Every finding on record at Trego Co-Lemke Memorial Hospital Ltcu

The facility identified a census of 30 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure staff reported witnessed staff-to-resident alleged abuse incidents to facility administration. Between an unknown date in September 2025 and November 16, 2025, several facility staff witnessed numerous alleged incidents of staff-to-resident abuse by the alleged perpetrator, Certified Nurse's Aide (CNA) M, and impacted cognitively impaired Residents (R) 1, R2, and R3. Facility staff witnessed CNA M flick, yell, yank, and forcefully restrain cognitively impaired residents over the approximately 3-month time frame. The failure of numerous staff to report allegations of abuse to the facility administration placed all of the residents who resided in the facility in immediate jeopardy.Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear).The Quarterly Minimum Data Set (MDS) dated 10/10/25 documented R1 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. The MDS documented R1 had no behaviors during the look-back period. The MDS documented R1 was independent for ambulation, was dependent on staff for toileting, and required moderate staff assistance for all other activities of daily living (ADL).The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/25/25 documented R1 had a BIMS score of zero, was unable to answer any of the questions when asked, but was able to communicate some basic needs verbally. The CAA documented R1 was frequently incontinent of bladder and required moderate staff assistance with transfers and was dependent with toileting hygiene.R1's 02/08/23 Care Plan included the following interventions: 01/22/24 - R1 had a memory impairment and required cuing and redirection as R1 was unable to make decisions without assistance. 01/22/24 - Staff directed to use task segmentation to support R1's short term memory deficits and break tasks up one step at a time.01/22/24 - Staff directed to cue, reorient, and supervise R1 as needed and to present R1 with just one thought, idea, question, or command at a time.Certified Medication Aide (CMA) R1's Notarized Witness Statement, dated 11/17/25, documented sometime in September 2025, CMA R assisted CNA M with R1 for toileting. CMA R stated R1 was hollering, which was her normal, and CNA M flicked R1 in the cheek with her finger and told R1 to shut up. R1 said, Ouch. CMA R stated she asked CNA M not to do that and left the room. CNA P's Notarized Witness Statement, dated 11/17/2025, documented on 11/10/25 CNA P assisted CNA M in getting R1 up for the day. CNA M yelled at R1 to get up out of bed. CNA M and CNA P got R1 to the bathroom. CNA M told R1 to get up off the toilet, and R1 would not get up. CNA M yelled at R1 again to get up, and when R1 would not get up, CNA M yanked R1's arm by her wrist and pulled her off the toilet. The same thing happened again after lunch.CNA O's unnotarized Witness Statement, dated 11/17/25, documented CNA M flicked R1 on her forehead when R1 was laughing and screaming to make R1 be quiet.On 11/19/25 at 11:30 AM, observation revealed R1 sat at the lunch table. R1 was able to make simple conversation, but was obviously confused. R1 required assistance with eating.On 11/19/25 at 01:30 PM, CMA R stated she had seen CMA M yell at R1 and flick her with her finger on R1's cheek to get R1 to be quiet. CMA R stated she had been trained in abuse, neglect, and exploitation, but did not report the incident to anyone because CNA M could be retaliative.On 11/19/25 at 01:45 PM, CNA P stated she had seen CNA M yell at R1 to get up multiple times and yank and pull on R1's arm to get up. CNA P stated she had been trained on abuse, neglect, and exploitation, and did not report the incident to anyone because CNA M could be mean and take things out on others, like tripping people and locking people in rooms and not letting them out.On 11/19/15 at 10:00 AM, Administrative Nurse D stated she had no idea any of this was going on with CNA M until she received an anonymous employee complaint form, which documented CNA M had abused a resident. Administrative Nurse D stated she immediately started the investigation into the allegation, and the more people she talked to, she realized there was a big problem. Administrative Nurse D stated all the employees at the facility were trained in abuse, neglect, and exploitation in July 2025.On 11/19/25 at 02:30 PM, Administrative Staff A stated the employees involved in not reporting abuse were wrong for not reporting. Administrative Staff A stated the employees chose to be a part of the problem and not a part of the solution.The facility's Abuse and Neglect Policy, dated 05/02/25, documented the purpose of the policy was to provide guidelines and a procedure for assuring residents in the long-term care were free from abuse and neglect. All residents have the right to be free from neglect and abuse. In accordance with state statutes, any person, including but not limited to physicians, professional or practical nurses, social worker, or any other personnel who knew or had reasonable cause to suspect a resident has been abused, neglected, or exploited, shall immediately report such knowledge or suspicion to the supervisor, risk manager, administrator, or chief of staff. Staff will receive education on abuse and neglect upon hire, annually, and anytime there is a policy and procedure change, and when the quality management process indicates a need for improvement. Training will include: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge related to allegations without fear of reprisal; How to recognize burnout, frustration, and stress that may lead to abuse; and what constitutes abuse, neglect, and misappropriation of property. - R2's Electronic Medical Record (EMR) documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and a history of other mental health disorders.The Quarterly Minimum Data Set (MDS) dated 09/15/25 documented R2 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. The MDS documented R1 had no behaviors during the look-back period. The MDS documented R2 was independent with eating, transfers, and bed mobility, but required partial to substantial staff assistance with all other activities of daily living (ADL).The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/13/25 documented R2 had a diagnosis of vascular dementia with anxiety. R1 admitted from home due to not being able to take care of himself due to dementia. Staff will assist R1 with establishing daily schedules and routines.R2's 03/03/25 Care Plan included the following interventions:03/04/25 - R2 may become anxious in new settings or changes. R2 likes to sing at these times.03/04/25 - Staff directed to observe R2 for unexplained changes in mood, psychosocial status or behavior. Changes may include increased confusion, odd behavior, increased anxiety, eating changes, weight loss, tearfulness, and crying episodes.03/04/25 - Staff directed to assist R2 with all of his ADLs.CNA O's Notarized Witness Statement, dated 11/17/25, documented CNA M assisted R2 in the hallway. CNA O was unclear what CNA M said to R2, but R2 told CNA M, Don't talk to me like that. CNA O stated she stepped in to help keep R2 calm, and CNA M just walked away.On 11/19/25 at 01:00 PM, R2 sat in his recliner and moaned, I don't feel good, over and over. An unidentified CNA came to check on R2 and asked him how he did not feel well.On 11/19/25 at 02:30 PM, CNA O stated she saw CNA M in the hallway with R2. CNA M leaned down in R2's face. R2 leaned back away from CNA M and said, Don't talk to me like that. CNA O stated she stepped in quickly because R2 could get upset quickly. CNA O did not hear what CNA M said to R2. CNA O stated she did not report the incident to anyone. CNA O stated she had been trained on abuse and neglect.On 11/19/15 at 10:00 AM, Administrative Nurse D stated she had no idea any of this was going on with CNA M until she received an anonymous employee complaint form, which documented CNA M had abused a resident. Administrative Nurse D stated she immediately started the investigation into the allegation, and the more people she talked to, she realized there was a big problem. Administrative Nurse D stated all the employees at the facility were trained in abuse, neglect, and exploitation in July 2025.On 11/19/25 at 02:30 PM, Administrative Staff A stated the employees involved in not reporting abuse were wrong for not reporting. Administrative Staff A stated the employees chose to be a part of the problem and not a part of the solution.The facility's Abuse and Neglect Policy, dated 05/02/25, documented the purpose of the policy was to provide guidelines and a procedure for assuring residents in the long-term care were free from abuse and neglect. All residents have the right to be free from neglect and abuse. In accordance with state statutes, any person, including but not limited to physicians, professional or practical nurses, social worker, or any other personnel who knew or had reasonable cause to suspect a resident has been abused, neglected, or exploited, shall immediately report such knowledge or suspicion to the supervisor, risk manager, administrator, or chief of staff. Staff will receive education on abuse and neglect upon hire, annually, and anytime there is a policy and procedure change, and when the quality management process indicates a need for improvement. Training will include: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge related to allegations without fear of reprisal; How to recognize burnout, frustration, and stress that may lead to abuse; and what constitutes abuse, neglect, and misappropriation of property. - R3's Electronic Medical Record (EMR) documented diagnoses of Post-Traumatic Stress Disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear).R3's Quarterly Minimum Data Set (MDS) dated 11/04/25 documented R3's Brief Interview for Mental Status (BIMS) score was 00, which indicated severely impaired cognition. The MDS documented R3 had no behaviors documented in the look-back period. The MDS documented R3 was independent with ambulation, bed mobility, and transfer, but was dependent on staff for all other ADLs.The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/16/25 documented R3 had a diagnosis of vascular dementia. R3 required assistance with ADLs, including toileting, dressing, personal cares, and eating. The CAA documented R3 had difficulty communicating, and staff needed to give R3 time to respond to simple questions and offer choices when she appeared anxious.R3's 05/18/23 Care Plan included the following interventions for R3:12/05/23 - Staff directed to provide R3 for opportunities for positive interaction, stop and talk with R3as she passed by.12/05/23 - Staff directed to provide R3 distraction to help prevent or de-escalate behaviors; remove R3 from the areas causing anxiety, offer music or pet/cat videos.05/18/23 - R3 had a history of sexual abuse and may have paranoia symptoms that are sexual in nature. Cue, reorient, and supervise as needed.05/18/23 - Staff directed to assist R3 with all ADLs.CNA N's Notarized Witness Statement, dated 11/17/25, documented sometime in October 2025, R3 did not want to sit at the table during lunch. CNA M got verbally aggressive with R3 and told her she needed to stay seated, and R3 was not allowed to get up. CNA N intervened and asked CNA M if she could assist R3. CNA M mumbled under her breath towards CNA N and left the table.CNA Q's Notarized Witness Statement, dated 11/19/25, documented on 11/14/25, CNA M held R3 down in her chair and would not let R3 get up. CNA M restrained R3's hands so R3 could not eat or drink.On 11/19/25 at 10:00 AM, observation revealed R1 ambulated throughout the facility with her daughter.On 11/19/25 at 02:45 PM, CNA Q stated she had been at the back table in the dining room and saw CNA M forcefully hold R3 down in her chair and restrain her hand so she could not eat or drink. CNA Q stated R3 liked to ambulate around the facility aimlessly, which seemed to keep her calm, and CNA M did not want R3 to get out of her chair. CNA Q stated she had been trained on abuse and neglect. CNA Q stated she did not report the incident because she was afraid of what CNA M might do.On 11/19/15 at 10:00 AM, Administrative Nurse D stated she had no idea any of this was going on with CNA M until she received an anonymous employee complaint form, which documented CNA M had abused a resident. Administrative Nurse D stated she immediately started the investigation into the allegation, and the more people she talked to, she realized there was a big problem. Administrative Nurse D stated all the employees at the facility were trained in abuse, neglect, and exploitation in July 2025.On 11/19/25 at 02:30 PM, Administrative Staff A stated the employees involved in not reporting abuse were wrong for not reporting. Administrative Staff A stated the employees chose to be a part of the problem and not a part of the solution.The facility's Abuse and Neglect Policy, dated 05/02/25, documented the purpose of the policy was to provide guidelines and a procedure for assuring residents in the long-term care were free from abuse and neglect. All residents have the right to be free from neglect and abuse. In accordance with state statutes, any person, including but not limited to physicians, professional or practical nurses, social worker, or any other personnel who knew or had reasonable cause to suspect a resident has been abused, neglected, or exploited, shall immediately report such knowledge or suspicion to the supervisor, risk manager, administrator, or chief of staff. Staff will receive education on abuse and neglect upon hire, annually, and anytime there is a policy and procedure change, and when the quality management process indicates a need for improvement. Training will include: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge related to allegations without fear of reprisal; How to recognize burnout, frustration, and stress that may lead to abuse; and what constitutes abuse, neglect, and misappropriation of property. On 11/19/25 at 03:30 PM, Administrative Staff A and Administrative Nurse D were provided the IJ template and notified of the facility's failure to report physical abuse allegations, delayed appropriate oversight, investigation, protective measures, and increased the likelihood of ongoing abuse, harm, and severe psychosocial impairment, including fear, humiliation, and mental anguish. The facility identified and implemented immediate corrective actions, which were completed on 11/19/24, prior to the surveyor entering the facility. The corrective actions included: Abuse and Neglect training with all employees completed 11/17/25, a Risk Management meeting regarding the allegations completed 11/19/25, notification of all residents families completed 11/19/25, notification of local police completed 11/19/25, social services assessments of R1, R2, and R3 to check for psychosocial concerns and will continued to meet with the residents weekly for four weeks, and completed interviews with alert and oriented residents residing in the facility.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 35 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 06/02/25, a review of the noon meal consisted of a grilled pork burger on a bun, onion rings, corn, and no-bake cookies. On 06/02/25 at 10:30 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 06/01/25 at 07:50 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled and started the dietary certification classes. On 06/04/25 at 11:44 AM, Administrative Nurse D verified DS BB had no dietary manager certification but had enrolled and started the dietary certification classes. Upon request, the facility failed to provide a policy regarding a certified dietary manager.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella and other waterborne pathogens). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 06/04/25 at 10:05 AM, Maintenance Staff U stated he had a log pointing out weekly flushing places, but was unaware of any routine facility water management checks. On 06/04/25 at 11:20 AM, Administrative Staff D verified the facility lacked a system to check regarding standing water and potential growth inside the facility and lacked a system to mitigate the risk of Legionella. The facility's Water Management Program Policy, revised 02/18/19 documented that the facility would provide and maintain safe and healthy working conditions, equipment, and systems of work for all staff, patients, and visitors. To prevent the growth of Legionella, water services shall operate at the following temperatures: 1. Cold water distribution and storage at 20 degrees centigrade (C) (68 degrees Fahrenheit (F) or below. 2. Hot water distribution at least 50 degrees C (122 degrees F) attainable at taps within two minutes of running. 3. Hot water storage at 60 degrees C (140 degrees F). The policy documented staff would monitor and record cold water outlet temperature measured after allowing the water to run at full flow for one minute. Hot water outlet temperatures should be measured after allowing the water to run at full flow for one minute. The policy documented all areas would be monitored and water temperature at hot and cold outlets should be measured and recorded at least twice per year. The results would be recorded on a log sheet by maintenance personnel and all failures and large variations would be investigated. Sporadically used outlets should be flushed weekly by maintenance personnel.

The facility had a census of 35 residents. The sample included 13 residents. Based on record review, and interview, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk for decreased quality of care. Findings included: - The Payroll Based Journal (PBJ-a required detail of staffing information submitted by nursing homes, provided by the Centers for Medicare and Medicaid Services (CMS)) documented that the facility lacked RN eight-hour coverage for the following days: 07/14/24 08/25/24 10/12/24 10/26/24 11/30/24 12/07/24 On 06/02/25 at 02:30 PM, Administrative Nurse D verified the above dates that there was not an RN in the long-term care. Administrative Nurse D stated that since they were attached to the hospital she thought they were able to have the RN from the hospital serve as their RN coverage. On 06/04/25 at 10:15 AM, Administrative Staff B stated she pulled staffing information from the timecard system to upload the information for the PBJ report. Administrative Staff B further stated that if there were any agency staff, she would get all the information required for the PBJ off the invoices. Administrative Staff B stated she thought the long-term care facility was able to use the RN from the hospital as coverage when they did not have an RN on duty. Upon request, a policy for PBJ was not provided by the facility.

The facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident abuse of Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for injury and ongoing abuse. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had moderately impaired cognition. R14 required partial assistance from staff for transfers, ambulation, personal hygiene, showers, and oral hygiene. R14 was independent with mobility and used a wheelchair. The Annual MDS, dated 04/18/25, documented R14 had moderately impaired cognition. R14 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R14 was independent with mobility and used a wheelchair. R14's Care Plan, dated 04/25/25, initiated on 05/05/25, directed staff to observe and notify the nurse for unexplained changes in mood, psychosocial status, or behavior. Staff were further directed to observe for increased confusion, odd/uncharacteristic behaviors, and changes in the amount of time spent with facility friends. The care plan further directed staff to observe R14 for increased anxiety, eating and dietary changes, tearfulness and crying episodes, and sleep disturbances. The Nurse's Note dated 02/17/25 at 01:46 PM documented that R14 was grabbed by R29, who had severely impaired cognition. R14 had been grabbed above the right knee. R14 had redness above the right knee but had no bruising noted. The Nurse's Note dated 02/17/25 at 02:09 PM documented R14 was removed from the situation, taken to her room, and assisted into her recliner. R14 stated she was fine and denied any pain. The EMR lacked documentation, further assessment, or any follow-up after the altercation. The EMR lacked documentation the nursing administration, family, or physician was notified of the resident-to-resident altercation. On 06/03/25 at 09:09 AM, Administrative Nurse D stated she was unaware of the resident-to-resident altercation. Administrative Nurse D stated staff are to tell her immediately when there is any type of altercation between residents so she could start the investigation. Administrative Nurse D further stated she would notify the physician and families of both residents and start an investigation. On 06/03/25 at 02:30 PM, R14 sat in her recliner, stated she was not afraid of any residents in the facility, and stated she received good care. On 06/03/25 at 12:40 PM, Certified Nurse Aide (CNA) M stated that on the day of the incident, she took R14 down the hall to her room to rest, which was down the South Hall. R14's room was at the end of the hall, and R29 was by the exit door, which was right next to R14's room. CNA M further stated that R14 told R29 hello, and R29 turned around quickly and grabbed R14's knee. R29 would not let go of R14's knee, and R14 stated, Ow, you're hurting me. CNA M stated she had to put her fingers under R29's hand so he would let go. CNA M stated that R29 left and propelled himself down the hallway. CNA M went to get the nurse to assess R14 because R14's knee was red but had no bruising. CNA M stated she talked to R14, about 30 minutes later, and there was slight redness to her knee but no bruising. CNA M stated that R29 did not have any further interaction with R14 that day or since that event. CNA M stated staff received abuse and behavior training at least yearly, and as needed. CNA M further stated that when a resident-to-resident altercation occurred, staff were trained to separate the residents and let the nurse know so the residents could be assessed for injury. On 06/04/05 at 08:35 AM, Social Service X stated she was unaware of the resident-to-resident altercation up until yesterday when Administrative Nurse D talked to her about it. Social Service X stated that she would have spent time with R14 to follow up and to see if she had any fears or concerns. Social Service X stated that she had not seen any changes in R14's behavior around the time of the incident or since. On 06/04/25 at 09:35 AM, Licensed Nurse (LN) G stated the CNA told her that R29 had grabbed R14 by the knee, so she went to R14's room to assess her for injury. LN G stated that R14's knee was a little red, but there was no bruising or any other injury. LN G stated she should have filled out an incident report and notified the administration per protocol but did not. LN G further stated she had notified the family but failed to document the conversation. LN G stated that staff received training on behaviors, and if there were any incidents, they had team huddles. The team would talk about the incident and discuss ways to prevent future incidents. The facility always had ongoing training for abuse and dementia with behaviors. LN G stated she passed information regarding the incident to the next shift, and R14 did not act afraid or concerned about the incident. On 06/04/25 at 10:00 AM, Administrative Nurse D stated she had reported the incident to the state agency. Administrative Nurse D stated she had taken the Abuse and Neglect policy around to the staff to do education and reminders of the protocol when there was any type of resident-to-resident altercation. The facility's Abuse and Neglect policy, dated 05/05/25, documented that all residents had the right to be free from neglect and abuse. Any person, including but not limited to physicians, professionals, practical nurses, social workers, or any other personnel who know or have reasonable cause to suspect that a resident has been abused, neglected, or exploited, shall immediately report it to the supervisor. The policy further stated that all incidents were investigated and may be reported to the state agency. If there was any resident-to-resident abuse, the resident must be protected from each other to prevent any occurrence. The facility's Resident to Resident Altercations undated policy documented that the goal was to keep residents and staff safe. The facility would do whatever possible to prevent and control resident-to-resident altercations to prevent mental, physical, sexual, and verbal abuse or exploitation of personal property from occurring, The Director of Nursing (DON) or designee would be immediately notified when a resident-to-resident abuse incident had occurred, and the primary care physician would also be notified. The Assistant Director of Nursing (ADON) or DON would immediately begin an investigation of the incident and would report the incident to the state reporting agency as required within two hours if a significant injury occurred or within 24 hours of the incident if no injury was found. The families of both residents involved would be notified of the incident, the result of the investigation, and the outcomes. All staff would be in-service annually and as needed for abuse, neglect, exploitation, and how to spot the warning signs of the resident-to-resident altercation to prevent incidents from occurring.

The facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to report to administration a resident-to-resident altercation for one resident, Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had moderately impaired cognition. R14 required partial assistance from staff for transfers, ambulation, personal hygiene, showers, and oral hygiene. R14 was independent with mobility and used a wheelchair. The Annual MDS, dated 04/18/25, documented R14 had moderately impaired cognition. R14 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R14 was independent with mobility and used a wheelchair. R14's Care Plan, dated 04/25/25, initiated on 05/05/23, directed staff to observe and notify the nurse for unexplained changes in mood, psychosocial status, or behavior. Staff were further directed to observe for increased confusion, odd/uncharacteristic behaviors, and changes in the amount of time spent with facility friends. The care plan further directed staff to observe R14 for increased anxiety, eating and dietary changes, tearfulness and crying episodes, and sleep disturbances. The Nurse's Note dated 02/17/25 at 01:46 PM documented that R14 was grabbed by R29, who had severely impaired cognition. R14 had been grabbed above the right knee. R14 had redness above the right knee but had no bruising noted. The Nurse's Note dated 02/17/25 at 02:09 PM documented R14 was removed from the situation, taken to her room, and assisted into her recliner. R14 stated she was fine and denied any pain. The EMR lacked documentation, further assessment, or any follow-up after the altercation. The EMR lacked documentation the nursing administration, family, or physician was notified of the resident-to-resident altercation. On 06/03/25 at 09:09 AM, Administrative Nurse D stated she was unaware of the resident-to-resident altercation. Administrative Nurse D stated staff are to tell her immediately when there is any type of altercation between residents so she could start the investigation. Administrative Nurse D further stated she would notify the physician and families of both residents and start an investigation. On 06/03/25 at 02:30 PM, R14 sat in her recliner, stated she was not afraid of any residents in the facility, and stated she received good care. On 06/03/25 at 12:40 PM, Certified Nurse Aide (CNA) M stated that on the day of the incident, she took R14 down the hall to her room to rest, which was down the South Hall. R14's room was at the end of the hall, and R29 was by the exit door, which was right next to R14's room. CNA M further stated that R14 told R29 hello, and R29 turned around quickly and grabbed R14's knee. R29 would not let go of R14's knee, and R14 stated, Ow, you're hurting me. CNA M stated she had to put her fingers under R29's hand so he would let go. CNA M stated that R29 left and propelled himself down the hallway. CNA M went to get the nurse to assess R14 because R14's knee was red but had no bruising. CNA M stated she talked to R14, about 30 minutes later, and there was slight redness to her knee but no bruising. CNA M stated that R29 did not have any further interaction with R14 that day or since that event. CNA M stated staff received abuse and behavior training at least yearly, and as needed. CNA M further stated that when a resident-to-resident altercation occurred, staff were trained to separate the residents and let the nurse know so the residents could be assessed for injury. On 06/04/05 at 08:35 AM, Social Service X stated she was unaware of the resident-to-resident altercation up until yesterday when Administrative Nurse D talked to her about it. Social Service X stated that she would have spent time with R14 to follow up and to see if she had any fears or concerns. Social Service X stated that she had not seen any changes in R14's behavior around the time of the incident or since. On 06/04/25 at 09:35 AM, Licensed Nurse (LN) G stated the CNA told her that R29 had grabbed R14 by the knee, so she went to R14's room to assess her for injury. LN G stated that R14's knee was a little red, but there was no bruising or any other injury. LN G stated she should have filled out an incident report and notified the administration per protocol but did not. LN G further stated she had notified the family but failed to document the conversation. LN G stated that staff received training on behaviors, and if there are any incidents, they have team huddles. The team would talk about the incident and discuss ways to prevent future incidents. The facility always had ongoing training for abuse and dementia with behaviors. LN G stated she passed information regarding the incident to the next shift, and R14 did not act afraid or concerned about the incident. The facility's Abuse and Neglect policy, dated 05/05/25, documented that all residents had the right to be free from neglect and abuse. Any person, including but not limited to physicians, professionals, practical nurses, social workers, or any other personnel who know or have reasonable cause to suspect that a resident has been abused, neglected, or exploited, shall immediately report it to the supervisor. The policy further stated that all incidents were investigated and may be reported to the state agency. If there was any resident-to-resident abuse, the resident must be protected from each other to prevent any occurrence. The facility's Resident to Resident Altercations undated policy documented that the goal was to keep residents and staff safe. The facility would do whatever possible to prevent and control resident-to-resident altercations to prevent mental, physical, sexual, and verbal abuse or exploitation of personal property from occurring, The Director of Nursing (DON) or designee would be immediately notified when a resident-to-resident abuse incident had occurred, and the primary care physician would also be notified. The Assistant Director of Nursing (ADON) or DON would immediately begin an investigation of the incident and would report the incident to the state reporting agency as required within two hours if a significant injury occurred or within 24 hours of the incident if no injury was found. The families of both residents involved would be notified of the incident, the result of the investigation, and the outcomes. All staff would be in-service annually and as needed for abuse, neglect, exploitation, and how to spot the warning signs of the resident-to-resident altercation to prevent incidents from occurring.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide services consistent with the standards of care for one of four residents reviewed for a urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI). This placed Resident (R) 20 at risk for catheter-related complications and future UTIs. Findings included: - R20's Electronic Medical Record (EMR) documented R20 had diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and a history of UTIs. R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had short and long-term memory problems and severe cognitive impairment. The MDS documented R20 had a urinary catheter and no UTI during the observation period. R20's Care Plan, revised 03/19/25, documented the resident had a urinary catheter and instructed staff to provide catheter care twice a day and as needed (PRN) which included cleansing urinary meatus (opening on the penis which leads into the body) around the proximal end of the catheter. The care plan documented R20 was on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The plan instructed staff to monitor and record any signs or symptoms of UTI. A review of R20's clinical record revealed that R20 had a positive UTI on 03/22/24, 08/28/24, and 05/19/25. The clinical record revealed on 05/28/25, R20 had penis discharge which was positive for infection. On 06/03/25 at 11:00 AM, Licensed Nurse (LN) I and Certified Nurse Aide (CNA) N applied gloves, gown, and goggles, propelled R20 into his bathroom, and then used a sit-to-stand lift to transfer R20 from his wheelchair to the toilet. Once over the toilet, CNA N pulled down R20's pants, removed and discarded his incontinent brief, and provided catheter care, including his meatus. CNA N, with the same soiled gloves on, left the bathroom, touched the resident's leg, sit to stand lift, went to the dresser, touched each drawer, retrieved a new incontinent brief, and then returned to the bathroom. CNA N (with the same soiled gloves) touched the lift, and the resident's leg, when she entered the bathroom, placed a new incontinent brief on R20, and fastened a lift jacket on the resident's waist. CNA N went outside the R20's bathroom door, (with the same soiled gloves) touched the control handles of the lift, and used the lift control to raise R20. CNA N assisted LN I in transferring the resident to a wheelchair and touched his wheelchair arms, and R20's feet to place them off the footstand onto the floor. Then CNA N removed and discarded her gloves and gown in a trash can. On 06/03/25 at 11:15 AM, CNA N verified she had not changed her gloves after providing catheter care and stated she should have. On 06/04/25 at 11:21 AM, Administrative Nurse D stated she would expect staff to change gloves during catheter care whenever they go from dirty to clean. Upon request, the facility failed to provide a policy regarding changing gloves during catheter cares.

The facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one resident, Resident (R) 29. This placed R29 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move). Findings included: - The Electronic Medical Record (EMR) documented R29 had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, hypertension (high blood pressure), and constipation (difficulty passing stool). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition. R29 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R29 required partial staff assistance with toilet hygiene. R29 was frequently incontinent of bladder but was always continent of bowel. R29 was not on a bowel toileting program and did not have constipation. The Bladder and Bowel Assessment, dated 04/22/25, documented R29 had a diagnosis of constipation, was always continent of bowel and required assistance from staff with toileting. R29's Care Plan, dated 05/16/25, initiated on 10/17/24, documented R29 had a history of constipation and directed staff to notify the nurse by day three of no bowel movement to implement protocol for bowel management. The update, dated 11/04/24, directed staff to encourage fluid intake as tolerated, administer medication as ordered for constipation The Physician's Order, dated 11/04/24, directed staff to administer a Bisacodyl (laxative) suppository 10 mg rectally (by way of the rectum), every 24 hours, as needed for constipation. The Physician's Order, dated 01/23/25, directed staff to administer Senexon (a laxative), 8.6-50 mg, two tablets by mouth, at bedtime for constipation. The Physician's Order, dated 02/05/25, directed staff to administer MiraLax (a laxative), 17 grams (gms) by mouth daily, for constipation and hold for loose stools. R29's Bowel Monitoring Record, dated May 2024, documented R29 did not have a bowel movement for the following days: 05/25/25 - 05/30/25 (six consecutive days) R29's Medication Administration for May 2025 lacked documentation the staff provided interventions during the lack of bowel elimination on the above dates. On 06/03/25 at 08:34 AM, observation revealed R29, in the sit-to-stand mechanical lift, and his pajama pants were saturated with feces. R29 was angry and combative with the staff. Licensed Nurse (LN) H informed R29 that staff needed to get him into the bathroom to assist R29 with getting cleaned up. Further observation revealed R29 was taken to the bathroom and lowered onto the toilet. On 06/03/25 at 08:45 AM, LN H stated that R29 could be combative with care and required a lot of patience. LN H further stated that R29 had a history of constipation. Staff used the facility's standing orders as needed if R29 did not have a bowel movement after three days. On 06/03/25 at 9:09 AM, Administrative Nurse D verified that she was unable to find any interventions for R29 after he had not had a bowel movement for six days, and staff were to use the standing orders as needed. On 06/03/25 at 12:50 PM, Certified Nurse Aide (CNA) M stated they documented in the computer when a resident had a bowel movement and notified the nurse if the resident did not have one for three days. The facility's Standing Orders protocol dated 07/31/24, directed staff to use the standing orders as verbal orders and send them to the physician for signature. The standing orders directed staff to initiate Milk of Magnesia (MOM -a laxative), 1 oz, by mouth, every day, as needed, if no bowel movement after three days, and if no results administer Bisacodyl suppository, 10 mg, rectally, and if no results, administer a tap water or soap suds enema (stimulates the colon to have a bowel movement), and if no results contact the physician.

The facility had a census of 35 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop and implement an antibiotic stewardship policy to ensure the appropriate and effective use of antibiotics, reducing antibiotic resistance and improving patient outcomes. This placed the 35 residents who resided in the facility at increased risk of receiving an infection and/or negative effects of antibiotic use. Findings included: - On 06/04/25 at 09:37 AM, Administrative Nurse D verified the facility lacked an antibiotic stewardship policy. Administrative Nurse D stated the facility had a cyberattack on its computer system, which erased all the facility's policies. Administrative Nurse D stated she had been typing out one policy at a time to get them back, but had not gotten around to the antibiotic stewardship policy. Upon request, the facility failed to provide an antibiotic stewardship policy.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to treat Resident (R) 25 with respect and dignity and failed to promote quality of life when staff performed an accucheck (blood sugar test) in a non-private area. This placed the resident at risk for impaired dignity. Findings included: - R25's Electronic Medical Record (EMR) recorded a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). On 09/18/23 at 11:49AM, observation revealed R25 sat in a recliner chair with her feet elevated in the living room. Further observation revealed Licensed Nurse (LN) G performed an accucheck on the resident while she was seated in the living room with six other residents also in the living room. When LN G completed the accucheck, she stated out loud your blood sugar is 123. On 09/18/23 at 12:10PM, LN G verified she should have taken R25 to a private area to perform the accucheck. On 09/20/23 at 07:50AM, Administrative Nurse D verified R25's accucheck should have been performed in a private area and not in the living room. The facility's Dignity policy, dated 2023, stated care for residents should be done in a manner and in an environment that maintains or enhances each resident's dignity/privacy with respect in full recognition of his/her individuality. The facility failed to provide dignity for R25, placing the resident at risk for embarrassment and an undignified experience.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include Resident (R) 25's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - R25's Electronic Medical Record (EMR) documented she had diagnoses of diabetes mellitus. R25's Annual Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented the resident was independently ambulatory and used a front wheeled walker for ambulation. R25 received insulin injections (hormone that lowers the level of glucose in the blood) seven days in the look back period. R25's medical record lacked a comprehensive care plan which addressed the use of insulin, signs of symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and direction for the nursing staff to care for the resident with diabetes mellitus. On 09/18/23 at 01:30PM, observation revealed R25 ambulated with her front wheeled walker to the sunroom. On 09/19/23 at 02:45PM, Administrative Nurse E verified the facility lacked a care plan for R25's diabetes mellitus and use of insulin. On 09/20/23 at 07:50AM, Administrative Nurse D verified the facility lacked a care plan for R25's diabetes mellitus and use of insulin. The facility's Care Planning policy, dated 2023, stated each resident is to have a comprehensive care plan regarding individual needs and care provided for each resident. The facility failed to develop a comprehensive care plan for R25, placing her at risk for inadequate care due to uncommunicated care needs.

The facility had a census of 34 residents. The sample included 12 residents with one reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement pressure reducing or offloading interventions to promote healing for Resident (R) 34, had a stage three (full thickness pressure injury extending through the skin into the tissue below) heel pressure ulcer. This placed the resident at risk for delayed healing, worsening of the wound, or additional pressure injuries. Findings included: - R34's Electronic Medical Record (EMR) documented R34 admitted to the facility 05/09/23. R34's EMR documented R34 had diagnoses of fracture of parts of lumbar sacral spine (lower back region of your spinal column or backbone) and pelvis (bones that connects the trunk and the legs), and had an unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer on his back. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 was at risk for developing a pressure ulcer, was on a turning/repositioning program, had a pressure reducing device for bed, and received nutrition or hydration interventions to manage skin problems; he received pressure ulcer /injury care. R34's Skin Integrity Care Plan, dated 05/19/23, instructed staff to encourage good nutrition and hydration for R34 in order to promote healthier skin. The care plan documented the resident had a history of pressure ulcer to areas on his back and buttock and instructed staff to apply treatment/ointment as order, reposition R34 every two hours, and treat pain as per orders prior to treatment/turning to ensure R34's comfort. R34's Activity of Daily Living (ADLs) Care Plan, revised on 08/21/23, documented R34 did not ambulate. R34 required two staff assistance with transfers using a sit to stand lift and required extensive staff assistance by one to two staff to turn and reposition in bed. R34's Pressure Ulcer Care Plan, revised on 08/21/23, documented R34 had a history of pressure ulcer to his lower back, and he had a pressure ulcer on his heel. The care plan instructed staff to assist R34 with turning/repositioning in bed at least every two hours, more often as needed (PRN) or requested. The plan directed R34 was seen by the wound care nurse for treatment of the pressure ulcer on his heel and instructed staff to see the Treatment Administration Record (TAR) for current treatment and recommendations. The Braden Scale, (scale for predicating risk for developing a pressure ulcer) dated 05/09/23, documented R34's score 12, which indicated R34 was at high risk for developing a pressure ulcer. The Skin/Wound Note, dated 05/15/23, documented R34's skin was intact. The Physician Order, dated 05/17/23, instructed staff to provide R34 with a house supplement with one scoop of protein powder, three times a day. The Skin/Wound Note, dated 05/22/23 at 02:09 PM documented staff removed the dressing from R34's mid lower back and the wound had dried red drainage. It measured 3.0 centimeters (cm) x 3.0 cm and had an open area measuring 10 cm long x 1.0 wide x 0.1 cm deep. The note documented staff covered the wound area with a band aid (adhesive bandage) dressing. The Skin/Wound Note, dated 08/07/23, documented R34 had an open, round area to his inner aspect of his right heel which measured 0.8 cm. The surrounding tissue was white. The wound measured 0.2 cm deep, with a small amount of drainage and was dark towards the toe. The wound had no odor. R34 complained of pain to touch, and the wound nurse was consulted. The Wound Consult Note, dated 08/09/23 at 2:30 PM, documented R34 presented to the wound clinic for an ulcer to his right heel which was likely a prior deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) that evolved into a stage three pressure injury. The note documented the wound nurse performed debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) to remove the non-viable tissue around the wound margins; no bleeding was produced. R34 tolerated the procedure with no complaints. The note documented the pressure ulcer measured 1 cm long x 0.8 cm wide x 0.2 cm deep. The wound nurse applied Xeroform (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) to the wound bed, covered with a cloth strip dressing and reinforced with cloth medical tape. The note documented the dressing would be changed on Monday, Wednesday, and Friday and R34 should follow up with wound care nurse weekly until healed. The Physician Order, dated 08/16/23, instructed staff to provide R34 with four ounces (oz) of Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine along with vitamin C and E) three times a day with meals. The Wound Consult Note, dated 08/16/23, documented R34's night medial heel pressure ulcer was yellow, had a small amount to serosanguineous (semi-thick blood-tinged drainage), and no odor. The surrounding tissue color had erythema (abnormal redness of skin): the surrounding tissue was dry, and the wound status was unchanged. The note documented the wound nurse debrided the wound and R34 had pain with the debridement The note documented the wound nurse wrapped the wound with petroleum gauze. The Wound Consult Note, dated 09/13/23, documented R34's right medial heel pressure ulcer had no drainage, and the wound nurse was unable to chart what the dressing looked like due to facility staff had removed it prior to her arrival to the facility. The note documented the same treatment was used. The Physician Order, dated 09/20/23 instructed staff to administer to R34 a multivitamin one time a day for wound healing. On 09/19/23 at 01:16 PM, observation revealed R34 sat in a wheelchair with gripper socks on, covered by sheep skin heel protector. Licensed Nurse (LN) I removed the protectors and sock revealing an area on R34's inner right heel, approximately 0.4 cm x 0.2cm with a black scab in the middle of the wound, The surrounding tissue was dry, peeling, and pink. Further observation revealed when LN I touched the black scab area, R34 pulled back his foot and stated, that hurts. LN I verified R34 developed the pressure ulcer in the facility. LN I stated it was a stage three pressure ulcer. LN I stated she was unaware why staff placed the sheep skin heel protector on R34's right medial heel pressure ulcer because it was not an effective pressure relieving device. LN I stated maybe staff were using it to make the resident more comfortable. Further observation revealed R34's family member entered the room and LN I stated she was worried about R34 having pain when she touched the scabbed area of the wound and would like to get an x-ray of the area. LN I did not provide pressure ulcer care to the area, and left the room at that time. On 9/19/23 at 02:12 PM, LN I stated she saw the resident in outpatient at hospital for wound care, and staff would bring him after his shower. She stated R34 never presented to with the sheep skin pressure ulcer protector. She said 09/19/23 was the first time she saw the sheep skin protector on R34's heel, and stated it was not an appropriate pressure relieving device. LN I stated she would tell Administrative Nurse D that it was not appropriate. LN I stated she would recommend heel protector boots for other residents but not for R34 due to the fact he was pretty well mobile and could reposition his legs himself. On 09/19/23 at 02:40PM, Administrative Nurse D verified when R34 was admitted , R34's interventions implemented to prevent him from developing pressure ulcers only included monitoring and repositioning every two hours and as needed. Administrative Nurse D acknowledged no pressure reducing or offloading was implemented once the pressure injury was identified on R34's heel and stated staff only put in additional interventions to prevent pressure ulcers if the physician ordered them or if LN I ordered an intervention. Administrative Nurse D stated she felt like the interventions were appropriate due to the resident could move his legs around in bed and propel his wheelchair. The facility's Pressure Ulcer Policy, revised 2022, documented the facility would identify at risk individuals needing prevention and specific factors placing them at risk. Upon admission from acute care, guidance would be followed according to admission orders for continued therapies. The interdisciplinary team would be notified so they may develop a relevant care plan to include prevention and management interventions' with measurable goals. The facility failed to implement interventions consistent with the standard of care, including offloading and/or pressure reducing boots to promote healing for R34's stage three medial heel pressure ulcer. This also placed R34 at risk for additional pressure ulcer injuries.

The facility had a census of 34. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported the lack of a stop date for Resident (R) 34's as needed (PRN) psychotropic (altering mood or thoughts) medication. The facility further failed to ensure the CP identified and reported the lack of pulse monitoring prior to administration of R19's metoprolol (blood pressure medication). This placed the resident at risk for unnecessary medication side effects. Findings included: - R34's Electronic Medical Record (EMR) documented the resident had diagnoses psychotic disturbance (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mood disturbance and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 received an antianxiety (class of medications that calm and relax people) daily during the look back period. R34's Antianxiety Medication Care Plan, revised on 08/21/23, instructed staff to monitor, document, and report any adverse reactions R34 had to his antianxiety therapy. The Physician Order, dated 08/15/23, instructed staff to administer R34 Ativan, 0.25 milligram (mg), PRN every 12 hours for anxiety disorder. The order lacked a stop date. The Pharmacy Regimen Review, dated 08/23/23 documented no irregularities. On 09/18/23 at 03:46 PM, observation revealed R34 sat quietly in a wheelchair at music activity. On 09/19/23 at 02:40 PM. Administrative Nurse D verified the facility's CP failed to identify and report R34's physician order for Ativan PRN without a stop date. Administrative Nurse D stated it should have a stop date. The facility's Drug Regime Review Policy, revised 2023, documented the consultant pharmacist would perform a drug regimen review on each elder living in this facility and at least monthly. The pharmacist contracted by the facility would review each resident medical record during each monthly or routine drug regime review which included inappropriate use of as needed (prn) antipsychotic medications The facility failed to ensure the CP identified and reported the lack of a stop date for R34's PRN psychotropic medication. This placed the resident at risk for unnecessary medication side effects. 41713 - The electronic medical record (EMR) for R19 documented diagnoses of hypertension (HTN- elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). The Admission Minimum Data Set (MDS) dated [DATE] documented R19 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R19 walked with a walker in room but required extensive assistance of one staff for locomotion off the unit. R19 was independent with cares with assist. R19 received insulin (hormone that lowers the level of glucose in the blood), an antidepressant (class of medications used to treat mood disorders), an anticoagulant (class of medication used to thin the blood and prevent clotting), and a diuretic (medication to promote the formation and excretion of urine) seven of seven days during the look back period. The Quarterly MDS dated [DATE] for R19 documented a BIMS score of 12 which indicated moderately impaired cognition. R19 required limited assist of one staff with activities of daily living (ADLs). R19 received insulin, an antidepressant, an anticoagulant, and diuretic seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 06/07/23 documented R19 required assist as needed with ADLs. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) Care Plan initiated for R19 directed to administer medications as ordered. Staff was to monitor and document for side effects and effectiveness. The Order Summary for R19 documented a physician's order dated 05/25/23 for metoprolol (beta-blocker medication used to treat lower blood pressure and pulse rate) 50 milligrams twice daily for hypertension. Review of R19's Medication Administration Record (MAR) and clinical record revealed that R19's pulse was not monitored prior to administration of the metoprolol. The CP Monthly Medication Review (MMR) from May 2023 to August 2023 revealed the pharmacist did not identify and report to the facility and physician the lack of pulse monitoring prior to metoprolol administration. On 09/19/23 at 08:15 AM R19 sat in his wheelchair and self-propelled himself back to his room. On 09/20/23 at 07:19 AM Administrative Nurse D stated the CP had access to all the resident's charts and reviewed the medical records monthly and would make the recommendations she identified and those would be sent to the physician for review. Administrative Nurse D stated that when an antihypertensive medication was entered into the MAR it should flag the individual entering the medication to enter the parameters for monitoring a pulse or blood pressure. Administrative Nurse D stated this must have been inadvertently omitted. On 09/21/23 at 09:29 AM Consultant GG stated that she did review the resident's medication orders, administration record, and labs monthly and would make recommendations on irregularities she had noted. Consultant GG stated she did make recommendations for medications that lacked a required pulse or blood pressure monitoring. Consultant GG stated she must have overlooked that for R19 and would make that recommendation during her next review. The Drug Regimen Review policy dated 2023 documented: a pharmacist contracted by the facility will review each resident medical record during each monthly or routine drug regimen review. The drug regimen review will identify medications used without adequate monitoring. The facility failed to ensure the CP identified and reported the lack of pulse monitoring prior to metoprolol administration for R19. This placed R19 at risk for unnecessary medication administration and possible adverse side effects.

The facility identified a census of 34 residents. The sample included 12 residents with five residents sampled for unnecessary medications. Based on observation, record review, interview, the facility failed to ensure nursing staff monitored a pulse prior to administering Resident (R) 19 metoprolol (a beta-blocker medication used to treat and lower blood pressure and pulse rate). This placed R19 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R19 documented diagnoses of hypertension (HTN - elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). The Admission Minimum Data Set (MDS) dated [DATE] documented R19 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R19 walked with a walker in room but required extensive assistance of one staff for locomotion off the unit. R19 was independent with cares with assist. R19 received insulin (hormone that lowers the level of glucose in the blood), an antidepressant (class of medications used to treat mood disorders), an anticoagulant (class of medication used to thin the blood and prevent clotting), and a diuretic (medication to promote the formation and excretion of urine) seven of seven days during the look back period. The Quarterly MDS dated [DATE] for R19 documented a BIMS score of 12 which indicated moderately impaired cognition. R19 required limited assist of one staff with activities of daily living (ADLs). R19 received insulin, an antidepressant, an anticoagulant, and diuretic seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 06/07/23 documented R19 required assist as needed with ADLs. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) Care Plan initiated for R19 directed to administer medications as ordered. Staff was to monitor and document for side effects and effectiveness. The Order Summary for R19 documented a physician's order dated 05/25/23 for metoprolol 50 milligrams twice daily for hypertension. Review of R19's Medication Administration Record (MAR) and clinical record from May 2023 to September 2023 revealed that R19's pulse was not monitored and recorded prior to administration of metoprolol. On 09/19/23 at 08:15 AM R19 sat in his wheelchair and self-propelled himself back to his room. On 09/19/23 at 07:40 AM Licensed Nurse (LN) H stated that R19's stated that a pulse should be obtained prior to metoprolol administration. LN H stated it looked like pulse for R19 was not being monitored but it should be. On 09/20/23 at 07:19 AM Administrative Nurse D stated that when a blood pressure medication was entered into the MAR it should flag the individual entering the medication to enter the parameters for monitoring a pulse or blood pressure. Administrative Nurse D stated this must have been inadvertently omitted on R19's MAR. The Medication Administration & Documentation policy revised 2023 documented: for residents on pulse altering medications, pulses will be obtained before medication administration and charted on EMAR under the supplementary documentation medication. The medication will be held if pulse was below 50. The facility failed to ensure that staff monitored R19's pulse prior to administration of metoprolol. This placed R19 at risk for unnecessary medication administration and possible adverse side effects.

The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on an as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R) 34. This placed the resident at risk for unnecessary medications and related complications. Findings included: - R34's Electronic Medical Record, (EMR) documented the resident had diagnoses psychotic disturbance (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mood disturbance and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 received an antianxiety (class of medications that calm and relax people) daily, during the look back period. R34's Antianxiety Medication Care Plan, revised on 08/21/23, instructed staff to monitor, document, and report any adverse reactions R34 had to his antianxiety therapy. The Physician Order, dated 08/15/23, instructed staff to administer R34 Ativan, 0.25 milligram (mg), PRN every 12 hours for anxiety disorder without a stop date. The Pharmacy Regimen Review, dated 08/23/23 documented no irregularities. On 09/18/23 at 03:46 PM, observation revealed R34 sat quietly in a wheelchair at music activity. On 09/19/23 at 02:40 PM. Administrative Nurse D verified R34's physician order for Ativan PRN without a stop date. Administrative Nurse D stated it should have a stop date, staff must have missed it. The facility's PRN Medication Administration Policy, revised 2023, documented review of controlled medications after 14 days of use if stop date is not indicated on the original order. The facility failed to obtain from the physician a stop date for R34's PRN psychotropic medication. This placed the resident at risk for unnecessary medication side effects.

The facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure communication and collaboration between the facility and hospice provider which included a description of the services, medication, and equipment provided to Resident (R)21. This deficient practice created a risk for missed opportunities for services and delayed treatment. Findings included: - The electronic medical record (EMR) for R21 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), major depressive disorder (a major mood disorder which causes persistent feelings pf sadness), and convulsions (a sudden, violent, irregular movement of a limb or of the body). The Significant Change Minimum Data Set (MDS) dated [DATE] for R21 documented she had both short and long-term memory problems and had severely impaired cognitive skills for daily decision making. R21 required extensive to total assistance of one to two staff for activities of daily living (ADLs). R21 was on hospice services. The Quarterly MDS dated [DATE] documented R21 had both short and long-term memory problems and had severely impaired cognitive skills for daily decision making. R21 required total dependence from staff for ADLs. R21 required hospice services. The Cognitive Loss Care Area Assessment (CAA) dated 04/08/23 documented R21 was on hospice. The Hospice Care Plan initiated 04/14/23 for R21 directed staff that hospice will provide supplies to manage incontinence, and medications to manage her diagnosis. The care plan directed staff that a hand brace/wash cloth roll was used as needed to extend R21's hand per her comfort. The care plan directed staff that R21 would be seen by hospice and nursing staff would update hospice of all conditional changes. This care plan was resolved 09/17/23, yet R21 still remained on hospice services as of 09/19/21. The care plan lacked staff direction on who the hospice provider was and the contact information. The care plan lacked how often hospice personnel would provide services/visit R21 at the facility. The care plan lacked direction on medications, equipoment, and other suplpies and services provided by hospice. The Orders tab for R21 recorded a physician's order dated 03/29/23 to admit R21 to hospice. A Hospice Admission was completed by the physician on 03/29/23. A Hospice Plan of Care was initiated by the hospice provider. On 09/19/23 at 09:16 AM R21 sat reclined in her Geri-chair (a recliner on wheels that can be pushed around like a wheelchair, usually with a removable tray);she had splint on her right hand, and was propelled by staff from dining room to commons area to watch tv. On 09/19/23 at 02:25 PM Administrative Nurse E stated hospice provided a book available for the family and staff that listed in detail about the hospice services but was not resident specific. Administrative Nurse E stated the hospice plan of care and other documents related to hospice had been scanned into R21's EMR that listed the medications, supplies and hospice visits for R21 so she did not think that the facility needed to care plan that information on R21's facility care plan. On 09/19/23 at 03:12 PM Administrative Nurse D stated that upon admission to hospice the facility received the hospice records for R21 but did not go that in depth on what was provided by hospice in R21's individual care plan as staff was told upon admission to hospice what supplies were provided, and the hospice supplies were kept separate from the facilities supplies. Administrative Nurse D stated she was not aware that all the hospice provider information, supplies and when the hospice nurse needed to be in the facility maintained care plan but said that would make sense so new staff or agency staff would be aware of what was provided by the hospice service. The Hospice policy dated 2023 documented the facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including: nursing services, nurse aide services, social services, chaplaincy services, durable medical equipment, medications, and grief support to family member. The facility failed to ensure communication and collaboration between the facility and the hospice provider which included a description of the services, medication, and equipment provided to R21 by hospice. This deficient practice created a risk for missed opportunities for services and delayed treatment.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for two of three days of the onsite survey. Findings included: - On 09/18/23 (Monday) observation revealed the facility lacked a posted daily nurse staffing hours. On 09/19/23 (Tuesday) observation revealed the facility lacked a posted daily nurse staffing hours. On 09/19/23 at 10:09 AM, Administrative Nurse D verified the facility lacked the posted daily nurse staffing hours on 09/18/23 and on 09/19/23. Administrative Nurse D stated her secretary was responsible for posting on the wall behind the nurse's desk, but her secretary had been out of facility yesterday and today and she forgot to post it. The facility's LTC Staffing Policy, undated, documented the director of nursing or designee would ensure the number of registered nurses, licensed practical nurse and certified nurse aides(direct care partners) scheduled for each day ; the name of the facility, the census of the facility, and the total number of hours of each position listed is posted at the entrance to the health center and would be kept current during each day by revising the form as staffing and census change. The form would be posted at the nurses desk and be accessible to residents, family members and others in the public. The schedule would also be located at the entrance of Long Term Care (LTC). The facility failed to post the daily nurse staffing hours for two of three days of the onsite survey.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to cover clean linens and/or clothing when delivering to resident rooms and failed to review or update infection control policies annually. This deficient practice placed the residents at increased risk for infection. Findings included: - On 05/25/22 at 08:15 AM, observation revealed laundry staff wheeled an uncovered cart of residents' clean clothing to the west hall. On 05/25/22 at 08:15 AM, Administrative Nurse D stated laundry staff did not use covers for the clean clothes but did for towels. On 05/25/22 at 08:18 AM, Laundry Staff U verified staff were to cover laundry carts when transporting clothing through the facility. She stated prior to and during the Covid (contagious respiratory infection) emergency, staff covered the carts. Laundry Staff U stated she was told covering the carts of clean linens was no longer required The facilities policies related to infection control were dated and/or last revision date: Infection Prevention and Control Plan- 2020 Antibiotic Stewardship Program- 10/19/17 Influenza and Pneumococcal Vaccines- 01/18/18 Covid 19 Procedures 08/2020 On 05/24/22 at 03:40 PM, Administrative Nurse D verified the policies were not updated or reviewed annually and acknowledged they should have been. The facility's Infection Prevention and Control Plan, dated 2020, documented the written infection prevention and control plan would be reviewed at least annually and updated as needed. The policy documented all staff were responsible for being knowledgeable and compliant with infection control policies and procedures. The facility failed to cover clean resident laundry when delivering clothing to resident rooms and failed to review or update infection control policies annually. This placed the residents at increased risk for infections.

The facility had a census of 31 residents with three reviewed for accidents. Based on record review and interview, the facility failed to ensure Resident (R)1 remained free from injuries related to accidents when a hot liquid spill resulted in a second degree burn to R1's right thigh. As a result of the burn, R1 required daily treatments to his groin/thigh and an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag). Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of heart failure (a condition with low heart output and the body becomes congested with fluid), [CONDITION(S)] (rapid, irregular heartbeat) and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status score of six, which indicated severely impaired cognitive function. The MDS documented R1 required extensive assistance of one to two staff for bed mobility, transfers, toilet use, personal hygiene, dressing, and bathing. The MDS documented R1 as independent with eating after set-up help. The Activity of Daily Living Care Area Assessment (CAA) dated 10/08/21 documented R1 required one to two staff assistance with transfers, ambulation, locomotion, and used the sit-to-stand lift for transfers. The Nutrition Care Plan dated 02/14/20, documented R1 was able to eat independently most days, but he may need assistance on some days due to shaking hands. The Mobility Care Plan, dated 02/25/20, documented R1 had difficulty with movement in his shoulders. R1 was unable to reach over his head and had difficulty straightening his arms out. The Safety Notes and Fall Care Plan, dated 08/31/21 documented R1 did not always recognize unsafe decisions. The Restorative Services Care Plan dated 11/30/21 documented R1 may need assistance with end-of-range reaching by staff holding the right or left elbow. The Hot Liquid Safety assessment dated [DATE] documented R1 was compromised cognitively, exhibited confusion and agitation, had poor muscle control and weakness, and could manage a coffee cup without assistance. The Safety with Hot Liquids Care Plan dated 12/27/21 documented R1 could drink hot liquids independently. The Nurses Note dated 01/02/22 at 07:30 AM documented R1 had increased anxiety and noted his right arm had tremors and shaking. The Nurses Note dated 01/03/22 at 05:03 AM documented R1 had increased anxiety throughout the night and R1 had right hand tremors and shaking of his right arm. The Behavior Note dated 01/09/22 at 05:21 AM documented R1 slept most of the night, but at 05:05 AM, R1 started yelling out and wanting to get up for the day. Nursing staff assisted him in getting dressed and out to the lobby. The Communications with MD/Family/Res Note dated 01/09/22 at 07:45 AM documented R1 was eating breakfast and spilled hot coffee into his lap. Staff assisted R1 to his room where his pants were removed, and [CONDITION(S)] were noted to R1's groin. Staff called the emergency room to let them know facility staff were bringing R1 to the emergency room . The emergency room Discharge Orders dated 01/09/22 directed nursing staff to apply [MEDICATION(S)] 1% (a burn cream) to the [CONDITION(S)] on the groin topically two time a day. The Skin/Wound Note dated 01/11/22 documented the [CONDITION(S)] to the groin and thigh had several intact blisters. The skin was red and very irritated. R1 denied pain. The Skin/Wound Note, dated 01/12/22, documented R1 had some intact blisters and some open skin. Staff applied [MEDICATION(S)] cream and covered the area with [MEDICATION(S)] dressing (non-adherent dressing) and secured with tape. R1 voiced no complaints of pain. The Skin Wound Note, dated 01/13/22 documented R1 continued with [MEDICATION(S)] cream to his right upper thigh groin area. Staff removed the old dressing and there were two large fluid filled blisters. R1 denied severe pain, but stated the area was tender. Staff applied [MEDICATION(S)] and a dressing to the area. The Skin/Wound Note, dated 01/14/22, documented the old dressing was removed and there was greenish-gray drainage on the old dressing. All blisters were open. R1's right mid-thigh had a light red area where a blister was located. The right mid/medial (inner or towards center of the body) area had a red area where the blister had been. The right inner area was greenish/gray surrounded by bright red skin that was warm to the touch. R1's doctor, Consultant GG, looked at the wounds and wrote new orders for an indwelling catheter to be inserted to try to prevent infection to the area due to urine incontinence. Consultant GG prescribed [MEDICATION(S)] (antibiotic) 500 milligrams twice a day for ten days, whirlpool to debride wound, and dressing change twice a day with [MEDICATION(S)] applied to [CONDITION(S)]. The Skin/Wound Note dated 01/18/22 documented the old dressings had brownish clear drainage on them. The lateral (outer, or away from the center of the body) and medial wound bed had tan eschar (a dry dark area of dead tissue) covering them and the wound in between the other two wounds had a light scab covering it. The Skin/Wound Note, dated 01/20/22, documented sanguineous (clear bloody) drainage noted to the removed dressing. Both [CONDITION(S)] were creamy yellow in color. The surrounding tissue was pink in color. There were no signs of infection. The Skin/Wound Note dated 01/25/22 documented physical therapy debrided (mechanically remove dead tissue to promote healing) the wounds and measured them. The lateral right thigh wound measured 7.2 centimeters (cm) by 1.7 cm. The middle right thigh wound measured 1.6 cm by 0.3 cm. The medial right thigh wound measured 5.6 cm by 1.4 cm. The Skin/Wound Note dated 01/28/22 documented physical therapy debrided the wounds, but they were unable to completely remove the eschar from the wound bases. Review of R1's EMR revealed dressing changes continued from 01/29/22 through 03/03/22 when R1 admitted to the hospital with the diagnosis of [CONDITION(S)] (high sodium levels). On 04/06/22 at 10:30 AM, Certified Nurse's Aide (CNA) M stated on the morning of 01/09/22 she was getting residents out to breakfast and she noticed R1 was completely soaked in his groin area and she thought it was odd because he was not normally incontinent at that time of the morning. She asked him what happened and R1 stated he spilled his drink. CNA M asked CNA N if R1 spilled his coffee and CNA N stated R1 spilled his coffee on himself. CNA M went and got the nurse and they took R1 back to his room and removed his pants and saw the blisters from the hot coffee. CNA M stated R1 was shaky with his arms and hands sometimes. CNA M stated the facility did not do anything special with coffee or hot liquids until after the incident, but now they have lids, and dietary staff waited for the coffee to cool a couple of minutes in the cups before serving it. 0n 04/06/22 at 01:00 PM, Licensed Nurse G stated that she did not know anything about the coffee spill to R1's lap until CNA M came and told her about it. They then took him back to his room and took off his pants. The liquid on the pants was cold to the touch though R1's skin was hot to the touch and blisters had formed. The area around the blisters was fiery red. LN G stated R1's arms shook at times. On 04/06/22 at 02:30 PM, CNA N stated on the morning of 01/09/22 she was just clocking in and heard a thud on the ground. She went into the dining room area and walked around looking for what had caused the noise and then saw the coffee cup and spilled coffee on the floor by R1. CNA N stated she went to R1 and patted him dry and asked him if he was okay and he said that he was. CNA N then went back to the assisted table to help the residents seated there. On 04/06/22 at 02:00 PM Administrative Nurse D stated she would expect her staff to get help immediately for a hot liquid spill to get the hot liquid away from the skin as soon as possible. Administrative Nurse D stated that R1's shaking seemed to only happen when he was anxious, and the facility found he was safe with hot liquids when they assessed him prior to the incident. The facility's undated Safe Serving of Coffee and Other Hot Liquids policy documented staff will work diligently at all times to create a safe environment for each and every resident of this facility while allowing each resident with choices and preferences with education related to specific risks. All residents will be assessed for the ability to safely handle hot liquids with fourteen days of admission, quarterly, and upon changes in condition. Hot beverages will be placed at least ten inches away from the edge of any table. Hot beverages will be placed near the dominant hand of the resident. When serving hot beverages staff will remind each resident that the served beverage is hot. The facility failed to ensure R1 remained free from injuries related to accidents when a hot liquid spill resulted in a second degree burn to R1's right thigh. On 01/11/22 the facility completed the following corrective actions: Hot Liquid Risk Assessments completed on all residents. All staff were educated of who needed adaptive cups or interventions for hot liquids. lf the resident required help for hot liquids, a discreet indicator was also posted in their room. Dining room aides were educated, report books updated, and information was shared with dining room and kitchen staff that worked in the long-term care area. Hot liquids policy was reviewed by all staff at in-service. Kitchen policy was reviewed regarding temperature of hot liquids. Continued monitoring of resident's injury which indicated no further problems or pain. All care plans were double checked for accuracy of the Hot Liquid Burn Assessment. The deficient practice was cited as past noncompliance.

The facility had a census of 32 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents. Certified Nurse Aide (CNA) M worked as a Restorative Aide (RA) without the 32-hour facility required Restorative Aide Training. He put a warm moist pack under Resident (R) 1's neck/upper back area while she laid on the therapy mat without having the correct amount of padding. R1, a severely cognitively impaired resident, had poor safety awareness, required cues to move, and did not always instigate any active movement. CNA M did not have proper training on wrapping the warm moist packs kept in 140-degree water in the hydrocollator (a liquid heating device that is used in physical therapy clinics to heat and store hot packs for therapeutic uses) before allowing R1 to lay on an improperly padded warm moist pack for 15 minutes. This caused R1 to obtain a second-degree burn. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Physician's Order Sheet, dated 04/05/21 listed diagnoses of depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia (progressive mental disorder characterized by failing memory and confusion). The Annual Minimum Data Set, (MDS) dated [DATE] documented the resident had severely impaired cognition, required limited assistance of one staff with bed mobility, required extensive assistance of one staff with dressing, and received restorative nursing program for passive range of motion one of the seven days in the seven day lookback period. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 01/22/21 documented R1 required assistance of one with all ADLs. The Restorative Services Care Plan, revised 04/27/20 documented the therapist recommended R1 participate in a therapy program two to five times a week. The Physical Therapy Evaluation, dated 01/20/21 documented R1 had poor safety awareness, required cues to move, tended to not instigate any active movement, and had difficulty holding her head in a neutral position. The therapy/restorative plan documented staff to see R1 two to five times a week with activities to include staff to lie resident supine working on gentle cervical range of motion into cervical flexion, frequent rotations, and cervical side bending liberally. Staff could place a hot moist pack to the neck to help with this discomfort and decreased range of motion. The Restorative Plan, revised 01/29/21 directed staff to place resident on back, while working on gentle cervical range of motion, into cervical flexion, with frequent rotations, and cervical side bending bilaterally. Staff may place a hot moist pack to the resident's neck to help with this discomfort and decreased range of motion. The Skin Observation Tool, dated 03/23/21 at 05:10 PM documented R1 had a burn wound 5-centimeter (cm) x 6 cm with a 1 cm x 1 cm blister forming between her shoulders. The Physician's Order, dated 03/25/21 directed staff to apply a dry 4 cm x 4 cm gauze dressing to the wound on the resident's mid-upper back and secure with cloth tape. This dressing was to be changed daily. The Nurse's Note, dated 03/24/21 Administrative Nurse D documented R1 had a 1 cm x 1 cm fluid filled intact blister with a red area, which measured 5 cm x 6 cm surrounding the blister. The resident stated it was tender to touch. There was no drainage noted and the area was left opened to air. In the Restorative Program Note, dated 3/24/2021 at 10:20 AM CNA M documented on 03/23/21 he went into R1's room at about 10:00 AM and walked R1 down to the rehabilitation room. He laid R1 down on the rehab bed, then wrapped a hot moist pack (out of the hydrocollator) in the provided wraps and had about 5 or 6 layers covering the pack. R1 laid on the hot moist pack for about 15 minutes. CNA M then removed the hot moist pack and performed range of motion stretches on R1's neck for about five minutes. He wheeled R1 back to her room in her wheelchair, assisted her to the bathroom, sat her in her chair in the position of comfort, and left her room. On 04/12/21 at 09:47 AM, an unidentified staff finished giving R1 a bath. R1 sat in a shower chair covered with towels and had a wound in the middle of her back just below the neck. The wound had a red area with a darker red area with a cream-colored slough (dead tissue, usually cream or yellow in color) in the middle. The wound's dark red area measured 1.8 cm x 1 cm, the cream colored center measured 1.3 cm x 0.3 cm. Licensed Nurse (LN) covered the wound with a 44 gauze dressing, secured with tape, and marked the dressing with the date and her initials. On 04/12/21 at 11:01 AM, observation of the hydrocollator revealed it was locked. LN G opened the lock and lid of the hydrocollator, which held warm moist packs and the water temperature was 140-degrees Fahrenheit. On 04/12/21 at 01:44 PM, CNA M demonstrated how he wrapped warm moist packs. He took the contour neck pack or the long one out of the hydrocollator using tongs, placed it on a cloth bed pad and a towel, then wrapped the pack up. CNA M stated that is how he has always prepared a warm moist pack to use on a resident. If this warm moist pack was used, it only had 4 layers of protection on the surface between the resident and the warm moist pack. LN G observed CNA M's demonstration of wrapping the warm moist pack and agreed there were either 4 layers or 6 layers of protection depending how the pack would be laid on the resident. LN G said she saw CNA M make warm moist packs for the resident's use, but did not go and count the layers of cushion before he used them on a resident. The layers protect a resident's skin from getting too hot. She stated she needed to do a better job of training CNA M on how to wrap warm moist packs to be used on residents. On 04/12/21 at 10:35 AM, CNA M stated he was a Restorative Aide at the facility since August of 2020. His job description to be a Restorative Aide required a Restorative Aide Training course, but he had not yet enrolled in the course. He stated he watched LN G for his training on how to do warm moist heat packs. CNA M stated on 03/23/21 about 10:00 AM he used the longer skinny hot pack out of the hydrocollator, and a wrap rolling it 3-4 times and put it under R1's upper back/neck as she laid on the mat. He asked R1 every 5 minutes if she was doing ok, she said yes. The warm moist pack was on R1 for about 15 minutes. He then walked the resident back to her room. On 03/24/21 CNA N found there was a burn on R1's neck area where staff placed the hot pack. On 04/12/21 at 01:33 PM LN G stated CNA M worked as a restorative aide off and on since August of 2020. LN G confirmed CNA M had not taken the Restorative Aide Course. Administrative Nurse N, and herself were responsible for making sure CNA M took the Restorative Aide Course. When CNA M started working the therapy department, LN G showed him how to a put on warm moist packs on residents but did not document it. She stated she was off on 03/23/21 and CNA M was in the therapy department by himself. On 04/13/21 at 08:37 AM LN D stated CNA M did not follow the facility's policy on proper protection wraps for the warm moist pack. He did not wrap the pack with enough layers to prevent R1 from getting a burn. LN D confirmed the restorative therapy staff should be using the warm moist pack covers and not cloth bed pads and towels for protective layers when placing hot packs on residents. The facility's Hot Packs Policy, revised 06/08/07, documented staff were to place hot packs in a hot pack cover and use a second hot pack cover and two to three towels to make eight to ten layers (of protection) between the hot pack and patient. The staff were to use more towels if the patient sat on or leaned on the hot pack. Staff were to place the hot pack on the area for 15 to 20 minutes, and were to watch carefully, due to the hot packs can cause 2nd degree [CONDITION(S)]. The facility failed to correctly apply a warm moist pack to a resident who had poor safety awareness, required cues to move, and did not always instigate any active movement. The CNA M did not have proper training on wrapping the warm moist packs that are kept in 140-degree water in the hydrocollator before allowing R1 to lay on an improperly padded warm moist pack for 15 minutes. This caused R1 to obtain a second-degree burn. The facility presented an acceptable plan for removal of the immediate jeopardy on 04/13/21 at 01:45 PM. The survey team validated that the immediate jeopardy was removed on 04/13/21 at 02:30 PM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a G (isolated with actual harm) scope and severity following the removal of the immediate jeopardy.

The facility had a census of 34 residents. The sample included 15 residents, of which 2 were reviewed for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure). Based on observation, interview, and record review the facility failed to develop and implement effective interventions to prevent development of pressure ulcers and failed to thoroughly assess the skin and wounds for 1 of 2 residents, who developed a facility acquired avoidable pressure ulcer, which worsened and required wound management from outside the facility, including debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). (#14) Findings included: - Resident #14's 4/2/18 (POS) Physician order [REDACTED]. Stage 3 (PU) pressure ulcer (full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed). The quarterly (MDS) Minimum Data Set, dated dated [DATE], documented the resident had intact cognition with a (BIMS) Brief Interview for mental Status score of 15. The MDS documented the resident was independent with eating, required limited assistance with bed mobility, extensive assistance of 1 staff with hygiene, and total assistance with locomotion and toileting. The resident did not walk, had impaired (ROM) range of motion in all 4 extremities, and used a walker and wheelchair for mobility. The MDS documented the resident received pain medications and interventions for almost constant pain, had no swallowing or dental issues, and weighed 105 pounds. The MDS documented the resident was not at risk for pressure ulcers and had no pressure ulcers or skin issues. The quarterly MDS, dated [DATE], documented the resident had a BIMS of 9 (indicating moderately impaired cognition), required extensive staff assistance with bed mobility, and total assistance with transfers, dressing, locomotion and toileting. The MDS documented the resident was at risk for pressure ulcers and had 2 Stage 3 pressure ulcers, which measured 0.6 x 1 x 0.1 (cm) centimeters, with slough (dead tissue, usually cream or yellow in color), which was not present on admission. The MDS documented the resident had 2 venous/arterial ulcers (caused by impaired blood flow), and the facility provided pressure relief to the resident's chair, pressure ulcer care, ointment other than to feet, and dressings to his/her feet. The annual MDS, dated [DATE], documented the resident had frequent mild pain, 1 unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (dead tissue that is tan, brown or black) in the wound bed) pressure ulcer, which measured 0.9 cm x 1.2 cm x 0, with slough. The 2/2/18 (CAA) Care Area Assessment summary for pressure ulcers documented the resident required extensive staff assistance getting in and out of bed, was able to turn self in bed, and had a pressure reducing pad in his/her wheelchair. The summary documented the resident had a history of [REDACTED]. The 8/9/17 care plan lacked interventions to prevent pressure ulcers and lacked skin intervention updates after the pressure areas to the resident's toes were noted on 10/7/17. An undated note on the care plan recorded 2nd and 4th left toe. The 2/15/18 care plan update directed staff to see the (TAR) Treatment Administration Record for current treatment for [REDACTED]. The care plan directed staff to encourage the resident to not wear shoes when sitting in the recliner. The care plan documented the resident attended a wound clinic. The 8/4/17 Braden scale (a tool used to assess the risk of pressure ulcers) score of 17 documented the resident was not at risk for pressure ulcers. The 10/7/17 at 5:30 PM, nurse's note documented the resident complained of pain to the bottom of his/her left toes and had reddened skin from pressure points on 3 toes. The note documented the nurse placed a dressing with foam to relieve pressure to the bottom of his/her foot. The 10/9/17 at 11:15 AM, nurse's note recorded the resident refused the foam dressing to his/her left foot. The note lacked further documentation of the resident's toes. The 10/9/17 weekly skin assessment documented the tip of the resident's left great toe was red, and the resident denied discomfort. The 10/16/17 weekly skin assessment documented no skin issues. The 10/17/17 physician order's directed staff to clean the tip of the resident's 4th left toe (BID) twice daily, and apply [MEDICATION NAME] (antibacterial) ointment until resolved. The 10/17/17 physician visit progress note documented a [DIAGNOSES REDACTED]. The note documented an infected [MEDICAL CONDITION] on the tip of the resident's left 4th toe with an overlying callus (an area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation). The physician's plan was debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) of the left 4th toe, and trim the callus. The 10/18/17 at 9:30 AM, nurse's note recorded staff noted an open area, approximately 1 cm x 1 cm, to the tip of the 4th left toe, and applied [MEDICATION NAME]. The 10/21/17 at 9:30 AM, nurse's note recorded a scant (small) amount of tan drainage on the Band-Aid removed from the resident's 4th left toe, no sign of infection, staff cleansed with soap and water, and applied [MEDICATION NAME] and a Band-Aid. The 10/23/17 at 9:00 AM, nurse's note recorded staff applied [MEDICATION NAME] and a Band-Aid to the tip of the 4th left toe open area. The 10/25/17 at 10:00 AM, nurse's note recorded a moderate amount of tan drainage on the Band-Aid from the 4th left toe, and the resident stated, my toe is sore today. The note documented the wound appeared more irritated. The 10/25/17 weekly skin assessment documented a wound to the tip of the 4th left toe, and lacked further information. The 10/29/17 at 10:15 AM, nurse's note recorded staff applied [MEDICATION NAME] to the 4th left toe, after cleansing with soap and water, and recorded no discomfort, swelling, or redness. The 10/31/17 fax from nursing notified the physician the resident's left 4th toe continued to have an open area, and the [MEDICATION NAME] was not helping. The physician ordered a wound consult for the non-healing ulcer of the left 4th toe. The 10/31/17 consultant wound nurse documentation recorded the resident's 4th and 2nd left toes, had a (PU) pressure ulcer on the bony prominence, with yellow slough (the medical record lacked information about a wound to the left 2nd toe before 10/31/17). The consultant documented a left 2nd toe, Stage 3 PU, measuring 0.5 x 0.5 x 0.2 cm, and a left 4th toe Stage 3 PU, measuring 0.6 x 1 x 0.1 cm. The documentation recorded both wounds had moderate serous (clear) drainage, [DIAGNOSES REDACTED] (redness) in the surrounding tissue, and no pain. The note documented the consultant applied [MEDICATION NAME] Ag (specialized foam dressing with silver to kill wound bacteria), covered with Polymem (dressings designed to facilitate healing, relieve pain, and reduce inflammation) cloth strip to be changed every 72 hours and (prn) as needed, to both wounds. The resident was not to wear shoes, and follow up with the wound nurse weekly until healed. The 11/3/17 PU risk assessment documented a score of 18, the resident was chairfast, made very limited position changes, and had a potential problem with friction/shearing. (moderate risk- 13-14, high risk - 10-12, very high risk - 9 or below) The 11/6/17 skin assessment of the left foot documented a callus on the 2nd and 4th toes, and lacked further assessment of the toes. The 11/8/17 care guide directed the nurse to see the TAR for treatments for the 2nd and 4th toes of the left foot. The 11/10/17 consultant wound nurse assessment documented the left 2nd toe had healed. The 4th left toe tip, measured 0.2 x 0.4 x 0.2 cm, Stage 3, with slough, a small amount serosanguineous (semi-thick reddish fluid) drainage, and the surrounding skin was pale. The note documented the wound was improving, and the consultant reinforced education to the patient and staff, that he/she was not to wear his/her left shoe. The 11/13/17 skin assessment documented the resident had 2nd and 4th left toe calluses, and lacked further assessment of the toes. The 11/19/17 at 10:38 am, nurse's note recorded the resident's wound to the fourth toe, left foot, was tan with white edges, no drainage present, and no complaint of discomfort to the affected area during the dressing change. The 11/20/17 skin assessment of the resident's 2nd and 4th left toes documented an open callus, and lacked further assessment of the toes. The 11/27/17 skin assessment documented the 2nd and 4th left toes had scabbed calluses. The 11/29/17 wound document recorded the 4th left toe had a 0.4 x 0.4 x 0.1 cm, open callus area. The 2nd left toe had a 0.4 x 0.4 x 0 callus area. The 12/2/17 at 11:11 AM, nurse's note recorded the resident had small, tan, scab-like areas to the tips of his/her 2nd and 4th toes on the left foot that were open to air. The note recorded staff left a message for the consultant wound nurse to re-evaluate the need for or change of the dressing order. The 12/4/17 skin assessment documented a dressing change to the 2nd and 4th left toes and lacked further assessment. The 12/6/17 consultant wound nurse assessment included: 4th left toe tip PU, measured 1 x 1 x 0.2 cm, 100% eschar (dead tissue), unchanged. 2nd left toe tip PU, open to air, mechanical debridement, pain with debridement, and dressing change. The Stage 3 pressure ulcer measured 0.3 x 0.4 x 0.5 cm, with undermining (caused by erosion under the wound edges, resulting in a large wound with a small opening) 0.2 cm at 12 o'clock. 50% slough/50% eschar, unchanged status. Consultant comments: eschar left in place with no debridement as edges are intact with no [DIAGNOSES REDACTED] or drainage. Patient to always leave shoe off, and may wear a gripper sock. Facility staff notified to continue to monitor and report any changes. Unable to assess depth due to eschar. Notified the physician for (PT) Physical Therapy referral for debridement of the left 2nd toe. Dressing will be decided after debridement. Reinforced to patient and staff that the resident's left shoe needed to always remain off. Follow up weekly with the wound nurse as needed and PT as needed, for future debridement, and will set up appointment with PT for sharp debridement. The 12/7/17 physician's orders [REDACTED]. The 12/11/17 x-ray of the resident's left foot, for a [DIAGNOSES REDACTED]. The 12/11/17 skin assessment documented staff performed a dressing change to the 2nd and 4th left toes, but lacked further assessment of the toes. The 12/14/17 physician progress notes [REDACTED]. The 12/17/17 at 8:54 AM, nurse's note recorded the left 2nd toe wound bed was pink, without drainage, and the resident denied pain or discomfort with treatment. The note lacked further information of the toes. The 12/18/17 skin assessment documented staff changed the dressing to the 2nd & 4th left toes, but lacked further assessment of the toes. The 12/27/17 skin assessment documented a new dark spot to the side of the right great toe, but lacked further assessment of the right great toe or left toes. The 12/30/17 at 9:19 AM, nurse's note recorded the wound to the tip of the left second toe had an open area, approximately 0.6 cm x 0.6 cm x 0.4 cm deep, tan colored, without drainage or pain. The note documented the wound to the tip of the fourth left toe, tan, and not open. The note lacked documentation of assessment of the dark spot on the right great toe. The 1/3/18 skin assessment documented staff performed dressing changes to the 2nd and 4th left toes, but lacked further assessment of the toes, including the right great toe. The 1/8/18 skin assessment documented staff performed dressing changes to the 2nd and 4th left toes, but lacked assessment of the toes, including the right great toe. The 1/15/18 skin assessment documented staff performed dressing changes to the 2nd and 4th left toes, but lacked assessment of the toes, including the right great toe. The 1/22/18 physician's orders [REDACTED]. The medical record lacked assessment of the resident's right great toe between 12/27/17 and the 1/22/18 physician's orders [REDACTED]. The 1/22/18 physician progress notes [REDACTED]. The note recorded the resident's left great toe was reddened, swollen, slightly scabbed over the ulcer on the tip of it. The note lacked information on the status of the resident's right great toe and 4th left toe. The 1/24/18 skin assessment documented staff completed treatment to the tips of the left 2nd and 4th toes, the resident complained of discomfort to the callus on his/her medial (side nearest to the body) of the great left toe, and staff ordered a wound consult. The 1/26/18 consultant wound nurse assessment documented the unstageable PU on the right medial great toe measured 0.9 cm x 1.2 x 0 cm, 100% eschar, no drainage, the surrounding skin dry with [MEDICAL CONDITION], and the wound status was deteriorating. The assessment documented the resident had recurring PU on his/her toes, likely from his/her shoes, and this was discussed numerous times with the resident. The 1/31/18 skin assessment documented a right great toe callus, staff applied dressings to the 2nd and 4th left toes, but lacked further information on the resident's skin status, including the resident's left great toe. The 2/7/18 skin assessment lacked documentation regarding ulcers on the resident's toes. The 2/12/18 skin assessment documented staff performed dressing changes to the 2nd and 4th left toes, but lacked skin assessment of the toes, including the left and right great toes. The 2/12/18 consultant wound nurse assessment documented the following: 4th left toe tip Stage 3 PU measured 0.6 x 0.8 x 0.4 cm, 100% necrotic (death of cells) slough, with undermining the entire circumference of wound, 0.3 cm. A small amount of [MEDICAL CONDITION] (a mixture of serum and pus, a potential sign of infection) drainage, wound status deteriorating, and the resident reported pain with the dressing change. 2nd right toe, medial, Stage 2 PU measured 0.9 x 0.4 x 0.1 cm, 100% granulated tissue, deteriorating status, and pain with dressing changes. Left Great toe, medial side, Stage 3 PU measured 0.5 x 0.6 x 0.1 cm, 100% slough, with a small amount of serous drainage. Right great toe, medial side, Stage 3 PU measured 0.6 x 0.4 x 0.1 cm, 100% slough, with a small amount of serous drainage. The 2/12/18 physician's orders [REDACTED]. Apply a Duoderm (dressing that forms a gel that creates an optimal moist wound healing environment) to the left medial and right great toes, change every 72 hours. Apply Polymem foam dressing daily and prn to the tip of left 4th toe. Leave the medial right 2nd toe wound, found 2/12/18, open to air. The 2/19/18 skin assessment documented staff performed dressing changes to the left 2nd and left 4th toes, but lacked further skin assessment of the left 2nd and 4th toes, the right and left great toes, and the right 2nd toe. The 2/19/18 physician's orders [REDACTED]. The 2/19/18 physical therapy initial wound assessment for non-healing wounds to the left 2nd and 4th toes, documented the resident had sores to his/her toes for at least 6 months, according to wound care nurse. The assessment documented calluses noted to tips of 2nd and 4th toes. The left 2nd toe, with palpation (examine by touch), had a small amount of serous drainage to the central area of the callus. The 4th toe wound bed was dry, callused. The note documented staff removed the callus from the tips of the left 2nd and 4th toes. The left 2nd toe had an open sore tunnel to the bone with palpation with tweezers, and no bleeding. The left 4th toe, after callus removed, had a reddened wound bed, a small amount of bleeding noted, and the central portion open to palpation of bone at the tip of the toe. Measurements included: left 2nd toe= 0.3 x 0.2 x 0.3 cm, no bleeding. left 4th toe= 0.5 x 0.4 x 0.2 cm, small amount of bleeding. The physical therapy notes documented they debrided callus tissue from the tip of left 2nd and 4th toes, noted a pin hole to the bone on both. The note documented PT reported the finding to the wound nurse, discussed findings with the physician's assistant, and recommended a specialist consult. The physical therapy documentation lacked notation the PU were now Stage 4 (exposed bone/muscle is visible or directly palpable). The 2/21/18 skin assessment documented staff changed the dressings to the left 2nd and 4th toes, noted improvement to both toes, and lacked further skin assessment of the left 2nd and 4th toes, the right and left great toes, and the right 2nd toe. The 2/26/18 PT wound documentation recorded PT debrided the left great toe, and the 2nd and 4th left toes. The great toe wound measured 0.4 x 0.2 cm, no depth. The 2nd toe wound measured 0.4 x 0.2 x 0.2 cm depth. The 4th toe wound measured 0.3 x 0.2 x 0.2 cm deep. The documentation lacked assessment of the resident's right great toe and right 2nd toe. The 2/26/18 skin assessment documented staff performed dressing changes to the left 2nd and 4th toes, and lacked further skin assessment of the left 2nd and 4th toes, the right and left great toes, and the right 2nd toe. The 2/28/18 skin assessment documented the left great toe had a callus, staff changed dressings on the medial right great toe and 2nd right toe, and 2nd and 4th left toes. The assessment lacked further documentation of the left 2nd and 4th toes, the right and left great toes, and the right 2nd toe. The 3/7/18 skin assessment documented no improvement noted to the medial right toe, callus medial 2nd right toe, but the 2nd and 4th right toe tips were improved, and lacked further skin assessment of the left 2nd and 4th toes, the right and left great toes, and the right 2nd toe. The 3/12/18 physician progress notes [REDACTED]. The 3/14/18 skin assessment lacked assessment of any of the resident's toes or wounds. The 3/14/18 orthopedic clinic orders informed staff a wound care consult was scheduled on 3/19/18, at 9:00 AM. The orders directed staff to allow the resident to wear soft shoes only, which do not put pressure on the ulcers, and watch for signs of infection. The 3/19/18 wound clinic orders directed staff to always offload the resident's feet, provide wound care with [MEDICATION NAME] (moist wound dressing) every other day, cover with foam on the right great toe, foam only to the left great toe, and discontinue all previous wound care orders. The 3/21/18 skin assessment lacked assessment of any of the resident's toes or wounds. The 4/11/18 consultant wound nurse documentation for the Stage 3 PU on the 4th left toe measured 0.2 x 0.4 x 0.2 cm, had necrotic tissue, slough 100%, with a small amount of serosanguineous drainage. The note recorded the wound was improving. The note recorded the left 2nd toe wound was healed. On 4/10/18 at 10:30 AM, observation revealed Nurse G performed a dressing change on the resident's left great toe. The great toe had a clean, dry, foam dressing, which the nurse removed. Further observation revealed Nurse G assessed the great toe wound on the medial side of the left great toe, approximately 0.5 cm, diameter with dry slough or callus. The nurse dated and applied a foam dressing. Observation revealed the first 3 left toes had approximately 0.2 diameter, dry, cream colored slough areas on the tips of the toes, and were open to air (not documented on the skin assessments). On 4/12/18 at 9:50 AM, observation revealed Nurse G changed dressings and assessed the wounds on the resident's right and left toes. The right medial great toe measured 0.7 diameter, with dry yellow slough in the center. The right foot had no other wounds. The left medial great toe was red colored with a small 0.3 diameter wound on the medial side and a discolored darker area on the bottom center of the toe. Nurse G cleansed the medial wound and applied foam dressing and [MEDICATION NAME] tape to the medial wound, and the tape covered the bottom wound. Observation revealed the first 3 left toes had approximately 0.2 diameter, dry, cream colored slough on the tips of the toes. The toes were left open to air. On 4/11/18 at 8:35 AM, Dietary Consultant II reported the facility staff had notified him/her when the resident developed a PU. He/she stated the resident had interventions in place, including supplements, and protein powder with meals. Dietary Consultant II verified the resident had steady weights and was independent with eating. On 4/11/18 at 9:45 AM, Nurse H stated the resident's wounds were healing, after going to the wound clinic and dressing orders were changed. Nurse H stated staff were to ensure the resident wore house slippers or soft shoes. Nurse H reported the resident's ulcers started after the family purchased new slip on shoes for the resident. On 4/11/18 at 1:30 PM, Consultant Wound Nurse GG stated he/she saw the resident's wounds a few times and recommended PT for debridement, and PT recommended the wound clinic after the sharp debridement had not helped. On 4/11/18 at 2:30 PM, Nurse I verified staff had not re-assessed the resident's toes until after the physician documented an ulcer. On 4/11/18 at 2:55 PM, Administrative Nurse D verified he/she expected staff to re-assess the resident's skin after noting reddened pressure areas on his/her toes, and to perform weekly skin assessments documenting what the areas of concern looked like. Administrative Nurse D verified he/she expected staff to update the care plan with new interventions after staff found the pressure areas on the resident's toes on 10/7/17, and he/she verified staff had not. Administrative Nurse D verified nursing was to notify the hospital wound nurse to assess the wound weekly when a resident developed a pressure ulcer. On 4/12/18 at 2:30 PM, Physician HH verified he/she expected the facility's nursing staff to assess the wounds and document the progress of the pressure ulcers weekly. Physician HH verified the resident's facility acquired PUs were potentially avoidable. The facility's Wound/Skin Assessment policy directed staff to perform a pressure sore risk assessment weekly x 4 weeks on admission, re-admission, quarterly, annual and with significant change. Weekly skin assessments were completed with documentation. Nurse aides were to notify the nurse of any observation of skin tears, bruising, or reddened areas. If skin treatment was required, a standing order was placed in the computer and on the TAR. If a wound was determined to be from pressure and required wound care, the wound care nurse and dietician were notified. The wound care nurse would measure and document the wounds weekly. Nursing staff would obtain and implement additional orders as needed. The facility failed to provide care and services to prevent the development of pressure ulcers for Resident #14, who developed 5 facility acquired, avoidable pressure ulcers, which worsened to Stage 3, and required wound management from an outside specialty clinic, which included debridement.

The facility had a census of 36 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 1 of 3 sampled residents with the necessary care and services (timely assessments of an open wound/burn) to attain or maintain the residents' highest practicable physical well-being. The resident's wound deteriorated within the 5 day time period staff failed to assess the wound. (Resident #1) Findings included: - Resident #1's clinical record included a 12/6/13 Quarterly MDS (Minimum Data Set) that identified the resident with severe cognitive impairment, the need for assistance of one staff member for transfers/bed mobility and ambulation, no current or recently associated pressure ulcers, and "moisture associated skin damage." CAAs (Care Area Assessment summaries) completed after the 3/8/13 Annual MDS did not trigger for further investigation of skin related issues/pressure ulcers. The 12/6/13 Care Plan described resident #1's, "failing memory" and increasing confusion. According to the care plan, the resident had the ability to roll side to side in bed without staff assistance, and required assistance of one staff for moving from a lying down position to a sitting position in bed. The care plan also noted use of a "personal heated rice pack" and directed staff to warm the rice bag up for the resident in the evenings. Additionally, the care plan warned staff to avoid use of warm moist packs due to a history [MEDICAL CONDITION] use of them. Nurses Notes included the following related to an injury/burn to resident #1's buttock: o 2/4/14 at 7:00 a.m. described the presence of a blister of unknown origin on the resident's right buttock. According to the entry, the CNA (certified nurse aide) found a rice bag in the room. o 2/5/14 at 7:10 a.m. described staff assistance with a whirlpool bath and assessment of resident #1's skin. According to the entry, "blister on right buttock has opened," and measured 2 cm. (centimeters) in diameter. Staff applied triple antibiotic ointment and a large Band-Aid to the open wound. The clinical record included no additional assessments of resident #1's right buttock wound until 2/10/14, five days later. Additional Nurses Notes at that time included: o 2/10/14 entry described measurement of the right buttock wound which staff described a 2.4 cm in diameter with a moist, pink/yellow center. According to the entry, staff notified resident #1's physician of the wound on this date, "due to slow healing," and received an order from the physician for a wound care consult. A faxed communication to the physician on 2/10/14 noted the presence of a blister on the right buttock which was open and measured 2.4 cm by 0.6 cm depth, an increase in the size of the wound from the 2/4/14 measurement in which staff described the wound as "2 cm. in diameter second degree burn." Notes from a 2/13/14 physician's visit included, "2nd degree burn to right buttocks 2.5 cm by 2.5 cm, likely from heating pad/rice pack." During an observation on 3/5/14 at 2:20 p.m., resident #1 had a small dressing over an area on the upper right buttock. When Licensed Nurse B removed the dressing, there was a scant amount of whitish colored drainage on the dressing. The wound had one pencil lead sized open area with an approximate quarter sized brighter pink, healed area surrounding it. During an interview on 3/5/14 at 4:35 p.m., Administrative Nurse A confirmed resident #1 received a second degree burn to the right upper buttock after a certified nurse aide placed a hot rice pack directly on the resident's skin. According to Nurse A, the burn presented as a blister initially and then the blister opened and it became an open wound. Facility nurses treated the wound according to facility protocol until the wound worsened and they notified the physician. In an e-mail sent on 3/14/14, Administrative Nurse A also confirmed licensed nurses failed to document assessments of the open wound in the 5 day time period between 2/5/14 and 2/10/14, the time period during which the wound deteriorated (increased in size). Attempts to contact resident #1's primary care physician were unsuccessful on 3/13/14 and 3/14/14. The facility failed to provide resident #1 with the necessary care and services (timely assessments of an open wound/burn) to attain or maintain the residents' highest practicable physical well-being. The resident's wound deteriorated within the 5 day time period staff failed to assess the wound.

The facility had a census of 36 residents, with 3 residents selected for sample. Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents received adequate supervision to prevent a second degree burn from the use of a hot rice pack. (Resident #1) Findings included: - Resident #1's clinical record included a 12/6/13 Quarterly MDS (Minimum Data Set) that identified the resident with severe cognitive impairment, the need for assistance of one staff member for transfers/bed mobility and ambulation, no current or recently associated pressure ulcers, and "moisture associated skin damage." CAAs (Care Area Assessment summaries) completed after the 3/8/13 Annual MDS did not trigger for further investigation of skin related issues/pressure ulcers. The 12/6/13 Care Plan described resident #1's, "failing memory" and increasing confusion. According to the care plan, the resident had the ability to roll side to side in bed without staff assistance, and required assistance of one staff for moving from a lying down position to a sitting position in bed. The care plan also noted use of a "personal heated rice pack" and directed staff to warm the rice bag up for the resident in the evenings. Additionally, the care plan warned staff to avoid use of warm moist packs due to a history of burns from use of them. physician's orders [REDACTED]." Nurses Notes included the following related to an injury/burn to resident #1's buttock: o 2/4/14 at 7:00 a.m. described the presence of a blister of unknown origin on the resident's right buttock. According to the entry, the CNA (certified nurse aide) found a rice bag in the room. o 2/5/14 at 7:10 a.m. described staff assistance with a whirlpool bath and assessment of resident #1's skin. According to the entry, "blister on right buttock has opened," and measured 2 cm. (centimeters) in diameter. Staff applied triple antibiotic ointment and a large Band-Aid to the open wound. The clinical record included no additional assessments of resident #1's right buttock wound until 2/10/14, five days later. Additional Nurses Notes at that time included: o 2/10/14 entry described measurement of the right buttock wound which staff described a 2.4 cm in diameter with a moist, pink/yellow center. According to the entry, staff notified resident #1's physician of the wound on this date, "due to slow healing," and received an order from the physician for a wound care consult. A faxed communication to the physician on 2/10/14 noted the presence of a blister on the right buttock which was open and measured 2.4 cm by 0.6 cm depth, an increase in the size of the wound from the 2/4/14 measurement in which staff described the wound as "2 cm. in diameter second degree burn." According to the fax, staff previously treated the right buttock wound with triple antibiotic ointment and covered it with a Band-Aid but, on that date, cleansed the wound with normal saline, applied antibiotic ointment and covered it with a special type of dressing. Notes from a 2/13/14 physician's visit included, "2nd degree burn to right buttocks 2.5 cm by 2.5 cm, likely from heating pad/rice pack." The physician directed staff to make sure the resident went to his/her next wound care appointment and to avoid use of heat packs/pads of any kind. On 3/5/14, resident #1's physician wrote a note that described his/her awareness of resident #1's personal use of a dry rice heat pack as needed for low back pain prior to the 2/13/14. According to the note, since the resident received the burn staff should not use hot packs of any kind in the future. In a written statement dated 2/12/14, Direct Care Staff C confirmed he/she heated a rice bag in the microwave for "exactly one minute" and then placed the heated bag directly onto resident #1's unclothed lower back. According to the statement, the resident moved the bag to where it felt most comfortable and the aide then left the room. During an observation on 3/5/14 at 2:20 p.m., resident #1 had a small dressing over an area on the upper right buttock. When Licensed Nurse B removed the dressing, there was a scant amount of whitish colored drainage on the dressing. The wound had only a pencil lead sized open area with an approximate quarter sized brighter pink, healed area surrounding it. During an interview on 3/5/14 at 4:35 p.m., Administrative Nurse A confirmed resident #1 received a second degree burn to the right upper buttock after a certified nurse aide placed a hot rice pack directly on the resident's skin. Nurse A reported a belief that nurse aide overheated the bag in the microwave prior to placing it on the resident's skin and then failed to remove the rice bag after a period of time. According to Nurse A, the facility lacked a policy related to use of rice packs prior to the 2/4/14 incident that directed staff on the length of time to heat the bag in the microwave, the amount of covering needed between the rice bag and the resident's skin, and the length of time to leave it in place. Nurse A reported the facility developed a policy for rice bag usage after the incident. According to the new policy, only licensed nurses could heat and apply rice bags to facility residents, and only after they wrapped them in at least 2 layers of towels and left them in place for no more than 1 hour with skin checks completed every 20 minutes during that hour. Attempts to reach resident #1's primary care physician were unsuccessful on 3/13/14 and 3/14/14. The facility failed to provide resident #1 with adequate supervision to prevent a second degree burn when staff placed a heated rice bag directly on the resident's skin without covering the bag and then failed to remove the bag and/or check the skin periodically while the bag was in place.

The facility had a census of 32 residents. Observations on initial tour revealed side rails attached to bed frames on 29 of 32 resident beds. According to staff, 20 of the 29 residents with side rails on their beds utilized at least one rail when they lay in bed. Based on observation, interview and record review, the facility failed to provide one sampled resident with adequate supervision and assistive devices to prevent accidents as related to side rails. Upon admission to the facility in July 2010, staff utilized a bed for Resident #1 that had 4 partial side rails attached to the bed frame. Without assessing for safety, staff developed a care plan that directed staff to raise 3 of the 4 side rails when resident #1 lay in bed. After using the side rails without assessing for safety for a two month time period, resident #1 became entrapped in the rails and sustained significant bruising to the abdomen and chest area. Facility failure to have a system in place to ensure completion of assessments for safety prior to utilizing side rails placed resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included a face sheet which noted admission to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. On 7/8/10, 7/12/10 and 7/21/10, staff completed, "Side Rail Review" documents for resident #1. These documents noted the number of rails used as well as the resident's preference for side rails. Although the document noted use of side rails, it did not include assessments of the resident's physical/cognitive abilities and the subsequent potential hazards of using side rails on the bed. A 7/21/10 Fall Risk Assessment identified resident #1 as, "high risk" for falls. The 7/28/10 Admission MDS (Minimum Data Set) identified resident #1 with long and short term memory problems, moderately impaired decision making abilities, the need for extensive staff assistance with bed mobility and transfers, an inability to ambulate, falls within the past 30 days as well as the past 31-180 days, and daily use of full bed rails on all open sides of the bed. The 7/21/10 care plan noted resident #1's cognitive impairment, and indicated the resident had the ability to reposition him/herself independently in bed. The care plan also indicated resident #1's bed had, "four 1/2 rails", and directed staff to raise three of four rails to assist with repositioning. Nurses Notes contained multiple entries related to resident #1's ability to move in bed, including: o 8/29/10 at 11:30 p.m.: "....pulls on bumper guards against side rails and pulls out and tosses to head of bed. Bumper guard replaced and resident again pulls out and continues to turn side to side in bed...." o 8/30/10 at 12:20 a.m.: "....resident is singing and continues to be restless, rolling from side to side every few minutes..." Then, on 9/6/10, staff found resident #1 entrapped in the side rails of his/her bed. According to a, "Falls Documentation Report" completed on 9/6/10 at 9:57 p.m., staff heard resident #1 calling for help. Upon entering the room., staff found resident #1, "...on knees with torso stuck between upper and lower partial bedrails." In order to remove the resident from the bedrails, multiple staff physically supported the resident's body while another staff member lowered one of the rails. According to this document, the resident sustained [REDACTED]. During an interview on 9/13/10 at 2:00 p.m., Administrative Nurse A reported the facility does not have a side rail policy other than the restraint policy which notes use of side rails might constitute a restraint. Nurse A confirmed the facility does not have a sytem in place to assess for potential hazards prior to utilizing side rails for any of the facility's 20 residents who currently utilize side rails. According to Nurse A, resident #1 used a bed with 4 partial rails because that was the bed that was in his/her room upon admission to the facility. Nurse A reported staff did not complete assessments related to side rails, including if the side rails posed a potential hazard to the resident due to the resident's specific physical and cognitive deficits. Nurse A also reported the facility did not attempt other methods to keep resident #1 safe prior to utilizing side rails. Nurse A reported the care plan directed staff to raise three rails, but she meant for staff to raise two rails on the, "wall side" of the bed and the rail at the head of the bed on the other side, for a total of three raised rails. Instead, staff raised one rail on the, "wall side" of the bed and both rails on the open side of the bed on 9/6/10, the night resident #1 became entrapped in the rails. According to Nurse A, staff changed the type of side rails used after the 9/6/10 entrapment, and resident #1's bed now had 2 full side rails attached to the frame, with only one rail raised when the resident lay in bed. During an interview on 9/13/10 at 2:30 p.m., Administrative Nurse B reported the facility had issues with excessive side rail usage in the past, and at that time implemented measures to ensure staff could not raise the rails on the beds. Nurse B confirmed most current facility residents utilize at least one side rail. Observations on 9/13/10 from 10:30 a.m. to 3:30 p.m. revealed resident #1's bed had two full side rails attached to the frame, with only one full rail on the, "wall side" of the bed raised when the resident lay in bed. During observations from 1:20 p.m. - 3:00 p.m., resident #1 moved about in the bed in a non-purposeful manner, repositioning him/herself as a result of frequent moving of the arms and legs. In summary, the facility failed to provide resident #1 with adequate supervision and assistive devices related to side rails to prevent accidents. The facility failed to have a system in place to ensure assessment of physical and cognitive abilities and potential hazards prior to utilizing side rails for resident #1, thereby placing resident #1 in immediate jeopardy. Resident #1 became entrapped in the side rails and sustained significant bruising to the chest and torso. The facility abated the immediate jeopardy on 9/15/10 at 8:00 a.m. when they implemented the following measures: o Assessed every facility resident for potential hazards related to side rail use, and removed and/or disabled side rails on 16 of 20 beds as a result of those safety assessments. o Designated specific staff members to monitor for compliance to ensure residents remained free of potential hazards related to side rail usage. After removal of the immediate jeopardy, facility failure to provide residents with adequate supervision and assistive devices to prevent accidents remained a deficient practice at a scope/severity of "D."