of the Administrator, the Medical Director, the Assistant Director of Nursing (ADON), the Wound Care Nurse, the MDS Coordinator, the Social Services Director, and the Therapy staff. The immediate interventions included (Named non-slip material), and replace Resident #10's transport chair with a Bariatric chair. During an interview on 1/16/2025 at 11:11 AM, Resident #10 stated on 1/3/2025 a Certified Nursing Assistant (CNA-M) transferred her to the transport chair (a narrow mobility chair) using a mechanical lift. Resident #10 stated, .I told [CNA M] I wasn't sitting in the chair right and needed to be pulled .she was in a hurry and seemed agitated .[CNA M] said you shouldn't be going anyway .coming back from activities I kept telling [CNA M] I was about to slip out of the chair, then I did .No one took my blood pressure .When therapy puts me in the wheelchair, I do not ever have a problem sliding out, the techs just rush . During an interview on 1/16/2025 at 12:45 PM, Family Member (FM) P stated, .[Named Resident #10] told staff multiple times during activities and going back to her room that she needed to be pulled up because she was sliding off of her chair .[CNA M] appeared agitated, and a couple of times [CNA M] said she didn't want to get her up .her feet were dragging the floor and she lost her shoe .[staff] stopped once when [Named Resident #10] yelled out .one tech said we need to get a lift, the dark haired tech [CNA M] said no we don't and told [Named Resident #10] she wasn't sliding out, then pulled [Resident #10] again and she slid out onto the floor . During a telephone interview on 1/16/2025 at 6:15 PM, the Activities Assistant stated on 1/3/2025 he walked behind staff pulling Resident #10 backwards with her feet dragging the floor when leaving activities. The Activities Assistant affirmed Resident #10 did tell staff she was sliding out of the chair and then [Resident #10] slid from the chair. During an interview on 1/17/2025 at 11:00 AM, CNA M stated on 1/3/2025 stated, .I was paged to activities because [Resident #10] was sliding out of her chair .she had slid down in the chair and the sling [ hammock-like support used to cradle a person's body during a transfer] was dislodged, there was no way to pull her back up .[Resident #10]'s feet were past the foot pedals, on the floor, and I had to pull her backwards .[Named CNA L] and another CNA [CNA K] walked with us down the hall .[Resident #10] said she was sliding out of the chair .no way to use [mechanical lift] in the hall .I was aggravated with the situation .when I got her up in the chair before activities, she complained about being wrong in the chair, I asked her then if she even wanted to go .it isn't safe for her to be in that chair [transfer chair] . When asked why she placed Resident #10 in the transfer chair instead of a wheelchair, CNA M responded, It's her chair, I guess she wants to use it. CNA M stated Resident #10 was sliding out of the chair and staff eased her to the floor then used a mechanical lift to place her in a Bariatric wheelchair (extra wide wheelchair). CNA M stated a nurse assessed the resident and checked vital signs. During an interview on 1/17/2025 at 12:14 PM, CNA K stated, .[Named Resident #10] was not sitting right in her chair .[Resident #10] had slid down and her feet were on the floor .[Named CNA M] came to get her and the resident was yelling because we couldn't get her feet on the foot pedal .[Named CNA M] pulled her backwards out of 600 Hall .[Named Resident #10] kept saying she was sliding out of the chair .I told [Named CNA M] [Resident #10] was sliding out .[Named CNA M] started pulling her backwards again and [Resident #10] slid out into the floor landing on the wheelchair foot pedal . CNA K affirmed she did not recall anyone actually assessing Resident #10 before staff lifted her with the mechanical lift. CNA K concluded the transport chair was not large enough for Resident #10 which caused her to slide out of the chair during transport. During an interview on 1/17/2025 at 12:55 PM, LPN N stated on 1/3/2025 Registered Nurse (RN) C told him to assist the CNAs with Resident #10 after a fall on 200 Hall. LPN N stated RN C was sitting at the nurse station charting when she requested his assistance. LPN N confirmed he did not assess Resident #10 after the fall and did not assist with lifting her from the floor. LPN N conceded the facility protocol required a nurse to perform a head to toe assessment after a fall before moving the resident. During a telephone interview on 1/17/2025 at 4:37 PM, the Physical Therapist (PT) stated on 1/3/2025 he was asked to assist with lifting Resident #10 from the floor after she slid out of her transport chair. The PT stated, .[Named Resident #10] was awake, alert and said nothing was hurting her .I assessed [Resident #10] by applying pressure to her shoulder and both hips .[Resident #10] only complained about the sling bothering her neck .no one has voiced concerns with [Named Resident #10]'s transport chair being too small .no chair ordered because the facility had Bariatric wheelchairs . During a telephone interview on 1/17/2025 at 5:05 PM, RN C stated on 1/3/2025 she did not witness Resident #10 slide out of the wheelchair. RN C stated, .I went to the hall and assessed the resident .I did not obtain vital signs until she was back in bed .I felt of her hips, applied pressure to both hips and lifted her pants leg to look for injuries to her legs .I asked [Named Resident #10] if she was in pain and she denied pain . RN C conceded the facility protocol requires the nurse to perform an assessment prior to moving a resident post fall which includes obtaining vital signs. During an interview on 1/17/2025 at 5:15 PM, CNA L stated on 1/3/2025 the 600 Hall nurse (LPN O) told her Resident #10 was sliding out of her chair and to get a mechanical lift to assist Resident #10 back into a sitting position. CNA L stated CNA M came to take Resident #10 back to her room and pulled her backwards in the transport chair because Resident #10's feet were dragging the floor. CNA L stated, .[Named CNA K] and I tried to help hold her in the chair going down the hall .[Resident #10] yelled a couple of times saying she was sliding out of the chair and then she did .I think [Named LPN N] assessed her but I don't know about vital signs .I think they did [obtain vital signs] . When asked if CNA M was agitated, CNA L replied, .Yes, she was huffy, short with answers, and making remarks, I am not sure exactly what she said . During a telephone interview on 1/17/2025 at 5:52 PM, LPN E stated, .The day [Named Resident #10] slid out of her chair I went to help get her up from the floor .several of us put the sling under her and lifted her up to a wheelchair .I went back to the nurses station and told [Named RN C] she could get vital signs now, the resident was back to her room . When asked if RN C had assessed Resident #10 prior to her being moved from the floor, LPN E replied, .I do not recall seeing [RN C] assess the resident, she stayed at the desk charting . During an interview on 1/17/2025 at 6:00 PM, the Director of Nursing (DON) stated she was not present in the facility on 1/3/2025, the day Resident #10 slid from her chair while being pulled backwards in the transport chair. The DON affirmed pulling a resident backwards in a wheelchair was not safe and conceded dragging a resident's feet during transport created a skin injury risk in addition to a fall risk. The DON stated she expected nursing staff to complete an assessment after a fall to prevent any potential additional injury to a resident.

Based on the Facility Assessment Tool review, facility policy review, medical record review, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 3 (Resident #5) sampled residents. The findings include: 1. Review of the Facility Assessment Tool dated 8/7/2024, revealed, .Diseases/conditions, physical and cognitive disabilities that the facility can accommodate .Respiratory System .Chronic Obstructive Pulmonary Disease (COPD) .Decisions regarding caring for residents with conditions not listed .In the event that a referral for admission is received or a current patient develops a new or unfamiliar diagnosis the clinical chart is reviewed .When considering the patient the IDT [Interdisciplinary Team] shall take into account the clinical capabilities of the staff .Specialized education shall be given to staff as necessary to manage new or less common diagnoses .prior to admission .Special Treatments and Conditions .Suctioning Tracheostomy [surgically created opening and placement of a tube/catheter/cannula in the windpipe/trachea, to help a person breathe] Care . 2. Review of the undated facility policy titled, Tracheostomy Care, revealed, .Tracheostomy care is the process of aseptically cleaning the tracheostomy tube and soma [stoma] site .Review physician's order .Gather the necessary equipment .Suction equipment .Trach care kit .Follow relevant infection control procedures .Suction the trach as necessary-following sterile suction technique .Precautions/Hazards .Accidental decannulation .Infection from poor aseptic technique . 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses which included COPD, Tracheostomy Status, and Acquired Absence of Larynx. Review of the physician's orders for Resident #5 revealed, .Trach: site care every shift and as needed as needed AND every shift .Start Date .10/22/2024 .End Date .12/24/2024 .Trach: suction as needed as needed .Start Date .10/22/2024 .End Date .12/24/2024 . Review of the Medication Administration Records dated 10/22/2024- 12-12-2024, for Resident #5 revealed trach site care was documented each shift by nursing staff. Continued review revealed documentation of as needed suctioning provided twice during his stay in the facility. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed Resident #5's primary medical condition category coded as Debility, Cardiorespiratory Conditions. Resident #5 was coded for Special Treatments, Procedures, and Programs which included Tracheostomy care. Review of the comprehensive care plan dated 10/23/2024, for Resident #5 revealed, .at risk for complications R/T [Related/To] tracheostomy .Trach care per MD [Medical Doctor] order .Trach change . Staff alleged Resident #5 provided his own trach care. There was no physician's order for self-care. During an interview on 1/9/2025 at 2:21 PM, Licensed Practical Nurse (LPN) E stated, .I talked to [Named Assistant Director of nursing-ADON and Interim Director of Nursing-DON] the day of [Resident #5's] admission .I told them that I did not have the experience or training to provide care for a trach patient .I never saw a replacement trach tube at [Resident #5's] bedside or in supply .I didn't feel confident to be responsible for a trach patient then and I don't know .We didn't have suction at the bedside and no trach care kits .I was told the admission could not be stopped and [Named Interim DON] called the nurses into the office and provided a quick true/false quiz on trachs .A respiratory consultant came in to set up oxygen for [Resident #5] and I asked him what could I do if the patient lost his airway, he said to call 911 [emergency assistance] and bag [mask bag device used to force air into the lungs] at the trach . LPN E affirmed the brief in-service true/false quiz was the only education on tracheostomy care and precautions provided by the facility. LPN E stated he had minimum training during his LPN course and did not feel it was adequate for hands on care of a tracheostomy. During an interview on 1/13/2025 at 1:55 PM, LPN F stated, .I had [Named Resident #5] on my assignment while he was here .[Resident #5] took care of his trach himself .was not compliant with care, sometimes he would take his trach tube out and leave it open .I don't believe I could put a trach tube back in if I needed to .[Named Interim DON] called us into the office and gave a test on trach care and I googled a video to watch about it [providing care of a tracheostomy] .I believe they handed out a packet of information too .I know there was a care kit at his bedside, not sure if there was a replacement tube in the kit . When asked if she felt the training provided by the facility was adequate to prepare her for Resident #5's care, LPN F replied, No. During a telephone interview on 1/14/2025 at 10:32 PM, LPN G stated, .I received a real quick in-service on trach care .a few questions on a test .I provided suction when [Resident #5] needed it .used a catheter suction .I don't think it [suctioning the trach] is a sterile procedure, I did use clean procedure .[Resident #5] provided his own trach care .I am not really familiar with an emergency kit for trachs . LPN G stated she did not receive an in-service video education related to tracheostomy care and wasn't aware of any type of packet with education provided by the facility. During an interview on 1/15/2025 at 2:53 PM, the ADON stated, .We only had one resident with a trach, [Named Resident #5] .a couple of the nurses were anxious about taking care of his trach .[Named Interim DON] provided some training, I think a video and a post test . When asked if the training was provided to all nursing staff, the ADON replied, I really don't remember. When asked if the video was provided by the DON during the in-service on 10/22/2024, the ADON replied, I'm not sure. The ADON stated there wasn't a specific Staff Development person and affirmed she provided most nursing education. When asked if she had received sufficient training related to tracheostomy care, the ADON replied, I'm not sure. During an interview on 1/16/2025 at 11:43 AM, the Nurse Practitioner (NP) stated, .[Named Resident #5] should not have provided his own trach care .I didn't feel confident that the nurses providing [Resident #5's] care were adequately trained for any type of acute airway compromise. I asked the nurses questions related to an acute airway emergency and trach care, the nurses could not answer correctly .I asked the Wound Care Nurse [LPN H] to assist the nurses with [Resident #5] care . The NP stated she voiced concerns related to staff competency in tracheostomy care to the ADON and the interim DON on the day of Resident #5's admission. When asked about Nursing Administration's response, the NP replied, The Interim DON called the nurses on duty into her office and provided a little 5 question quiz on trach care, which was not adequate. During an interview on 1/17/2025 at 5:25 PM, the Wound Care Nurse (LPN H) stated, .The DON talked to some of the nurses in the office when [Resident #5] was admitted .gave a quick questionnaire, watched a video, and I believe there was a packet .we had not had a trach patient here before [Resident #5] .I have never provided trach care to anyone, here or anywhere else .a couple of the nurses voiced concerns about caring for [Resident #5] .I was never present during trach care for [Resident #5] . When asked if she felt confident to provide care for a tracheostomy patient during an acute airway compromise, LPN H did not reply. During an interview on 1/17/2025 at 6:00 PM, the DON was asked if the competency check-off sheet provided for nursing staff was sufficient to ensure staff had the skill set to provide tracheostomy care. The DON stated, .The check off sheet provided during orientation of nursing staff simply determines a basic knowledge of skills .When a resident is admitted with special care needs, such as a tracheostomy, staff need to have a comprehensive in-service to ensure competency in care .nursing staff should be confident when providing care of all residents and be encouraged to request additional training in order to reach competency for resident safety . The DON reviewed the in-service 5-question true/false quiz and confirmed it was not adequate training. The facility provided an in-service record titled, Trach Care, dated 10/22/2024. The documents provided included a sign in sheet for 8 staff nurses and 1 MDS nurse (which did not include all nursing staff assigned to care for Resident #5) and a Tracheostomy Care Quiz. Review of the 5-question true/false quiz revealed, .1. It is not necessary to have a spare tracheostomy cannula at hand, if cannula is dislodged placing cannula back is permitted .2. After tracheostomy decannulation [removal of the tracheostomy tube] oxygenation is of high priority .3. If resident is dependent on tracheostomy cannulation and tracheostomy becomes decannulated, it becomes an emergency .4. If a resident is observed struggling to oxygenate with tracheostomy cannula in place, immediately notify nurse .5. Always have oxygen and suctioning machine available at resident's bedside .

Based on facility policy reviews, medical record review, and interviews, the facility failed to report allegations of suspected abuse within 2 hours for 1 of 2 sampled residents (Resident #1) reviewed for allegations of abuse. The findings include: Review of the policy titled, Abuse Prevention Program Policy, updated on 1/9/2017, revealed, .Abuse Reporting .this policy will define how the investigation of abuse allegations and mistreatment will be conducted and outline the process of reporting .any alleged violations involving mistreatment, abuse .must be reported to the Administrator and Director of Nursing .or person in charge .notify the following persons or agencies of such incident immediately .the investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Review of the undated policy titled, Resident Rights, revealed, .Abuse .you have the right to be free from verbal, sexual, physical or mental abuse .In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. During an interview on 3/20/2023 at 2:15 PM, the Assistant Director of Nursing (ADON) stated, Adult Protective Services [APS] came to the facility .investigating a complaint made by [named Resident #1] alleging she was not being taken care of properly. I informed the Director of Nursing [DON] that APS was there to investigate the allegations made by [named Resident #1]. When asked to define the definition of Neglect, the ADON replied, not providing care to the resident. During an interview on 3/21/2023 at 1:37, APS stated, I came to the facility on [DATE] to investigate a complaint of neglect for [named Resident #1]. I spoke with the ADON about the concerns regarding the allegation of neglect for [named Resident #1]. During an interview on 3/22/2023 at 2:02 PM, the Administrator confirmed the allegations of Neglect made by Resident #1 were not investigated by the facility or reported to the State Agency.

Based on facility policy reviews, medical record review, and interviews, the facility failed to thoroughly investigate an allegation of neglect for 1 of 2 sampled residents (Resident #1) reviewed with allegations of abuse. The findings include: Review of the policy titled, Abuse Prevention Program Policy, updated on 1/9/2017 revealed, .Abuse Reporting .this policy will define how the investigation of abuse allegations and mistreatment will be conducted and outline the process of reporting .any alleged violations involving mistreatment, abuse .must be reported to the Administrator and Director of Nursing .or person in charge of the facility, will notify the following persons or agencies of such incident immediately .the investigator will submit a final report of the conclusion of the investigation in writing within five (5) working days of the incident . Review of the undated policy titled, Resident Rights, revealed, .Abuse .you have the right to be free from verbal, sexual, physical or mental abuse .In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4, Type II Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. During an interview on 3/20/2023 at 2:15 PM, the Assistant Director of Nursing (ADON) stated, Adult Protective Services [APS] came to the facility .investigating a complaint made by [Resident #1] alleging she was not being taken care of properly. I informed the Director of Nursing [DON] that APS was there to investigate the allegations made by [named Resident #1]. When asked to define the definition of Neglect, the ADON replied, not providing care to the resident. During an interview on 3/21/2023 at 1:37, APS stated, I came to the facility on [DATE] to investigate a complaint of neglect for [named Resident #1]. I spoke with the ADON about the concerns regarding the allegation of neglect for [named Resident #1]. During an interview on 3/22/2023 at 2:02 PM, the Administrator confirmed the allegation of neglect made by Resident #1 was not investigated or reported to the State Agency.

Based on facility policy review, medical record review, and interviews, the facility failed to develop and implement a baseline care plan to include the instructions needed to provide effective and person-centered care for 1 of 4 sampled residents (Resident #2) reviewed for care plans. The findings include: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care, revealed, .It is the policy of the facility to ensure that every resident has a Baseline Care Plan completed and implemented within 48 hours of Admission .intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan of delivery of care and services by receiving a written summary of the Baseline Care Plan .The Baseline Care Plan Assessment will be completed within 48 hours of admission and will address areas of imminent concern . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included COVID-19, Atrial Fibrillation, Muscle Weakness, History of Falling and Thrombocytopenia (low amount of platelets in blood which prevents clotting and can cause excessive bleeding-bruising). Review of the Baseline Care Plan for Resident #2 revealed the following questions were incomplete and/or Not Assessed .advanced directives, eating, personal hygiene, toilet use, dressing, bathing, bed mobility, transfer, and walking in room. Questions regarding urinary and bowel continence, skin risk, mental health and behavioral concerns were also incomplete. The Baseline Care Plan was signed and dated 1/29/2023 by the ADON (Assistant Director of Nursing). No other disciplines signed the Baseline Care Plan. During an interview on 3/20/2023 at 2:37 PM, the ADON stated, The baseline care plan is initiated during the admission process .We have 48 hours for all disciplines to complete the care plan . The ADON confirmed the care plan for Resident #2 was incomplete and areas that were not assessed for interventions. During an interview on 3/22/2023 at 12:15 PM, the Social Services Director (SSD) stated, The baseline care plan will be completed within 48 hours according to the policy .it was not completed [for Resident #2] .I did not go over the plan of care with [Resident #2]'s resident representative .

Based on facility policy review, medical record review, and interview the facility failed to notify the responsible party of a room change to a secure unit for 1 of 3 residents (Resident #7) reviewed. The findings include: Review of the facility's undated policy for the special care unit (secure unit) titled, Admission and Discharge Policy and Procedure, revealed .The criteria for admission is the standard by which [named facility] selects potential residents and is also the basis for the criteria by which a resident may be discharged from [named facility]. A specialized screening process begins prior to the admission to [named facility] and continues until the time of discharge. If a resident does not meet the admission criteria in one or more of the following areas, the resident may not be selected for admission [to named facility]. 1. Must have a diagnosis of Alzheimer's or Dementia. 2. Must not exhibit behaviors that may result in injury to self or others .5. Must be mobile: ambulatory, self-propelled wheelchair, and must be able to transfer with a 1-2 person assist and weight bear pivot . Review of the facility's undated policy titled, Room Changes-Resident Rights revealed .It is the policy of the facility to conduct any room changes/transfers in compliance with the regulations related to the different specified locations in the facility including the distinct part areas .Resident/responsible party will be informed of their right to refuse to transfer to another room in the purpose of the transfer is to: Relocate a resident of a SNF [skilled nursing facility] from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction, Hypothyroidism, and a History of Falling. Review of Resident #7 undated care plan revealed .Alteration in behaviors as evidenced by: [named Resident #7] is resistant with care, verbally aggressive with staff, and physically, aggressive with staff during care. Makes false statements, hallucinates . Review of the Nurse Practioner (NP) Notes dated 7/14/2022 revealed, .She is being seen today for routine follow-up and lab analysis .Patient requiring assistance with personal hygiene, toileting, transfers and mobility. She continues to have anxiety. MHN [Mental health Nurse] NP to see . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Inventory for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #7 required extensive assistance from two staff for bed mobility and toileting. Resident #7 was frequently incontinent of bowel and bladder. Review of the Progress Notes dated 7/16/2022 revealed .Resident combative with confusion during any care provided. Will scream out during brief/bed changes/transfers, attempts to hit staff during care, threatens to report all of staff during care . Review of the Progress Notes dated 7/18/2022 revealed, .I have a doctors appointment when this nurse entered resident was attempting to exit the bed. This nurse and CNA [Certified Nursing Assistant] assisted her back in bed in proper alignment. Resident began screaming and pinched this nurses left arm leaving a red mark. Resident reminded that it was 0400 [4:00 AM] and still nighttime and she also did not have an appointment at the time. Resident began to get agitated and accused this nurse of causing the bruising on her arms and legs. Noted no bruising to legs or arms, reminded resident staff is here to assist and care for her. Resident was provided with peri-care, ice water and morning medications. Resident lying in bed with lights on and eyes open, respirations even unlabored . Review of the NP Notes dated 7/18/2022 revealed .She has been anxious. She is here for continued care .She needs help with bathing, grooming, dressing, and toileting . During a telephone interview on 11/15/2022 at 9:30 AM, Family Member #1 stated the facility did not inform Family Member #1 that Resident #7 was moved to a secure unit or of the room change. During a telephone interview on 11/15/2022 at 4:26 PM, License Practical Nurse (LPN) #5 stated she never worked on the secure unit unless an assigned nurse did not come into work. The management decided who was placed in the secure unit. LPN #5 confirmed that the responsible party or the resident, if they were their own responsible party, had to be notified before moving them to another room or unit. During an interview on 11/16/2022 at 10:42 AM, the Social Service Director (SSD) stated that Resident #7 was initially admitted to the 500 halls (non-secure long term care unit). The only residents admitted to the secure unit were residents who wandered, or who had behaviors, a history of falling, Dementia, exit seeking, or a history of elopement. The SSD stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) decided for residents to be admitted to the secure unit. The SSD stated that the family should be notified before moving a resident to the secure unit. The SSD confirmed she did not see any documentation in the EHR (electronic health record) of notification to the family for Resident #7 for the transfer to the secure unit. During a telephone interview on 11/16/2022 at 12:20 PM, the NP stated that the facility did not inform her of Resident #7's move to the secure unit, and the NP did not have input on which residents were admitted to the secure unit. The NP stated she would not have written an order for admittance to the secure unit for Resident #7. During an interview on 11/16/2022 at 1:44 PM, the ADON stated that residents were admitted to the secure unit dependent on their prior hospitalization , exit-seeking behaviors, and wandering behaviors. The ADON stated the DON was the decision maker for transferring a resident to the secure unit. The ADON stated the nursing staff did not have to obtain an order from the physician before transferring a resident to the secure unit. THE ADON stated she did not remember why Resident #7 was moved to the secure unit and confirmed she did not see any documentation for the notification of the responsible party to the secure unit for Resident #7.

Based on facility policy review, medical record review, and interview, the facility failed to inform a resident's representative/responsible party of an identified pressure ulcer and failed to consult with the resident's physician of a significant decline requiring transfer to the secure unit for 1 of 3 (Resident #7) sampled residents. The findings include: Review of the facility's undated policy titled, Changes in Residents Condition or Status, revealed .It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status . Review of the facility's undated policy titled, Preventative Skin Care revealed .It is the intent of the facility that the facility provide preventive skin care through careful washing, rinsing, and drying to keep residents clean, comfortable, well groomed, and free from pressure sores . Review of the facility's undated policy for the special care unit (secure unit) titled, Admission and Discharge Policy and Procedure, revealed .The criteria for admission is the standard by which [named facility] selects potential residents and is also the basis for the criteria by which a resident may be discharged from [named facility]. A specialized screening process begins prior to the admission to [named facility] and continues until the time of discharge. If a resident does not meet the admission criteria in one or more of the following areas, the resident may not be selected for admission [to named facility]. 1. Must have a diagnosis of Alzheimer's or Dementia. 2. Must not exhibit behaviors that may result in injury to self or others .5. Must be mobile: ambulatory, self-propelled wheelchair, and must be able to transfer with a 1-2 person assist and weight bear pivot . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Myocardial Infarction, Hypothyroidism, and a History of Falling. Review of Resident #7 undated care plan revealed .[named Resident #7] has an alteration in skin integrity and is at risk additional and/or worsening of skin integrity issues related to: Impaired cognition, Incontinence of bowel, Impaired Mobility Status, Comorbidities, and Resistance to ADL [activities of daily living] Care . Review of the Weekly Wound Evaluation dated 7/12/2022 revealed Resident #7 had a Stage 2 pressure ulcer to the coccyx documented as present upon admission. The measurements of the Stage 2 pressure ulcer on 7/12/2022 was 8.0 centimeters (cm) in length, 7.0 cm in width, and 0.5 cm in depth. Resident #7 had a suspected deep tissue injury to the right heel documented as present upon admission. The measurements of the suspected deep tissue injury were 1.3 cm in length and 2.1 cm in width. The Wound Care Nurse documented, Upon admission, skin assessment completed. Discoloration noted to R [right] heel and SDTI [Suspected Deep Tissue Injury]/open area coccyx .NP [Nurse Practitioner]/DON [Director of Nursing] aware of skin integrity . The Wound Care Nurse documented Resident #7 was self responsible, and she updated Resident #7 on the status of the wound. There was no documentation found that the resident's representative/responsible party was notified of the identification of a pressure wound or the wound status. Review of the Admission Agreement dated 7/13/2022 revealed that Family Member #1 was the representative/responsible party for Resident #7. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Inventory for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Continued review revealed Resident #7 required extensive assistance from two staff for bed mobility and toileting. Resident #7 was frequently incontinent of bowel and bladder. During a telephone interview on 11/15/2022 at 9:30 AM, Family Member #1 stated he could not remember when he was told about the wound but was told on 7/20/2022 Resident #7 was being discharged because the wound had declined. During an interview on 11/16/2022 at 4:12 PM, the Wound Care Nurse stated she did not remember if she contacted the family regarding the wound upon discovery at admission. Review of Resident #7 undated care plan revealed .Alteration in behaviors as evidenced by: [named Resident #7] is resistant with care, verbally aggressive with staff, and physically, aggressive with staff during care. Makes false statements, hallucinates . Review of the Nurse Practioner (NP) Notes dated 7/14/2022 revealed, .She is being seen today for routine follow-up and lab analysis .Patient requiring assistance with personal hygiene, toileting, transfers and mobility. She continues to have anxiety. MHN [Mental health Nurse] NP to see . Review of the Progress Notes dated 7/16/2022 revealed .Resident combative with confusion during any care provided. Will scream out during brief/bed changes/transfers, attempts to hit staff during care, threatens to report all of staff during care . Review of the Progress Notes dated 7/18/2022 revealed, .I have a doctors appointment when this nurse entered resident was attempting to exit the bed. This nurse and CNA [Certified Nursing Assistant] assisted her back in bed in proper alignment. Resident began screaming and pinched this nurses left arm leaving a red mark. Resident reminded that it was 0400 [4:00 AM] and still nighttime and she also did not have an appointment at the time. Resident began to get agitated and accused this nurse of causing the bruising on her arms and legs. Noted no bruising to legs or arms, reminded resident staff is here to assist and care for her. Resident was provided with peri-care, ice water and morning medications. Resident lying in bed with lights on and eyes open, respirations even unlabored . Review of the NP Notes dated 7/18/2022 revealed .She has been anxious. She is here for continued care .She needs help with bathing, grooming, dressing, and toileting . During a telephone interview on 11/15/2022 at 4:26 PM, License Practical Nurse (LPN) #5 stated she never worked on the secure unit unless an assigned nurse did not come into work. The management decided who was placed in the secure unit. During an interview on 11/16/2022 at 10:42 AM, the Social Service Director (SSD) stated that Resident #7 was initially admitted to the 500 halls (non-secure long term care unit). The only residents admitted to the secure unit were residents who wandered, or who had behaviors, a history of falling, Dementia, exit seeking, or a history of elopement. The SSD stated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) decided for residents to be admitted to the secure unit. During a telephone interview on 11/16/2022 at 12:20 PM, the NP stated that the facility did not inform her of Resident #7's move to the secure unit, and the NP did not have input on which residents were admitted to the secure unit. The NP stated she would not have written an order for admittance to the secure unit for Resident #7. During an interview on 11/16/2022 at 1:44 PM, the ADON stated that residents were admitted to the secure unit dependent on their prior hospitalization , exit-seeking behaviors, and wandering behaviors. The ADON stated the DON was the decision maker for transferring a resident to the secure unit. The ADON stated the nursing staff did not have to obtain an order from the physician before transferring a resident to the secure unit. THE ADON stated she did not remember why Resident #7 was moved to the secure unit. During a telephone interview on 12/2/2022 at 9:14 AM, the Medical Director stated he did not recall giving verbal or written orders for admittance to the secure unit because he had over 20 buildings with residents that he sees.

Based on facility policy review, medical record review, and interview the facility failed to document medication administrations on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the undated facility's policy titled Medication Administration revealed .To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .4. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication that are refused by the resident or are not administered for other reasons will be circled on the particular day of no administration. The reason for not administering the medication will be documented on the back of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day scheduled Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status assessment score of 3 which indicated severe cognitive impairment. Review of the hospital discharge orders dated 1/27/2022 revealed .[MEDICATION(S)] ([MEDICATION(S)]) 10 mg [milligrams]. Instructions: Combined with [MEDICATION(S)] HCL [[MEDICATION(S)]] 28 mg to make [MEDICATION(S)] [treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] HCI Tablet 10 mg 1 tablet by mouth one time a day .[MEDICATION(S)] HCI 10 mg give 2 tablets by mouth two times a day for Dementia . Continued review revealed 3/2/2022 -3/10/2022 were not marked as administered or refused on the MAR. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Capsule Extended Release 24-hour 28-10 mg ([MEDICATION(S)] HCI-[MEDICATION(S)] HCI) Give 1 capsule by mouth one time a day .Family to provide . Continued review revealed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the count sheet dated 3/1/2022 revealed the [MEDICATION(S)] 28/10 mg tablet was signed out 3/2/2022 -3/19/2022. Continued review revealed the facility received 20 tablets from the family. During a telephone interview on 5/5/2022 at 4:28 PM, the Assisted Director of Nursing (ADON) confirmed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on facility policy review, medical record review, and interview the facility failed to have complete admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's undated policy titled, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . At the time of admission the facility must have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Not PPS Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status Score of 15, which indicated no cognitive impairment. Resident #1 required extensive assistance with one staff member. Further review revealed Resident #1 had pain medication over the last five days and rated her pain at a 4 out of a 0 to 10 pain scale. Review of the Hospital Discharge Orders dated 11/4/2021 revealed .Dressing changes every third day with Xeroform gauze, 4x4 gauze, ABD pad, kerlix roll. Changed on 11/2/2021 . Review of the Hospital Discharge Medication Orders dated 11/4/2021 revealed .[MEDICATION(S)] with Acetaminophen ([MEDICATION(S)] 5/325) 1 tablet by mouth every 6 hours as needed. For pain scale of 4-10. Quantity 10 tablets. 3 days . Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 3/15/2022 at 5:28 PM, LPN #3 stated she added admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 confirmed the floor nurse needed to double-check the orders once the resident arrived at the facility to make sure any orders were not missed. During an interview on 3/15/2022 at 7:09 PM, the Director Of Nursing confirmed the the nurses should have double-checked the copies of discharge orders against what was already sent from the hospital in the electronic health record (EHR).

Based on facility policy review, medical record review, and interview the facility failed to sign the medication administration record for 1 of 3 sampled residents (Resident #1) reviewed for medication administration. The findings include: Review of the facility's undated policy titled, Medication Administration revealed .To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .Medication Administration Record will be signed after for each medication administered to the resident .The reason for not administering the medication will be documented on the back of the Medication Administration Record . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Not PPS Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status Score of 15, which indicated no cognitive impairment. Resident #1 required extensive assistance with one staff member. Further review revealed Resident #1 had pain medication over the last five days and rated her pain at a 4 out of a 0 to 10 pain scale. Review of the MAR dated 11/1/2021-11/30/2021 revealed on 11/6/2021 the [MEDICATION(S)] Sodium Chloride Solution Reconstituted 500 mg/ml [milligram/milliliter] Use 500 mg intravenously every 8 hours for left foot Diabetic Ulcer was not signed as given or refused for the 2:00 AM dose. Continued review revealed the Normal Saline Flush of 0.9 % use 10 ml every 8 hours before and after antibiotic administration was not signed as given or refused. Review of the MAR dated 11/1/2021-11/30/2021 revealed on 11/7/2021 the 9:00 PM dose of Insulin [MEDICATION(S)] Solution Pen-Injector 100 Unit/ML Inject 20 ML Unit Subcutaneously at bedtime related to Type 2 Diabetes was not signed as given or refused. Review of MAR dated 11/1/2021-11/30/2021 revealed the wound care dressing was added on 11/7/2021 for 6:00 AM. Continued review revealed the wound care was not signed as completed or refused by the resident. During a telephone interview on 3/15/2022 at 4:00 PM, Licensed Practical Nurse (LPN) #1 confirmed she remembered Resident #1 and recalled flushing Resident #1's IV [intravenous] line during her shift but could not recall if she hanged any IV antibiotics. During an interview on 3/15/2022 at 7:09 PM, the Director Of Nursing confirmed if the medication was not signed out for the insulin and IV antibiotic, then it was not administered.

Based on facility documentation and interview the facility failed to employ a licensed nurse for 1 of 3 new hires reviewed. The findings include: Review of the undated Job description revealed .Licensed Practical Nurse: 3. Must possess a current, unencumbered, active license to practice as an RN or LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] in this state . Review of the Executive Order No. 83 dated [DATE] revealed, .Practical nursing graduates may practice under supervision without examination . Review of the Executive Order No. 90 dated [DATE] revealed the Governor had extended Executive Order No. 83 from [DATE] to [DATE]. Review of the facility application dated [DATE], revealed the unlicensed new graduate applied for a Licensed Practical Nurse (LPN) position at the facility and indicated they were not licensed. Review of the orientation packet dated [DATE], revealed the unlicensed new graduate was hired on [DATE]. Continued interview revealed the recent unlicensed graduate had completed orientation on [DATE]. Review of the Division of Health Licensure and Regulation Division of Health-Related Boards dated [DATE], revealed a Licensed Practical Nurse license was issued [DATE] and expired [DATE]. During an interview on [DATE] at 11:27 AM, the Human Resource Director stated she was responsible for verifying nursing and Certified Nurse Aides (CNAs) licenses. Continued interview confirmed she was permitted to hire an unlicensed new graduate nurse because she would be orienting for three months with a nurse. During an interview on [DATE] at 11:57 AM, Licensed Practical Nurse (LPN) #1 confirmed she was one of the preceptors to the new graduate and was with them the whole time while they oriented. LPN #1 confirmed the recent graduate had her electronic health record ID to sign off on medication and treatments administered to the residents. LPN #1 confirmed she did not recall how long the orientation period was and only sat down on [DATE] to fill out the orientation checklist. LPN #1 was aware the new graduate was unlicensed while orienting. During an interview on [DATE] at 7:04 PM, the Director of Nursing (DON) confirmed the unlicensed new graduate had gone to school with her daughter. She came to the facility and applied for a position after graduation. The recent unlicensed graduate was orienting with a licensed nurse and had applied for a date to test to become certified. The DON was under the impression the State was allowing current graduate nurses to orient for 90 days one on one with another licensed nurse while waiting to test.

Based on facility policy review, medical record review, observation, and interview the facility staff failed to don PPE prior to entering a resident's room for 1 of 3 sampled residents (Resident #2) observed. The findings include: Review of the facility's policy titled, Infection Control: COVID-19 Prevention, Visitation, Surveillance and Education Guidelines dated 3/15/2020 revealed .Avoiding close contact with person(s) that present with respiratory illnesses through social distancing and appropriate PPE usage . Observation on the 200 Hall on 3/14/2022 at 11:13 AM and 11:16 AM revealed no staff was on the hall where the new admission was housed behind the double doors. Resident #2 asked for assistance when he saw the surveyor and then coaxed to use his call light. Certified Nurse Aide (CNA) #1 entered the resident's room without donning PPE. Continued observation at 11:16 AM CNA #1 leaves the room. Observation and interview of the 200 Hall on 3/14/2022 at 11:18 AM revealed CNA #1 entered Resident #2's room again to deliver water. CNA #1 confirmed when asked the appropriate attire when entering a resident's room on isolation stated, I guess I need to wear a gown when I enter the room. During an interview on 3/14/2022 at 11:21 PM, Registered Nurse (RN) #2 confirmed that all staff must wear an N95, goggles, face shield, and gowns before entering a resident room on isolation. During an interview on 3/15/2022 at 7:09 PM, the Director Of Nursing (DON) confirmed the staff was to follow the signage on the doors as to what PPE was required before entering a resident's room.

Based on facility policy review, observation, and interview the facility failed to handle ready to eat food in a sanitary manner and failed to practice hand hygiene after touching kitchen objects before donning gloves. The findings include: Review of the facility's undated policy titled, Meal Service revealed, .There is no bare hand contact with ready to eat foods . Observation in the kitchen on 3/14/2022 at 4:40 PM revealed the Cook had opened the warmer and picked up a grill cheesed sandwich with her bare hands. Observation in the kitchen on 3/14/2022 at 4:48 PM revealed the Cook removed her gloves to open the refrigerator and retrieve a salad. The Cook donned new gloves without washing her hands. During an interview on 3/15/2022 at 10:10 AM, the Dietary Manager confirmed she expected the Cook to wash her hands before starting the tray line and after touching other objects in the kitchen before donning her gloves. Continued interview revealed she had not received concerns regarding the food choices served to the residents. The kitchen served tuna fish once in a while because most of the residents did not like tuna.

Based on medical record review, facility documentation review and interview, the facility failed to follow a care plan while caring for 1 (Resident #1) of 2 residents reviewed for following a comprehensive care plan. This failure resulted in a fracture of the surgical neck (a [MEDICATION(S)] below the tubercles [rounded projection] of the greater and lesser tubercles of the humerus [large bone in upper arm]) and greater tuberosity causing Harm to Resident #1. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the of the Resident Assessment and Care Screening Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 03 indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with a 2-person physical assistance for bed mobility, and dressing. Further review revealed Resident #1 required total dependence with transfers and toilet use. Review of Resident #1's care plan dated 8/5/2020 and revised on 8/30/2021, revealed .Bed Mobility: [named resident] Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Position in bed q (every) 2h (hour) as resident will allow with pillow/wedge support, partial Right side lying supine leg flexed, partial left side lying, 2 staff members to turn and position at all times .[named resident] Resident #1 at risk for falls related to: weakness and diabetes .Intervention dated 8/27/2021: Ensure two staff assist with turning while in bed . Review of Visual/Bedside Kardex Report revealed .Bed Mobility, make sure that 2 staff assist with turning while resident is in bed. Continued review revealed 8/27/21 Ensure two staff with turning while in bed . Review of the Resident Fall Report dated 8/27/2021, revealed .tech [certified nursing assistant] (CNA) #1 came to me [licensed practical nurse] (LPN) #1 and stated the resident (Resident #1) fell out of bed while getting changed. I entered the room and observed the resident on the floor laying on her right side between her (Resident #1's) bed and roommates' bed, resident (Resident #1) was alert. Tech (CNA #1) stated as she (CNA #1) rolled resident (Resident #1) over to be changed residents (Resident #1's) leg went off the bed and her (Resident #1's) top half went also . Review of the Order Recap Report dated 8/1/2021-8/31/2021, revealed .May transfer to hospital, verbal, date: 8/27/2021 .sling to right arm. Monitor for s/s (signs/symptoms) of swelling/redness to site. Monitor for pain. every shift for Monitor s/s of swelling and pain, dated 8/27/2021 .[MEDICATION(S)] HCI capsule 5 MG (milligram), Give 1 capsule by mouth as needed for pain BID (twice per day) . Review of Resident #1's Hospital Discharge instructions dated 8/27/2021,revealed .Assessment: Closed fracture of proximal end of right humerus .Imaging: XRAY Right Shoulder-2+ Views . During a telephone interview on 9/16/2021 at 2:36 PM, CNA (certified nursing assistant) #1 stated when rolling her (Resident #1) she (Resident #1) was rolling away from me (CNA #1). During further interview CNA #1 stated when she (Resident #1) slid off of the bed she (Resident #1) slid off of the left side of the bed. During continued interview CNA #1 stated with any total care patient, they (residents) should always be a 2-person assist, I just knew my abilities. During further interview CNA #1 confirmed she did not use a 2nd person while turning Resident #1. During a telephone interview on 9/16/2021 at 3:45 PM, LPN #1 stated the tech (CNA #1) said she was the only one in the room changing her (Resident #1). During a telephone interview on 9/16/2021 at 4:05 PM, CNA #3 stated I have only been on the 400 hall twice, today and Tuesday. When CNA #3 was asked how many people would need to assist a total care resident CNA #3 stated it depends on their care plan. During continued interview CNA #3 stated [named resident] Resident #1 is care planned for a 2-person assist. During further interview CNA #3 stated as a tech with 10-years of experience, I could provide care for her (Resident #1) by myself, but I am not going to violate a care plan. During an interview on 9/16/2021 at 4:15 PM, CNA #4 stated I usually wouldn't try to assist someone new. We would use 2 people if an assessment is not done. During continued interview CNA #4 stated that it is one thing I like about here (facility) it was always a 2-person (for total care residents). During further interview CNA #4 stated I always had someone to help me with [named resident] Resident #1. During an interview on 9/16/2021 at 4:36 PM, the therapy director stated [named resident] Resident #1 is a full body lift, me personally I would go and ask for help. During continued interview the therapy director confirmed, if MDS assessment is extensive assistance with 2-person assistance, then the resident should be care planned for two people. During an interview on 9/16/2021 at 4:42 PM, the Interim Director of Nursing (DON) confirmed, based on Resident #1's care plan and MDS, the CNA (CNA #1) should have used 2 people for turns.

Based on policy review, medical record review, facility documentation review and interview, the facility failed to prevent an injury during resident care for 1 (Resident #1) of 2 residents reviewed for falls. This failure resulted in a fracture of the surgical neck (a [MEDICATION(S)] below the tubercles [rounded projection] of the greater and lesser tubercles of the humerus [large bone in upper arm]) and greater tuberosity causing Harm to Resident #1. The findings include: Review of the undated facility policy INCIDENTS/ACCIDENTS/FALLS revealed .It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of [named] computer system. The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, and Generalized Anxiety Disorder. Review of the of the Resident Assessment and Care Screening Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 03 indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with a 2-person physical assistance for bed mobility, and dressing. Further review revealed Resident #1 required total dependence with transfers and toilet use. Review of the Fall Risk Review form dated 8/26/2021 showed Resident #1 had a total score of 14 which represents a high risk for falls. Review of Resident #1's progress note dated 8/26/2021 at 10:20 PM, revealed .nurse was informed by tech (technician) that resident had fallen out of bed during toileting. once nurse reached the room resident was lying on the floor on her right side between her bed and roommates bed. residents arms were at her side. resident was alert/confused. nurse assessed resident and asked if she was in any pain. resident stated' no.' nurse assisted tech with getting resident back on her bed. vitals were obtained and within normal limits.no visible skin tears or bleeding. resident currently in bed asleep. notified family, np (nurse practitioner), and adon (Assistant Director of Nursing). residents daughter asked for a xray .daughter requested that tech no longer be assigned to her mom. will continue to monitor . Review of Resident #1's nursing progress note dated 8/27/2021 at 00:04, revealed .spoke with [named Resident #1's daughter] and advised that mobile x-ray would not be out till the morning to perform x-rays of resident and that if she liked we could send resident over to the ED [emergency room ] for eval [evaluation] and treatment. she then stated 'I´m not sending my mom to covid land, and as long as the x-rays get done and mom is not laying in bed in pain I´m ok with that.' will continue to monitor . Review of Resident #1's Radiology Report dated 8/27/2021 at 11:50 AM, revealed .SHOULDER COMPLETE, MIN (minimum) 2V (views), RIGHT .Acute fracture of the surgical neck and greater tuberosity as noted . Review of Resident #1's nursing progress note dated 8/27/2021 at 13:00 (1:00 PM), revealed .Mobile X-Ray to facility for requested x-rays of resident r/t (related to) previous fall. After final review, a fx (fracture) of the right shoulder was confirmed. Resident was then transported to [named hospital] ER (emergency room ) for eval and tx (treatment) via non-emergent [named] EMS (Emergency Medical Service) . Review of Resident #1's nursing progress note dated 8/27/2021 at 15:20 (3:20 PM) revealed .Resident returned from [named] ER. Right arm immobilized with a sling. Per report, pt (patient) to f/u (follow-up) with ortho in one week. Pt has no c/o (complaint of) pain at this time. VSS (vital signs stable) . Review of the Resident Fall Report dated 8/27/2021, revealed .tech (CNA) #1 came to me (LPN) #1 and stated the resident (Resident #1) fell out of bed while getting changed. I entered the room and observed the resident on the floor laying on her right side between her (Resident #1's) bed and roommates' bed, resident (Resident #1) was alert. Tech (CNA #1) stated as she (CNA #1) rolled resident (Resident #1) over to be changed residents (Resident #1's) leg went off the bed and her (Resident #1's) top half went also . During a telephone interview on 9/16/2021 at 2:36 PM, CNA (certified nursing assistant) #1 stated . [named resident] Resident #1 is every 2-hour turn and I try to time it with my rounds . During continued interview CNA #1 stated the side rails were quarter rails and were up, she [named resident] Resident #1 has an air mattress, typically there is not a fitted sheet on the air mattress, as she was rolled over her feet rolled off of the bed and she (Resident #1) followed. During further interview CNA #1 stated as soon as it happened, I came to the other side. I didn't touch her (Resident #1) and got her nurse, Licensed Practical Nurse (LPN) #1, her nurse (LPN #1) did the assessment, called the family and the on-call doctor. During continued interview CNA #1 stated, the family requested that I (CNA #1) not take care of her (Resident #1). During further interview CNA #1 stated when rolling her (Resident #1) she (Resident #1) was rolling away from me (CNA #1). During continued interview CNA #1 stated when she (Resident #1) slid off of the bed she (Resident #1) slid to the left side of the bed. During further interview CNA #1 stated with any total care patient, they should be always 2-person, I just knew my abilities and usually when she rolls over when she turns, she could hold on the side rails to assist. During a telephone interview on 9/16/2021 at 3:45 PM, LPN #1 stated at the time [named resident] (Resident #1) was on the 500-hall, I was on the 400-hall at the time of the fall and [named CNA] CNA #1 stated she (CNA #1) needed help, I went to [named residents] Resident #1's room and when I got to the room [named resident] Resident #1 was laying on the left side of the bed on her right side. During continued interview LPN #1 stated the Tech (CNA #1) stated she was rolling pt (patient) over and her legs slipped off the bed and the resident (Resident #1) followed. During continued interview LPN #1 stated the tech (CNA #1) said she was the only one in the room changing her (Resident #1). During a telephone interview on 9/16/2021 at 4:05 PM, CNA #3 stated I have only been on the 400 hall twice, today and Tuesday. When CNA #3 was asked how many people would need to assist a total care resident CNA #3 replied it depends on their care plan. During continued interview CNA #3 stated as a tech with 10-years of experience, I could provide care for her (Resident #1) by myself, but I am not going to violate a care plan. During an interview on 9/16/2021 at 4:11 PM, CNA #2 stated usually we know who is a 2-person assist but if there is someone new, therapy would tell us. During continued interview CNA #2 stated [named resident] Resident #1 is easier to do with 2-persons, the air mattresses are hard, I always had someone to help me with her because it would be too hard. During an interview on 9/16/2021 at 4:23 PM, the MDS (minimum data set) nurse stated, the care plan is driven in part by the MDS and some of it is therapy. During continued interview the MDS nurse confirmed resident Care Plans are generated from the residents' MDS assessments. During an interview on 9/16/2021 at 4:51 PM, the Administrator confirmed [named CNA] CNA #1 should have used a 2-person assist to turn [named resident] Resident #1 based on the care plan and MDS assessment.

Based on policy review, observation, record review, and interview, the facility failed to prevent the significant weight loss for 1 (Resident #9) resident of the sample. The failure to prevent significant weight loss for this resident resulted in actual harm. The facility identified a census of 76 residents. Sample size included 31 residents of which 3 were reviewed for nutrition. The findings included: 1. The facility's policy for Nutrition Care Process dated 2/12/15 listed the 4 steps in the Nutrition Care Process: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation. Nutrition intervention consists of 2 interrelated components, planning and implementation. Implementing the nutrition intervention is the action phase which includes: carrying out and communicating the plan of care, continued data collection and revising interventions if warranted by resident response. Nutrition monitoring and evaluation is to determine the amount of progress made to reach the specified goals and tracking of resident outcomes relevant to the nutrition [DIAGNOSES REDACTED]. 2. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score (BIMS) of 10, indicating moderate cognitive impairment, required extensive assistance of 2 people for transfers, and required limited assistance of 1 for eating. The MDS documented the resident had no swallowing issues (even though the resident had the [DIAGNOSES REDACTED]. The resident received a mechanically altered therapeutic diet. The Care Area Assessment for cognition dated 6/3/15 revealed the resident was admitted for skilled services related to the [DIAGNOSES REDACTED]. The care plan listed the interventions initiated on 6/9/15: regular mechanical soft diet, monitor meal consumption daily, proper positioning at meals, provide adaptive feeding devices as ordered, such as scoop plate and built up utensils, provide assistance with meals as needed, screen/evaluation by rehab services as indicated, assure resident is monitored during mealtime if needed, obtain and update food/beverage preferences, vitamin/mineral supplements as ordered, and weekly weights. The care plan revealed the resident had self-feeding difficulty and chewing difficulty as related to history of [MEDICAL CONDITION] with deficits. The Weight Record listed the following: 5/22/15 - 167.4 pounds (#) 5/25/15 - 165.2 # 6/2/15 - 164 # 6/8/15 - 164 # 6/29/15 - 163 # 7/15/15 - 145.4 # 7/16/15 - 146 # 7/20/15 - 142.6 # 7/27/15 - 141 # 8/4/15 - 143.7 # 8/12/15 - 144.8 # 8/17/15 - 144.5 # 9/7/15 - 145 # Consisting of a 22.4 pound or 13.3 percent weight loss in less than 5 months. The resident's total protein 7/8/15 was 6.3 with the normal range of 6.7 to 8.5 grams/deciliter and the [MEDICATION NAME] was 2.1 with the normal range of 3.4 to 5.0 grams/deciliter. The 7/15/15 hemoglobin level was 9.9 with the normal range of 13 to 16 grams/deciliter. The hematocrit was 30.5 with the normal range of 39 to 50 percent. The 5/28/15 Nutrition Data Form revealed the resident weighed 165.2 pounds and had not had a change in weight. The resident used a scoop plate and built up utensils. The resident was admitted on a concentrated carbohydrate, mechanical soft diet and the resident received Ensure with lunch. The resident had a blister on the right heel. The 6/9/15 Nutrition Assessment revealed the resident required increased protein related to wound healing. The resident received a concentrated carbohydrate, mechanical soft diet, staff to monitor intake, weight, and labs. The resident received Ensure daily and vitamin supplements. The resident had lost 3.4 # since admission but not a significant change. Resident to have a frozen nutritional treats (high calorie supplement) added two times a day. No other recommendations made. Review of the clinical record lacked evidence the resident received the frozen nutritional treats two times a day. The 7/16/15 timed 2:43 PM Change of Condition Situation form revealed the resident had a 17 # weight loss in 2 weeks a 10 percent weight loss since readmission from the hospital. Staff to add Glucerna (high calorie supplement) 1 can two times a day. Review of the clinical record lacked evidence the resident received the Glucerna two times a day. The 7/23/2015 timed 2:16 PM Change of Condition Situation form revealed this resident weighed 142.6 #. The resident lost 2.8 # this week and continues to be a significant weight loss. Recommended to add 2 Cal (high calorie supplement) 60 milliliters two times a day. Review of the clinical record lacked evidence the resident received the 2 Cal two times a day. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The quarterly Nutrition/Wound Review dated 8/25/2015 and timed 10:24 AM, revealed the resident continues to receive treatments to multiple wounds. The resident continues to receive a regular mechanical soft diet and has a history of a significant weight loss since admission. The dietician recommended to add a multivitamin with minerals daily and Prostat 30 milliliters two times a day to add 22 grams of protein and 160 kilocalories. The 8/25/15 Nutrition Data Form revealed the resident weighed 144 pounds. The resident has had weight loss and a Stage 3 and unstageable wound. The resident has a swallowing disorder and continues on a regular mechanical soft diet. The resident has had a significant weight loss since admission. The dietician recommended to add a multivitamin with minerals daily and Prostat 30 milliliters two times a day. The physician's orders [REDACTED]. The progress note dated 8/26/2015 and timed 7:58 PM revealed the nurse practitioner ordered a protein shake since the resident refused the ordered Prostat. The resident received Glucerna at lunch every day and staff will clarify the order for the protein shake. The clinical record lacked evidence the resident received the protein shake or the Prostat two times a day. The progress note dated 9/10/2015 and timed 5:25 PM revealed the staff fed the resident and the resident was able to feed him/herself finger foods. Observations on 9/15/15 at 4:05 PM, revealed the resident had no teeth noted on the top and missing teeth noted on the bottom. Observations on 9/16/15 at 12:51 PM, revealed the staff served the resident a mechanical soft diet of broccoli, macaroni and cheese, fish, fruit bake, water, tea, and 1 can of Glucerna. The resident did not have built up silverware or a scoop plate. The resident ate without supervision. At 1:26 PM, observations revealed the resident ate 50 percent of the macaroni and cheese and fish, 25 percent of the fruit bake, 100 percent of the Glucerna and tea, and did not drink the water or eat any of the broccoli. Observations revealed the staff did not supervise the resident, did not encourage the resident to eat, or provide a substitute. Observations on 9/17/15 at 8:15 AM, revealed the resident ate breakfast in bed, unsupervised. The staff served the resident scrambled eggs, cube potatoes, hot cereal, 1 piece of toast, milk, water, and juice. The resident did not have a scoop plate or built-up silverware. Interview with Direct Care Staff #10 on 9/16/15 at 4:30 PM, revealed the resident can eat without supervision. The resident usually ate 50 to 75 percent of his/her meal. This staff also stated the resident did not have teeth and he/she did not know if the resident had dentures. Interview with Dietary staff #11 on 9/16/15 at 4:57 PM, revealed the dietician completes the Dietary Data form and within 14 days completes the admission assessment. Dietary staff do not document the resident's likes or dislikes unless they are very distinct and then would document them on the dietary sheet. Interview with Dietary Staff #15 on 9/17/15 at 9:16 AM, revealed the resident received a mechanical soft diet with thin liquids. The resident received Glucerna 1 can a day at lunch since 8/27/15. On 6/9/15 the resident was to receive a frozen treat (magic cup) high calorie supplement, but the clinical record lacked evidence the staff provided it for the resident. Review of the clinical record also lacks evidence the resident received the 2 cal supplement two times a day or the Glucerna 1 can two times a day. The protein shake was the Glucerna 1 can at lunch every day started on 8/27/15. Occupational therapy on 5/24/15 ordered the scoop plate and built-up silverware and those were not restarted when the resident returned from the hospital on [DATE]. Interview with Licensed Nurse #4 and #9 on 9/17/15 at 10:45 AM, revealed the dietician's recommendations go to the Director of Nursing (DON) and the DON contacts the physician. The recommendations from the Change of Condition meetings are followed up on by nursing and dietary. Interview with Therapy Staff #16 on 9/17/15 at 12:08 PM, revealed the resident originally had the order for the scoop plate and the built-up silverware due to [MEDICAL CONDITION] resident had. The facility failed to implement interventions as planned for the prevention of significant weight loss for this cognitively impaired resident, which resulted in actual harm to this resident.

Based on policy review, record review, observation, and interview, the facility failed to conduct comprehensive and/or accurate resident assessments initially and/or periodically as necessary to assess each resident's functional capacity for 2 of 31 residents reviewed for comprehensive assessments (Resident #85 - pressure ulcers and 1 - psychosocial). The failure of the facility to properly assess Resident #85's skin condition, develop and implement an appropriate plan of care following the facility policy, resulted in Resident #85 developing a pressure ulcer, which resulted in actual harm to this resident. The facility identified a census of 76 residents. The sample included 31 residents. The findings included: 1. Review of the medical record for Resident #85 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #85 was not interviewable. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as being at risk for pressure ulcers but not having any unhealed pressure ulcers. Review of the MDS assessment dated [DATE] revealed the resident was coded as being at risk for pressure ulcers but not having any unhealed pressure ulcers even though the medical record indicated the resident had a pressure ulcer. Review of Resident #85's care plan dated 5/6/14 revealed a problem identified with altered skin integrity, not pressure related. Interventions included weekly skin inspection, monitor for signs and symptoms of infection, and provide pressure reduction/relieving mattress. The care plan did not contain any interventions for turning or positioning. Review of the weekly skin assessment sheets revealed on 4/20/15, a wound was noted on the right buttocks and was being labeled an abrasion. A wound evaluation flow sheet starting 6/15/15 labeled the wound as an abrasion but listed measurements of 1.5 centimeters (cm) by 2.2 cm and clear drainage. On 6/29/15, the wound had the same measurements but the classification was changed to a stage 2 pressure ulcer. On 7/28/15, the wound measurements were 1.5 cm x 1.5 cm x 0.5 cm and the classification was changed again to unstageable. Interview with Nursing Staff #24 on 9/14/15 at 3:00 PM, revealed Resident #85 had an unstageable pressure ulcer to his/her right hip. Wound care observations for Resident #85 on 9/15/15 at 3:50 PM, Nursing Staff #22 revealed that the resident developed the pressure ulcer on his/her right hip or buttocks from a poorly fitted geriatric chair. At first they called the wound an abrasion and then it was decided to call it a pressure ulcer. Nursing Staff #22 further revealed the wound was infected and now the resident was in isolation. Interview with Clinical Staff #21 on 9/17/15 at 9:53 AM, revealed he/she started coming back into the facility every 2 weeks and making rounds with the treatment nurses and assessing the wounds. Initially Resident #85 presented with what the facility was calling an abrasion. I think we determined it was a pressure ulcer when it opened up. We determined that it developed from the geriatric chair that wasn't fitted properly because of the increased contractions in his/her legs. The wound bed appears pink from what I can see but it doesn't go straight back, it tunnels upward. It wasn't healing and the cultures indicated there was an infection. Resident #85 is currently in isolation from the infection. He/she confirmed that this was the resident's first pressure ulcer. Interview with Administrative Staff #12 on 9/17/15 at 11:25 AM, revealed Resident #85 only has abrasions not pressure ulcers and that is why the last 2 MDS assessments do not have pressure ulcers listed. Administrative Staff #12 stated We identified that we had issues with assessing and staging of our wounds when the new Director of Nursing came. The last assessment was done on 8/2/15. I didn't have the information at that time calling it a pressure ulcer The Administrative Staff #12 confirmed that he/she does not do the actual physical assessments, he/she just gets the information off the chart documentation. Interview with Administrative Staff #4 on 9/17/15 at 2:18 P.M. revealed the facility had problems with identifying and assessing wounds when he/she started working in the building in July. Administrative Staff #4 could not confirm what Administrative Staff #12 looked at when completing the required assessments. Failure of the facility to properly assess Resident #85's skin condition, develop and implement an appropriate plan of care following the facility policy, resulted in Resident #85 developing a pressure ulcer, which resulted in actual harm to this resident. 2. The facility's Psychosocial Assessment policy (dated 2/26/15) was reviewed and indicated As members of the interdisciplinary care plan (ICP) team, the social services staff will participate in the development of a comprehensive assessment on each resident. The facility 's Psychosocial Assessment policy indicated The social services staff will complete a psychosocial assessment for each new resident in conjunction with the ARD (Assessment Reference Date) of the admission MDS/RAI (Minimum Data Set/Resident Assessment Instrument). Assessment information will be reviewed in conjunction with each subsequent MDS/RAI- quarterly assessment, annual reassessment, significant change in status reassessment, and/or as required . 3. Medical record review revealed Resident #1's most recent re-admitted was on 12/25/12. Resident #1 had diagnoses, of Hypertension, [MEDICAL CONDITIONS] Disorder, [MEDICAL CONDITION], Hypopotassemia, Vitamin D Deficiency, Dysphagia, Urinary Incontinence, and Joint contractures in multiple sites. This resident has resided at the facility for the past [AGE] years. Resident #1's annual MDS dated [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) could not be completed due to resident is rarely/never understood. The MDS indicated Resident #1 was given the staff assessment for Mental Status which indicate Resident #1 was assessed as severely impaired - never/rarely made decisions. The MDS indicated Resident #1 had highly impaired - absence of useful hearing, had no speech - absence of spoken words, rarely/never understood by others, rarely/never understands others, and has highly impaired vision defined by object identification in question, but eyes appear to follow `objects. Resident #1's MDS indicated the resident was total dependence - full staff performance every time during entire 7-day period for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS indicated Resident #1 required complete staff assistance to perform transferring between surfaces including to or from: bed, chair, wheelchair, standing position. The MDS indicated Resident #1 required total staff assistance for locomotion on unit - how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatments). Review of Resident #1's MDS for Functional Limitation in Range of Motion indicated impairment on both sides for both upper extremities and lower extremities. A review of an activities assessment dated [DATE] revealed the resident's preferences are, playing with chew toys, relaxation with hand massages, soothing music and wall toys. The facility was unable to provide more recent activities assessment. An additional review of the resident's medical record revealed [REDACTED]. The facility was unable to provide a Social Work assessment or Psychosocial assessment for Resident #1 who had been assessed as having severe cognitive and communication limitations. Interview on 9/17/15 at 9:02 AM with the Activity Director, revealed it was the responsibility of the floor staff and volunteers to ensure the bed bound residents received one-to-one visits and bedside activities. The Activities Director also stated that he/she was responsible for documenting the resident's participation in the activities program and was unable to explain why there was a lack of documentation of the resident's assessment and participation in activities. Interview with the Director of Social Service (DSS) on 9/17/15 at 4:54 PM, revealed Resident #1 had not had a recent social work assessment or a psychosocial assessment. The DSS indicated the psychosocial assessment was a part of the initial facility Social Work assessment. The DSS indicated Resident #1 did not have a status change and therefore, he/she was not reassessed. The DSS indicated no initial Social Work or Psychosocial assessment could be located for Resident #1. The facility failed to ensure Resident #1's psychosocial and activity needs were assessed in conjunction with each subsequent MDS/RAI .

Based on policy review, record review, observation, and interview, the facility failed to monitor and provide treatment to prevent impactions for 1 (Resident #9) resident that resulted in the resident requiring manual removal of stool on two occasions causing harm to this resident. The facility identified a census of 76 residents. Sample size included 31 residents. The findings included: 1. The facility's policy for bowel monitoring which was called Clinical Start-Up, revealed the Director of Nursing or designee will complete a comprehensive overview of care delivery every morning at a minimum. The nurse will review the 24 Hour Report and Clinical Startup application's Observation Alerts which included the resident that had not had a BM in 3 days. 2. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and the [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment, required extensive assistance of 2 people for transfers, and required extensive assistance of 1 staff with toileting. The care plan listed the interventions for toileting assistance as needed and regular mechanical soft diet with the initiation date of 6/9/15. Review of the Bowel and Bladder Detail Report, Progress Notes and Medication Administration Records from 5/22/15 to 9/16/15 revealed: 6/1/15 the resident had an extra large bowel movement (BM) and then did not have another BM until 6/6/15, 5 days later. The staff did not administer an as needed (prn) medication for constipation from 6/1/15 to 6/6/15. 7/16/15 the resident had a medium BM and did not have another BM until 7/24/15, 8 days later. The resident had orders for Senna two times a day prn for constipation and [MEDICATION NAME] Powder prn for constipation. The staff did not administer either of these medications from 7/16/15 to 7/24/15. 7/24/15 the resident had 2 large BMs and did not have another BM until 7/31/15, 7 days later. The staff did not administer the prn Senna or the [MEDICATION NAME] Powder for constipation from 7/24/15 to 7/31/15. 8/2/15 the resident had a medium BM and did not have another BM until 8/8/15, 6 days later. The resident had orders for Senna prn and Milk of Magnesia prn for constipation and the staff did not administer the Senna and did not administer the prn Milk of Magnesia until 8/6/15. 8/10/15 the resident had an extra large BM and did not have another BM until 8/17/15, 7 days later. The staff did not administer the prn Senna or the Milk of Magnesia as ordered during this time period. Review of the progress note dated 8/10/15 and timed 2:02 PM, revealed the resident attempted to have a bowel movement and was unable to push it out. The nurse removed and extra large impaction and then received an order to give the resident a soap suds enema. 8/17/115 the resident had a BM and did not have another BM until 8/22/15, 5 days later. The staff did not administer the prn Senna or the Milk of Magnesia as ordered during this time period. The progress note dated 8/17/15 and timed 1:13 PM, revealed the resident sat on the toilet several times that day attempting to have a BM. The nurse manually removed a large impaction. The nurse documented there was still stool felt up high. The nurse received and order for an enema. The nurse administered the enema and then manually removed another extra large amount of stool. 9/4/15 the resident had a small BM and did not have another BM until 9/10/15, 6 days later. The resident had prn orders for the Senna and Milk of Magnesia for constipation and the staff did not administer them during this time frame. Interview with Licensed Nurses #13 and #14 on 9/17/15 at 8:34 AM, revealed the direct care staff document the BMs in the Kiosk (computer program), the night nurse prints off the report that notifies the staff which residents have not had a BM in 3 days. Management also prints off the report and reviews it at their morning meeting. There are not standing orders for the treatment of [REDACTED]. Interview with Licensed Nurse #9 on 9/17/15 at 1:59 PM, revealed if a resident does not have a BM within 3 days it will flag on a report that is ran every morning and will continue to flag on the report until the resident has a BM. This nurse was unsure why the resident went so many days without a BM. The facility failed to monitor and provide preventive treatment multiple times for this resident with a [DIAGNOSES REDACTED].

Based on policy/procedure review, clinical record review, observation, and interview, the facility failed to accurately assess, monitor, and provide care and services to ensure that a resident without a pressure ulcer did not develop them. Failure to provide appropriate care and services to prevent 2 residents (Resident #85 and 1) from developing a pressure ulcer and 1 (Resident #85) developed a pressure ulcer and ultimate infection, of 4 residents reviewed for pressure ulcers, which resulted in actual harm for Resident #85. The facility identified a census of 76 residents, sample size included 31 residents. The findings included: 1. Review of the facility's Skin Integrity Guideline policy revealed the following documentation and care interventions for skin integrity: 1. Evaluation/Observation is to be completed within the first twenty four hours of admission/quarterly/significant change of condition using the Clinical Health Status Tool. 2. If identified risk present, the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. 3. Patients/Residents utilizing a wheelchair as a primary mode of transportation will have a pressure redistribution device in place as indicated by the individualized plan of care. 4. Pressure redistribution mattresses are in place as indicated by the individualized plan of care. 5. If there is decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness and implemented as indicated by the individualized plan of care. 6. Patients/Residents will be observed by the CNA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented. 7. Reposition every two hours, or as needed and tolerated, taking into consideration patient/resident tolerance and choice, tissue tolerance, current condition of skin. Indicate frequency in the individualized plan of care. 8. Initiate positioning schedule to meet individual patient/resident needs and minimize concentrated pressure to skin as indicated by the individualized plan of care. 9. If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for appropriateness. 10. Positioning devices such as pillows or foam wedges are recommended to keep bony prominences from direct contact with one another. 2. Review of the medical record for Resident #85 revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident had no pressure ulcers on admission. Resident #85 was not interviewable. A confidential interview on 9/14/15 at 11:52 AM, revealed Resident #85 had developed a pressure ulcer on the right hip or buttocks and now it was infected and the resident had been placed in isolation. The interview further revealed that the resident was not being showered or turned often enough to promote healing. Interview with Nursing Staff #24 on 9/14/15 at 3:00 PM, revealed Resident #85 had an unstageable pressure ulcer to the right hip. The wound was now infected and the resident was in isolation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as being at risk for pressure ulcers but not having any unhealed pressure ulcers. Review of the MDS assessment dated [DATE] revealed the resident was coded as being at risk for pressure ulcers but not having any unhealed pressure ulcers even though the medical record indicated the resident had a pressure ulcer. Review of Resident #85's care plan dated 5/6/14 revealed a problem identified with altered skin integrity, not pressure related. Interventions included weekly skin inspection, monitor for signs and symptoms of infection, and provide pressure reduction/relieving mattress. The care plan did not contain any interventions for turning or positioning. Review of Resident #85's care plan dated 7/21/15 revealed a pressure ulcer actual, or at risk, due to a pressure ulcer being present. Interventions included an air mattress, weekly skin inspection, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream, skin assessment to be completed per Living Center Policy, treatments as ordered, and weekly wound assessment. The care plan included 2 types of mattress, 3 references to skin or wound assessments, and no mention of turning or positioning of the resident. Review of the Certified Nursing Aide (CNA) plan of care dated 9/14/15 for Resident #85 did not include any identified turning or positioning schedule. The residents shower schedule was Monday/Thursday, on the night shift but review of the shower documentation for 7/1/15 - 9/14/15 revealed the resident had not received any showers during that time period. Review of the weekly skin assessment sheets revealed on 4/20/15, a wound was noted on the right buttocks and was being labeled an abrasion. A wound evaluation flow sheet starting 6/15/15 labeled the wound as an abrasion but listed measurements of 1.5 centimeters (cm) by 2.2 cm and clear drainage. On 6/29/15, the wound had the same measurements but the classification was changed to a stage 2 pressure ulcer. On 7/28/15, the wound measurements were 1.5 cm x 1.5 cm x 0.5 cm and the classification was changed again to unstageable. Review of the Quarterly Interdisciplinary Resident Review dated 8/1/15 revealed there was nothing coded under skin conditions. A wound care observation was conducted with Nursing Staff #22 on 9/15/15 at 3:50 PM, for Resident #85. While providing wound care, the nurse removed the old dressing and packing from Resident #85's pressure ulcer. The nurse then proceeded to remove her soiled gloves and don new gloves without washing her hands. Measurements of the wound were taken including the tunneling and the nurse proceeded to remove her soiled gloves and don new gloves without washing her hands. Lack of hand washing during wound care could contribute to infection and cross contamination. Observations of Resident #85 on 9/16/15 at 9:00 AM, revealed the resident to be lying on his/her left side in bed. He was wearing the same blue shirt from 9/15/15. He/she did not respond to questions. Observations of Resident #85 on 9/16/15 at 10:00 AM, revealed the resident continued to lie on the left side. Observations of Resident #85 on 9/16/15 at 11:30 AM, revealed the resident to be in the same position. There was no evidence of turning or positioning by staff. During the wound care observation for Resident #85 on 9/15/15 at 3:50 PM, Nursing Staff #22 revealed that the resident developed the pressure ulcer on his/her right hip or buttocks from a poorly fitted geriatric chair. At first they called the wound an abrasion and then it was decided to call it a pressure ulcer. Nursing Staff #22 further revealed the wound was infected and now the resident was in isolation. Interview with Direct Care Staff #20 on 9/16/15 at 9:30 AM, revealed each resident has a shower assignment twice a week. Direct Care Staff #20 also revealed that the CNA assigned to Resident #85 did not show up for work today and he/she was pulled from restorative to help out. He/she was waiting for another CNA to come in and take over the assignment. At 12:30 PM, on 9/16/15, Direct Care Staff #20 informed the surveyor that he/she had partially bathed and repositioned Resident #85 because the other CNA never showed up. Interview with Nurse Staff #7 on 9/16/15 at 11:43 AM, revealed Resident #85 was total care and could not assist with anything. The resident can't help with bathing and you have to anticipate his/her needs because he/she doesn't communicate much. Interview with Clinical Staff #21 on 9/17/15 at 9:53 AM, revealed he/she started coming back into the facility every 2 weeks and making rounds with the treatment nurses and assessing the wounds. Initially Resident #85 presented with what the facility was calling an abrasion. I think we determined it was a pressure ulcer when it opened up. We determined that it developed from the geriatric chair that wasn't fitted properly because of the increased contractions in his/her legs. The wound bed appears pink from what I can see but it doesn't go straight back, it tunnels upward. The wound wasn't healing and the cultures indicated it was infected. The resident was placed in isolation due to the infection. Clinical Staff #21 confirmed that this was the resident's first pressure ulcer. Interview with Administrative Staff #4 on 9/17/15 at 2:45 PM, revealed staff are to wash their hands prior to a treatment, prior to donning gloves, after removing soiled gloves, and before and after any contact with a resident. He/she stated that hand washing education is mandatory on hire but beyond that he/she isn't sure what the education program entails. Interview with Nursing Staff #22 on 9/17/15 at 5:30 PM, Nursing Staff #22 confirmed that hand washing was lacking during the wound care observation. Interview with Administrative Staff #12 on 9/17/15 at 11:25 AM, revealed Resident #85 only had abrasions not pressure ulcers and that is why the last 2 MDS assessments do not have pressure ulcers listed. Administrative Staff #12 stated We identified that we had issues with assessing and staging of our wounds when the new Director of Nursing came. The last assessment was done on 8/2/15. I didn't have the information at that time calling it a pressure ulcer. The Administrative Staff #12 confirmed that he/she does not do the actual physical assessments, he/she just gets the information off the chart documentation. Interview with Administrative Staff #4 on 9/17/15 at 2:18 PM, revealed the facility had problems with identifying and assessing wounds when he/she started working in the building. Administrative Staff #4 could not confirm what Administrative Staff #12 looked at when completing the required assessments. Failure of the facility to properly assess Resident #85's skin condition, develop and implement an appropriate plan of care following the facility policy, that included a turning and positioning schedule, resulted in Resident #85 developing a pressure ulcer and ultimate infection, which resulted in actual harm for this resident. 3. Medical record review revealed Resident #1's most recent re-admitted was on 12/25/12. Resident #1 had [DIAGNOSES REDACTED]. This resident has resided at the facility for the past [AGE] years. Resident #1's annual MDS dated [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) could not be completed due to resident is rarely/never understood. The MDS indicated Resident #1 was given the staff assessment for Mental Status which indicate Resident #1 was assessed as severely impaired - never/rarely made decisions. The MDS indicated Resident #1 had highly impaired - absence of useful hearing , had no speech - absence of spoken words, rarely/never understood my others, rarely/never understands others, and has highly impaired. Resident #1's MDS indicated the resident was total dependence for bed mobility and required complete staff assistance to perform transferring between surfaces. The MDS dated [DATE] indicated Resident #1 had an unhealed stage II pressure ulcer and had one unstageable pressure ulcers with suspected deep tissue injury in evolution. Resident #1's MDS for Functional Limitation in Range of Motion indicated impairment on both sides for both upper extremities and lower extremities. Resident #1's MDS dated [DATE] indicated he/she had no Range of motion (passive), had no Range of motion (active), and had no use of splint or brace assistance performed (for at least 15 minutes a day) in the last 7 calendar days. The physician's orders [REDACTED]. Apply TAO (Triple Antibiotic Ointment) and non-adherent dressing to 2nd digit on left hand, insert rolled washcloth daily and PRN (as needed) one time a day. The physician's orders [REDACTED]. Record review revealed Resident #1 had a care plan initiated on 3/6/14 for Pressure ulcer actual or at risk due to: Assistance required in bed mobility, Bowel incontinence. The care plan goal was Skin will remain intact. Resident #1's skin integrity (pressure related) care plan indicated the following interventions: · 8/3/14 SDTI (Suspected Deep Tissue Injury) noted on top of L (left) foot at metacarpal area. Skin prep daily. · 8/27/15 Stage 2 (pressure ulcer) to left hand 2nd digit (finger). · 9/8/15 SDTI top lateral foot. · Complete Braden Scale per Living Center Policy. · Conduct weekly skin inspection. · Monitor skin under braces and splints. · Nutritional and Hydration support. · Provide pressure reducing wheelchair cushion. · Provide pressure reducing wheelchair cushion. · Provide pressure reduction/relieving mattress. · Provide thorough skin care after incontinent episodes and apply barrier cream. · Skin assessment to be completed per Living Center Policy. Resident #1's record review indicated a care plan for range of motion (ROM) dated 1/29/15 which indicated Resident #1 had a physical functioning deficit related ROM limitations of left hand and elbow related to contractures. A revision dated 4/22/15 indicted Resident #1 had a palm wound has healed/ need for splint left arm. Resident #1's ROM care plan's goal was the following: · Will be able to wear left arm splint 1-2 hrs (hours) daily. · Will be able to wear palm protectors when not having ROM. · No skin issues with splint or palm protectors. · I will maintain my current ROM. Resident #1's ROM care plan indicated the following interventions: · 4/22 apply arm splint for 1-2 hr daily. · Apply palm protectors following cleansing and PROM to left hand. Apply in AM shift as resident will allow. · Dry hand and notify wound nurse when completed to have treatment to hand. Make sure that after she has done wound care that there is a rolled wash cloth or gauze in the hand to prevent moisture build up. · Inspect skin with care. Report reddened areas, rashes, bruising, or open areas and report to charge nurse and restorative Director. · Monitor and report changes in ROM ability. · Soak hand in warm water and massage before doing range of motion. · Use caution when applying wash cloth or gauze to hand to prevent sheering of hand. The record review for Resident #1's wound flow sheets initiated for a Stage II Pressure Ulcer (In-house acquired) on Resident #1's left hand (palm) indicated the following: · Wound Evaluation Flow Sheet dated 8/30/15 indicated a Left hand (palm) had a Stage II (pressure ulcer measured 1.5 cm (centimeter) x (by) 1.5 cm x (by) 0.0 cm discovered on 8/25/15. The entry indicated hand contracted. Area caused by friction from placing a cloth in hand. · Wound evaluation dated 9/6/15 indicated the Stage II pressure ulcer measured 1.3 cm x 1.5 cm x 0.0 cm. The evaluation indicated wound stable, no changes. · Wound evaluation dated 9/11/15 indicated the stage II pressure ulcer measured 0.5 cm x 0.5 cm x 0.0 cm and indicated wound healing. Continue current interventions. A review of Resident #1's Restorative by Day Report from 1/1/15 to 9/08/15 which indicated the following dates for Range of Motion - Passive: · January 2015: None · February 2015: None · March 2015: 3/15, 3/17, 3/18, 3/19, 3/20, 3/25, 3/26, 3/30, and 3/31/15. · April 2015: 4/1, 4/2, 4/3, 4/8, 4/9, 4/12, 4/13, 4/16-4/24, 4/27, and 4/28/15. · May 2015: 5/4, 5/7, 5/8, 5/14-5/17 and 5/27/15. · June 2015: 6/10, 6/12, 6/13, 6/19, 6/22-6/25, and 6/26/15. · July 2015: 7/10, 7/17, 7/18. 7/25, and 7/29/15. · August 2015: 8/6, 8/8, 8/14, 8/18, 8/19, 8/27 and 8/31/15. Record review of Resident #1's Restorative Program Summary Report for the program Passive ROM to left hand daily with initiation date of 3/20/15 indicated the following entries: · 04/07/15 - (Resident #1) continues to receive PROM (passive range of motion) to his left hand. The application of splint was stopped until the pressure area on his palm healed. (He/she) continues to resist having his hand held or soaked. It is necessary to use warm water to soak his hand in prior to doing PROM. This helps to relax his fingers. The hand is then dried and wound nurse dresses and treats the wound. The area is healing but continues to have moisture build up. A hand roll of gauze or a rolled wash cloth is placed between the fingers following the treatment. Restorative will continue to do PROM for 60-90 days to continue to work with the contractures. · 04/22/15 - Wound in left hand has healed. Pressure relieving hand rolls have been used at this time to prevent finger contractures. We will attempt to apply the splint to maintain wrist and fingers at present level. · 5/29/15 - Continue have PROM daily. No signs of changed (change). Needs to have hand soaked ad (and) cleansed prior PROM. There is still resistance in his fingers. (He/she) was in the hospital over the week end related to aspiration penemonia (Pneumonia). We have resued (resumed) (his/her) treatment since (his/her) return. This will continue to be a functional maintenance with (him/her) at this time. · 6/25/15 - Continues to be stable at this time. We continue to do treatment to maintain his function and to prevent further contractures. · 8/25/15 - Continue functional maintane (maintenance) with (him/her) with the splinting. (He/she) has an open areal (area) on his palm and is being treated by the wound care nurse at this time. On 9/14/15 at 10:15 AM, Resident #1 was observed in his/her room lying in a supine position in bed at a 30 degree angle with knees bent. Resident #1 had a fall mat next to his bed. Resident #1 had contractures of both upper extremities and both lower extremities. At 4:24 PM, Resident #1 continued to be in bed at with no splint or adaptive/protective devices in place. On 9/15/15 at 8:50 AM, Resident #1 was observed in bed. Resident #1 was not wearing any splints, adaptive, or protective equipment. At 1:55 PM, Resident #1 was observed in bed. He/she had a left arm splint in place and a washcloth being held in his/her left hand in the palm. On 9/16/15 at 9: 54 AM, Resident #1 was wearing a splint to the left arm in a 90 degree angle and had a washcloth in his/her left hand being held in the palm. Interview with the Director of Restorative Services on 9/17/14 at 4:17 PM, indicated Resident #1's ROM was not done in accordance with the frequency assessed as necessary to assist in the maintenance of current level range of motion and to prevent recurrent and newly acquired pressure ulcers of Resident #1's left hand. The facility failed to adhere to the care plan interventions developed to prevent the reoccurrence of Stage II pressure ulcer for Resident #1's left hand contracture.