Every finding on record at Trinity Homes

Based on record review, review of the facility reported incident (FRI) and investigation, review of competency/verification/training documents, and staff interview, the facility failed to provide supervision and assistance devices to prevent an accident for 1 of 1 sampled resident (Resident #1) injured during a facility van transport. Failure to secure the shoulder strap on the resident during transport resulted in Resident #1 sustaining a leg fracture. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident. Findings include:The surveyor determined a deficient practice existed 11/17/25. The facility implemented corrective action on 11/18/25. Review of the initial FRI report, dated 11/17/25 at 2:00 p.m. stated, Resident was being transported back to facility. Resident fell out of wheelchair when stopping at a stoplight. Resident was sent to ER [emergency room] due to pain in lower extremity.During an interview on 11/19/25 at 9:45 a.m., an administrative staff member (#2) stated Resident #1 was admitted to the hospital on [DATE] and had surgery on 11/18/25 to repair a fractured femur (upper thigh bone).Review of Resident #1's medical record occurred on 11/19/25. A progress note, dated 11/17/25 at 2:00 p.m. stated, Resident was in the van on the way from an appointment. He had been leaning forward in the wheelchair. At a stoplight, he fell out of his wheelchair. Resident stated a vehicle in front of them slammed on the brakes so the transporter had to slam on the brakes. The resident then fell out of his wheelchair. A resident assist was called upon return to facility. Resident has an abrasion to his right knee with some light bruising and swelling. He also complains of shooting pain from his knee to his hip. NP [nurse practitioner] notified with order to send to ER for evaluation and treat.Review of the facility's investigation of the incident identified the driver of the van (Transporter #7) didn't realize he/she had not placed the shoulder strap seatbelt on the resident in the van until he heard the resident fall. The report stated when the transporter was securing the wheelchair to the floor of the van, both the transporter and the resident were visiting and forgot to secure the seatbelt that crosses over the resident. During the facility's interview with Resident #1, the resident confirmed that he and the transporter were talking and he was distracted by their conversation. During an interview on the morning of 11/19/25, an administrative nursing staff member (#3) stated there are three employees who transport residents in the van, and provided documentation that all three employees had completed a Competency Verification/Training Checklist - Van Driver prior to becoming transporters. During an interview on the afternoon of 11/19/25, an administrative staff member (#2) stated as part of the investigation he/she interviewed other alert residents who had been transported in the van during the month of November 2025. The staff member confirmed all the residents interviewed stated they have been secured by the crossover belt by the drivers (including Transporter #7) when transported in the van and they felt safe. One of the residents interviewed rode in the van the morning of 11/17/25 and stated the driver (Transporter #7) secured the shoulder strap seatbelt.The facility failed to ensure the shoulder strap seatbelt was secured on Resident #1 while being transported in the van and resulted in a fracture. Based on the following information, non-compliance is considered past non-compliance. The facility implemented corrective actions for other residents who may be affected by the deficient practice as follows:* Immediately suspended the van driver until investigation completed.* Immediately suspended all resident van transportation until education provided to staff.* Completed investigation of Resident #1's incident and injury.* Implemented a Wheelchair Van Checklist to be used every pre-departure.* Provided education to the van drivers on 11/18/25 and will continue education for transporter/van driver (#7) prior to return to work. * Implemented quality assurance audits on each van driver to ensure safety checklist is used to secure resident in the van or bus.

1. Based on observation, record review, and resident and staff interviews, the facility failed to properly utilize assistive devices necessary to prevent accidents for 1 of 5 residents (Resident #29) observed for transfers. Failure to utilize a gait belt during transfers placed the resident at risk of injury. Findings include: Review of Resident #29's medical record occurred on all days of survey. The current care plan stated, . Transfers: Pivot transfer to and from bed with gaitbelt and assist of 1 [staff]. Non-weight bearing to right leg. -Observation on 08/11/25 at 2:57 p.m. showed Resident #29 seated on a motorized scooter. When asked how staff assisted with transfers between the scooter and other surfaces, Resident #29 stated, They grab the back of my pants and swing me over. Observation on 08/12/25 at 11:35 a.m. showed Resident #29 rested in bed. Two certified nurse aides (CNAs) (#8 and #9) entered the resident's room and assisted the resident to sit on the edge of the bed. The CNA (#8) grabbed the resident by the back of the pants and lifted/slid the resident to the electric scooter. The CNA (#8) failed to apply and use a gait belt to transfer Resident #29. During an interview on the afternoon of 08/13/25, an administrative nurse (#1) confirmed he expected staff to utilize a gait belt when transferring Resident #29. 2. Based on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remain free from accident hazards for 1 of 1 sampled resident (Resident #10) reviewed for smoking. Failure to provide an environment free from accident hazards by limiting access to cigarette lighters placed all residents, staff, and visitors at risk for injury from fire. Findings include: Review of the facility policy titled Smoke Free Facility occurred on 08/14/25. This policy, dated October 2022, stated, . It is policy of this facility to provide a safe and healthy environment for residents. If a resident does not abide by the smoking policy, care plan revisions shall be documented and implemented to promote safety. Smoking material found in plain view in the resident room will be removed immediately . Review of the facility's admission packet occurred on all days of survey and stated, . SMOKE FREE FACILITY-RESIDENT POLICY . Residents will not be allowed to keep lighters or cigarettes in their rooms or on [NAME] Property. Smoking materials found in resident rooms will be removed immediately and no smoking policy will be reviewed. Review of Resident #10's medical record occurred on all days of survey. The care plan stated, . [resident's name] smokes tobacco when not on [NAME] property. [Resident's name] has signed a contract with [NAME] Homes, agreeing to this arrangement due to [NAME] Homes being a non-smoking facility. [Resident's name] will abide by the contract that she has signed . Inform nurse or Social Services of any problems or concerns. The contract, dated 04/21/21 and signed by the resident, stated, . [Resident's name] is aware the [NAME] Homes is a non-smoking facility and has agreed she will not smoke on any part of [NAME]'s property. [Resident's name] has agreed to carry her cell phone and contact staff or 911 for help if/when needed. The intention of this agreement is to keep [Resident #10's name] safe, as well as the residents, staff, and visitors . Observation on 08/12/25 at 11:37 a.m. showed Resident #10 seated in a power wheelchair in her room preparing to go outside and smoke. The resident placed a see-through netted pouch around her neck containing a visible pack of cigarettes. Prior to leaving her room, the resident asked a certified nurse aide (CNA) (#18) to hand her a personal cell phone and placed the phone into the pouch. The surveyor and Resident #10 exited the building and the resident drove to the end of the sidewalk in front of the building (more than 20 feet away). The resident removed the cigarettes and a lighter from the pouch and lit a cigarette. When finished, the resident placed the cigarettes, lighter, and cell phone back into the pouch, entered the building, kept the smoking materials with her, and drove her wheelchair back to her room. During an interview on 08/13/25 at 2:33 p.m., a nurse manager (#1) stated residents are not allowed to have cigarettes and lighters in their rooms but they don't always give them back. The facility failed to remove visible smoking materials from Resident #10 per facility policy and failed to implement methods and expectations for residents safe and secure storage of lighters/smoking materials. 3. Based on medical record review, review of facility policy, and staff interview, the facility failed to provide appropriate supervision to prevent an elopement for 1 of 1 sampled resident (Resident #1) who left the facility without notifying staff. Failure to monitor residents with decreased safety awareness resulted in Resident #1 exiting the facility and may have placed the resident in dangerous situations. Findings include: Review of the facility policy titled Code Purple – Missing Resident occurred on occurred on 08/14/25. This policy, revised July 2024, stated, . If a resident is not located in their room or in the dining room on a unit, the floor nurse on that unit must do the following: Search immediate area of the nursing unit . Additional searching of area surrounding [the facility] . Review of Resident #1's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified as cognitively intact. The current care plan stated, . [Resident #1] was recently admitted to [the] hospital due to a fall in the home that resulted in multiple subacute pelvic fractures . impaired gait, impaired anticipatory and reactionary balance, and decreased safety awareness . Resident unsafe to return home at this time . A progress note, dated 08/02/25 at 4:23 p.m., stated, This writer was alerted by another resident that [Resident #1] had left the nursing home to go to [the] [name] convenience store [located two blocks from the facility]. This writer went to look for [the] resident and found her sitting in her wheelchair by the kerbside [sic] and she stated she was tired. [The] Resident was having a difficult time navigating the uneven terrain, and she also stated that the nursing home looked like a school to her. [The] Resident stated that she had gone to [convenience store name] to purchase a candy bar but was unable to get back due to 'being tired.' This writer pushed [the] resident back to her room. [The] Resident's family . was updated. Weekend Manager, Social services and DON [Director of Nursing] were also updated. During an interview on 08/13/25 at 5:20 p.m., two administrative nurses (#1 and #13) confirmed staff failed to complete an incident report following Resident #1's elopement. 4. Based on review of the facility reported incident (FRI) report, record review, review of facility policy, and staff interview, the facility failed to provide appropriate supervision/assistance to prevent accidents for 1 of 14 sampled residents (Resident #3) who fell from her wheelchair during transport. Failure to utilize foot pedals during transport resulted in Resident #3's sustaining an injury to her forehead. This is considered past non-compliance based on review of the corrective actions the facility implemented following the incident. Findings include: Review of the power point presentation handout related to falls occurred on 08/14/25. The handout stated, . Wheelchair Leg Rests: Make sure foot pedals are in place with the resident's feet up on them prior to pushing them in the wheelchair. DO NOT PUSH A RESIDENT IN A WHEELCHAIR WITHOUT LEGRESTS ON. Leg rests may be removed and placed in the bag on the back of the wheelchair if the resident is independent with propelling their own wheelchair . Review of Resident #3's medical record occurred on all days of survey. The current care plan stated, . [Resident #3] is not able to perform own ADL's [Activities of Daily Living] due to behaviors and decreased mobility . Mobility . 1 staff to push chair behind. Rock-n-go for mobility and comfort. Ensure foot pedals are in use while staff is pushing chair . [Resident #3] is at risk for falls and fall related injuries . Falls Prevention . Ensure that the foot pedals of the resident's rock n go are on when transporting the resident . Review of the FRI report, submitted to the state agency on 02/19/25, stated, . [Certified nurse aide's (CNA's) [name] was pushing [Resident #3] to her room in her wheelchair and [Resident #3] fell forward out of the chair. [Resident #3] is always very agitated, restless, and last evening had been leaning over in her chair messing with her leg wraps and also continuously trying to stand up. [CNA's name] was telling her she needed to lean back in her chair, and she fell out forward. She did receive a bump on her head, was sent to the ER [emergency room], and returned with no further injury. The progress notes identified the following:* 02/18/25 at 11:15 p.m., Resident was drowsy at start of shift. approx [approximately] 1600 [4:00 p.m.] she started to become fidgety and obsessed with bending over in wheelchair fussing with the velcro on her foot wraps. She became more agitated and restless and the concern for her safety was growing. She continued to fidget and attempt to get out of chair. Finding it impossible to keep her in the recliner, she was placed back in wheelchair with 1:1 observation. was being wheeled to the shower room to . toilet her. The CNA had just reminded resident to sit up and not lean forward. At that moment the resident fell face first onto [the] floor. (2100 [9:00 p.m.]) She remained as per her normal orientation. She had a small scratch on right cheek which was cleaned and did not bleed anymore. she had a large goose egg sized swelling to her right forehead. Resident was assessed and no other apparent injuries. we attempted to place an icepack on her forehead and assess VS [vital signs]. (2115 [9:15 p.m.]) Supervisor, provider and daughter were notified. Orders to transfer to ER [emergency room] for assessment were received and family agreed. Ambulance was called (2130 [9:30 p.m.]) and arrived at (2145 [9:45 p.m.]) for transport. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by:* Completing an investigation on 02/18/25, including an interview with the CNA who transported Resident #3,* Determining the CNA transported Resident #3 without placing foot pedals on her wheelchair, resulting in a fall from her wheelchair, injury, and placed all residents at risk for falls with/without injury.* Immediately re-educating the CNA following the incident and re-educating all staff on the importance of utilizing foot pedals during resident transport.* Completing quality assurance audits to ensure resident safety during transport.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 11 sampled residents (Resident #12, #29 and #59) and 1 supplemental resident (Resident #126) observed for cares and/or medication administration. Failure to practice infection control standards related to enhanced barrier precautions (EBP), glove use, hand hygiene, and disinfecting of shared equipment has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Copy of Enhanced Barrier precautions occurred on 08/14/25. This policy, dated September 2024, stated, . Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multi-Drug Resistant Organism] as well as those that have . open wound that requires a dressing. high-contact activities . dressing . transferring . Review of the facility policy titled Blood glucose/Hypoglycemia occurred on 08/14/25. This policy, dated, December 2022, stated, . Glucometers will be cleaned and disinfected after each use using a Super Sani Cloth Germicidal wipe . Review of the facility policy titled Medications-Administration Of Sub-Q [subcutaneous-under the skin] occurred on 08/14/25. This policy, dated November 2023, stated, ADMINISTRATION OF SUBCUATNEOUS MEDICATIONS . Perform hand hygiene and apply clean gloves. Select appropriate injection site . inject needle . withdraw needle . remove gloves and perform hand hygiene. ENHANCED BARRIER PRECAUTIONS Review of Resident #29's medical record occurred on all days of survey. A history and physical note, dated 04/10/25, stated, . positive wound culture. Showed MRSA [Methicillin-resistant Staphylococcus aureus - an MDRO] . MRSA infection of chronic ulcer . The current care plan stated, . has a chronic open area to her right lower leg . enhanced barrier precautions in place per guidelines . Observation on 08/12/25 at 11:35 a.m. showed Resident #29's room with an EBP sign and a personal protective equipment (PPE) storage unit on the door. A certified nurse aid (CNA) (#9) applied a gown and gloves, and a CNA (#8) applied gloves and entered the room. The CNA (#8) applied the resident's shoes and pants, both CNAs assisted Resident #29 to sit on the edge of the bed, and the CNA (#8) transferred the resident to the scooter. The CNAs (#8 and #9) removed their soiled PPE, performed hand hygiene and exited the room. The CNA (#8) failed to apply a gown prior to dressing and transferring Resident #29. During an interview on 08/13/25 at 3:15 p.m., an administrative nurse (#10) confirmed she expected staff to wear the appropriate PPE to provide care for residents in EBP. MEDICATION ADMINISTRATION/GLUCOMETER USE Observations on 08/14/25 showed the following: -7:56 a.m. and 8:12 a.m., A nurse (#12) administered insulin to Residents #59 and #126 without wearing gloves. The nurse (#12) confirmed he failed to wear gloves during the insulin administrations. -8:30 a.m., A nurse (#11) checked Resident #12's blood sugar level using a shared glucometer and then placed the glucometer into a docking station without sanitizing it. When asked if there were more blood sugar checks to complete, the nurse (#11) stated, one more. The surveyor requested the nurse disinfect the glucometer with a Sani-cloth.

Based on observation, review of facility policy, and staff interview, the facility failed to discard expired food and supplements in 2 of 6 food storage areas (Main kitchen and 4 North kitchenette) observed. Failure to discard expired food/supplements has the potential to affect the quality of the item served to residents related to safety and nutrition.Findings include: Review of the facility policy titled Dietary Policy/Procedure occurred on 08/14/25. This undated policy stated, . PURPOSE: To assure that foods served are wholesome and not out dated. All foods rotated by date and stored properly. Observations showed the following: -08/11/25 at 1:15 p.m., main kitchen: the large walk-in freezer contained a partially uncovered pan of corned beef dated March 2024. -08/13/25 (morning), 4 North kitchenette: an opened container of Prosource (dietary supplement) expired October 2024. -08/13/25 at 3:00 p.m., main kitchen: approximately 42 boxed containers of Ensure Clear (dietary supplement) with expiration dates from April 2025 through August 1, 2025. During an interview on 08/14/25 at 9:00 a.m., a dietary supervisor (#16) verified the facility lacked a consistent process to monitor for expired foods/supplements, and staff should discard the expired food/supplements.

Based on record review, review of facility policy, and resident, resident representative, and staff interviews, the facility failed to ensure the right to participate in the development and implementation of a person-centered plan of care for 2 of 31 sampled residents (Resident #6 and #118). Failure to ensure residents or their representative received notice of care planning conferences and/or interviewed the resident or their representative regarding care concerns/needs if they chose not to attend the conferences, limited their right to make decisions/provide input related to the resident's care, treatment, and services.Findings include: Review of the facility policy titled Care Planning occurred on 08/14/25. This policy, dated April 2025, stated, . It is the policy of [NAME] Nursing Care Facility that a written plan of care be developed and maintained for each resident in coordination with all services and individuals involved in the care of the resident. Family members, support persons with the permission of the resident, and/or resident will be invited to attend the care planning conference.-Review of Resident #6's medical record occurred on all days of survey and identified care planning conferences held on 03/05/25 and 05/25/25. During an interview on 08/12/25 at 8:55 a.m., Resident #6 expressed unawareness of the care planning conference and never attended the conferences. The record lacked evidence Resident #6 received notice of the care conferences held on 03/05/24 and 05/25/25 care conferences and/or staff interviewed the resident regarding care concerns or needs. During an interview on 08/13/25 at 11:45 a.m., an administrative staff member (#17) confirmed the medical record lacked evidence staff invited Resident #6 to the care planning conferences or interviewed the resident regarding care concerns and needs.-Review of Resident #118's medical record occurred on all days of survey and identified a care planning conference held on 06/25/25. During an interview on 08/12/25 at 1:55 p.m., Resident #118's personal representative stated she did not receive notification from the facility regarding the care planning conference. The record lacked evidence the resident's representative received notice of the care planning conference.

Based on observation, review of facility policy, and staff interview, the facility failed to ensure accurate medication labeling for 1 of 8 residents (Resident #12) observed during medication administration and failed to discard expired medications in 3 of 7 medication storage areas (3 North East cart and cupboard and 3 South refrigerator) reviewed. Failure to ensure medication labels reflect the current physician orders may result in inaccurate dosages and failure to discard expired medications may result in decreased effectiveness of the prescribed medication.Findings include: -Review of the facility policy titled Medication Administration and Crushing Medications occurred on 08/14/25. This policy, revised January 2021, stated, . administer medications as ordered by a provider. Read the medication label and compare with the HER [sic] [electronic health record (EHR)] ensuring the five rights . Right dose . Observation on 08/14/25 at 8:36 a.m. showed a nurse (#11) removed Resident #12's Novolog insulin pen from the medication cart. The label on the insulin pen and on a box with additional insulin pens identified 20 units before meals and at bedtime. The current physician's order identified 25 units before meals and before bedtime. When asked, a nurse manager (#3) and the nurse (#11) stated Resident #12 received a recent order change and both confirmed the label on the insulin pen and box failed to reflect the change. -Review of the facility policy titled Supplies - Outdated - [NAME] Homes occurred on 08/14/25. This policy, revised January 2023, stated, OUTDATED SUPPLIES 1. All supplies will be checked once a month. 2. Supplies that are outdated will be discarded. Observations of medication storage showed the following: -08/12/25 at 5:15 p.m., a tube of Muscle Rub topical cream with an expiration date of 08/2024 located in the medication cart on 3 North East. -08/14/25 at 11:38 a.m., one box of Acetaminophen 650 milligrams (mg) suppositories with an expiration date of 12/2024, and one box of Bisacodyl 10mg suppositories with an expiration date of 07/2025 located in the medication refrigerator on 3 South. -08/14/25 at 11:45 a.m., one bottle of aspirin 325mg with an expiration date of 05/2025 located in the medication cupboard on 3 North East. During an interview on 08/14/25 at 1:50 p.m., supervisory staff members (#1, #10, and #13) agreed staff should remove expired medications from the storage areas.

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 9 residents (Resident #65 and #96) observed during medication administration. Two medication errors occurred during staff administration of 27 medications, resulting in a 7% error rate. Failure to follow physicians' orders and administer medications in the correct dose and at the correct time may result in residents receiving an ineffective and/or inaccurate dose and experiencing adverse reactions.Findings include: Review of the facility's policy titled Medication Administration and Crushing Medications occurred on 8/14/25. This policy, approved October 2024, stated, . OBJECTIVE: 1. To administer medications as ordered by a provider . Provider's Order must be obtained and observed for all medications. Read the medication label and compare with the HER [sic] [electronic health record (EHR)] ensuring the five rights: a. Right drug . Right dose . Right route . Right time . Right resident. Review of Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education Inc., New Jersey, page 835, stated, Process of Administering Medications . Medications prescribed more frequently than daily, but no more frequently than every 4 hours . [Administer] Within 1 hour before or after the scheduled time. -Observation on 08/11/25 at 4:32 p.m. showed a nurse (#15) administered one drop of Refresh eye drops to both of Resident #65's eyes. The Refresh label stated two drops left eye twice daily. After returning to the medication cart, the nurse confirmed the order stated two drops to left eye twice daily. Review of Resident #65's physician's order verified two drops to left eye until redness resolves then discontinue. -Review of Resident #96's medical record occurred on all days of survey and showed a physician's order for Cefepime 2 Gram (an antibiotic medication) every 12 hours for 14 days for bacteremia/sepsis. Review of Resident #96's electronic medication administration record (EMAR) showed scheduled administration times for the Cefepime at 9:00 a.m. and 9:00 p.m. Observation on 08/12/25 at 10:49 a.m. showed a nurse (#2) administered the Cefepime. This exceeded the one-hour after the scheduled time of 9:00 a.m. by 49 minutes. During an interview on 08/13/25 at 2:00 p.m., an administrative nurse (#1) stated he expected staff to administer medication within an hour prior to the scheduled time to an hour after the scheduled time.

Based on observation, record review, review of facility policy, and staff, resident, and family interviews the facility failed to offer and/or assist with fluids for 3 of 8 residents (Resident #2, #13, and #14) who required staff assistance for fluid intake. Failure to provide fluids to dependent residents may result in dehydration, constipation, and urinary tract infections. Findings include: Review of the facility policy titled, Fluids and dehydration occurred on 08/14/25. This policy, revised May 2019, stated, . The information gathered from the nutritional assessment, along with current standards of practice, will be used to develop an individualized care plan that addresses the resident's specific . hydration concerns and preferences . Interventions to improve a resident's hydration status may include but not limited to the following . Offer the resident a variety of fluids during and between meals . Provide assistance with drinking . - During an interview on 08/11/25 at 2:39 p.m., Resident #2 stated, I don't know why they didn't bring me any water. Observation showed an empty glass of water sitting on the bedside table. A few minutes later, an unidentified certified nurse aide (CNA) entered the room and Resident #2 immediately asked the CNA for water. Review of Resident #2's medical record occurred on all days of survey. The physician's orders identified, . chart fluids q [every] shift . The current care plan stated, . At risk for dehydration r/t [related to] diuretic medication use, recent infection. Dehydration observation weekly as ordered . Offer and encourage fluids at and between meals. At risk for constipation R/T opioid medication use . Offer and encourage fluids at and between meals . - During an interview on 08/11/25 at 2:28 p.m., Resident #13's family member stated, They [staff] drop off water and don't offer or assist her. She is weak and can't even hold a cup. Review of Resident #13's medical record occurred on all days of survey. The current care plan stated, . At risk for constipation . Offer and encourage fluids at and between meals . At risk for dehydration . Dehydration observation weekly as ordered . Offer and encourage fluids at and between meals . Observations on 08/13/25 showed the following:* 1:20 p.m., Two CNAs (#19 and #20) assisted Resident #13 with cares and exited the room. The CNAs (#19 and #20) failed to offer the water located on the bedside table prior to exiting the room.* 5:00 p.m. A CNA (#21) assisted Resident #13's with cares and exited the room. The CNA (#21) failed to offer the water located on the bedside table prior to exiting the room. Review of Resident #14's medical record occurred on all days of survey. Diagnoses included vascular dementia. The care plan stated, . Offer and encourage fluids . [Resident #14's name] is not able to do her own ADL's [activities of daily living] . Potential for dehydration. History of UTI [urinary tract infection]. Resident needs total assistance with eating . Observation on 08/13/25 at 3:35 p.m. showed two certified nurse aides (CNAs) (#4 and #5) assisted Resident #14 with cares and transferred the resident to the wheelchair and exited the room. The CNAs failed to offer water located on the bedside table. During an interview on 08/14/25 at 1:17 p.m., an administrative staff member (#1) stated he expected staff to offer dependent residents water with cares. 039484

Based on observation, record review, and resident and staff interviews, the facility failed to provide appropriate services and assistance to maintain bowel continence for 1 of 2 sampled residents (Resident #4) observed during toileting/incontinence cares. Failure to provide alternate toileting methods may result in unnecessary incontinence, a loss of dignity, and avoidable skin issues. Findings include:Review of Resident #4's medical record occurred on all days of survey. Diagnosis included weakness, right femur fracture (occurred prior to admission) and pressure ulcer to sacral region. Physician orders, dated 07/25/25, stated, . Activity Level: Up with assist . partial weight bearing as tolerated for two weeks and then transition to weight bearing as tolerated. The care plan stated, . foley catheter R/T [related to] wound healing. Toileting: Frequently incontinent. brief changes assistance of 1 [staff]. Toileting to be done every 2 to 4 hours and prn [as needed]. The resident's quarterly Minimum Data Set (MDS), dated [DATE], identified cognitively intact, dependent on staff for toileting, no physical or verbal behaviors, and no rejection of care.Observation on 08/13/25 at 11:18 a.m. showed Resident #4 incontinent of bowel with stool noted on the wound dressing. The nurses (#23 and #24) provided perineal cares, changed the incontinent product, and changed the wound dressing. During an interview on 08/11/25 at 4:41 p.m., Resident #4 stated she wears an incontinent product and They just change me. I can't get out of bed with this fracture. During an interview on 08/14/25 at 8:00 a.m., a therapy staff member (#6), stated, We do not get her (Resident #4) out of bed because she requires the hoyer lift [mechanical lift] and we do not want to risk her coccyx wound getting worse from shearing. The staff member (#6) also stated, We have tried to stand her (Resident #4) at bedside and she is unable to. She just isn't there yet. We will try the sit to stand lift with two of us and see if she can do that. During an interview on 08/14/25 at 8:08 a.m., an administrative staff nurse (#7) stated Resident #4 does not get out of bed per her choice, and staff only check and change her. The administrative staff nurse confirmed facility staff have not attempted alternate toileting methods, such as the bed pan, bedside commode, etc. The medical record lacked evidence the facility staff educated Resident #4 on her current weight bearing status and offered alternate toileting methods, which may have resulted in avoidable incontinence, decreased dignity, and risk of further skin breakdown.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to prevent skin breakdown and pressure ulcers for 1 of 4 sampled residents (Resident #4) reviewed with pressure ulcers. Failure to consistently reposition residents for pressure relief may result in delayed healing of current pressure ulcers and/or the development of new pressure ulcers.Findings include:Review of the facility policy titled Skin Management occurred on 08/14/25. This policy, dated December 2022, stated, Once residents are identified at risk of skin breakdown, prevention guidelines will be implemented, including but not limited to: turn schedule .Follow individualized prevention protocols for each resident . Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present.Review of Resident #4's medical record occurred on all days of survey. Diagnosis included a pressure ulcer to the sacral region noted upon admission [DATE]) to the facility. Physician's orders stated, . 05/07/2025 Turn/reposition schedule every 2/3 [2-3 hours] hours . 05/15/25 Consult General Surgery . worsening coccyx pressure ulcer . 06/19/25 Wound Vac (a therapeutic technique that uses suction to promote wound healing) to sacral wound .Resident #4's care plan, stated . Bed mobility: staff assist of 1 for re-positioning . has a pressure ulcer to coccyx. turn [NAME] [sic] 2-3 hours . resident bedbound due to stage IV sacral wound . A Minimum Data Set, dated [DATE], identified Resident #4 dependent upon facility staff to roll left and right.Resident #4's medical record showed the resident's wound was debrided by a surgeon on 06/19/25, and included the following nursing progress note, dated 06/19/25 at 11:14 a.m., stated, . Resident to MD [medical doctor] appointment at surgeon's office. Per note from [nurse practitioner's name], resident will now receive wound vac orders: white foam to tunnel and exposed bone . measures 10x10x2 [10 centimeters (cm) length by 10 cm width by 2 cm depth] with a 4cm tunnel at 5 oclock, [sic] 5% bone exposed, 10% yellow slough and 85% red wound bed. Review of the wound care documentation, dated 08/07/25, showed a stage IV (full thickness tissue loss, exposing underlying bone, muscle or tendon) pressure ulcer to Resident #4's sacral region and measured 11 centimeters (cm) by 10.5 cm width and 2 cm undermining.Resident #4's repositioning record, dated July 15 to August 13, 2025, identified the following:- Not repositioned: 1 day zero times- Repositioned once: 6 days - Repositioned twice: 14 days - Repositioned three times: 7 days - Repositioned four times: 1 day During an interview on 08/14/25 at 9:49 a.m., an administrative staff member (#7) confirmed Resident #4's turning and repositioning task failed to show staff repositioned the resident every 2-3 hours. The administrative staff member stated she expected facility staff to reposition the resident every two to three hours. During an interview on 08/14/25 at 1:17 p.m., an administrative staff member (#1) stated staff should reposition Resident #4 every 2-3 hours.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 6 sampled resident (Resident #6) observed during dressing changes. Failure to complete dressing changes as physician ordered placed the resident at risk for delayed wound healing. Findings include:Review of the facility policy titled Skin Management occurred on 08/14/25. This policy, dated December 2022, stated, . Wound Care Guidelines . Floor nurse will observe wound daily . Wound care dressings will be dated and initialed. Floor nurse will document observed wounds . in the resident's EHR [electronic health record].Review of Resident #6's medical record occurred on all days of survey. A physician's order, dated 11/27/24, identified a dressing change to the resident's right leg once a day. Observation on 08/12/25 at 9:30 a.m. showed a nurse (#12) removed a dressing dated 08/10/25 from Resident #6's right leg. The nurse (#12) stated, I don't know what happened. They must have forgot to change the dressing yesterday.

Based on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 23 sampled residents (Resident #4 and #104) dependent on staff for personal hygiene. Failure to provide assistance with hair, oral, and nail care may result in poor hygiene and decreased self-esteem and quality of life. Findings include: The facility failed to provide a policy for activities of daily living. -Observation on 08/11/25 at 4:29 p.m. showed Resident #4's hair uncombed. The resident stated, I only get my hair combed about once a week and teeth brushed occasionally. Review of Resident #4's medical record occurred on all days of survey. The care plan stated, . [Resident #4's name] is not able to perform her own ADL's [activities of daily living] related to weakness and right femur fracture. Grooming/Personal Hygiene: staff assistance of one for assistance at bedside. Encourage [Resident #4's name] to . comb hair Oral hygiene: partials/own teeth. Oral cares bid [twice a day] . Encourage [Resident #4's name] to brush own teeth after set up . Review of Resident #4's personal hygiene task record from 07/14/25 to 08/09/25 identified the facility staff failed to assist the resident with personal hygiene (combing hair and brushing teeth) five times. -Observation on 08/11/2025 at 2:56 p.m. showed Resident #104's great toenails to both feet approximately three-fourths inches in length with jagged edges. Review of Resident #104's medical record occurred on all days of survey. The care plan stated, . Hand and foot nail care to be done by CNA [certified nurse aid] . During an interview on 08/14/25 at 1:17 p.m. an administrative staff nurse (#1) stated he expected the CNAs to assist dependent residents with all ADLs including combing hair and brushing teeth twice a day.

Based on record review, review of professional reference, review of facility policy, and staff interview, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 1 sampled resident (Resident #30) with orders for a physical therapy/occupational therapy (PT/OT) evaluation. Failure to transcribe and obtain a PT/OT evaluation placed Resident #30 at risk for delayed treatment. Findings include:Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out.Review of the facility policy titled Provider Orders occurred on 08/14/25. This policy, dated September 2022, stated, . PHYSICIANS ORDERS . all orders must be on the chart of the resident . Observed, sign, date and time, in red, beneath the providers written orders on Provider order sheets. enter order into the electronic health record. Review of Resident #30's medical record occurred on all days of survey. Diagnoses included arthritis, weakness, and difficulty walking. A provider's progress note, dated 05/07/25, stated, . chronic ambulatory dysfunction . wheelchair bound . currently a Hoyer [mechanical lift] transfer . An undated physician's order, scanned into the medical record, stated, PT/OT evaluate transfer/maneuver electric wheelchair safely. The physician's order lacked evidence facility staff acknowledged the order. The record lacked documentation of a PT/OT evaluation for electric wheelchair use. Observations on all days of survey showed an electric wheelchair Resident #30's room. During an interview on 08/11/25 3:14 p.m., Resident #30 identified she would like to receive some therapy and to use her electric wheelchair. During an interview on 08/13/25 at 8:15 a.m., a therapy manager (#6) confirmed therapy staff had not received notification of an evaluation order for Resident #30. During an interview on 08/13/25 at 11:00 a.m., an administrative nurse (#7) confirmed the provider wrote the order, failed to date it, and facility staff failed to carry out the order.

Based on record review, review of facility policy, and staff interview, the facility failed to thoroughly investigate alleged violations of neglect for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to thoroughly investigate Resident #1's elopement, implement corrective actions, and evaluate the effectiveness of those actions, placed Resident #1 and other residents at risk for possible neglect and/or injury.Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . The supervisor will then contact the Director of Nursing and/or Director of Social Services to initiate the investigation process. All staff with knowledge of the alleged incident will be required to make a written, signed, and dated statement. All residents involved in the allegation will be interviewed and a statement will be written up. The care plan will be updated accordingly to reflect any new interventions or changes.Review of Resident #1's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified cognitively intact. The current care plan stated, . [Resident #1] was recently admitted to hospital due to a fall in the home that resulted in multiple subacute pelvic fractures . impaired gait, impaired anticipatory and reactionary balance, and decreased safety awareness . Resident unsafe to return home at this time . A progress note, dated 08/02/25 at 4:23 p.m., stated, This writer was alerted by another resident that [Resident #1] had left the nursing home to go to [name of store] convenience store [located two blocks from the facility]. This writer went to look for resident and found her sitting in her wheelchair by the kerbside [sic] and she stated she was tired. Resident was having a difficult time navigating the uneven terrain, and she also stated that the nursing home looked like a school to her. Resident stated that she had gone to [convenience store name] to purchase a candy bar but was unable to get back due to 'being tired.' This writer pushed resident back to her room. Resident's family . was updated. Weekend Manager, Social services and DON [Director of Nursing] were also updated. During an interview on 08/13/25 at 5:20 p.m., two administrative nurses (#1 and #13) confirmed staff failed to complete an incident report following Resident #1's elopement. Facility staff failed to complete an incident report after locating Resident #1, including:* Identifying how long Resident #1 was missing from the facility prior to locating her, the weather conditions/appropriateness of her clothing, etc.,* Documenting the results of the physical assessment,* Assessing Resident #1's safety awareness after being told she self-propelled her wheelchair two blocks from the facility, had difficulty navigating the uneven terrain, and thought the facility looked like a school, * re-educating Resident #1's on the procedure for leaving the facility, i.e.: sign-out book.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 31 sampled residents (Resident #84) reviewed for advance directives. Failure to ensure the resident's medical record reflected the most current resident wishes may result in unwanted treatment. Findings include:Review of the facility policy titled Code Status occurred on 08/14/25. This policy, revised October 2021, stated, . Nursing services will verify order between providers orders and/or resident's decision and that the code order in the electronic health record matches whatever the resident/residents representative has signed .Review of Resident #84's medical record occurred on all days of survey and identified a physician's order, dated 02/18/25, indicating a full code status. The resident identification ribbon in the electronic health record (EHR) also showed a full code status. On 08/12/25 at 5:25 p.m., a management staff member (#17) presented the surveyor a code status form dated 08/12/25 indicating Do Not Resuscitate (DNR) signed by the resident's Power of Attorney (POA). The staff member (#17) stated Resident #84 returned from the hospital today (08/12/25) and the code status changed. Resident #84's medical record showed facility staff failed to change the full code status to DNR in the EHR until 08/13/25 at 8:30 a.m. During an interview on the morning of 08/13/25, an administrative staff member (#1) confirmed staff failed to change the code status to DNR.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure all alleged violations involving possible abuse/neglect were reported immediately to officials including the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to immediately report alleged violations to the SSA placed Resident #1 and other residents at risk for possible neglect and/or injury.Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 08/14/25. This policy, revised August 2023, stated, . Neglect: Means the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress . The Director of Nursing and/or Director of Social Services will report the alleged . neglect . to the Administration and/or their designee and the State Health Department. An initial Allegation of Abuse Reporting form will be completed through the State Health Dept [Department] website . within 24 hours. The results of all investigations are reported to the Administrator or his designated representative and the State Health Department within five working days of the alleged incident .Review of Resident #1's medical record occurred on all days of survey. The admission Minimum Data Set (MDS), dated [DATE], identified cognitively intact. The current care plan stated, . [Resident #1] was recently admitted to [the] hospital due to a fall in the home that resulted in multiple subacute pelvic fractures . impaired gait, impaired anticipatory and reactionary balance, and decreased safety awareness . Resident unsafe to return home at this time . A progress note, dated 08/02/25 at 4:23 p.m., stated, This writer was alerted by another resident that [Resident #1] had left the nursing home to go to [name of store] convenience store [located two blocks from the facility]. This writer went to look for resident and found her sitting in her wheelchair by the kerbside [sic] and she stated she was tired. Resident was having a difficult time navigating the uneven terrain, and she also stated that the nursing home looked like a school to her. Resident stated that she had gone to [convenience store name] to purchase a candy bar but was unable to get back due to 'being tired.' This writer pushed resident back to her room. Resident's family . was updated. Weekend Manager, Social services and DON [Director of Nursing] were also updated. During an interview on 08/13/25 at 5:20 p.m., two administrative nurses (#1 and #13) confirmed staff failed to complete an incident report following Resident #1's elopement. The medical record failed to reflect facility staff reported Resident #1's elopement to the State Health Department.

Based on observation, record review, review of a facility reported incident, policy review, and staff interview, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #2) with impaired cognition who displayed sexual behaviors towards each other. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 05/18/25. The facility implemented corrective action immediately, completed corrective action on 05/19/25, and continues with staff education and monitoring. Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 05/20/25. This policy, revised August 2023, stated, . Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Sexual Abuse-all residents have the right to initiate a relationship with another individual . The determination of capacity to consent to a sexual relationship will be reviewed by a team that will include the provider and social worker at a minimum . If capacity for consent is not evident, the team will update the plan for the resident(s) to prevent any sexual abuse. Review of a facility reported incident, dated 05/18/25, indicated a certified nurse aide (CNA) (#1) entered Resident #2's room and observed Resident #1 laying on Resident #2's bed with her shirt pulled up and Resident #2 touching her breasts. The report stated, . [Resident #2's name] was not hurting her . and she [Resident #1] was not showing any signs up [sic] being upset. It was stopped and both residents were removed from the room. Both have very poor short-term memories and are on the secured unit. - Review of Resident #1's medical record occurred on 05/20/25. Diagnoses included Alzheimer's disease and dementia with agitation. The care plan stated, . Her behaviors can be very unpredictable, and she has a hx [history] of becoming very angry and abusive. She also has a hx of wandering at home and has also been wandering since she was admitted looking for a way out and going into other resident's rooms . Will also remove her clothes and come walking down the hall and an episode of being found in a male resident's room with her shirt pulled up, exposing her breasts. Monitor her when she is ambulating around the unit. Offer female CNA's to intervene as men seem to agitate her worse. Assist her to her room and assist her to put her clothes back on when needed. Monitor her whereabouts and remove her from other residents' rooms. Resident #1's progress notes included the following: * 05/18/25 at 7:45 p.m., Resident was found in another resident's room. She was laying in the bed with her shirt pulled up. She was letting the male resident feel her breasts. She has a history of being combative if it's something she does not want to do. She was redirected out of the room and brought to the dining room. No further contact between the two were made. * 05/19/25 at 11:49 a.m., Social Services visited with [Resident #1's] son [name] this morning about the incident that happened last evening with a male resident on the unit. It appears to be an isolated incident, as it is the first time there have been any kind of relations between the two of them. Staff will be monitoring both residents very close to avoid any future physical interactions between the two of them. - Observation on 05/20/25 at 10:52 a.m. showed Resident #2 asleep on his bed with a stop sign hung across his open door. Review of Resident #2's medical record occurred on 05/20/25. Diagnoses included Alzheimer's disease and dementia. A quarterly MDS, dated [DATE], identified severe cognitive impairment. The care plan stated, . has made inappropriate comments to female staff. Occasional episodes of cursing/screaming at CNA, rejection of cares and false beliefs. Episode of touching a female residents' breasts. Let [Resident #2] know when comments are not appropriate. Leave and return later, try another caregiver. Remove any female residents from [Resident #2]'s room as needed and explain he cannot have any sexual relations with any of the female residents. Review of Resident #2's progress noted included the following: * 05/18/2025, [Recorded as Late Entry on 05/19/2025 10:44 AM] 19:45 [7:45 p.m.] Resident was found in his room. There was a female resident laying on his bed with her shirt pulled up. He was feeling her breasts. He was redirected out of his room. He was brought to the nurses' station. He has not made contact with the other resident again. During an interview on 05/20/25 at 11:05 a.m., a nurse manager (#2) stated Resident #1 will hit and kick if she doesn't want to do something and showed no distress upon discovery with Resident #2. She stated the staff monitored Resident #1 and #2 closely after the incident and observed no signs of distress. The nurse stated neither resident has mentioned this incident since it happened, staff don't believe the residents remember the incident as both have very short-term memories, and there has never been an incident like this before with either of these two residents. Sexual contact is nonconsensual if a resident appears to want the contact to occur but lacks the cognitive ability to consent. Therefore, the facility failed to ensure Residents #1 and #2, both lacking the cognitive ability to consent, remained free from sexual abuse, defined as non-consensual sexual contact of any type. Based on the following information, non-compliance at F600 is considered past non-compliance. The facility implemented corrective actions to ensure the deficient practice does not recur by: * completed an investigation following the incident * implemented measures immediately after the incident to separate the two residents * required staff to be located in/observing the hallway as much as possible * increased rounding checks on all residents from every hour to every half hour * educated the staff on duty on 05/18/25 and at the start of each shift thereafter, regarding the incident and monitoring the residents' location closely * added WATCH HALLS TO MAKE SURE RESIDENTS ARE NOT WANDERING INTO OTHER RESIDENTS' ROOMS to the CNA care cards * updated the residents' care plans * staff meeting on 05/20/25 to further educate staff regarding vulnerable adults, reporting requirements, monitoring the hallway, and 30-minute rounding on all residents.

Based on record review, review of the facility reported incident, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse from 1 of 1 sampled resident (Resident #1) with verbal, physical, and sexual behaviors towards other residents. Failure to assess, care plan, and operationalize a plan/process resulted in fear, anxiety, pain, and an unsafe environment for all residents residing in the memory care unit. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated, . Abuse: the willful infliction of injury, unreasonable confinement, intimidation . with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse . Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question and those residents that have had aggressive behavior directed at them . must be protected from further injury or mental anguish. Documentation must be in place to identify the steps taken to identify the problems, the corrective action taken, and follow-up monitoring. In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken . Re-direct resident and take to a quiet area if possible. Contact resident provider, follow provider's orders, and update family. Social Services to monitor for trends or patterns and update the residents Care Plan as needed. A facility reported incident, received by the state agency on 08/23/24, stated Resident #1 kicked a female resident in the stomach which cause her to fall. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included anxiety, dementia, mood disturbance, and psychotic disturbance. The quarterly Minimum Data Set (MDS), dated [DATE], indicated severe cognitive deficits and behaviors. The progress notes identified the following: * 07/02/24 at 7:06 p.m., Resident [#1] is calling another resident a piece of [explicit word]. He then got into an altercation with another resident. * 07/07/24 at 5:32 p.m., Resident went down to end of hall and blocked another resident against the wall and was swearing at him. Other [sic] resident was begging him to just leave him alone. A cna [certified nurse aid] got them seperated [sic] . He then came up behind the other resident swearing at him and kicked him in the back. Got them seperated [sic] again and he went after him again and kicked his hand. The other resident then punched him [Resident #1] in the chest. * 07/07/24 at 11:20 p.m., Resident is growling at another resident and trying to get close to other resident to kick him. Residents kept seperated [sic]. * 07/09/24 at 11:44 p.m., Resident went up to another resident and grabbed her breasts. Both residents were separated and redirected immediately. * 07/11/24 at 7:21 p.m., The resident kicked another resident's wheelchair. He was taken to another room . * 07/14/24 at 4:54 p.m., Resident moving around dining room [NAME] [sic] other residents pieces of [explicit word]. * 07/18/24 at 12:45 a.m., Resident was blocking door from another resident, Did not verbal [sic] respond to resident when she was yelling at him. Resident did come with me to a different spot and had an HS [hour of sleep] snack. * 07/20/24 at 7:13 p.m., Resident kicked the back of another resident's wheelchair. He also yelled, 'You stupid [explicit word]' to a different resident. He was redirected each time to another area. * 07/22/24 at 5:55 p.m., Resident yelling and cursing at other residents. * 07/27/24 at 8:15 p.m., . Female residents afraid of going near resident. * 07/28/24 at 3:05 a.m., Resident [#1] grabbed another female resident by her arm. No injuries noted at this time. Resident is immediately redirected away from the other resident. * 07/29/24 at 10:37 p.m., Resident is trying to pinch resident [sic] breast after supper. Unable to redirect him away from the females. * 07/30/24 at 2:17 p.m., Resident was glaring at another resident. He was redirected away from her before anything happened. * 07/30/24 at 4:59 p.m., . He was grabbing female resident [sic] breast [sic] or talking sexual to them. He would not let a female resident go by him so staff had to get the resident by him . * 07/30/24 at 11:20 p.m., Resident sat at the main door after supper. Cussed at other residents. * 08/01/24 at 9:32 p.m., before supper started to get near female residents. Then he proceeded to kick another male resident [sic] wheelchair and call him '[explicit word].' when taking residents to the table for supper [Resident #1] would go and stare at the female resident and call her '[explicit word]' and stare at her . [Resident #1] would then try and quickly get near another female resident if staff looked away. Informed [Resident #1] that he needs to stay away from other residents especially the ladies. It is not appropriate for him to touch other residents or call them names. The minute we turned our back he was headed to a table with female residents. * 08/02/24 at 11:16 a.m., Nursing staff called Social Services last evening to report [Resident #1] was having a lot of behaviors. Some changes have been made to his psychotropic medications and he is being monitored closely. * 08/03/24 at 10:54 a.m., The resident would not let another resident's family leave by blocking the exit door. He also tried to grab one of their breast [sic] as they tried to leave. Staff redirected the resident to another area. * 08/03/24 at 9:49 p.m., resident kicked at female resident when she was walking past him after supper. * 08/04/24 at 1:59 p.m., CNA reported . she tried to redirect him [Resident #1] from hitting another resident. She directed him to another room. * 08/04/24 at 9:30 p.m., Resident going up to other female resident [sic], stares at them then calls them [explicit word]. Unable to redirect as he goes to another resident and tries to kick them [sic], grab them [sic] or call them [sic] names. Resident assisted to bed. * 08/07/24 at 11:01 a.m., Resident grabbed a female resident's left breast after breakfast. Female resident yelled at him and walked away and came to the nurses' desk. Resident's breast was red, no bruising. * 08/07/24 at 6:51 p.m., Resident was making faces at another resident in the dining room. Other resident told him to stop looking at her and then she threw her apple juice on him. Both residents were separated . * 08/08/24 at 6:53 p.m., The resident propels his wheelchair fast towards other residents and he changes the look on his face, which scares them. One resident threw food at him. Staff redirected him to his room . * 08/08/24 at 11:10 p.m., The nurse was walking up the hallways on the unit, when she observed resident stomping his feet as he was propelling fast in his wheelchair towards a female resident who was quietly sitting in her wheelchair in the hallways [sic]. There was no physical interaction. The female resident appeared frightened and the suggestion was made to go to her room and she complied and was taken to her room. As the nurse was prepared to leave, the resident stated, 'he is creepy.' * 08/11/24 at 3:48 a.m., Resident [#1] went up to a female resident and said 'your [sic] a [explicit word].' He was calling . residents 'pieces of shit' and saying '[explicit word] you.' Resident very difficult to redirect. * 08/11/24 at 1:50 p.m., Resident was wandering around the halls most of shift. He was in a confrontation with another resident. * 08/12/24 at 6:59 p.m., [Physician] here for rounds. Updated her on the residents' behaviors. Called pharmacy requesting medication combination side effects. Carbidopa-levodopa [Parkinson's medication] can cause increased labito [sic] [sexual drive]. * 08/12/24 at 11:14 p.m., Resident pedaled himself quickly toward another resident at the door. Tried to grab the resident. [Resident #1] moved away from the door, then turned and went right back to the door. Other resident left the dining room. [Resident #1] kicked and attempted to hit at another resident in the dining room. [Resident #1] taken to his room . [Family Nurse Practitioner] called. Update given on behaviors. New orders received. Will update family in the morning. * 08/13/24 at 1:35 p.m., Resident was blocking the hall not letting other residents go by. * 08/13/24 at 9:36 p.m., [Sic] was calling another resident inappropriate names after supper. * 08/18/24 at 6:45 p.m., Resident propelling towards a resident and grabbed both her breast [sic]. He was taken to his room where [sic] sat peacefully. * 08/22/24 at 1:00 p.m., The CNA called out for this nurse at [1:00 p.m.] She said she witnessed the resident propelling quickly down the hall towards another resident. The other resident was moving towards the wall to move out of his way. Everywhere the other resident moved he would block her. Then he kicked her in the stomach. The other resident fell to the ground. This nurse and CNA took him to his room . * 08/25/24 at 9:16 p.m., After supper resident [#1] was kicking another resident's wheelchair and saying '[explicit word] you.' able to redirect. Then went to another resident and called him an [explicit word]. Told resident if he continued to kick other residents wheelchairs and call people names then he would need to go to bed. * 08/27/24 at 6:25 a.m., . Resident is very agitated and aggressive towards . residents tonight. He pinched another resident on her face, no injuries noted. He ran into the back of another resident's heels, no injuries noted at this time. He is going up to . residents growling at them and calling them '[explicit words].' He is trying to kick . resident. He is blocking people so they can't get by him. Resident followed this nurse into a female resident's room and refused to leave. Tylenol was given and ice cream for a snack. This nurse called the social worker about his behaviors. [Physician] was notified about resident's behaviors and a one time order for Ativan was given. * 08/30/24 at 1:18 p.m., Resident was following female . resident around, hard to redirect, resident removed from common area from other residents . * 08/31/24 at 12:38 a.m., Resident was kicking other resident [sic] wheelchair after supper. Also calling other resident [sic] '[explicit word].' . * 08/31/24 at 2:22 p.m., Resident propelling his wheelchair fast towards other residents and telling them to move. * 08/31/24 at 9:18 p.m., Resident continue to move his wheelchair fast around the dining room. Stops at different residents and calls them '[explicit word]' or says '[explicit word] You.' Also kicked a couple wheelchairs of different residents. * 09/01/24 at 2:03 p.m., Resident propelled quickly towards other residents. CNA . tried to redirect . * 09/04/24 at 6:04 a.m., Resident is going up to residents and saying '[explicit word] You.' Attempts made to redirect . Resident #1's care plan stated, . At times becomes physically and verbally abusive when he can't communicate his need. If [Resident #1] is upset, allow time for him to calm down, then re-approach. Distract him from behaviors by offering food, beverage or activity. Remove [Resident #1] from area if he is calling other residents names, growling, or if agitated. Assess any changes in . behavior and report to . Social Services. [Resident #1] receives psychotropic medication . Monitor for changes in . behaviors and report to MD [medical doctor]/NP [nurse practitioner] as needed. The current care card also stated, . Observe and report any changes in mental status caused by situational stressor . Provide opportunities for expression of feelings related to situational stressor . The care plan failed to identify the situational stressors affecting Resident #1 and failed to address his sexually abusive behaviors towards the female residents. During an interview on 09/04/24 at 4:50 p.m., a managerial nurse (#2) indicated staff remove Resident #1 from the area whenever he behaves aggressively towards other residents. During an interview of 09/04/24 at 5:15 p.m., an administrative staff member (#1) reported the memory care unit staff failed notify her when Resident #1 grabbed the breasts of female residents. The facility failed to assess and monitor patterns and trends of behaviors in an effort to protect other residents from abuse and minimize Resident #1's physical aggression towards other residents. The facility failed to ensure Resident #1 did not infringe upon the rights of other residents to be free from verbal, mental, physical, and/or sexual abuse.

Based on record review, review of facility policy, and staff interviews, the facility failed to provide adequate dementia care and services for 1 of 1 sampled resident (Resident #1) with dementia and verbal, physical, and sexual abusive behaviors. Failure to adequately assess for necessary care and services and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #1 and had a negative impact on other residents. Findings include: The facility failed to provide a policy on dementia care. Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 09/05/24. This policy, revised August 2023, stated,. Residents who mistreat, are aggressive towards . other residents . must have a care plan in place that addresses the behavior(s) in question . In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken . Social Services to monitor for trends or patterns and update the residents Care Plan as needed. Review of Resident #1's medical record occurred on all days of survey. Diagnoses included anxiety, dementia, mood disturbance, and psychotic disturbance. The current physician's orders included: * Two 125 milligram (mg) Depakote Sprinkles capsules daily for mood stabilization started 08/31/23, * 20 mg Escitalopram Oxalate daily for major depressive disorder started 08/06/24, * 25 mg Hydroxyzine HCI daily for anxiety started 07/27/24, and * 0.5 mg Risperdal twice daily for agitation started 08/23/24. The current care plan stated, . At times becomes physically and verbally abusive when he can't communicate his need. Exit seeking. Calls other residents and staff vulgar names. Growls at . other residents. If [Resident #1] is upset, allow time for him to calm down, then re-approach. Distract him from behaviors by offering food, beverage or activity. He used to like to sort cards, work jigsaw puzzles and play with dominos. Remove [Resident #1] from area if he is calling other residents names, growling, or if agitated. Assess any changes in his mood or behavior and report to nurse and Social Services. [Resident #1] receives psychotropic medication . Monitor for changes in mood/behaviors and report to MD [medical doctor]/NP [nurse practitioner] as needed. The care card also stated, . Observe and report any changes in mental status caused by situational stressor . Provide opportunities for expression of feelings related to situational stressor . The care plan failed to identify the situational stressors affecting Resident #1 and failed to address his sexually abusive behaviors towards female residents. The progress notes identified the following: * 07/02/24 at 7:06 p.m., Resident [#1] is calling another resident a piece of [explicit word]. He then got into an altercation with another resident. * 07/07/24 at 5:32 p.m., Resident went down to end of hall and blocked another resident against the wall and was swearing at him. Other [sic] resident was begging him to just leave him alone. A cna [certified nurse aid] got them seperated [sic] . He then came up behind the other resident swearing at him and kicked him in the back. Got them seperated [sic] again and he went after him again and kicked his hand. The other resident then punched him [Resident #1] in the chest. * 07/07/24 at 11:20 p.m., Resident is growling at another resident and trying to get close to other resident to kick him. Residents kept seperated [sic]. * 07/09/24 at 11:44 p.m., Resident went up to another resident and grabbed her breasts. Both residents were separated and redirected immediately. * 07/11/24 at 7:21 p.m., The resident kicked another resident's wheelchair. He was taken to another room . * 07/14/24 at 4:54 p.m., Resident moving around dining room [NAME] [sic] other residents pieces of [explicit word]. * 07/18/24 at 12:45 a.m., Resident was blocking door from another resident, Did not verbal [sic] respond to resident when she was yelling at him. Resident did come with me to a different spot and had an HS [hour of sleep] snack. * 07/20/24 at 7:13 p.m., Resident kicked the back of another resident's wheelchair. He also yelled, 'You stupid [explicit word]' to a different resident. He was redirected each time to another area. * 07/22/24 at 5:55 p.m., Resident yelling and cursing at other residents. * 07/27/24 at 8:15 p.m., . Female residents afraid of going near resident. * 07/28/24 at 3:05 a.m., Resident [#1] grabbed another female resident by her arm. No injuries noted at this time. Resident is immediately redirected away from the other resident. * 07/29/24 at 10:37 p.m., Resident is trying to pinch resident [sic] breast after supper. Unable to redirect him away from the females. * 07/30/24 at 2:17 p.m., Resident was glaring at another resident. He was redirected away from her before anything happened. * 07/30/24 at 4:59 p.m., . He was grabbing female resident [sic] breast [sic] or talking sexual to them. He would not let a female resident go by him so staff had to get the resident by him . * 07/30/24 at 11:20 p.m., Resident sat at the main door after supper. Cussed at other residents. * 08/01/24 at 9:32 p.m., before supper started to get near female residents. Then he proceeded to kick another male resident [sic] wheelchair and call him '[explicit word].' when taking residents to the table for supper [Resident #1] would go and stare at the female resident and call her '[explicit word]' and stare at her . [Resident #1] would then try and quickly get near another female resident if staff looked away. Informed [Resident #1] that he needs to stay away from other residents especially the ladies. It is not appropriate for him to touch other residents or call them names. The minute we turned our back he was headed to a table with female residents. * 08/02/24 at 11:16 a.m., Nursing staff called Social Services last evening to report [Resident #1] was having a lot of behaviors. Some changes have been made to his psychotropic medications and he is being monitored closely. * 08/03/24 at 10:54 a.m., The resident would not let another resident's family leave by blocking the exit door. He also tried to grab one of their breast [sic] as they tried to leave. Staff redirected the resident to another area. * 08/03/24 at 9:49 p.m., resident kicked at female resident when she was walking past him after supper. * 08/04/24 at 1:59 p.m., CNA reported . she tried to redirect him [Resident #1] from hitting another resident. She directed him to another room. * 08/04/24 at 9:30 p.m., Resident going up to other female resident [sic], stares at them then calls them [explicit word]. Unable to redirect as he goes to another resident and tries to kick them [sic], grab them [sic] or call them [sic] names. Resident assisted to bed. * 08/07/24 at 11:01 a.m., Resident grabbed a female resident's left breast after breakfast. Female resident yelled at him and walked away and came to the nurses' desk. Resident's breast was red, no bruising. * 08/07/24 at 6:51 p.m., Resident was making faces at another resident in the dining room. Other resident told him to stop looking at her and then she threw her apple juice on him. Both residents were separated . * 08/08/24 at 6:53 p.m., The resident propels his wheelchair fast towards other residents and he changes the look on his face, which scares them. One resident threw food at him. Staff redirected him to his room . * 08/08/24 at 11:10 p.m., The nurse was walking up the hallways on the unit, when she observed resident stomping his feet as he was propelling fast in his wheelchair towards a female resident who was quietly sitting in her wheelchair in the hallways [sic]. There was no physical interaction. The female resident appeared frightened and the suggestion was made to go to her room and she complied and was taken to her room. As the nurse was prepared to leave, the resident stated, 'he is creepy.' * 08/11/24 at 3:48 a.m., Resident [#1] went up to a female resident and said 'your [sic] a [explicit word].' He was calling . residents 'pieces of shit' and saying '[explicit word] you.' Resident very difficult to redirect. * 08/11/24 at 1:50 p.m., Resident was wandering around the halls most of shift. He was in a confrontation with another resident. * 08/12/24 at 6:59 p.m., [Physician] here for rounds. Updated her on the residents' behaviors. Called pharmacy requesting medication combination side effects. Carbidopa-levodopa [Parkinson's medication] can cause increased labito [sic] [sexual drive]. * 08/12/24 at 11:14 p.m., Resident pedaled himself quickly toward another resident at the door. Tried to grab the resident. [Resident #1] moved away from the door, then turned and went right back to the door. Other resident left the dining room. [Resident #1] kicked and attempted to hit at another resident in the dining room. [Resident #1] taken to his room . [Family Nurse Practitioner] called. Update given on behaviors. New orders received. Will update family in the morning. * 08/13/24 at 1:35 p.m., Resident was blocking the hall not letting other residents go by. * 08/13/24 at 9:36 p.m., [Sic] was calling another resident inappropriate names after supper. * 08/18/24 at 6:45 p.m., Resident propelling towards a resident and grabbed both her breast [sic]. He was taken to his room where [sic] sat peacefully. * 08/22/24 at 1:00 p.m., The CNA called out for this nurse at [1:00 p.m.] She said she witnessed the resident propelling quickly down the hall towards another resident. The other resident was moving towards the wall to move out of his way. Everywhere the other resident moved he would block her. Then he kicked her in the stomach. The other resident fell to the ground. This nurse and CNA took him to his room . * 08/25/24 at 9:16 p.m., After supper resident [#1] was kicking another resident's wheelchair and saying '[explicit word] you.' able to redirect. Then went to another resident and called him an [explicit word]. Told resident if he continued to kick other residents wheelchairs and call people names then he would need to go to bed. * 08/27/24 at 6:25 a.m., . Resident is very agitated and aggressive towards . residents tonight. He pinched another resident on her face, no injuries noted. He ran into the back of another resident's heels, no injuries noted at this time. He is going up to . residents growling at them and calling them '[explicit words].' He is trying to kick . resident. He is blocking people so they can't get by him. Resident followed this nurse into a female resident's room and refused to leave. Tylenol was given and ice cream for a snack. This nurse called the social worker about his behaviors. [Physician] was notified about resident's behaviors and a one time order for Ativan was given. * 08/30/24 at 1:18 p.m., Resident was following female . resident around, hard to redirect, resident removed from common area from other residents . * 08/31/24 at 12:38 a.m., Resident was kicking other resident [sic] wheelchair after supper. Also calling other resident [sic] '[explicit word].' . * 08/31/24 at 2:22 p.m., Resident propelling his wheelchair fast towards other residents and telling them to move. * 08/31/24 at 9:18 p.m., Resident continue to move his wheelchair fast around the dining room. Stops at different residents and calls them '[explicit word]' or says '[explicit word] You.' Also kicked a couple wheelchairs of different residents. * 09/01/24 at 2:03 p.m., Resident propelled quickly towards other residents. CNA . tried to redirect . * 09/04/24 at 6:04 a.m., Resident is going up to residents and saying '[explicit word] You.' Attempts made to redirect . The Behavioral Health Clinic Notes stated the following: * 07/26/24, . one day he was grabbing breasts and arms of female staff . He has been telling other residents that they are pieces of [explicit word] . Staff noted he had been watching the door . it was reported by staff that they have been taking him outside and that he enjoys this. He does say yes to watching the door hoping to go outside. * 08/09/24, . I did speak with staff who reported . one day . he was pretty rude in the evening to staff and other residents but that otherwise he has been doing ok. Staff noted that he does still enjoy going outside and that they noticed improvement in his mood when he is able to go outside. * 08/23/24, . patient [Resident #1] was in his wheelchair in front of the door when I arrived I did have to ask him to move in order to open the door enough to get in. Received a call from the nurses at the nursing home regarding behavior of [Resident #1]. Cornering staff, sexually inappropriate, mean comments and door watching he did just have a dose of Sinemet 25-100 added which can cause increase in sexual attention, this dose was added as well as adding Seroquel 50 mg in the am. Documentation failed to show staff reported Resident #1's intimidating and verbally, physically, and sexually abusive behaviors towards other residents on the unit. During an interview on 09/04/24 at 4:50 p.m., when asked if staff attempted to identify the situational stressors/triggers that lead to Resident #1's aggressive/abusive behaviors towards other residents, a managerial nurse (#2) responded, No. During an interview of 09/04/24 at 5:15 p.m., an administrative staff member (#1) acknowledged staff failed to notify her of Resident #1's behaviors towards female residents, such as grabbing their breasts. The facility failed to assess and monitor patterns and trends of behaviors in an effort to minimize these behaviors, recognize unmet needs, and prevent situations/triggers which may lead to behaviors and verbal, physical, or sexual abuse toward other residents. The facility failed to develop an effective behavior management program, consistently implement purposeful and meaningful activities, such as going outside, in an attempt to manage the behaviors exhibited by Resident #1, evaluate the behavior management program on an on-going basis, and modify interventions as needed. The facility failed to ensure Resident #1 did not infringe upon the rights of others while still allowing him to achieve his highest level of well-being. These failures resulted in verbal, physical, and sexual abuse from Resident #1 towards other residents and residents experiencing fear and anxiety related to Resident #1's abusive behaviors.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 5 sampled residents (Resident #68) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in an avoidable facility acquired pressure ulcer. Findings include: Review of the facility policy titled Skin Management -[NAME] Homes occurred on 08/08/24. This policy revised, December 2022, stated, . Nursing will follow the skin care procedures outlined below to . 2. Maintain the integrity of the resident's skin through monitoring and timely interventional skin care management . 8. Braden Scale will be repeated upon resident changes in condition . The resident's care plan will be updated by the nurse to include goals for prevention and management of pressure injuries with appropriate interventions. The care plan will be reviewed . at change of condition . Appropriate pressure reduction/relief devices: 1. Turn and positioning system 2. Heel protectors, therapeutic boots, or items ordered by provider . Floor nurse will observe wound daily . If dressing is soiled or not intact at any point . the dressing will be replaced . Review of Resident #68's medical record occurred on all days of survey. Diagnoses included end stage renal disease, diabetes mellitus, peripheral vascular disease, a Stage 2 pressure ulcer on the left heel. An admission Minimum Data Set (MDS), dated [DATE], identified moderate to maximum assistance with activities of daily living, dependent for transfers, a Stage 1 pressure ulcer. The current care plan stated, . is at risk for skin break down and for developing a pressure ulcer due to impaired mobility, diabetes, ESRD [end stage renal disease], CHF [congestive heart failure] . will have intact skin, free of redness, blisters, or discoloration . Pressure Ulcer Care/Prevention: Pressure relieving mattress & [and] pressure relieving wheelchair cushion. Notify nurse of new or changes in skin breakdown, redness, blisters, bruises, discoloration. Turn and reposition every 2 to 4 hours and prn [as needed]. Float heels off mattress. refuses to wear prevalon boots [pressure reducing boots] . The care plan failed to include the left heel pressure ulcer. Review of nurse's notes identified the following: * 04/23/24 at 11:20 p.m., . Dressing changed on her toes on both feet, noticed a foul smell with greenish discharge on the old dressing, complained too that her left heel is sore, on assessment they are red, intact, blanchable, applied calmoseptine [skin protectant]. Updated [provider name] by fax about the wound and the left heel. * 05/30/24 at 9:58 a.m., Resident stated to PT [physical therapist], the CNA [certified nurse aide] says 'my left heel is black'. PT removed ace wrap and found that resident has what appears to be a deep tissue injury on the left heel. PT encouraged resident to wear prevalon boots day and night. Resident . she is not doing any standing or walking, and prevalon boots would be better. PT informed nurse of this . PT also suggested perhaps a mepilex [protective dressing] over the left heel. * 07/18/24 at 2:47 p.m., . she is to be NWB [non-weight bearing] on her L [left] foot for fear of wound and bone damage. [Resident] will be a hoyer [full-body mechanical] lift for transfers until her next follow up. Review of podiatry progress notes/consultation form identified the following: * 06/14/24 . This patient is high risk for other potential complications and infections. She needs to continue with offloading to protect her heels from decubitus (injury to skin and underlying tissue resulting from prolonged pressure on the skin) ulcerations. * 07/16/24 . She has decubitus ulceration on the left heel . She apparently is not doing [sic] enough pressure off her left foot . she will need to be protected at the nursing home otherwise she will lose her legs. * 07/16/24 podiatry consult form, . new decub (decubitus) stage 3 . KEEP on Prevalon boots BIL (bilateral) . Review of wound management documentation/Braden Skin Risk Assessments (scale to determine pressure ulcer risk)/Focused Skin Observations identified the following: * 05/05/24 . Focused observation skin - left heel red and sore . * 05/09/24 . Focused observation skin - left heel, red, sore . * 06/07/24 . Braden Skin Risk Score 15 at risk [of developing pressure ulcers]. * 07/16/24 . Wound Location Left heel . Length . 1.3 cm [centimeter] Width . 1.3 cm . * 07/29/24 . Wound Location Left heel . Length . 1 cm Width . 1 cm . * 08/04/24 . Wound Location Left heel . Length . 1 cm Width . 1 cm . Exudate Amount . light . Exudate color and consistency . serosanguinous (pale red to pink, thin and watery [drainage]) . A physician's order dated 07/16/24, stated, Prevalon Boots to bilateral feet @ [at] all times. Daily Betadine [skin disinfectant] and bandages to all wounds. Observations of Resident #68 showed the following: * 08/05/24 at 2:49 p.m., Seated in a recliner in her room with the foot rest elevated and wearing ankle socks, and the Prevalon boots in a chair across the room. * 08/06/24 at 7:56 a.m., Out of facility for dialysis, and the Prevalon boots in a chair in her room. * 08/06/24 at 2:00 p.m. and 4:47 p.m., Seated in a wheelchair in her room, feet on the foot pedals, ankle socks on, and not wearing Prevalon boots. * 08/07/24 at 7:53 a.m., Laying in bed, feet directly on the mattress, and the Prevalon boots in a chair across the room. The resident stated she wore Prevalon boots during the night but takes them off when she wakes up because I just can't function with them. * 08/07/24 at 8:11 a.m., Two certified nurse aides (CNAs) (#25 and #28) transferred the resident from bed to the wheelchair with a full-body mechanical lift. The resident wore no socks or shoes, no dressing to the left heel. The CNAs failed to apply the Prevalon boots to the resident's feet. The resident's bare feet with open wound to the left heel rested directly on the carpeted floor. The CNA (#25) stated the resident doesn't wear the Prevalon boots during the day. The CNA (#25) spoke to the nurse but failed to inform her of the absence of Resident #68's dressing to her left heel. * 08/07/24 at 11:11 a.m. and 2:22 p.m., Seated in the wheelchair in her room with her bare feet directly on the carpeted floor. * 08/07/24 at 2:22 p.m., The nurse (#24) applied a dressing to the ulcer but failed to apply Prevalon boots. During an interview on 08/07/24 at 1:54 p.m., an administrative nurse (#1) stated Resident #68 intermittently refused to wear the Prevalon boots, confirmed he expected staff to document patient refusals of care or treatments, to follow infection control measures during wound care, and to cover open wounds. The facility failed to follow through after the development of a pressure injury to Resident #68's left heel. The facility lacked regular assessments of the size and condition of the wound including care planning interventions to aid in healing. observation showed staff failed to implement the use of preventative devices and document the resident's refusal. Due to the resident's risk factors which can cause a delay in healing and this resident to develop a pressure injury and may cause future complications.

1. Based on observation, record review, review of facility investigation, and resident and staff interview the facility failed to provide adequate supervision to prevent accidents for 1 of 1 sampled resident (Resident #61) who required surgical intervention for an injury. Failure to provide adequate supervision during a transfer from the shower resulted in Resident #61 experiencing severe pain, a hematoma (collection of blood in a tissue) which required three hospitalization s and surgical intervention, cellulitis (infection of the skin), and increased anxiety and depression. Findings include: Review of the facility reported incident form occurred on 08/05/24. The form, dated 07/25/24, stated, . On 07/16/24 at 5:00 p.m. after [Resident #61's] shower was complete, [certified nurse aide name] [CNA] (#27) went to pull her out in the shower chair and [Resident #61's] left leg hit the shower wall . [Resident #61] immediately complained of pain to the area . Review of Resident #61's medical record occurred on all days of survey. Diagnoses include atrial fibrillation, anemia, long term use of anticoagulants, cellulitis of left lower limb, and contusion of left lower leg. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition, and dependent on staff for shower transfers. Observation on 08/05/24 at 11:33 a.m. showed Resident #61 resting in bed with a wound VAC (vacuum-assisted closure device) to her lower left leg. During an interview at this time, the resident indicated the wound vac is for the injury that occurred when the CNA transferred her from the shower room and hit her leg on the wall. The resident stated her leg immediately started hurting after it hit the wall, the pain continued to get worse. The resident indicated during the week between the injury and her final hospitalization her leg worsened, and it was horrendously painful. She stated she went to the hospital three times, underwent surgery to debride [remove damaged tissue] my leg, and resulted in the need for a the wound vac. She indicated being frustrated with the incident and results because she was progressing in her therapy prior to the injury and now is unable to stand. She stated her blood thinners had been stopped and now every time I feel a flutter or twinge in my, chest I worry about a heart attack or a stroke. Review of nurse's notes identified the following: * 07/16/24 at 5:00 p.m., . The attention of this nurse was called because according to her the resident is in severe pain due to a bump on her lateral lower leg, on assessment noticed a hematoma measuring about 4cm [centimeter] x [by] 4 cm in diameter. Asked what happened and she and the CNA relayed that she bumped her leg on the wall when they were wheeling her out of the shower room. Applied ice, elevated her leg, and gave PRN [as needed] Tyl;enol [sic] [pain relieving medication] 1000 mg [milligram]. After supper around 1800 [6:00 p.m.], she was crying and said she's still in a lot of pain, her hematoma became bigger with the surrounding area red. Paged [provider name] the on call and gave an order to sent [sic] her to the ER [emergency room ]. * 07/17/24 at 3:13 a.m., Received resident from EMT [emergency medical technician]; Alert and oriented complaining of Left leg pain; with new Doctor's order for pain. Left leg with ace wrap and swollen with hematoma noted. * 07/17/24 at 3:53 p.m., Resident complained of having pain on the left leg with ace wrap and swollen with hematoma, PRN tab Tramadol [narcotic pain medication] 50mg was given with good effect . * 07/18/24 at 11:34 a.m., I visited with [Resident #61] about the hematoma to her left lower leg. She explained to me that when she was in the shower chair on 7-16-24 the CNA pulled her sideways and her left lower leg hit the corner of the shower wall. [Resident #61] is not able to bend her legs completely. * 07/20/24 at 2:15 p.m., Resident insisted she go to the emergency room today for her left lower leg hematoma. She states was previously at the ER, however, states her condition has changed and hasn't been assessed. I did inform her I spoke with the on-call provider who declined to send the patient to the emergency and recommended that the patient take her pain medication. * 07/20/24 at 10:23 p.m., The NP [nurse practitioner] went to see the resident and measured the swollen left leg with hematoma and still intact at 10X12 cm; ordered to send the resident to E.R. for treatment and further evaluation. After 10 mins [minutes] resident was calling and that she is scarred [sic] that her left left [sic] is draining fluids and dried blood. Resident was sent to E.R. immediately. * 07/24/24 at 3:00 p.m., Resident was brought back to the facility by the ambulance, alert, oriented, responsive, and not in pain. Left leg still swollen and with purplish discoloration, wound kept open and with ace wrap from left ankle to left foot. * 07/26/24 at 1:53 p.m.,. OT [occupational therapist] expressed concern for hematoma to L [left] lower leg is now open and draining . After observing hematoma . contacted NP . * 07/26/24 at 3:19 p.m., . Pt [physical therapist] notified this nurse of open area to posterior Lt [left]leg, stated large amount eschar [dead tissue] to area, looked at wound, hematoma open with a large amount coagulated [clotted] dark blood escaping, call to NP [name], stated she would stop and look at area and speak with resident, remains on antibiotic without adverse reaction. * 07/26/24 at 8:08 p.m., NP [name] came to review the resident and ordered that Resident should be sent to ER for Evaluation of worsening left lower extremity hematoma with necrotic tissue. Resident was taken to ER by EMT at 7pm. * 07/31/24 at 3:30 p.m., Resident was brought back to this facility by ambulance . wound back [sic] intact draining bloody discharge . *08/06/24 at 11:51 p.m., Writer visited with resident on Monday afternoon. She is worried about her bill . She owns a home and wants to be able to return to it. We had a good discussion about how she is holding up mentally. She was hoping to be home by now and now feels like she is starting over. [Resident #61] verbalized being depressed and having a lot on her mind that makes it hard to sleep, she stopped her blood thinner so now whenever she feels something strange, she worries it may be a stroke or heart attack. [Resident #61] said she does not want to die and has no plans to harm herself but feels like she is going to die in here. I asked [Resident #61] if she is interested in speaking to someone and she is, she has an order for a psych consult and is on the list to see the psychiatrist. Review of provider notes identified the following: * 07/16/24 at 9:09 p.m., . presents because of pain and swelling of her left lower leg. She was being brought out of the shower room in a wheelchair when the aide ran her leg into the door frame. She had immediate pain and it began swelling right away . There is a raised 7 x 6 cm x 2 cm raised ecchymotic [bruised] soft/fluctuant [unstable] area on the . left lower leg. she states that after the third dose of morphine [narcotic pain medication] she has finally get [sic] pain relief . * 07/20/24 at 5:00 p.m., . being seen today for evaluation of worsening swelling and pain to left lower extremity. Skin: Measured 12 cm x 10 cm . Surrounding skin appears to have swelling, mild erythema [redness], warmth, and tenderness. Assessment and plan 1. Worsening pain and swelling to LLE [left lower extremity] due to recent trauma. Large intact fluid filled blister with hematoma noted. There is concern for cellulitis - send to ER for evaluation and treatment. * 07/24/24 at 12:00 a.m., . HPI [history of present illness] presented back to the emergency room . with worsening pain swelling and acute drainage from the hematoma. In the emergency room she had a CT scan [computerized tomography] which showed enlarging hematoma measuring 16 cm x 25 cm x 4.7 cm. * 07/26/24 at 5:23 p.m., . evaluated at bedside today for concerns by nursing staff today for worsening left lower extremity hematoma and cellulitis. She was recently sent to the ER and admitted from 7/20/2024 to 7/24/2024 for acute traumatic enlarging left lower extremity hematoma, left lower extremity cellulitis, and acute blood loss anemia [not enough healthy red blood cells to carry oxygen]. She was treated with antibiotics and given blood transfusions. SKIN: large area of necrotic tissue to posterior [back] left lower extremity with large open area and covered with clotted blood. Hematoma measures 25.5 cm x 25 cm. Assessment and plan Hematoma with necrotic skin tissue - There is a concern for developing large necrotic tissue, and worsening cellulitis send to ER for evaluation and treatment. * 07/31/24 at 11:00 a.m., . presented to . hospital 07/26/24 due to large left lower extremity hematoma. Underwent debridement of wound, lower lateral left hematoma 20 cm x 20 cm on 07/28/24 . Wound vac to LLE . wound bed measures approximately 19 cm x 20 cm x 0.3 cm . positive cultures obtained in OR [operating room]. Placed on oral abx [antibiotics] . Review of the facility investigation contained a written statement from the CNA (#27), dated 07/22/24, and stated I, [CNA #27] was giving [Resident #61] a shower on 7/16/24. When we was [sic] finished I had pushed her sideways out the shower door due to her showering in a bari [bariatric] chair, which was a small area, and opening the door at the same time. As I was pushing her out the shower door I didn't realize she had put her leg out & her leg hit the corner of the wall. The facility failed to ensure the CNA (#27) provided a safe transfer for Resident #61 from the shower room which resulted in an injury to the resident's lower leg and lead to a hematoma, increased pain, three hospitalization s, surgical debridement, and placement of a wound vac. 28398 2. Based on observation, record review, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 3 sampled residents (Resident #4) observed during a sit-to-stand lift transfer and (Resident #36) observed with bruises. Failure to use a mechanical lift properly and/or re-evaluate the suitability of a mechanical lift transfer, and monitor/ensure safe transfer methods placed Residents #4 and #36 at risk for injury. Findings include: Review of the EZ Way Smart Stand [type of sit-to-stand mechanical lift] 400, 500 & 800 lb [pound] Capacities Operator's Instructions, revised 09/29/23, pages 2-6, stated, . As patients do vary in size, shape, weight and temperament, these conditions must be taken in to [sic] consideration when deciding if the EZ Way Smart Stand is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. Attach harness 1) Position the harness around the upper body of the patient so the sides of the harness are between the patient's torso and arm, resting 2-3 inches below the underarm. 2) For the safety of the patient, securely fasten the safety strap around the patient's torso. 3) Secure the buckle and pull the strap to tighten. Raise the patient . As the patient is being raised, simultaneously tighten the safety strap buckled around their torso. Stop lifting when the patient is in a standing position. Review of the facility policy titled Transporting Resident For Care Outside The Facility occurred on 08/08/24. This policy, revised February 2023, stated . If there is no family available for transport [NAME] Home will provide a transporter [employee that accompanies residents]. Arrangements can be made with [name of transport company for transportation by bus or van with wheelchair lift. If [transport company] is not available, contact Plan Operations and complete a work order . Notify nursing staff on the Unit of transport. Documentation in Nurses' Notes includes the date, time, who is accompanying the resident, the time of their return and any changes noted upon return. The facility failed to provide a policy for transportation via ambulance van. - Review of Resident #4's medical record occurred on all days of survey. Diagnoses included Alzheimer's disease, muscle weakness, and repeated falls. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment, verbal and other behaviors, functional limitation in range of motion to bilateral lower extremities, dependent with chair-to-bed-to-chair transfers and toilet transfers. The care plan, revised 11/17/23, stated, . Toileting: . Staff assist of 2 and PAL [Portable Aquatic Lift - type of sit-to-stand mechanical lift] to transfer to toilet. Transferring: Assist of 2 and PAL . Resident #4's nurses' notes stated the following: * 01/19/24 at 1:24 p.m., [Resident #4] seen 1/18/24 for re-evaluation for RNP [restorative nursing program]. [Resident #4] requires training with standing and transfers. She is transferring with PAL and 2 staff. Upper body exercises continue as tolerated as well as XBOX [type of workout game]. * 02/26/24 at 1:21 p.m., [Resident #4] was discontinued from the RNP. She will continue to transfer via PAL and 2 staff. Observation on 08/05/24 at 4:56 p.m. showed two certified nurse aides (CNAs) (#6 and #7) transferred Resident #4 with an EZ Way sit-to-stand mechanical lift from the bed to her wheelchair, to the bathroom toilet, and back to her wheelchair. The resident yelled loudly as the CNAs assisted her to sit at the edge of the bed, then placed the lift harness, safety strap, and shin strap, and instructed the resident to hold the handles. As the CNAs (#6 and #7) lifted Resident #4 to a semi-standing position, she yelled loudly as the safety strap slid up her torso, and the CNAs lowered her back to the bed to adjust the safety strap. As the CNAs raised Resident #4 from the bed and encouraged her to stand up straight, her right arm/elbow rose to a nearly horizontal position. The resident whined, moaned, and/or yelled throughout the transfer to the toilet and again while the CNAs raised her from the toilet, provided perineal cares, and changed her brief. Resident #4's right shoulder, upper arm, and elbow rose above a horizontal position and the left arm/elbow nearly to a horizontal position as the CNAs transferred her from the bathroom to her wheelchair. The CNAs (#6 and #7) instructed the resident throughout the transfer to stand up straight as she sagged against the harness and safety strap, with the harness pushing up into her axilla. One CNA (#7) stated Resident #4 is declining with how she stands in the stand lift. Observation on 08/06/24 at 09:08 a.m. showed two CNAs (#8 and #9) transferred Resident #4 from her wheelchair to the bathroom toilet, back to her wheelchair and then to bed. The CNAs placed the EZ Way harness, safety strap (loosely around her torso), and shin strap, then cued the resident to hold the lift handles and stand up straight as she sagged against the harness which pulled up on her axilla. As the CNAs (#8 and #9) raised Resident #4 with the lift, her right arm/elbow moved up and away from her body in a horizontal position, throughout the transfer. Observation on 08/07/24 at 4:41 p.m. showed two CNAs (#6 and #7) applied the EZ Way stand harness, safety strap, and shin strap, while the resident frequently hollered oh boy, ouwwhh. The CNAs cued Resident #4 to hold the lift handles and placed her feet on the foot plate. A CNA (#6) tightened the safety strap as they raised the resident up, and the resident hollered [Explicit word], ouwwhh, do you have to have that so damn tight? Resident #4 failed to bear weight as the CNAs transferred her into the bathroom. During the transfer, the resident's right arm/elbow rose to a horizontal position and her left arm/elbow close to a horizontal position. As the CNAs (#6 and #7) lowered Resident #4 on the toilet, she hollered loudly ouch, that hurts indicating her breast. A CNA (#6) removed the safety strap which had pulled up under her breast. Upon standing the resident from the toilet to provide perineal cares, the CNAs attached the safety strap loosely with the resident's right upper arm/elbow in a horizontal position and the left arm/elbow nearly horizontal. The CNAs failed to tighten the safety strap during the transfer. The CNAs watched the resident's elbows which stuck out and upward, as they exited the bathroom to prevent the resident's elbows from hitting the door frame. When asked about elbow position during transfers, the CNA (#6) stated, I would want my arms down at my sides. A CNA (#7) stated she believed the resident used the stand lift about six months and doesn't feel like she bears her weight in the lift. When asked, a CNA (#6) stated staff should tell the nurse if concerns noted with a transfer, and the nurse would have physical therapy evaluate the use of the lift. During an interview on 08/08/24 at 12:01 p.m., a staff nurse (#20) agreed a resident's arms should not be in a horizontal position during a sit-to-stand mechanical lift transfer. Staff failed to provide safe transfers with the mechanical sit-to-stand lift. The facility failed to monitor Resident #4's upper/lower body strength and appropriate use of the stand lift and failed to periodically monitor and re-evaluate the suitability of the stand lift to meet Resident #4's needs and ensure safe transfers. 45873 - Review of Resident #36's medical record occurred on all days of survey. Diagnoses included muscle weakness and difficulty walking. The current care plan stated, . [Resident] is not able to do his own ADL's or activities of daily living due to weakness . Power wheelchair for locomotion. [Resident] is at risk for bleeding and bruising related to blood thinner medication. [Resident] is at risk for falls due to weakness. Edited: 08/05/2024 When going out for an appointment, communicate with transport to only use lift system and not ramp when getting in/out the van. During an interview on 08/05/24 at 12:46 p.m., when asked about the large bruises on right arm, Resident #36 stated, I was coming back from a doctor's appointment and the transportation van had a ramp instead of a lift. The ramp was too steep, and my power wheelchair doesn't have brakes. I started going down too fast, and I tipped over and fell out. The resident indicated bruises on his legs and knees. Review of Resident #36's progress notes showed the following: *07/29/24 at 1:55 p.m. Resident states he was coming down the ramp in his electric scooter, off of the bus after returning from his appointment. Resident states the entire wheelchair tipped over and fell off the ramp. Resident states he hit his head, his right elbow, has a small abrasion, and his right outer calf has a large hematoma. Provider and care giver were notified. *07/29/24 at 11:29 p.m. Resident has bruise on the right elbow due to fall. No new bruise observed, no complain of pain, alert and oriented. *07/30/24 at 8:11 a.m. [Resident] requested PRN [as needed] Tylenol last night for c/o [complaints of] being sore and his right hamstring and leg were hurting him from the fall. He also requested some ice to put on his hamstring. He showed staff all his bruises on his right elbow and sore areas. He slept all night and this morning after 0630 [6:30 a.m.] he said that he was 'very sore' this morning and he was slower because of it. He told staff all about what happened and about using a ramp to get off the bus and how he had no brakes with his electric wheelchair and everything that happened after that. *7/30/24 at 9:36 a.m. Resident alert, no changes noted in mentation. Hematoma [swollen bruise] to R [right] leg appears stable, but tender to the touch. Bruising to R arm also stable. All skin areas are intact. *07/31/24 at 11:58 p.m. Continues on fall monitoring r/t [related to] recent fall with multicolored bruising to right upper arm / elbow and right outer shin. *08/05/24 at 8:14 a.m. Falls committee meeting on 7/30/24. Recommendation: communicate with transport to only use lift system and not ramp when getting in/out [sic] the van. Care plan has been reviewed. No other concerns/issues raised. During an interview on 08/07/24 at 10:00 a.m., two administrative staff mambers (#1 and #11) confirmed Resident #36 fell out of his wheelchair when exiting a transport van, the transport company completed an incident report, and the facility did not complete an incident report or investigation. The facility failed to evaluate the transfer requirements and safety needs of Resident #36 during van transportation.

Based on record review, review of facility investigation, and review of facility policy, the facility failed to ensure adequate supervision and assistance for 1 of 2 sampled residents (Resident #68) who required staff assistance with transfers and experienced a fall with fracture injury. Findings include: Review of the facility policy titled Fall prevention policy occurred on 08/23/23. This policy, dated May 2022, stated, . residents will be assessed for risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . provide additional interventions as directed by the resident's assessment . rounding to be performed hourly . ambulation and toileting assistance . the plan of care will be revised and updated as needed . Review of Resident #68's medical record occurred on all days of survey. The care plan at the time of the fall showed Resident #68 transferred and ambulated with the assist of one. Nursing progress notes identified the following: *06/28/2023 at 11:39 p.m., . was on the other other side of the hall, when this nurse heard someone calling 'help' from the other side of the hall, asked one of the CNAs [certified nurse aide] to see where the yell was coming from . found resident lying on her right side on the floor in her room . asked what happened . resident stated she went to get her shirt from her closet and when she was going back to her bed she fell . *06/29/2023 at 01:15 a.m., Resident continuously complaining of severe left shoulder pain after the fall . stated she fell and landed on her left side . On call provider notified with order to send the resident to the ER [emergency room ] for evaluation . *06/29/2023 at 6:58 a.m., Resident back to facility at 5:35 a.m. has a fracture on left upper arm . wearing a splint on the affected arm . Physician Progress Notes, dated 07/06/23, stated, . had a fall one week prior and found to have displaced left humeral shaft fracture . having quite a bit of pain . medications for pain . Review of the facility's investigation of the incident identified the following: * . [Resident #68] suffered a fall last night around 11:30 p.m., was sent to the ER, and returned early this morning with a diagnosis of a fractured left upper arm. When the day staff were asking [Resident #68] about her fall this morning, after she woke up, she said she got up alone, to get a shirt out of her closet and fell on her way back to bed. She reported that she asked the CNA [#7] to assist her to get a clean shirt and CNA [#7] told her she didn't need a clean shirt and didn't assist her. That is when [Resident #68] did it herself. She had an accident and wanted her PJ's [pajamas] to match . * The facility investigative team completed the following summary, dated 06/29/23, with a CNA [#7], a witness to the incident. The CNA stated, . [Resident #68] requested to change her shirt so it matched her pajama pants . [CNA #7] admitted saying, 'it is not going to kill you to wear the shirt you have on.' . [CNA #7] said she had to go and left [Resident #68] standing at her dresser. [Resident #68] fell right after [CNA #7] left the room. During an interview on 08/24/23 at 11:43 a.m., an administrative staff (#1) confirmed Resident #68 required the assistance of one staff member for transfers/ambulating and stated she expected staff to follow the care plan. The facility failed to ensure Resident #68 received care and services necessary to attain the highest degree of safety possible during cares to prevent a fall with injury.

CLEANING SOLUTION HAZARDS 1. Based on observation, staff interview, and review of manufacturer's labels, the facility failed to maintain a safe environment (chemicals used by housekeeping staff) when cleaning the facility. The practice of leaving the housekeeping chemicals unattended placed cognitively impaired/wandering residents at risk for accidents and injury. Findings include: Observation on 02/07/17 at 8:20 a.m. showed an unattended (for approximately seventeen minutes) cleaning cart in the hallway between two resident rooms on the 3 South Unit. The cart contained the following cleaning chemical: * an open bucket on top of the cart contained a mixture of water and Coverage Plus NPD Disinfectant (a disinfectant that may be harmful if inhaled or absorbed through the skin and may cause moderate eye irritation), * an open plastic jug and mop bucket on the lower level contained a mixture of water and Coverage Plus NPD. During an interview on 02/07/17 at 8:41 a.m., the nurse (#13) on duty reported having one wandering resident on the unit. The observation showed the unattended cleaning cart parked outside the wandering resident's room. Observation on 02/07/17 at 9:46 a.m. showed an unattended (for approximately six minutes) cleaning cart in the hallway on the 3 East Unit. The cart contained the following cleaning chemical: * an open bucket on top of the cart contained a mixture of water and Coverage Plus NPD, * an open plastic jug and mop bucket on the lower level contained a mixture of water and Coverage Plus NPD. During an interview on 02/07/17 at approximately 9:49 a.m., an unidentified nurse reported having one wandering resident on the unit. She stated, (Resident) wanders. We're trying to get him placed in 4 North, the locked unit. Observation on 02/07/17 at 10:11 a.m. showed an unattended (for approximately eight minutes) cleaning cart in the hallway on the 4 North (locked Alzheimer's) Unit. The cart contained the following cleaning chemical: * an open bucket on top of the cart contained a mixture of water and Coverage Plus NPD, * an open plastic jug and mop bucket on the lower level contained a mixture of water and Coverage Plus NPD. During this observation, a resident exited a resident room on the right side of the hallway, walk over to the unattended cleaning cart, and stared at the items on the top of the cart before entering another resident room on the left side of the hallway. SMOKING HAZARDS During the standard recertification survey on 02/07/17, the team determined a potential Immediate Jeopardy (IJ) situation existed. The IJ potential resulted from an observation at approximately 9:00 a.m. when observation showed Resident #3 outside, smoking in potentially hazardous weather conditions. After observation and interview with the facility staff, the survey team met at 11:00 a.m. and determined corrective action needed to occur. At 11:07 a.m., the team contacted the managerial staff at the State Agency (SA) to report the findings and to discuss a potential IJ situation. At 12:20 p.m., the survey team notified the facility administrator of the IJ and that they must develop a plan for abatement. At 4:38 p.m., the facility provided a written plan of correction for the IJ. The team reviewed and accepted the written plan. At 4:55 p.m., the team determined the IJ situation abated, reduced the scope and severity level to D, and informed the administrator of this action. 2. Based on observation, record review, and resident/staff interviews, the facility failed to ensure 1 of 1 sampled resident (Resident #3) who utilized her wheelchair to leave the facility campus to smoke could do so safely. Failure to identify how she would acquire assistance from staff (if needed) once she had left the facility may result in an avoidable accident with/without injury. Findings include: Review of Resident #3's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], identified Resident #3 as cognitively intact and supervision of one person required for transfers, walking in room/corridor, and locomotion on/off unit. Even though the facility identified Resident #3 as non-interviewable, they determined she was safe to smoke independently, on her Smoking Questionnaire, dated 01/15/17. Resident #3's physician's orders [REDACTED]. The current care guide addressing Resident #3's safety identified, . goes outside to smoke in designated area. Observation showed the following: * 02/07/17 at 8:50 a.m., Resident #3 held a cigarette in one hand as she self propelled her wheelchair through the dining room. She was wearing a hat and unfastened coat. An unidentified certified nursing assistant (CNA) stopped Resident #3 and assisted her with the snaps on her coat. When asked where the designated smoking area was located, the CNA stated, off property. They (residents) are not supposed to smoke. Resident #3 added, I stay close to the building. If I go to where I'm supposed to, I will never make it back in. An electric wheelchair would make it through the snow. I'd be slipping and sliding all over the place. Resident #3 then rode the elevator to the first floor, put on one glove, and exited the building through a set of doors on the east side of the building. (At 8:54 a.m. the temperature in Minot registered at -6 degrees Fahrenheit with a wind speed of 10 mile per hour. In those conditions, frostbite can occur within ten-to-thirty minutes.) At the same time, an unidentified maintenance staff member was observed cleaning the sidewalk in front of the doors with an enclosed, riding snow blower. Resident #3 self propelled her wheelchair next to a table and chairs to the right of the door, lit her cigarette, and began smoking. She then propelled her wheelchair to the left of the door and finished her cigarette. * 02/06/17 at approximately 9:00 a.m., The unidentified maintenance staff member was observed assisting Resident #3 with her wheelchair, before he pushed her back into the building. * 02/06/17 at 9:20 a.m., Resident #3 was sitting in her wheelchair in her room. When asked why the staff member had assisted her, she stated, I was stuck in the snow, that's why he got out to help me. He knew I was stuck, and said 'Let me help you.' When asked how she would have gotten back into the facility if he hadn't been present, she stated, I don't know, maybe someone on the inside would have seen me and bring me back in. I'm too scared to go out where I'm supposed to. When asked if she requested her cigarette from the nurse and/or signed out prior to leaving the Unit, she stated, I keep my own cigarettes and lighter in my dresser. No, I don't sign out. During an interview on 02/07/17 at 11:45 a.m., when asked if Resident #3 requested her cigarette from the nurse and/or signed out before leaving the Unit, a nurse (#13) and certified medication aide (CMA) (#25) indicated Resident #3 keeps them herself. The nurse (#13) stated, No, she doesn't have to check out to smoke unless she leaves the grounds. There is a spot outside the back doors, by the edge of the (parking) lot. There is an ashtray next to the parking lot. When asked how residents who smoke contact staff if they require assistance, the nurse (#13) stated, They (residents) usually have walkie-talkies. The CMA (#25) contradicted her, by stating, They don't have walkies. They were throwing them away. Most (residents) have cell phones. (There are) one or two that don't. If they are out there for a long time, we'd go check on them. When asked how would you know to check on the resident, if you were unaware they had left the facility to smoke, the staff members (#13 and #25) failed to respond. During an interview on 02/07/17 at 12:20 p.m., an administrative staff member (#2) reported, We encourage residents and families to have a phone. I'm not sure if (Resident #3) has a phone. We do have walkie-talkies too. Observation showed the following: * 02/07/17 at 1:20 p.m. Resident #3 held a cigarette in one hand as she self propelled her wheelchair towards the exit. She was wearing a hat and coat, with only one snap secured. When asked if she had a cell phone or walkie-talkie on her person, she stated, I don't have the right charger (for my phone). No, no walkie-talkie. I told you they don't do that. Resident #3 exited the building through the set of doors on the east side of the building. Facility staff had cleared the sidewalk to the north, but the sidewalk to the south remained covered in snow. * 02/07/17 at approximately 1:40 p.m., Resident #3 finished her cigarette, pushed the handicapped button near the door, held onto the door frame, and rocked her chair two-to-three times before passing over the transition strip between the sidewalk and building. The facility failed to ensure Resident #3 received the care and services necessary for personal safety while smoking. The facility failed to ensure (given her [DIAGNOSES REDACTED].#3 was capable of self-propelling her wheelchair through the snow to/from the designated smoking area. The facility failed to identify/care plan how Resident #3 would acquire assistance from staff (if needed) once she'd left the facility.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 03/10/16 Based on observation, record review, facility policy, and staff interview, the facility failed to provide the necessary treatment and services to prevent the development of pressure ulcers for 3 of 9 sampled residents (Resident #1, #2, and #11). Failure to implement preventative measures resulted in Resident #2 and #11 developing pressure ulcers on their heels, and placed Resident #1 at risk of developing an ulcer. Findings include: Review of the facility policy titled Pressure Ulcer Prevention Protocol occurred on 02/09/17. This policy, undated, stated, . Elevate/Float heels off bed using pillows . Staff member must be able to pass hand freely between mattress and heel . without touching once pillows . are in place. Use pressure reduction cushion while resident in . chair. - Review of Resident #2's medical record occurred February 06-09, 2017. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition, limited assistance of one person required for transfers, dressing, and toileting, unhealed Stage 3 pressure ulcer, pressure reducing device for chair/bed, and ointments/medications. The progress notes identified the following: * 09/11/16 at 8:19 a.m., . Resident was able to move left foot but complained of moderate to severe pain with movement of left leg. order received to send to ER (emergency room ) for evaluation. * 09/11/16 at 1:36 p.m., Returned to facility at 1305 (1:05 p.m.) . Knee immobilizer in place to left leg and to be worn when resident is out of bed . * 09/13/16 at 9:41 a.m., Resident is up in wheel chair . resident stated '. it (is) just uncomfortable with this brace on' . * 09/28/16 at 7:30 a.m., . resident . stated 'my left hip pop (sic) out again,' resident left foot and knee was (sic) inverting inward, but was able to move her toes . order resident to ER for eval (evaluation) of the left hip . * 09/28/16 at 1:29 p.m., Resident return (sic) from ER with no new orders . * 10/13/16 at 5:22 p.m.,Wound care note: Assessed a stage II pressure ulcer to top of left ankle/foot area measuring 0.5 x (by) 0.5 x 0.1 cms (centimeters). Wound bed is covered with a thin red scab. The ulcer is on a bony prominence of the foot and the pressure is from the leg brace resting on it. Staff is now aware of the importance of making sure is in proper placement on the left leg. * 10/19/16 at 3:22 p.m., Wound care note: . Resident has an area on her left top foot, .5 x .5, resident stated 'that's where this brace is rubbing' . Assessed a deep tissue injury to left heel measuring 2.5 x 3.3 cms. Wound bed is deep maroon and spongy to palpation. Resident does not wear shoes on that foot. Her leg immobilizer was lower than it should be and her foot was resting on it. Leg immobilizer taken off. Staff educated on proper application of leg immobilizer. Review of the Ulcer Management History, dated 10/13/16-02/09/17, described the following: * 10/13/16 - A round Stage II pressure ulcer to the top of the left foot/ankle, wound bed covered 100% by a thin, red scab, measuring 0.5 x 0.5 x 0.1 cm, with dark red/purple [DIAGNOSES REDACTED]tous periwound. 02/09/17 - An irregular Stage II pressure ulcer to the dorsal left foot, wound bed 100% red, measuring 0.8 x 0.4 x 0.1 cm, with intact periwound. * 10/13/16 - An elongated, unstageable pressure ulcer to the left heel, wound bed covered 100% by thin, black eschar, measuring 0.3 x 0.2 cm with an unknown depth/tunneling, with intact periwound. 02/09/17 - An irregular shaped, unstageable pressure ulcer to the left heel, wound bed covered 100% by black eschar, measuring 2.4 x 2.5 cm with an unknown depth/tunneling, with intact periwound. During an interview on 02/09/17 at 8:57 a.m., when asked if the facility educated staff on how to properly apply Resident #2's leg immobilizer prior to her developing two pressure ulcers, the managerial nurse (#18) stated, I don't believe education was provided prior to the ulcer(s), no. Failure to provide staff education and failure to ensure staff correctly applied Resident #2's leg immobilizer resulted in her developing two pressure ulcers, a Stage II ulcer to the top of her left foot/ankle and an unstageable ulcer to her left heel. The Bed Mobility Assistance assessment, dated 12/15/16, identified Resident #2 required assistance to reposition herself in bed and likes to sit in her recliner in room. Both the current care plan addressing Resident #2's skin integrity and the current care guide identified, . Approach: . cushion to recliner . at all times. Observation showed the following: * Early afternoon on 02/08/17, Resident #2 sat in her recliner, with no cushion visible. * 02/09/17 at 8:25 a.m., Resident #2 sat in her recliner, with no cushion visible. During an interview on 02/09/17 at 9:25 a.m., a CNA (#24) confirmed Resident #2 did not have a cushion in her recliner. During an interview on 02/09/17 at 10:20 a.m., a managerial nurse (#18) reported, (Resident #2's) cushion is being laundered. We don't have any extras to replace the one in laundry between cleanings. Failure to ensure staff placed a cushion in Resident #2's recliner at all times per her care plan/guide placed her at risk of developing a pressure ulcers to her buttocks/coccyx. - Review of Resident #11's medical record occurred February 06-09, 2017. [DIAGNOSES REDACTED]. A quarterly MDS, dated [DATE], identified short and long-term memory problems, moderately independent daily decision making, supervision with one person assist for bed mobility, walking in room and corridor, at risk for pressure ulcers, no unhealed pressure ulcers, no pressure relieving devices for her bed, and no skin problems. A progress note, dated 02/02/17 at 2:20 p.m., stated, Wound care note: Resident seen as per concerns of (named two nursing staff members). Assessed a deep tissue injury to right lateral foot in the inferior ankle area measuring 3 x 4 cms. Area is black underneath soft skin. The deep tissue injury is part of a drained and unroofed (partially opened) blister measuring 4 x 7 cms. Nursing staff says the area had drained a large amount of serous drainage earlier today. Scant amount of serous drainage noted now. No odor. Periwound to the area is pink and blanchable. Resident denies pain. Resident has swim buddies (swimming noodles) in her bed and it is possible that she rested her foot against a swim buddy in her sleep causing excessive pressure to the area. Floor nurses will see about getting a perimeter mattress for resident to eliminate the need for swim buddies. Discussed with (above nurses) the use of Prevalon Boots or heel protectors but they were concerned that resident would walk in them and end up falling. Resident is not aware of her own safety needs. A General Maintenance Request, showed the facility requested a perimeter mattress for Resident #11 on 02/03/17. An Ulcer Management record, dated 02/07/17, stated . location - lateral/foot heel . % Wound Black - 100% black under intact skin . Wound Length (in cm) - 3, Wound Width (in cm) - 4 . Drainage Amount - Moderate (dressing saturated, involves 25-75% or (sic) dressing) Drainage Color - Serous, Odor - No, Pain - No, Periwound - [MEDICAL CONDITION] 2+ . Comments: Deep tissue injury (DTI) remains in the center of a mostly unroofed blister. Some clear fluid build up is noted in the blister. The DTI is slightly boggy with palpation. Periwound of the blister is pink and intact. Resident pulls away and verbally reacts during wound assessment and dressing change but denies painwhen (sic) she is asked and states It's maybe (sic) anticipatory. During an observation, on 02/07/17 at 2:00 p.m., a nurse (#26) completed an assessment and a dressing change to Resident #11's right lateral heel. Observation showed Resident #11 continued to have swim buddies in place in her bed. The swim buddy on the exit side of the bed did not follow the edge of the mattress, but angled into the bed and the resident's left leg went over the swim buddy. During an interview, on 02/07/17, immediately following the dressing change, the nurse (#26) identified staff are not using protective boots for Resident #11 due to fall risks but she did direct staff to remove the swim buddies as she felt they may have contributed to the pressure wound. When informed the swim buddies remained, the nurse (#26) went back into the room, confirmed the swim buddies were there, and indicated she expected staff to remove them from Resident #11's bed on 02/02/17. Failure to remove the swim buddies from Resident #11's bed after the development of a pressure area may contribute to the development of other pressure areas. Observation of the resident laying on the swim buddy demonstrated the continued possibility of unrelieved pressure from the swim buddies. - Review of Resident #1's medical record occurred February 06-09, 2017. [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], identified severely impaired cognition and extensive assistance of one or more persons required for Activities of Daily Living (ADLs). The Bed Mobility Assistance assessment, dated 01/12/17, identified Resident #1 required assistance to reposition herself in bed. The current care plan addressing Resident #1's skin integrity failed to address appropriate positioning when in bed. The current care guide identified, . pillows under feet and float heals. Placing pillows directly under Resident #1's feet contradicts the preventative measure of floating her heels. Observation showed the following: * 02/07/17 at 8:42 a.m., showed two CNAs (#19 and #20) provided Resident #1's cares as she laid in bed. The CNAs (#19 and #20) placed a pillow under her knees/calves, resulting in Resident #1's heels resting directly on the mattress. * Early afternoon on 02/07/17, Resident #1 laid in bed with a pillow placed under her knees/calves, resulting in her heels resting directly on the mattress. * 02/07/17 at 3:10 p.m., Resident #1 laid in bed with her heels resting directly against the foot board. * 02/08/17 at 9:40 a.m., showed two CNAs (#19 and #20) provided Resident #1's cares as she laid in bed. The CNAs (#14 and #24) placed a pillow under her knees/calves, resulting in Resident #1's left heel resting directly on the mattress. * 02/08/17 at 10:15 a.m., Resident #1 laid in bed with her left heel resting directly on the mattress. During an interview on 02/09/17 at 10:20 a.m., a managerial nurse (#18) offered no additional information. Failure to ensure Resident #1's heels floated per her care guide placed her at risk of developing a pressure ulcer to one or both heels.

FALL PREVENTION 1. Based on information received from the complainants, observation, record review, and staff interview, the facility failed to provide adequate supervision and assistive devices for 1 of 3 sampled residents (Resident #4) and two closed record residents (Resident #7 and #8) who fell /fractured. Failure to implement interventions correctly and consistently, evaluate the effectiveness of interventions, modify/replace interventions as needed, and evaluate the effectiveness of new interventions, resulted in Resident #8 experiencing additional falls with injury, and may have resulted in Resident #4 and #7 experiencing additional falls with/without injury. Findings include: Information submitted by the complainants identified the facility failed to reassess fall prevention interventions and make revisions as deemed appropriate resulting in Resident #8 experiencing numerous falls; two with serious injury. - Review of Resident #8's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The quarterly Minimal Data Set (MDS), dated [DATE], identified severely impaired cognitive skills, extensive assistance of two or more persons required for transfers, and history of falls. The safety care plan, dated 03/14/16, identified, . at risk for falls . Call light within reach . hourly rounds with offering toilet and fluids . PT/OT (physical therapy/occupational therapy) as ordered . An additional entry, made after the resident's fifth fall, dated 05/23/16, identified . Physical Therapy - to encourage more movement. No other interventions were care planned despite the fact Resident #8 fell an additional ten times, sustained a left hip fracture, left orbital and maxillary sinus fractures, and a subdural hematoma. Review of Resident #8's Falls Documentation identified the following falls and interventions: * 02/19/16, At (5:05 p.m.) . Resident fell . Hallway of the unit. Resident is restless, walks aimlessly around the unit. Response to fall - Frequent rounding for this resident, redirection whenever he feels he is lost. Resident educated to always ask for help for needs. Hallway and room freed from clutter. All staff educated to keep a close eye on him being new to the unit. * 03/23/16, At 11:00 a.m. CNA calls for help, she found this resident sitting in (sic) the floor, beside bathroom door. Resident said he's trying to go to the bathroom but got off balance. Resident's room . Weakness and balance problems. Skin tears to left hand, right forarm and right elbow. Abrasion to right knee. Response to fall - Resident was advised to use call light when needed (sic) help * 05/01/16, At 3:00 a.m. Resident was found sitting on floor nearby resident bed. Resident stated he tried to go to bathroom by himself. Abrasion to bilateral knees. Skin tear to left forearm and left hand. Response to fall - Educated resident to use call light for help and wait for staff to come assist. * 05/01/16, At 11:50 a.m. Resident found sitting on butt on floor on the side of the bed by CNA. (room number) . resident was getting up on his own. skin tear to left forearm and c/o (complained of) again of pain to his left hip area. The corresponding Incident Report identified, . Sent to . and admitted to Hospital. Resident will be evaluated when returns after surgery. Response to fall - reminded resident to use call light for assistance. The Emergency Documentation from the hospital, dated 05/01/16, identified, . The patient presents following fall. The onset was had (sic) an unwitnessed fall early this morning and then had another unwitnessed fall around noon. Left hip. The character of symptoms is pain . severe, 10/10 . and loss of mobility . discoloration of skin over left forehead and around left eye. The Discharge Documentation, dated 05/09/16, identified, He was identified to have a left hip fracture. the surgery went forward on May 5 . Patient being discharged back to (Nursing Home) . Review of Resident #8's Falls Documentation also identified the following falls and interventions: * 05/21/16, At (1:30 p.m.) . staff found him in the bathroom drying (sic) to get on toilet. he started to fall and staff quided (sic) him to the floor, sitting in postion (sic) . he was trying to go to the bathroom . The Fall Prevention (Hourly Rounds) form, dated 05/21/16, identified staff monitored Resident #8's whereabouts at 12:00 p.m. and 2:48 p.m. The form identified Resident #8 at lunch at 12:00 p.m. and staff had no concerns at 2:48 p.m. Response to fall - just monitor. Re educated resident not to get up without help * 06/02/16, At (7:10 p.m.) . He was seated on his wheelchair next to his bed. Apparently he stood up by himself without asking help from his CNA who was preparing stuff for his night cares, lost balance and fell . He got a skin tear to his upper arm. Response to fall - Resident reeducated to always ask for help esp (especially) with transfers as he is still unsteady. Staff also reminded to always tell resident to wait for help. Room freed from clutter, call light within reach, toileting needs always offered during roundings. * 06/03/16, At (4:00 p.m.) . Resident was found by CNA on the floor lying on his right side. He said he went to his closet to grab a new shirt, lost his balance & (and) fell . He denied hitting his head, he does not have any pain complaints at this time. No new injury was found. confusion . Response to fall - Resident reminded to use his call light for his needs. Frequency of roundings. * 06/07/16, At 10:50 a.m. resident said he's trying to get to his bed but he slipped from his W/C (wheelchair) down to the floor . Resident trying to get into his bed without asking for help or forget (sic) to use his call light. Response to fall - lay resident down in his bed after every meal or activity. Place on hourly rounding * 06/08/16, At (4:40 p.m.) . Resident was found by CNA laying on his back in his room. When asked regarding what happened, he said he tried to reach for something from the table. Was helped back up to his wheelchair. A skin tear on his left hand was found upon assessment. confusion . Left hand skin tear . Response to fall - ReOrientation on call light use. Resident on hourly rounding. * 06/11/16, At 11:35 a.m. Resident was found on the floor sitting beside hois (sic) bed. Resident says he tries to get up and slipped on the floor. Resident was confused, that he had a fractured hip and still weak and needs assistance when getting up . Response to fall - on hourly rounding. First to lay down after meals and first to get up for meals. * 06/21/16, At (4:30 p.m.) . Resident attempts to stand at nurses desk indepdently (sic) and falls to floor onto left side . Response to fall - encourage resident to stay in w/c and ask for assistance to stand. * 06/24/16, (4:00 p.m.) . Resident was found by CNA on Left side-lying position on the floor in his room. When asked regarding what happened, resident said he did not know. confusion & dementia . Bruising & Swelling on Left eye, Nosebleed on Left nare, Abrasions on Left knee, redness on neck. The Fall Prevention (Hourly Rounds) forms, dated 06/24/16, identified staff monitored Resident #8's whereabouts/needs at exactly 4:00 p.m. with no concerns noted. Response to fall - Frequent reOrientation on call light use on roundings & reminded to ask for assistance on needs, still on hourly roundingd (sic). The Emergency Documentation from the hospital, dated 06/24/16, identified, . The patient presents following Fall. with c/o left eye and facial swelling and bruising . Pupil: Both eyes . unreactive. Pt (patient) is also reported to have had recurrent falls. Acute left orbital and maxillary sinus fracture as described above. Scattered acute subarachnoid hemorrhages . Right medial temporal lobe contusion . Review of Resident #8's Falls Documentation also identified the following falls and interventions: * 07/01/16, At (4:05 p.m.) . Resident fell . In the hallway, close to his bedroom. Resident propelled his w/c, stood up without asking for help. Skin tear to right cheek, bruise and abrasion to right shoulder. Response to fall - Resident reeducated to always ask help on transfer, neurochecks for 24-hr (hours), skin care protocol initite (sic), dressing to rt (right) cheek skin tear done. Hospitalist-on-call and family updated. * 07/03/16, At 7:00 a.m. found him sitting on the floor on his buttock. Legs straight out. back against the bed side table . in his room . not sure he is very busy . Abrasions to: left knee measures 3 cm (centimeters) by 4 cm., left shoulder 4 cm by 4 cm. left buttock 4 cm by 3 cm . Response to fall - will monitor. * 07/11/16, At 10:20 p.m. Resident was found kneeling on floor nearby resident's bed. Resident has no injuries note (sic) . Resident stated he tried to get out of bed by himself. Response to fall - Educated staff to check on resident frequently. The Emergency Documentation from the hospital, dated 07/12/16, identified, . just discharged yesterday with the chief [DIAGNOSES REDACTED]. hypoxic, and bradycardic, and was transferred to the emergency room . family has agreed to comfort care with limited measures. The progress notes, dated February 19-July 12, 2016, identified the following interventions: * 25 entries - call light within reach, educated to use call light, encouraged to use call light, reminders to use call light, reminded to ask for assistance when needed * 7 entries - hourly rounds * 7 entries - low bed * 5 entries - side rail * 3 entries - PT * 1 entry - first up before a meal and first in bed after a meal * 1 entry - walk list A progress note, dated 03/04/16, identified Resident #8 was unable to comprehend the use of the call light. Staff made this entry two weeks after Resident #8 was admitted to the facility and following his first fall. A document summarizing communication with a member of Resident #8's family, dated 07/11/16, identified the family member had contacted the facility with their concerns. The facility informed the family member they round hourly and try to keep (Resident #8) occupied so he doesn't try to get up on his own. Staff (would) also be educated on falls precautions with Resident #8 . The facility provided 29 days of Fall Prevention (Hourly Rounds) forms, dated May 21-July 12, 2016, specific to Resident #8. The forms failed to identify the date staff collected data on 8 of 29 days. Staff failed to complete the forms on 7 of 29 days. The documentation showed staff failed to thoroughly/accurately complete the hourly rounds form as evidenced by ranges from 1 to 14 hours per day. - Random observations during initial tour on 10/12/16 at 10:05 a.m. showed the following: * Room 253, Staff last documented on the hourly rounds form at 6:00 a.m. * Room 260, Staff last documented on one of the resident's hourly rounds form at 11:00 a.m. and on the other resident's hourly rounds form at 6:00 a.m. - Random observations on 10/13/16 at 10:15 a.m. showed the following: * Room 363-2, Room 364-1, and Room 365-2, Staff last documented on the hourly rounds form at 6:00 a.m. * Room 364-2, Staff last documented on the hourly rounds form at 6:00 a.m. Staff made an additional entry at 9:00 a.m. They failed to document hourly rounds between 6:00 a.m. and 9:00 a.m. * Room 358-1, Staff last documented on the hourly rounds form at 8:00 a.m. During an interview on 10/13/16 at 10:30 a.m., a managerial nurse (#17) reported staff perform hourly checks to prevent falls, to anticipate (the residents') needs. He stated the top two (needs) are hydration and toileting. He confirmed staff are expected to sign the form on an hourly basis after checking on the residents' whereabouts/needs. During an interview on the afternoon of 10/13/16, an administrative nurse (#7) reported the Fall Prevention (Hourly Rounds) forms are not part of the permanent record. During an interview on the afternoon of 10/13/16 fall safety issues were discussed with administrative staff members (#6 and #7). The staff members provided no additional information. The facility failed to ensure staff implemented Resident #8's fall prevention interventions correctly and consistently, failed to evaluate the effectiveness of those interventions, failed to modify/replace those interventions as needed, and failed to evaluate the effectiveness of any new interventions as evidenced by the following: * The care plan identified call light within reach, despite the fact Resident #8 had severe cognitive deficits and staff identified he was unable to utilize his call light appropriately two weeks post admission to the facility. * Although the care plan identified hourly rounds, the facility failed to ensure staff checked on Resident #8's whereabouts/needs on an hourly basis as evidenced by record review. Staff failed to document the date observations were made, failed to complete the hourly rounds form as evidenced by ranges from 1 to 14 hours per day, and/or documented Resident #8's whereabouts/needs were monitored the exact time of a fall with no concerns noted. Observations made during the complaint survey showed these practices continue to occur. * One additional intervention identified on Resident #8's care plan was PT/OT as ordered, despite the fact Resident #8 fell fifteen times within a five month period, resulting in significant injuries. - Review of Resident #4's medical record occurred on 10/13/16 and [DIAGNOSES REDACTED]. The record identified the resident received hospice services, experienced intermittent confusion, had an indwelling urinary catheter, and received morphine (used for severe pain) and lorazepam (used for restlessness or anxiety). The current care plan stated, . Safety - at risk for falls, at risk for injury, oxygen precautions, aspiration precautions, hourly rounding, immobilizer and ace wrap to displaced right femur fracture . Approach . Resident assessed at risk for falls, Requires ½ siderails . call light within reach . falls precautions (approaches started 06/21/16) . Review of Resident #4's progress notes and corresponding falls documentation/reports identified the following falls and interventions: *06/22/16 - At (7:15 p.m.) resident was found on the floor by CNA. He was at the end of the bed on his back with his feet on the floor. He stated he needed help getting up because he was weak. Myself and two CNA (sic) finally got resident up with gait belt. He had abrasion on right knee and the catheter was on the bed. Complaints of right knee pain he stated, 'I was going to the garbage can.' No other complaints of pain . Contacted the son and call bell near. Response to fall - remind resident to use call bell for assistance when wanting toget (sic) up. *07/11/16 - No progress note, but a falls documentation note, dated 07/11/16 at 7:45 a.m., stated, CNA found resident sitting on floor with back against bed and feet out in fron tof (sic) him . Resident was attempting to self-transfer to the w/c (wheelchair) . Instructed resident to use call light when he needs assistance. Response to fall - Instructed resident to use call light when he needs assistance. *Falls Committee Progress Note 07/12/16, charted 07/20/16, Previous Interventions: (left blank), Current Interventions: Call light within reach, assist of two gait belt, cue resident, allow additional time, fall precautions, Committee Notes: continue with current interventions . *08/15/16 at 4:43 a.m. - CNA heard resident call for help found him on the floor beside the bed. He says he lost his balance was trying to sit on the edge of the bed and toppled off the bed. Resident has a scrape above his left eye, an abrasion to the left cheek, a skin tear to the left hand and had a nose bleed. Resident is alert and orientated with neuros (neurological checks) intact. Resident is cleaned up and back in the bed we reminded him to use his call light for assistance and will do frequent rounding. I have notified his wife . and the hospice nurse on call. Response to fall - will do more frequent rounding, resident was reminded to use his call light for assistance. *09/06/16 - At 155 PM (1:55) I heard a thud and resident yelled help me I went int (sic) the room and he was laying on the floor saying my leg hurts. He did have his right leg turned in to the medial side. I did call the hospice nurse and the provider her (sic) at the nursing home. (Name of provider) came and gave order to send him to the ER (emergency room ). The hospice nurse was here as well and suggested the same. The son was here very shortly after he fell . The ambulance came and placed him on a back board took him to the ER . Response to fall - He was sent to the ER for eval. Review of a physician's progress note from the ER, dated 09/06/16, stated, . History of Present Illness, The patient presents with Extremity injury major . PT (patient) is currently on hospice care at a nursing home. PT states he got out of bed and took a step and his leg just gave out. PT complains of pain to his right leg . Physical Examination . Right, hip, deformity anterior dislocation, ankle/foot: right, internally rotated . Alert and oriented to person, place, time, and situation . Impression and Plan, Fracture (fx) of distal femur . [DIAGNOSES REDACTED] metastatic to bone . Pathologic fx . A nursing progress note, dated 09/09/16, stated, Unit received call from Hospice Nurse this shift stating that resident will return back from the hospital on [DATE]. Hi/low bed ordered for resident and received this shift . During an interview on 10/13/16, an administrative nurse (#10) provided no additional information regarding interventions attempted to address Resident #4's falls. The facility failed to provide proactive interventions to address Resident #4's risk for falls and failed to reassess and implement individualized interventions specific to his health status and needs at the time of his falls. Resident #4 did not receive a low bed until returning from the hospital after his fourth fall. - Review of Resident #7's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Resident #7's care plan stated, Problem: AMBULATION - walks independently, has a cane in room but does not use it . Approach: Ambulatory - Walks independently. Has a cane in room to use if needed. Problem: SAFETY . Approach: Resident assessed at risk for falls, Call light within reach . Problem: TRANSFERRING - independent - no supervision required . Approach: Stand-by Assistance with Transfers, Cue resident before & (and) during transfers, Uses cane and/or walker, Give verbal cues as needed before/during transfer for sequencing and direction - Independent uses cane . Review of Resident #7's progress notes and corresponding falls documentation/reports identified the following falls and interventions: *11/16/15 at 9:17 p.m.: Resident was observed sitting on the floor in the TV room by the nurses station. He was sitting on the left side of his walker. Visual body check and AROM (active range of motion) showed no injuries. Family notified. Response to fall - already in place *12/28/15 at 2:43 a.m.: Resident seen by staff in the bathroom with BM (bowel movement) all over his body, he was cleaning him when suddenly resident rolled his eyes and passed out in his arms, resident was lowered down to the floor. No injuries sustained. Response to fall - Reoriented to call light, visited more frequently. *01/07/16 at 9:30 a.m.: CNA and med (medication) aide found resident kneeling on floor in dining room . unable to explain what happened. Assessed for any injuries and none noted no redness observed to knees. Response to fall - already in place *01/12/16 2:46 p.m.: Resident was walking in hallway with his cane, lost his balance and fell . assessed for injury with none noted. Response to fall - Continue with current plan of care. *01/23/16 at 7:00 p.m.: Notified by CNA that resident had fallen. Resident apparently lowered himself slowly to the floor. Vitals signs WNL (within normal limits), resident resting in bed at this time. No injuries noted, no pain reported to resident. Response to fall - closer monitoring when resident is ambulating. * 01/27/16 at 10:38 a.m.: New order received (sic) for PT (physical therapy) for strengthening and gait training . *01/28/16: resident observed in sitting position in hallway on floor alert to self no pain noted no injury noted . Response to fall - encourage resident to use walker and to use seat on walker when he wants to rest *02/11/16 at 9:36 p.m.: 1445. (2:45 p.m.) Resident was observed by roommate's family, falling to the floor near nurse double doors. No injuries noted. Response to fall - Assisted to sit in w/c (wheelchair) et (and) given boost. Resident unable to explain why he fell *02/14/16 at 8:52 p.m.: CNA observed resident sitting on dining room floor. Resident denies any pain related to fall. No injuries . Response to fall - Closer monitoring, encourage resident to use walk (sic). *02/17/16 at 5:30 a.m.: Resident was found on the floor. No injuries . Response to fall - monitor for pain and latent injuries for 3 days *02/23/16 at 12:43 p.m.: Cna reports that when she was transfering (sic) resident to shower chair he went down on his knees and now has three small red areas to left knee and one red area to right knee, will monitor. Response to fall - encourage use of walker with transfers *02/24/16 at 3:30 p.m.: Resident observed by staff reaching for the railing et (and) fell , hitting is (sic) left shoulder. No injuries . Response to fall - assisted to sitting on the couch, by staff members, continues to wonder (sic) around the unit. Do encourage resident to use can et walk near the wall railing. The progress notes failed to include any Falls Committee Progress Notes. During an interview on 10/13/16 at 11:00 a.m., two administrative nurses (#7 and #11) stated staff provided showers almost daily due to Resident #7's behaviors regarding bowels and in hopes of preventing falls. They also stated the special care unit is specialized and they let residents be as independent as they can. The facility failed to provide proactive interventions to address Resident #7's risk for falls and failed to reassess and implement individualized interventions specific to his needs at the time of his falls. TRANSFERS 2. Based on observation, record review and staff interview, the facility failed to provide adequate assistive devices necessary to prevent accidents for 1 of 3 sampled residents (Resident #1) observed during transfers. Failure to apply and utilize a gait belt and report a fall placed the resident at risk for sustaining an injury. Findings include: Review of Resident #1's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The care guide stated, Transfer: Transfers with a gaitbelt and assist of 1. (Resident #1) will transfer self without notifying staff at times. The care plan stated, Problem: AMBULATION . one person assistance, Refuses to use a walker and wear gait belt . Problem: SAFETY - potential for falls related to unsteady gait, poor safety awareness, refuses to use a walker, and antidepressant med (medication) use, mattress next to bed - will lay on mat per her wishes, hourly rounding, high low bed . Approach . Floor mat next to bed while resident in bed. (Resident #1) will crawl onto mat herself and want to lay there for a time . Problem: TRANSFERRING - self care deficit- requires extensive assistance . Approach: Transfers with a gaitbelt and assist of 1. (Resident #1) will transfer self without notifying staff at times. Observation during initial tour on 10/12/16 at 10:30 a.m. showed Resident #1 kneeling on the bedroom floor in front of her sofa. Two mattresses were in the room but not on the floor. A falls prevention worksheet posted on Resident #1's door showed staff last signed off the safety checks at 6:00 a.m. (3 1/2 hours prior to this observation). A certified nursing assistant (CNA) (#12) walked by Resident #1's room and saw her kneeling on the floor. The CNA signed off the safety checks through 10:00 a.m., gowned and gloved, and entered Resident #1's room. The CNA (#12) lifted under both of Resident #1's axilla and the resident said ow. The CNA asked the resident to help and the CNA lowered the resident to the floor. Resident #1 started to get up and the CNA said I can help you and lifted Resident #1's buttocks up and onto the couch. The CNA (#12) failed to notify the nurse regarding Resident #1 kneeling on the floor and potential fall and failed to use a gait belt to transfer the resident. Review of the progress notes failed to reflect this incident and Resident #1's potential fall. During an interview on 10/13/16 at 10:10 a.m., an administrative nurse (#10) stated she would expect staff to first notify the nurse the resident is on the floor and she would expect staff to attempt to apply a gaitbelt (Resident #1 refuses at times) and assist the resident off the floor with two staff members. She also stated she would expect staff to complete the hourly safety checks and document on the fall prevention sheet.

1. Based on observation, record review, staff interview, and review of internal facility information (e-mails), the facility failed to ensure 2 of 2 sampled residents (Resident #3 and #20) received the care and services necessary to attain the highest degree of safety possible while drinking hot coffee. Failure to provide coffee at a safe temperature resulted in Resident #3 and #20 sustaining burns on their bodies and caused these residents unnecessary discomfort and pain. Failure of the facility to implement a system to monitor the temperature of the coffee dispensing machines used by residents has the potential to result in additional burns to residents who drink coffee. Findings include: - Review of Resident #3's medical record occurred on February ,[DATE], 2013. Medical [DIAGNOSES REDACTED]. Resident #3's Progress Notes from [DATE] stated: [DATE] at 9:45 p.m. - ". . . Went out to dining room (adjacent to the 2 West Nursing Unit) to eat - able to feed self . . . ." [DATE] at 9:30 a.m. - "(resident's first name) spilled hot coffee on his right upper thigh he did obtain a water filled blister which is intact, ice applied to right upper thigh, leg is cool to touch denies any discomfort he stated 'It feels better then it did this morning.' Daughter . . . notified of incident, also reminded staff to put ice chips or cold water in his coffee." [DATE] at 12:47 a.m. - "Blister right thigh now open. It is 0.5 cm (centimeters) in diameter. No s/s (signs/symptoms) of infection present and resident does not c/o (complain of) pain to area." [DATE] at 5:47 a.m. - "Resident scratched at thigh blister early in the shift. Area cleaned and ointment applied then covered with non adherent dressing . . . ." Review of the Progress Notes from [DATE]-30, 2012 failed to provide any information regarding Resident #3's blister to his right thigh related to the coffee burn. Resident #3's [DATE] care plan, provided by the facility for review, failed to show evidence the facility implemented any interventions to prevent further burn incidents. During an interview on the morning of [DATE], the surveyor asked an administrative nurse (#26) to provide additional information regarding the coffee burn sustained by Resident #3 on [DATE] (specifically, what time of day did the incident occur, what type of eating assistance did the resident require at the time of the incident, did the resident have a cover/lid on the coffee cup prior to the incident, was the resident attended by staff at the time of the incident, and what correction action was implemented by the facility following the incident). On [DATE] at 2:00 p.m., an administrative nurse (#26) stated the facility did not have any incident report or additional information available for review regarding the coffee burn sustained by Resident #3. This administrative nurse (#26) stated she expected the nurse who knew of the burn to complete an incident report. When asked if any staff member in the facility initiated monitoring the temperature of the coffee dispensing machine used by residents following the [DATE] incident, an administrative nurse (#26) stated she did not know. - Review of Resident #20's medical record occurred on February ,[DATE], 2013. Resident #20's Progress Notes, dated February ,[DATE], 2013, stated, *[DATE] at 2:15 p.m. - "resident was up in her wheelchair having coffee, coffee spilled on abdomen 11 cm wide X (by) 9 cm, left groin 6 x 4 cm, right groin 4 x 4 cm, all areas reddened. (name of doctor) taking call notified and residents (sic) daughter (name) updated: (regarding) incident." *[DATE] at 3:25 a.m. - " . . . Resident did sustain burns from earlier coffee spill. Large area to abdomen, around umbilicus is red but free of blisters. Left inner thigh is red and has a large blister present. The right inner thigh has a smaller area of red with moderate sized blister. Triple antibiotic ointment applied as earlier ordered and resident settled in bed . . . ." *[DATE] at 8:43 p.m. - "Resident up in chair per usual routine. Offers no complaints of pain or discomfort from coffee spill to her abdomen and leg/groin area. Cream applied to help with healing." *[DATE] at 6:56 p.m.- "Residents (sic) adoment (sic) area is red and skin has peeled off in most areas. Resident combative when trying to apply cream to burn area." *[DATE] at 1:34 p.m. - "Monitoring - Monitor Skin 3 open areas on abdomen are covered with yellow exudate. no drainage. cleansed areas with NS (normal saline) and covered with silvadene cream; covered with Telfa." *[DATE] at 1:00 p.m. - "Monitoring - Monitor Skin abdomen is much improved some yellow eschar remains to three small open areas." The facility's wound care nurse assessed Resident #20's wounds on February 13, 19 and 25, 2013. A progress note dated, [DATE] stated, "Wound care note: Assessed burns to resident's abdomen and bilateral medial upper thighs. Right abdomen has two wounds: Superior: 0.5 X 1.5 cms with a wound bed that is 100% (percent) yellow; Inferior: 4 X 3 cms with a wound bed that is 80% yellow and 20% red. Left abdomen has a wound measuring 3.3 X 1.2 cms with a wound bed that is 90% yellow and 10% red. Left medial thigh has a wound that measures 4 X 1.5 cms with wound bed that is 80% red and 20% yellow. Also noted two long linear intact blisters to left medial upper thigh and 1 long linear blister that remains intact to right medial upper thigh. Resident became combative and would not allow any further measurements to be done . . . Resident does express some discomfort during treatment and assessment. Current treatment is silvadene applied as per MD (medical doctor) orders." Resident #20's current quarterly MDS, dated [DATE], identified the resident displayed short and long term memory impairment and required extensive one person assistance with meals. Review of Resident #20's current Care Guide (a part of the care plan located in each resident's room used by certified nurse aides) identified "Eating" and stated, "Deliver (and) setup tray. Covered mugs. Colored plate. Provide cuing for eating. Starts to feed self. Staff assist as resident allows. Encourage intake of fluids." Review of a facility form titled "Bruises/Injuries of Unknown Origin" occurred on the morning of [DATE]. This form, dated [DATE], stated Resident #20 sustained coffee burns to her abdomen which measured "11 cm wide (by) 9 cm" to her left groin which measured "6 (by) 4 cm " and to her right groin which measured "4 (by) 4 cm." The form stated a potential cause of the incident as "top came off coffee cup." Environmental changes implemented of "make sure top for cup is on securely" and a plan of action to "monitor (burn) areas affected." On the morning of [DATE], a surveyor checked and obtained a temperature reading of 151.7 degrees Fahrenheit for the coffee dispensed directly from the machine located in the 4 East Dining Room. During interview on [DATE] at 11:00 a.m. an administrative nurse (#32) stated the facility could not determine if the coffee lid was incorrectly placed by staff when they provided Resident #20 the cup or if the resident loosened the lid herself. This administrative nurse stated the coffee involved in the incident came out of a dispensing machine located in the 4 East Dining Room and she did not know if any facility staff member checks/monitors the temperature of the coffee in the machines and stated "that would be done by dietary (referring to the dietary department)." During interview on [DATE] at 11:20 a.m. an administrative nurse (#26) stated the coffee burn incident involving Resident #20 was discussed by the facility's administrative team during the daily morning "standup meeting" (which occurred on Monday, February 04. The burn incident involving Resident #20 occurred on Saturday, February 02). When asked to provide evidence of monitoring the temperatures of the coffee machines following this incident, this nurse stated she recalled e-mail communication between herself and the dietician which stated the reading was 160 degrees. Review of these e-mails, provided by an administrative nurse (#26) identified the first e-mail communications took place on [DATE] (13 days after the incident). An e-mail dated [DATE] at 11:28 from the dietician to the administrative nurse (#26) stated, "(employee name) went and temped all the floors (referring to checking the temperatures of the coffee machines. The first time the facility checked the temperatures occurred 13 days after Resident #20 sustained her burn). She said all were at 160 degrees . . . (employee name) called . . . the guy who works with the coffee machines and he will be coming to check on them as well . . . ." An e-mail dated [DATE] at 11:30 a.m. from an administrative nurse (#26) to the dietician stated, "So is 160 considered too high?" An e-mail dated [DATE] at 11:50 a.m. from the dietician to an administrative nurse (#26) stated, "I'm not too sure if there are specific nursing home guidelines, but from what I can find in research it says that hot beverages should be served between ,[DATE] degrees, and 140 degrees is preferred drinking temperature . . . I feel like 160 is reasonable because once it is poured into a cup it says the temp drops about 10 degrees . . . ." Review of these e-mails failed to ensure the facility implemented a system to periodically monitor and check the temperatures of the coffee dispensing machines used for residents. 2. Based on observation, record review, review of manufacturer's operating instructions for a mechanical Hoyer lift, and review of facility policy, the facility failed to appropriately utilize assistance devices for 1 of 5 sampled residents observed transferred by staff using a mechanical Hoyer lift (Resident #14), 4 of 12 sampled residents (Resident #4, #6, #8, #10) and 1 supplemental resident (Resident #33) observed transferred by staff with a gait belt, and 1 of 16 sampled residents (Resident #20) observed transported by staff in a wheelchair. Failure to ensure the correct placement of a mechanical Hoyer lift sling has the potential to cause injury to Resident #33. Failure to appropriately utilize gait belts resulted in Resident #4, #6, #8, #10 and #33 experiencing discomfort during transfers and placed them at risk for falls and/or injuries. Failure to utilize wheelchair foot rests may result in injury and pain to Resident #20. Findings include: Review of the facility policy titled "Gait Belts" occurred on [DATE]. This policy, dated ,[DATE], stated, "POLICY: Gait belts will be used on residents who require staff assistance with transfers or ambulations. Each resident . . . will have their own gait belt . . . PURPOSE: To provide support during transfers and ambulation without unnecessary strain on resident's upper extremities. PROCEDURE: . . . 4. Wrap the gait belt snugly around the resident's waist. The belt should neither bind the resident nor slip around the resident's waist . . . 5. Place one foot one (sic) either side of the resident's legs, with one of your feet about ,[DATE] inches ahead of the other. Bend hips and knees. 6. Ask the resident to use their arms if possible, to push themselves up from the bed, w/c (wheelchair) or commode. May support the resident's arms, but do not use their arms to pull the resident up. Grab the back of the gait belt and on signal, ie (such as) on the count of three, lift the resident to a standing position. Hold onto the gait belt until resident is eased into the chair . . . ." Review of the operating instructions for the hoyer lift occurred on [DATE]. This manual, dated 2000, stated, ". . . Safety summary . . . Before transferring a patient from a stationary object (wheelchair, commode, or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again. . . ." Review of Resident #14's medical record occurred on all days of survey. The resident's current Care Guide (used by the facility direct care staff) identified the resident at risk for falls, used a commode/shower chair for bathing, and needed total assistance of two persons and a mechanical lift for transfers. - Observation on [DATE] at 7:47 a.m., showed two certified nurse assistants (CNAs #6 and #7) assisted Resident #14 to transfer from a rolling commode/shower chair to her bed utilizing a manual Hoyer lift. A CNA (#6) raised the lift causing Resident #14 to be suspended in the air with the commode/shower chair still attached. Without lowering the resident back to the floor, the other CNA (#7) pulled down on the shower chair to detach it from the resident while she remained suspended in the air. When the chair and the resident separated, the resident stated, "I just about slid out." Observation showed the shower sling inappropriately placed under the resident. - Review of Resident #4's medical record occurred on February ,[DATE], 2013. Medical [DIAGNOSES REDACTED]. Resident #4's quarterly MDS, dated [DATE], identified the resident displayed severe cognitive impairment, required extensive physical assistance with bed mobility, dressing and eating; and total physical assistance with transfers, locomotion on/off the unit, and toilet use. Review of Resident #4's current Care Guide included the heading of "Transfer" and stated, "Cue resident before (and) after transfers. Performs transfer slowly. 2 assist with gait belt." Observation on [DATE] at 9:00 a.m. showed two CNAs (#13 and #18) transferred Resident #4 from his wheelchair to his bed. A CNA (#13) locked the wheelchair brakes, placed the gait belt around Resident #4's waist loosely, and failed to snugly tighten the gait belt. The CNAs counted to three and instructed Resident #4 to stand up. Observation showed the resident failed to bear weight on his legs and the gait belt slid up around Resident #4's chest as the CNAs (#13 and #18) lifted the resident onto the edge of the bed. Observation on [DATE] at 11:10 a.m. showed two CNAs (#13 and #18) assisted Resident #4 to sit at the edge of his bed. A CNA (#13) placed the gait belt loosely around Resident #4's waist and failed to snugly tighten the gait belt. The CNAs (#13 and #18) grabbed the gait belt which caused the gait belt to slide up underneath Resident #4's armpits. Observation showed Resident #4's feet did not touch the floor during the transfer and the CNAs (#13 and #18) lifted the resident into his wheelchair. Observation on [DATE] at 5:15 p.m. showed two CNAs (#13 and #19) assisted Resident #4 to sit at the edge of his bed. A CNA (#13) loosely placed the gait belt around Resident #4's waist. The CNAs grabbed the gait belt which caused the gait belt to slide up underneath Resident #4's armpits. Observation showed Resident #4 failed to bear weight on his legs when the CNAs assisted him to stand. A CNA (#19) grabbed the waistband of the resident's pants when transferring the resident to the wheelchair. Observation on [DATE] at 11:30 a.m. showed two CNAs (#13 and #19) assisted Resident #4 to sit at the edge of his bed. A CNA (#13) loosely placed the gait belt around Resident #4's waist. Observation showed a three to four inch gap between the gait belt and Resident #4's waist. The CNAs (#13 and #18) grabbed the gait belt which caused the gait belt to slide underneath Resident #4's armpits. Observation showed Resident #4 stood, beared weight on his legs, and assisted staff with the pivot transfer to his wheelchair. - Review of Resident #33's Care Guide, dated [DATE], indicated a transfer belt is needed with transfers and identified the resident as a fall risk. Observation on [DATE] at 5:10 p.m. showed Resident #33 stood from her wheelchair and walked down the hallway. A nurse (#8) observed Resident #33 walking and assisted/guided the resident by holding underneath the resident's right arm. A CNA (#9) joined them and grabbed underneath Resident #33's left arm. Observation showed that neither of these staff members (#8 and #9) attempted to place a gait belt around Resident #33's waist while the resident was in the hallway. These staff members (#8 and #9) assisted Resident #33 into the bathroom and onto the toilet. The nurse (#8) remained in the bathroom while the CNA (#9) obtained the resident's wheelchair. When the resident indicated she had finished voiding, the nurse (#8) provided pericares and with the CNA (#9) placed a brief and pulled up the resident's pants. The CNA moved behind the wheelchair and the nurse placed his hand on the resident's back to guide Resident #33 into her wheelchair. - Review of Resident #10's current "Care Guide", stated, "Transfer belt (gait belt), Staff to physically pivot resident, Transfers with assist of 1, Performs transfer slowly . . ." Observation on [DATE] at 7:53 a.m. showed a CNA (#29) assisting Resident #10 in the bathroom. The CNA (#29) failed to place a transfer belt around Resident #10's waist and assisted her to stand up from the toilet by lifting under her left arm, pulling on her shoulder. As the resident stood, the CNA (#29) provided perineal care and finished dressing Resident #10. The resident became unsteady at times and the CNA (#29) steadied her by placing a hand on her torso or hip. The CNA (#29) then assisted Resident #10 to pivot and sit in her wheelchair without using a transfer belt. Facility staff failed to place a transfer belt prior to transferring and caring for Resident #10 as identified by the resident's care guide. - Review of Resident #8's medical record occurred on February ,[DATE], 2013. [DIAGNOSES REDACTED]. The resident's "Care Guide," dated [DATE], stated, ". . . Transfer: Transfer belt, Transfer w/ (with) walker - two persons, . . ." Observation on [DATE] at 7:50 a.m. showed two CNAs (#20 and #21) assisted Resident #8 with morning cares. When they finished, one CNA (#20) positioned Resident #8 on the edge of the bed and placed her hands under the resident's armpits and the other CNA (#21) grasped the back of the resident's pants. In one motion, the CNAs pivot transferred Resident #8 into her wheelchair. The CNAs failed to utilize a gait belt during the transfer. - Review of Resident #6's medical record occurred on all days of survey. The "Care Guide," dated [DATE], stated, ". . . Transfer: Transfers with gait belt, assist of 1 and pivot board . . ." Observation on [DATE] at 5:45 a.m. showed Resident #6 seated on the edge of her bed. A CNA (#22) loosely applied a gait belt to the resident, lifted her under her armpits, and pivot transferred her into a wheelchair. The CNA failed to tighten or utilize the gait belt. Observation on [DATE] at 9:00 a.m. showed two CNAs (#23 and #24) transferred Resident #6 from her wheelchair to a recliner. The CNA (#24) grasped the gait belt and the other CNA (#23) lifted underneath the resident's right armpit. - Observation on [DATE] at 8:35 a.m. showed Resident #20 asleep and seated in her wheelchair at the dining room table. A CNA (#25) attempted to assist and/or encourage her to eat her meal but the resident did not respond. The CNA removed Resident #20 from the table and transported her to her room. During the transport, the resident's feet bent backwards and her toes dragged on the carpet. Observation showed foot rests sitting on a chair in Resident #20's room. Failure to utilize the foot rests may result in pain and/or injury for Resident #20.

Based on observation, record review, review of facility policy and procedure, and staff interview, the facility failed to ensure residents of the special care unit were free from verbal, mental, or physical abuse from 2 of 2 sampled residents (Resident #1 and #2). Failure to ensure residents were free from abuse resulted in Resident #2 experiencing an arm fracture and Resident #1 and #2 continuing to verbally abuse, push, slap, and knock down unidentified residents of the special care unit. Findings include: Review of the facility policy and procedure "Investigation and Reporting of Abuse" occurred on 02/27/13. This document, revised November 2012, stated "POLICY: All actual and alleged incidents of Abuse, Abuse including Injuries of Unknown Source . . . will be reported and investigated . . . and all staff will be provided initial and annual in-service training on prevention . . . of abuse . . . and prohibit verbal, mental . . . or physical abuse . . . *NOTE: . . . Residents who mistreat, abuse . . . other residents . . . must have a care plan in place that addresses the behavior(s) in question and those residents being abused, neglected . . . must be protected from further injury or mental anguish. Documentation must be in place to identify the steps taken to identify the problems, the corrective action taken, and follow-up monitoring. CATASTROPHIC EVENTS AND REACTIONS: In a situation where there is an aggressive resident or a catastrophic event such as pushing, hitting, throwing objects, etc. the following steps should be taken: a) Re-direct resident and take to a quiet area if possible. b) If resident cannot be re-directed call for Resident Assistance and/or call 911 for support staff. c) Contact resident MD (physician) if necessary and follow physician's orders. d) To ensure safety of all residents/staff, staff should remain with the resident until help arrives or situation subsides. e) Monitor closely for any further behaviors. f) Document in Care Plan: See Abuse Policy. . . ." During the initial tour of the facility's special care unit, on 02/24/13 at 10:00 a.m., a supervisory nursing staff member (#41) reported Resident #2 experienced a fractured left shoulder approximately one month earlier after being pushed down by Resident #1. This staff member also reported Resident #1 demonstrated physical behaviors towards other residents and recently returned to the unit after an acute hospital stay following the incident of Resident #2's fracture. - Review of Resident #1's medical record occurred on February 24-27, 2013. The facility admitted the resident in August 2012. The facility transferred the resident to the acute care hospital for the period January 30, 2013 to February 07, 2013. Current [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], identified the resident usually made himself understood, sometimes understood others, and for the seven day assessment period: demonstrated fluctuating inattention and disorganized thinking, physical behaviors occurred one to three days, other behaviors such as hitting, pacing, verbal or vocal symptoms occurred four to six days, wandering occurred four to six days, and walking in the corridor required limited assistance of two or more persons. Resident #1's Cognitive Care Area Assessment (CAA), dated 11/30/12, identified the resident demonstrated fluctuating inattention and disorganized thinking. The Mood and Behavior CAAs, dated 11/30/12, identified socially inappropriate behaviors, rummaging, pacing, and wandering with approaches of direction and re-direction. Resident #1's current care plan, dated 02/27/13, identified the following: "Problem, BEHAVIOR-Hallucinations-voids inappropriately, spits/wanders in and out of rooms/moves furniture about at times may upend tables-may be physically abusive to other residents/when hallucination (sic), monitor for lashing out at the hallucinations. (updated) (02/25/13), GOAL . . . will accept re-direction from staff and not be physically abusive to other residents. . . . APPROACH . . . Therapeutic Activities . . . enjoys playing ball (09/05/12) . . . Consult w/ (with) Psychiatry (09/13/12) . . . Refer Behavioral Issues to Behavioral Health (09/28/12) . . . Make referral to geropsyche units for new placement (02/12/13) . . ." Resident #1's current Care Guide (used by facility direct care staff), dated 02/27/13, stated "Behavior Approaches . . . monitor interactions with female residents. Redirect from inappropriate behavior by removing resident from situation, Spend 1:1 time with resident, Distract from behavior w/snack/drink/walk, Leave alone and return later, Speak to resident calmly & (and) with simple terms, Decrease stimuli (calm supportive environment), Monitor wandering, Monitor physical aggression, Monitor agitation/restlessness, Monitor resistance/refusal of care, Monitor for inappropriate elimination . . . Protect from injury to self, Protect from injury to others, Tipping over furniture/moves w/c (wheelchair), etc." Resident #1's current physician orders included the following medications: [REDACTED] *[MEDICATION NAME] Sprinkles (anticonvulsant which may be used to treat mania) 500 milligrams (mg), two times each day (BID), initiated 02/13/13. *[MEDICATION NAME] (antipsychotic) 200 mg, one time each day (QD), initiated 02/13/13. Prior to Resident #1's acute hospital admission on 01/30/13, his physician orders included the following medications: [REDACTED] *[MEDICATION NAME] (antipsychotic) 2.5 mg, QD, initiated 10/22/12. *[MEDICATION NAME] (antidepressant) 125 mg, QD, initiated 11/02/12. Resident #1's Nurse's Notes identified the resident's physically and verbally aggressive behaviors towards other residents, including the following examples: *09/18/12 - Female resident yelling at him in the hall. Resident #1 struck the female resident in the chest. Facility staff re-directed Resident #1. *09/30/12 - Female resident yelling at him, Resident #1 struck her with a magazine. Facility staff contacted the physician and administered [MEDICATION NAME] 5 mg. *10/04/12 - Resident #1 was close to a female resident who yelled at him, he struck her in the arm. *10/13/12 - Resident #1 was pulling on the water fountain in the hall, a female resident yelled at him, and Resident #1 struck her. *10/16/12, 9:40 a.m. - While seated at the dining room table, Resident #1 struck a female resident in the mouth and the female resident threw coffee on Resident #1. Facility staff separated the residents. Facility staff monitored Resident #1 and did not observe any skin redness or burns. *10/16/12, 8:47 p.m. - Resident #1 entered a female resident's room and pushed the resident against the door. Facility staff removed Resident #1 from the room. *12/18/12 - Resident #1 tugging on a female resident's clothes, she threw coffee on Resident #1, and he hit her in the face. Facility staff monitored Resident #1 and did not observe any skin redness or burns. *01/13/13 - Resident #1 was close to a female resident, she yelled at him, and he slapped her. Facility staff separated the residents. *01/29/13, 9:15 p.m. - Resident #1 was walking by another resident (identified as Resident #2) in the hall. Resident #2 told him to move and Resident #1 pushed Resident #2 to the floor. *01/30/13, 1:14 p.m. - Resident #1 admitted to the acute care facility emergency department for psychiatric evaluation. *02/12/13 - Resident #1 grabbed a female resident's walker and struck the resident in the chest. Facility staff re-directed the resident. Facility staff contacted Resident #1's family member and physician requesting return to the acute care facility for psychiatric evaluation, request denied. Facility staff began seeking placement of Resident #1 in geriatric psychiatric unit. Resident #1's Behavior Notes, dated, 01/25/13, identified a female resident yelled at Resident #1 and he struck her. During interview, on 02/27/13 at 8:15 a.m., a supervisory nursing staff member (#41) reported the facility did not identify the residents involved in the incidents with Resident #1. This staff member could identify Resident #2 in the incident on 01/29/13 because of the fractured shoulder experienced by Resident #2. The staff member (#41) reported it was unknown if any of the residents involved in the incidents previously identified experienced an injury, except as noted, since the facility did not identify the residents involved. Observation on February 24-27, 2013 showed Resident #1 in bed, in a wheelchair, or in a recliner. Resident #1 provided support with his lower extremities during stand and pivot transfers with a gait belt and assistance of two persons. Observation did not show Resident #1 ambulating with staff or attempting to rise independently from the wheelchair. During interview, on 02/27/13 at 8:15 a.m., a supervisory nursing staff member (#41) reported the facility's approaches to Resident #1's behaviors were limited to re-direction and medications. Medication adjustment occurred 10/22/12 and 11/02/12 as identified. This staff member reported Resident #1's family member and physician refused to have the resident returned to the acute care facility for psychiatric evaluation and medication adjustment after the incident on 02/12/13 and the facility began seeking geriatric psychiatric unit placement for the resident at that time. The staff member (#41) also reported Resident #1's physical status has declined since 02/12/13 which has resulted in reduced behaviors. The facility staff documented Resident #1's physically aggressive behaviors towards other residents as identified in the medical record. The facility staff responded to the behaviors with re-direction and medications. Resident #1's physically aggressive behaviors continued. The resident's care plan and medical record lacked indications if Resident #1 targeted a particular resident or time of day or area of the unit. Failure to identify and track and trend this information limited the facility staff's ability to develop and implement a behavior monitoring plan for Resident #1. Resident #1 continued with physically aggressive behaviors which resulted in the fracture of Resident #2's left humerus. - Review of Resident #2's medical record occurred on February 24-27, 2013. The facility admitted the resident in August 2010. The resident's current [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident made herself understood and understands others and during the seven day assessment period demonstrated: fluctuating disorganized thinking, physical and verbal behaviors one to three days, walked in corridor and locomotion on the unit with supervision only, and experienced one fall with a major injury since the prior assessment. Resident #2's Cognitive CAA, dated 08/16/12, identified disorganized thinking and dementia. The resident's Behavior CAA, dated 08/16/12, identified dementia and staff to provide re-direction. Resident #2's current care plan, effective date 02/01/13, stated "Problem, BEHAVIOR-Can be physically abusive to other residents and staff-verbally abusive and socially inappropriate and disruptive . . . GOAL . . . will interact appropriately with staff and other residents, accept re-direction as needed . . . APPROACH . . . monitor behaviors-any aggression to other residents? . . . (01/17/13) . . ." and "Problem, Fracture to left shoulder (01/30/13) . . . Approach, Immobilizer on continuously q (every) shift. (01/30/13) . . ." Resident #2's current Care Guide, dated 02/27/13, used by facility direct care staff, stated "Behavior Approaches, Document mood and behaviors-responds well to TLC (tender loving care)-validate her concerns . . . Redirect from inappropriate behavior, Redirect from inappropriate behavior by removing resident from situation, Provide verbal reminders R/T (related to) behavior, Spend 1:1 time with the resident, Call family re: (regarding) behavior, Decrease stimuli (calm supportive environment), Monitor wandering, Monitor verbal aggression, Monitor physical aggression, Monitor agitation/restlessness, Monitor sadness/depression, Monitor anxiety, Maintain consistent environment & routine, Protect from injury to others." Resident #2's physician orders included: *[MEDICATION NAME] (Alzheimer's dementia medication) 10 mg, BID, initiated 02/19/13. *[MEDICATION NAME] Patch ([MEDICATION NAME]) (opioid pain medication) 12 micrograms, every 72 hours, initiated 02/09/13. Resident #2's Nurse's Notes identified physically and verbally aggressive behaviors towards other residents and included the following examples: *12/23/12 - Intentionally ran walker into two residents. No injuries noted to the other residents. *01/17/13 - Struck resident that wandered near her room. Pushed walker at another resident in a wheelchair. *01/18/13 - Pinched a female resident. *01/22/13 - Tells roommate to leave room. *01/23/13 - Aggressive towards roommate. Moved to a private room. *01/29/13 - Pushed to the floor by another resident (identified as Resident #1). Complains of arm pain. Taken by ambulance to the acute care facility. Returned to the facility that evening with left arm in an immobilizer, [DIAGNOSES REDACTED]. During interview, on 02/27/13 at 8:15 a.m., a supervisory nursing staff member (#41) reported the facility did not identify the residents involved in the incidents with Resident #2. This staff member could identify Resident #1 in the incident on 01/29/13 because of the fractured shoulder experienced by Resident #2. The staff member (#41) reported it was unknown if any of the residents involved in the incidents previously identified experienced an injury, except as noted, since the facility did not identify the residents involved. Observation on February 24-27, 2013 identified Resident #2 ambulated independently on the special care unit with a four wheeled walker utilizing her right hand, and her left arm in a immobilizer at her side. The resident repeatedly called out "Help me." Facility staff approached the resident to offer assistance, returned the resident to her room for toileting, and the resident continued to call "Help me." Observation on 02/26/13 at 5:15 p.m., during the evening meal, identified Resident #2 wandering in the unit with her walker as noted above. She repeatedly stated "Look at the mess." Staff attempted to re-direct her to the dining room for her evening meal. Facility staff assisted other residents with their meals and Resident #2 continued to wander in and out of the dining room and state "Look at the mess." Resident #2 approached other residents leaving the dining room in a threatening manner, telling them to "Shut up." Resident #2 approached the surveyor, repeatedly stated "Look at the mess", did not respond to verbal encouragement to return to her room or the dining room, and struck the surveyor's arm multiple times. Facility staff re-directed Resident #2 after they finished assisting other residents with the evening meal. During interview, on 02/27/13 at 8:15 a.m., a supervisory nursing staff member (#41) reported the facility's approaches to Resident #2's behaviors were limited to re-direction. Review of Resident #2's medical record and resident observations identified physically and verbally aggressive behaviors towards other residents, staff, and visitors. The facility's response to the behaviors was limited to re-direction. The resident's care plan and medical record lacked indications if Resident #2 targeted a particular resident or time of day or area of the unit. It is unknown if Resident #2 was the aggressor during the incident of 01/29/13. Failure to identify and track and trend this information limited the facility staff's ability to develop and implement a behavior monitoring plan for Resident #2. Failure to implement a behavior plan for Resident #2 resulted in continued physically and verbally aggressive behaviors by Resident #2 towards other residents, staff, and visitors.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 03/15/12. Based on observation, medical record review, information received from the complainant, staff interview, and resident interview, the facility failed to provide necessary treatment and services to aid in the prevention and promote the healing of pressure ulcers for 2 of 4 sampled residents (Resident #2 and #4) identified with a pressure ulcer. Failure to consistently implement interventions to prevent and promote healing of pressure ulcers resulted in delayed healing and pain for Resident #2 and the deterioration of Resident #4's pressure ulcer. Findings include: Information received from the complainant identified concerns that staff failed to implement interventions which resulted in the deterioration of pressure ulcers. - Review of Resident #2's medical record occurred on August 15-16, 2012. The current Minimum Data Set (MDS), dated [DATE], identified moderate cognitive impairment, facial expressions of pain, pain or possible pain observed daily, extensive assistance from two or more people for bed mobility, no functional limitation in range of motion, and one unstageable pressure ulcer. A "Progress Note," dated 01/10/12, stated, ". . . Wound care note: assessed 1 x 2 cms (centimeters) nonblanchable reddened area to left heel. Area is slightly spongy. Rest of heel is red, but blanchable. . . ." Resident #2's current "Care Guide" (part of the care plan) stated, ". . . Skin . . . Resident has a large pressure ulcer to left heel. Turn and reposition resident every 2 hours . . . heel lifts on both feet at all times & duro safe (sic) (i.e. DermaSaver, a flexible "sleeve" with padding that fits over the heel/ankle area to reduce pressure and cushion the skin) protector to left heel & Rt (right) elbow, float heels/both feet off of bed. . . ." A message sent to the physician, dated 03/13/12, stated, ". . . Resident having a lot (sic) of pain to L. (left) heel due to wound. . . . Resident gets prn (as needed) meds (medications) around the clock (and) at times not getting adequate pain relief. Moaning/crying @ night. . . ." The physician responded with an order to increase Resident #2's [MEDICATION NAME] (a narcotic pain reliever) patch from 12 micrograms (mcg) to 25 mcg. Current medications included a [MEDICATION NAME] 50 micrograms changed every 72 hours (increased on 04/11/12), [MEDICATION NAME] (an anticonvulsant used to treat nerve pain) 300 milligrams (mg) twice a day (increased 07/07/12), [MEDICATION NAME] 5/325 mg (a narcotic pain reliever) every four hours prn, and [MEDICATION NAME] (a non-narcotic pain reliever) 50 mg every six hours prn. Resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]*June 2012: [MEDICATION NAME] given 45 times and [MEDICATION NAME] given nine times for complaints of heel/foot pain. *July 2012: [MEDICATION NAME] given 32 times and [MEDICATION NAME] given four times for complaints of left heel/foot pain. *August 1-15, 2012: [MEDICATION NAME] given 16 times for complaints of heel/foot pain. Resident #2's progress notes stated the following: *06/14/12: ". . . Pharmacy review--Resident continues [MEDICATION NAME] 50mcg/hr patch, prn [MEDICATION NAME]/acet ([MEDICATION NAME]) ([MEDICATION NAME]) and prn [MEDICATION NAME]. Staff reports resident c/o pain mostly to (left) heel. . . ." *07/02/12: ". . . Location of pain: foot left . . . states it hurts alot (sic) . . . foot repositioned . . . Medications - [MEDICATION NAME] . . ." *07/06/12: ". . . Location of pain: left foot . . . states pain never goes away . . . foot repositioned . . . Medications - [MEDICATION NAME] . . ." *07/10/12: ". . . Location of pain: left heel . . . facial grimace, moaning . . . float heels, repositioning . . . Medications - [MEDICATION NAME] . . ." *07/16/12: ". . . Location of pain: left heel . . . crying, moaning . . . repositioned left foot . . . Medications - [MEDICATION NAME] . . ." *07/24/12: ". . . Locations of pain: left foot . . . moaning/complaning (sic) off load foot . . . Medications - [MEDICATION NAME] . . ." *07/30/12: ". . . Location of pain: left heel . . . grimacing in bed . . . repositioned heel . . . Medications - [MEDICATION NAME] . . ." *08/01/12: ". . . Location of pain: left heel . . . verbal c/o pain and facial grimace . . . repositioned left heel . . . Medications - [MEDICATION NAME] . . ." *08/03/12: ". . . Wound care note: Assessed pressure ulcer to left heel. Ulcer measures 5.3 x 4.2 cms with a wound bed that is 50% red, 30% yellow, and 20% black. This is a decline from last week . . ." *08/06/12: ". . . Location of pain: left heel . . . verbal c/o pain . . . repositioned foot . . . Medications - [MEDICATION NAME] . . ." *08/09/12: ". . . Location of pain: left heel . . . asks for pain med . . . groans . . . repositioned foot . . . Medications - [MEDICATION NAME] . . ." *08/13/12: ". . . Location of pain: left hel (sic) ulcer . . . grimace and verbal c/o pain . . . elevated left foot . . . Medications - [MEDICATION NAME] . . ." *08/15/12: ". . . Location of pain: left heel . . . grimace on face and c/o pain . . . repositioned left foot . . . Medications - [MEDICATION NAME] . . ." Although Resident #2 continued to complain of left heel/foot pain after 07/07/12 (when the [MEDICATION NAME] was increased), record review showed no further adjustments made in the resident's pain medication since that date. Weekly pressure ulcer monitoring records showed the following: *01/10/12: Stage 1, 1 x 2 cm *01/13/12: Stage 1, 0.2 x 0.3 cm *01/20/12: Stage 1, 0.8 x 0.3 cm *01/27/12: Stage 1, 0.8 x 0.3 cm *02/03/12: Stage 2, 1 x 4 x 0.1 cm *02/17/12: Unstageable, 5 x 6 cm *02/24/12: Unstageable, 5 x 6 cm *03/02/12: Unstageable, 4.5 x 6.5 cm *03/09/12: Unstageable, 5 x 6 cm *03/16/12: Unstageable, 4.5 x 6 cm *03/23/12: Unstageable, 4.8 x 5.7 cm *03/30/12: Unstageable, 5 x 5.8 x < 0.4 cm *04/06/12: Unstageable, 6 x 5.5 cm *04/13/12: Unstageable, 4 x 5.6 cm *04/20/12: Unstageable, 4.8 x 5.5 cm *04/27/12: Unstageable, 5 x 5.3 cm *05/04/12: Unstageable, 4 x 4.8 cm *05/14/12: Unstageable, 4.8 x 5.2 cm *05/18/12: Unstageable, 4 x 5 cm *05/25/12: Unstageable, 4.3 x 4.8 cm *06/01/12: Unstageable, 4.5 cm x 5.5 cm *06/08/12: Unstageable, 4.5 x 4.2 cm *06/22/12: Unstageable, 5 x 5 cm *07/06/12: Unstageable, 4.8 cm x 5.2 cm *07/14/12: Unstageable, 5 x 5 cm *07/20/12: Unstageable, 4 x 4.5 cm *07/27/12: Unstageable, 4.3 x 4.5 x 0.3 cm *08/03/12: Unstageable, 5.3 x 4.2 cm *08/10/12: Unstageable, 5.5 x 4.5 cm *The medical record lacked measurements for the weeks of 02/10/12, 06/15/12, and 06/29/12. A physician's orders [REDACTED]." A physician's orders [REDACTED]. . . Wet to Dry Dressing Change Two times daily . . .apply santyl ointment (used to help debride wounds) to wound on left heel and diluted [MEDICATION NAME] may do dressing once or twice a day . . ." A "Physician's Consultation Sheet," dated 08/08/12, stated, ". . . (left) heel wound debrided today . . . calcaneous exposed . . . no obvious infection . . . Back to Santyl ointment qd (daily) or BID (twice a day) . . ." Observations throughout the afternoon of 08/15/12 and the morning of 08/16/12 showed Resident #2 seated in her wheelchair with a gauze bandage to her left heel/foot and a pillow propped under her heels/feet. Observation showed no DermaSaver or heel lift boot in place on either foot, and her heels/feet resting directly on the pillow. Observation on 08/16/12 from 1:04 p.m. until approximately 3:00 p.m. showed Resident #2 lying in bed with a pillow under her left leg; however, her left heel/foot still rested directly on the mattress. Observation showed no pillow under her right leg; as a result, her right heel/foot also rested directly on the mattress. Observation showed no DermaSaver or heel lift boots in place. The resident identified she was having pain in her left heel and stated, "Ya, it hurts!" Resident #2's "ADL (activities of daily living) Administration Record" identified the following task: "Heel Lifts Three times daily Continuous Date Ordered: Feb (February) 03, 2012." The "ADL Administration Record" contained three spaces each day for staff to sign to indicate if they were in place. Staff signed off the heel lifts on the afternoon of 08/15/12 and the morning of 08/16/12, although observation showed Resident #2 did not have them in place. Inaccurately documentating Resident #2's use of heel lift boots may have delayed implementation of alternative pressure-reducing interventions. During an interview on the afternoon of 08/16/12, a nurse (#1) stated she initiated the DermaSaver sleeve on 02/03/12 for Resident #2 to wear on her left heel, and the heel lift boots for Resident #2 to wear "as she (Resident #2) tolerates." The nurse stated it is hard to position Resident #2 as she has contractures. The nurse also updated Resident #2's "ADL Administration Record on 08/16/12 to show "Heel Protectors Three times daily Continuous (meaning the DermaSaver)." The nurse removed the heel lift boots from Resident #2's plan of care and stated the resident refuses to wear them at times, so they would use pillows in bed instead. The medical record lacked evidence of Resident #2's refusal to wear heel lift boots. Failure to float Resident #2's heels, consistently implement the DermaSaver sleeve, re-evaluate the treatment plan when Resident #2 refused to wear heel lift boots, and effectively manage pain resulted in delayed healing of Resident #2's pressure ulcer and unresolved pain issues. - Review of Resident #4's medical record occurred on August 15-16, 2012. [DIAGNOSES REDACTED]. The current MDS, dated [DATE], identified short-term memory problems, moderately impaired daily decision-making skills, and extensive assistance from two or more people for bed mobility. Resident #4's "Progress Notes" showed the following: *08/07/12: ". . . Right heel noted to have a nickle-sized (sic) red area and left heel noted to have a quarter-sized blister. Heels floated and message left for wound nurse. Wife was here when areas were found and is aware. . . ." *08/08/12: ". . . Wound care note: Assessed heels for redness and blisters. Right heel: noted slightly pink and blanchable area to heel- skin remains intact. Left heel: Noted flat blister with reddened margins measuring 2.2 x 2.4 cms (centimeters). . . . Recommend . . . to not wear shoes when possible. . . ." Resident #4's Treatment Administration Record (TAR) identified an order for [REDACTED]. Resident #4's current "Care Guide" stated, ". . . Skin . . . No shoes until left heel blister resolved, Heels kept off bed through use of pillows. . . ." Observations throughout the afternoon of 08/15/12 and on 08/16/12 at 8:18 a.m. showed Resident #4 in his wheelchair with shoes on his feet. Observation on 08/16/12 at 9:32 a.m. showed a nurse (#1) entered Resident #4's room to assess his heel and change the dressing. After the nurse removed his shoes and socks, observation showed Resident #4's left heel without a dressing in place. The nurse stated, "he's supposed to have a dressing on." The nurse assessed the left heel ulcer, which measured 3.2 centimeters (cm) by 2.4 cm, and stated, "I will say, it's gotten worse." The nurse covered the heel with a dressing and asked Resident #4, "Does that hurt?" The resident replied, "Yeah, a little bit." The nurse identified Resident #4 should not be wearing shoes, and applied DermaSavers to both feet. Failure to ensure Resident #4's left heel ulcer dressing remained in place and implement pressure-relieving interventions (the use of DermaSavers and removal of his shoes) resulted in the deterioration of Resident #4's facility-acquired pressure ulcer.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide necessary treatment and services to aid in the prevention and promote the healing of pressure ulcers for 4 of 9 sampled residents with pressure ulcers (Resident #7, #10, #14, and #16). Failure to reposition residents with existing pressure sores and failure to properly use pressure relieving air mattresses placed these residents and all residents at risk for skin breakdown and worsening of existing pressure ulcers. Findings include: Review of the facility policy titled "Routine Care of Pressure Sores" occurred on 03/15/12. This policy, dated 2011, stated, ". . . Procedure: . . . 2. Institute measures to reduce or relieve pressure. Keep head of bed at or below 30 degree angle and flat when not contraindicated. Use knee gatch when head of bed is elevated. If knee gatch is contraindicated, use foot board. 3. Utilize a pressure reduction device, in conjunction with a position change schedule. . . ." - Review of Resident #16's medical record occurred on all days of survey. Medical [DIAGNOSES REDACTED]. A physician's order, dated 12/16/11, identified a First Step Air Overlay (a pressure relieving air mattress). The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance for bed mobility and toilet use, total assistance for transfers and personal hygiene, and at risk for pressure ulcers. The most recent MDS, dated [DATE], identified the resident required extensive assistance for bed mobility and personal hygiene, total assistance for transfers and toilet use, and a Stage IV pressure ulcer. Review of Resident #16's current Care Guide (a part of the care plan used by certified nurse aides (CNAs)), occurred on the afternoon of 03/13/12. This guide stated, ". . . Skin: Check/change & (and) provide peri-care w/ (with) each incontinent episode, Pressure relief cushion on chair, First step air overlay mattress . . ." The Care Guide and Care Planning Report failed to identify the resident's Stage IV pressure ulcer to her coccyx and additional interventions to aid in the healing of the ulcer. Review of Resident #16's progress notes and ulcer management notes identified the following: * 12/14/11 - "open area on coccyx noted 0.4 cm (centimeter) depth. no tunneling noted. 1.2 cm length, 1 cm width, wound bed dark red, small amount of slough . . ." * 12/16/11 - "unstageble pressure ulcer to coccyx 2 x (by) .5 x .3 (cm) . . . have spoken to family about more bed rest until pressure ulcer resolved. Family agreed." * 12/23/11 - "1.8 x 1.0 x 0.3 cm (slight increase from last week)" * 01/13/12 - ". . . DC'd (discontinued) current treatment change to . . ." * 01/25/12 - "no change in pressure ulcer. Treatment changed . . ." * 02/13/12 - "Noted foul odor from coccyx, gauze was turquoise green in color . . ." * 02/23/12 - "Noted increase in depth and slough remains. Slight odor and increase in yellow excudate noted. Treatment . . . ongoing since 01/26/12. Resident experiencing much pain with area. . . . New orders for surgical consult received." * 02/24/12 - Coccyx pressure ulcer 2.0 x 1.0 cm * 02/26/12 - (treatment changed) . . . "Surgical consult 03/05/12." * 03/02/12 - Coccyx pressure ulcer 3.0 x 1.2 cm * 03/09/12 - Coccyx pressure ulcer 4.5 x 1.0 cm * 03/14/12 - "Daughter (name) so discouraged . . . coccyx wound worse, now stage 4 with bone exposed . . ." Observation of Resident #16 showed the following: * 03/12/12 at 11:15 a.m. - Observation showed the resident laying on her bed with a bedspread, sheet, airflow disposable pad, and the hoyer pad between her and the pressure relieving mattress. * 03/13/12 at 8:55 a.m. - Two certified nursing assistants (#29 and #30) transferred the resident from her wheelchair to the bed. The CNAs placed her on top of the bedspread, a sheet, and a disposable pad. * 03/13/12 at 10:30 a.m. - The resident returned from a doctor's appointment. Two CNAs (#30 and #31) layed her on her bed with a wrinkled bedspread, sheet, and disposable pad between her and the pressure relieving mattress. * 03/15/12 at 10:15 a.m. - Observation showed the resident laying on her bed with 2 sheets, a bedspread, and a disposable pad between her and the pressure relieving mattress. During an interview on 03/14/12 at 9:25 a.m., a wound nurse (#5) stated for the airflow mattress to work effectively, only a sheet and a airflow disposable pad should be between Resident #16 and the mattress. Even though the facility implemented the First Step Air Overlay air mattress on 12/16/11, failure to utilize the mattress correctly contributed to the worsening of Resident #16's coccyx pressure ulcer. - Review of Resident #10's medical record occurred on March 13-15, 2012. The facility readmitted the resident to the facility on [DATE] after hospitalization and identified the left heel as "reddened" and "spongy" on 01/10/12. The MDS, dated [DATE], identified the left heel pressure sore as "unstageable", "4.5" cm long, "6.5" cm wide and no depth identified. The MDS also identified the resident required extensive assistance of two or more persons for bed mobility. Resident #10's Care Guide stated "Bed Mobility, Assist to reposition in bed."; and, "Skin, . . . Positioning, repositioning . . . First step select air mattress . . ." The resident's current care plan, dated 02/02/10, stated "Problem, Bed Mobility . . . Requires extensive assistance . . . Goals . . . will turn & (and) position successfully w/ (with) physical help. . . .;" and, dated 02/22/12, "Problem, Skin integrity . . . Approach . . . First Step Air Overlay (mattress) . . ." Observation throughout the day on 03/13/12 showed the following: * 7:45 a.m. - Resident #10 laying on her left side with the left heel supported off the mattress. * 8:30 a.m. - The resident remained on her left side, certified nursing assistant (CNA) (#15) fed the resident her breakfast. * 8:55 a.m. - A CNA (#17) provided the resident a bed bath, changed the resident's brief, turned her from side to side during the bath, and positioned her on the her left side with the heel supported off the mattress at the end of the cares. The CNA offered to get the resident up to the beauty shop and resident declined. * 12:13 p.m. - The resident remained on her left side with the left heel supported off the mattress. CNA (#17) fed the resident lunch. * 2:55 p.m. - The resident was sleeping on her left side with her left heel supported off the mattress. * 3:50 p.m. - Two CNAs (#18) and (#19) offered and the resident agreed to be transferred from the bed to a wheelchair with a full body lift. During the more than eight hour period of observation facility staff did not offer to reposition Resident #10 except as noted at 8:55 a.m. Random observations showed the resident remained on her left side with the left heel supported off the mattress. It is unknown how long she was on her left side before 7:45 a.m. During interview, on 03/15/12 at 11:50 a.m., a supervisory nursing staff member (#12) reported facility staff should have repositioned Resident #10 from her left side. - Review of Resident #7's medical record occurred on March 13-15, 2012. [DIAGNOSES REDACTED]. The resident's medical record identified a physician's order for a First Step Air Overlay. Review of Resident #7's Care Guide occurred on 03/13/12. The Care Guide stated, "Skin: Check/change & Provide peri-care w/ each incontinent episode, Moisturizing Lotion with care, Pressure relief cushion on chair, first step select air overlay mattress, padded footrests of w/c (wheelchair) . . ." Observation on 03/13/12 at 7:50 a.m. showed Resident #7 asleep on her right side on a First Step mattress. The unit used to inflate the mattress was not turned on, and the air mattress was not fully inflated. At 8:12 a.m., two nursing staff members (#5 and #11) entered the room to assess the resident's pressure ulcers. The nurse (#5) identified the air mattress was not on, and the other nurse (#11) stated, "I must have forgotten to turn it on when I laid her down (after breakfast)." The nurse (#5) then turned on the unit used to inflate the air mattress. Failure to utilize the mattress correctly does not allow the mattress to aid in healing the resident's Stage II pressure ulcer. - Review of Resident #14's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance with bed mobility, and limited range of motion of the upper and lower extremity on one side of her body. The current Care Guide stated, " . . . Skin-Turn and reposition resident q (every) 2 h (hours) and prn (as needed), . . . Pressure relief mattress . . . " Observation on 03/13/12 from 9:20 a.m. to 11:45 a.m. (two hours and 20 minutes) showed Resident #14 in bed with the First Step mattress in place and the resident positioned on her back. Observation on 03/13/12 at 2:10 p.m., showed a wound nurse (#5) assessed Resident #14's ulcers. Observation and interview with the nurse (#5) showed a fitted sheet, a cloth soaker pad, and a disposable soaker pad (not made for this particular mattress) all on top of the First Step mattress. Observation showed the blue mattress cover, which comes with the First Step mattress and aids in repositioning the resident, underneath the mattress (between the bed frame and the mattress). The wound nurse (#5) instructed the CNA (#6) not to use fitted sheets, and to use the disposable soaker pads designed for the First Step mattress. After the nurse completed wound care, the CNA (#6) positioned the resident on her back. Observation showed Resident #14 positioned on back from 2:10 p.m. to 5:00 p.m. (two hours and 50 minutes). An interview with an administrative nursing staff member (#2) occurred on 03/15/12 at 11:25 a.m. The staff member (#2) agreed facility staff failed to reposition Resident #14 as indicated in the resident's Care Guide.

1. Based on observation, record review, review of facility policy/procedure, and staff interview, the facility failed to provide the necessary care and services regarding pain management for 1 of 1 sampled resident (Resident #2) who experienced pain after a fall and for 2 of 4 sampled residents (Resident #6 and #16) who expressed pain during the survey. Failure to initiate an effective pain management regimen for Resident #2 to control her pain following her falls; and failure to provide pain medication for Resident #16 when she voiced pain and for Resident #6 when she communicated non-verbal signs of pain; resulted in these residents experiencing unrelieved pain without appropriate management. Findings include: Review of the facility policy titled "Comfort Verses Discomfort" occurred on 03/15/12. This policy, dated 2009, stated, ". . . Procedure: The assessment of the residents' pain level will be recorded using the verbal or nonverbal rating scales, and results recorded in the residents' record. . . . If there is evidence of uncontrolled pain, reassessment will be documented. . . . Physician re-notification does not need to be daily, but periodically as deemed appropriate by nursing staff . . . Staff members including nurses and C.N.A.'s (certified nurse aides) will receive instructions on how to perform pain assessment, the tools used and how to comply with the above policy." - Review of Resident #2's medical record occurred on all days of survey. Resident #2's medical [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS), dated [DATE], identified the resident displayed short and long term memory problems; moderate impairment in daily decision making; independent with bed mobility, transfer, and ambulation; received a scheduled pain medication during the past five days; daily indicators of pain which included vocal complaints and facial expressions of pain; and sustained fall without injury and two or more falls with minor injuries. Resident #2's December 2011 Medication Administration Records (MARs) identified physician orders for the following pain medications: *Tylenol (also known as [MEDICATION NAME], an over-the-counter (OTC) pain medication) 650 milligrams (mg) every four hours as needed; ordered on [DATE] *Advil (also known as [MEDICATION NAME], an OTC nonsteroidal anti-[MEDICAL CONDITION] (NSAID) medication) 400 mg four times a day at 12:01 a.m., 6 a.m., 11 a.m., and 5 p.m., ordered on [DATE] *Tylenol Extra Strength [PHONE NUMBER] mg as needed; no frequency specified on the MAR and ordered on [DATE] *[MEDICATION NAME] (a narcotic medication) patch 12.5 micrograms (mcg) every three days; ordered on [DATE] *[MEDICATION NAME] 5/500 mg (a narcotic pain medication containing 5 mg of [MEDICATION NAME] (a narcotic) and 500 mg of Tylenol) every six hours around the clock dosing for two days; ordered on [DATE]. Resident #2's Progress Notes from December 01-16, 2012 showed the resident experienced difficulty sleeping at night and would wander the hallways. Summarization of Resident #2's "Falls Documentation," (a computerized form containing a description of what happened, when, where, and why it occurred, if the resident sustained [REDACTED]. Resident #2's Falls Documentation, dated 12/16/11 at 10:50 p.m., stated, "CNA heard noise while in day area, turned to see (name of Resident #2) sitting on floor." The facility concluded this fall occurred because the "resident unsteady, behind in sleep." Resident #2 incurred "swelling to right knee" following this fall. The adjustment/intervention implemented by the facility following this fall was to "continue close observation." A Progress Note, dated 12/17/11 at 5:02 a.m., identified Resident #2's right knee as "slightly larger than the left, but appears this may be a chronic condition rather than new occurrence . . . has c/o (complaints of) groin discomfort when tries to get up from chair especially the right groin area and once c/o discomfort in lower back to sacral area when stood, has remained in chair all night possible due to discomfort in groin when trying to stand." At 5:44 a.m., a Progress Note identified when Resident #2 attempted to stand she placed her hand on her right hip and then sat back down. At 7:26 a.m., a Progress Note stated three staff needed to assist the resident with transferring, and the resident "jumped and looked distressed" when the nurse manipulated her right knee and leg. The facility sent Resident #2 to the emergency room (ER) on the morning of 12/17/11 to obtain x-rays. Resident #2 returned to the facility with a [DIAGNOSES REDACTED]. Upon return from the ER at 2:45 p.m., facility staff noted Resident #2 experienced "discomfort with movement." Resident #2's MAR showed facility staff failed to administer/provide any type of as needed pain medication to Resident #2. A Progress Note, dated 12/18/11 at 6:34 a.m., stated: ". . . this am incontinent of urine, agitated with brief change and c/o of pain in right groin with turning, spit out the [MEDICATION NAME] . . . and bit off end of plastic spoon in anger, tried to get out of bed but layed back on bed from pain right groin when tried to stand." Resident #2's Falls Documentation, dated 12/18/11 at 6:35 a.m., identified facility staff found Resident #2 on the floor in room. Resident #2 received 650 mg of Tylenol at 7:58 a.m. (a hour and half after exhibiting signs of pain), and facility staff documented the effectiveness (two and half hours later) as "sleeping" at 10:30 a.m. A Progress Note, dated 12/18/11 at 10:41 a.m., a Progress Note stated, "Heard screaming from room . . . found resident sitting on floor with back against bed . . . Tried to check her ROM (range of motion) but grabs her inner rt (right) thigh area stating it hurts . . . With assist of 4 able to satand (sic) her up and place her in a w/c. Continues to whimper that it hurts. Refuses to put feet on foot pedals. Tries to bite and/or hit staff if we try to move her at all. Had been given [MEDICATION NAME] (approximately) 30 min (minutes) ago . . . ." Nursing staff applied warm packs to the resident's right thigh area to promote pain relief. At 3:30 p.m., charting identified the resident "becomes agitated with transfers" and "won't allow staff to touch her rt inner thing area--states it hurts too much." Resident #2's MAR showed facility staff administered Tylenol 650 mg at 6:16 p.m.(two and half hours later). On 12/19/11 at 3:07 p.m., a Progress Note stated, ". . . requiring the assist of 3 when transferring in and out of w/c or on and off of bsc (bedside commode). To be monitored during transfers as she will bite, hit or pinch due to the pain she is feeling . . . ." Resident #2's MAR showed facility staff administered as needed pain medication (Tylenol) once to the resident on December 19 (at 8:50 p.m.). On 12/20/11 at 12:06 p.m., a Progress Note stated, ". . . She does complain of pain to right leg with movement . . . Becomes restless (at) times sitting in the w/c as she is more accustomed to ambulating ad lib (per self) throughout the unit." The MAR showed facility staff administered as needed pain medication (Tylenol) twice to Resident #2 (at 2:32 a.m. and 8:13 p.m.). On 12/21/11 at 6:53 a.m., ". . . Resident . . . does yell out with movement . . . Resident remains restless and has had to be settled several times . . . ." The MAR showed facility staff administered as needed pain medication (Tylenol - unsure if 500 or 1000 mg was provided) twice to Resident #2 (at 2:15 a.m. and 8:07 a.m.). The facility contacted Resident #2's doctor on 12/22/11 to inform him of the resident's continued "terrible" pain with movement. The doctor responded with orders for [MEDICATION NAME] 12.5 mcg every three days, routinely administered [MEDICATION NAME] 5/500 mg every six hours for two days, a hospice consult, and instructions to provide an update of the resident's status in two days. On 12/23/11, the facility received an order to send Resident #2 to the ER for x-rays. The record showed Resident #2 was admitted to the hospital for treatment of [REDACTED]. Resident #2 experienced increased pain to her right hip/groin area following a fall the morning of December 18. Nursing staff sent two separate faxes to Resident #2's doctor dated December 19 and 21 requesting an order for [REDACTED]. Nursing staff once again contacted the doctor on December 22 to inform him of Resident #2's "terrible" pain with movement. Resident #2's MAR identified facility staff failed to promptly administer oral pain medications in an attempt to provide relief of and/or manage her pain for four days. During an interview on the morning of 03/15/12, an administrative nurse (#7) provided no explanation/rationale why nursing staff failed to provide PRN pain medications promptly to treat Resident #2's signs and symptoms of acute pain, why nursing staff failed to assess and locate the potential cause(s) of her increased pain (following her fall on December 18), and failed to inform the doctor of her increase verbalizations of pain with movement for four days (December 18-21). Failure of the facility to provide the necessary care and services to treat Resident #2's pain resulted in the resident experiencing avoidable pain and delayed treatment of [REDACTED]. - Review of Resident #16's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 200 mg three times a day and Tylenol with [MEDICATION NAME] (an opioid pain reliever) every six hours as needed (PRN). The quarterly MDS, dated [DATE], identified Resident #16 as having short and long term memory difficulties, rarely/never makes herself understood, sometimes able to understand others, experienced pain one to two days a week, and pain interventions included scheduled pain medication and non-medicine type interventions. The most recent pain assessment, dated 01/23/12, confirmed the quarterly MDS. Review of Resident #16's progress notes identified the following: * 03/10/12 - "Facial grimacing noted. Asked to squeeze her hand to indicate pain scale and Res (resident) squeezed as hard as 10. Pain scale 10/10 ("0" indicating no pain and "10" the worst pain). Non med interventions - repositioning." Even though the resident expressed pain of a "10", facility did not administer any PRN medication. * 03/14/12 - "Daughter (name) 'so discouraged (from appointment with the doctor). Coccyx wound worse, now Stage 4 with bone exposed and he (doctor) recommended a [MEDICAL CONDITION]. (daughter's name) not in favor. Told infection will kill her (Resident #16)." Review of the PRN MAR identified Resident #16 received no Tylenol with [MEDICATION NAME] from 09/16/11 to 01/18/12. Facility staff administered the PRN medication on: * 01/19/12 * 01/21/12 * 02/20/12 * 03/20/12 Observation on 03/14/12 at 8:00 a.m. showed Resident #16 seated in a rocking wheelchair in the dining room. The resident picked at the right side of her pants and appeared to lift her her right hip. The resident remained in her wheelchair until 9:25 a.m. At that time, two CNA's (#30 and #33) utilized a hoyer lift (full body mechanical lift) and transferred Resident #16 into her bed. Observation showed the resident grinding her teeth. The CNA (#30) stated, "She does that when she's ready (to go to bed)." Two nurses (#34 and #5) entered the room, assessed the resident's coccyx pressure ulcer, cleansed the area, and applied a new dressing. Observation showed Resident #16 shaking and clutching the siderail so tightly her knuckles turned white. The nurse (#5) stated, "I know this hurts." The medical record identified worsening of Resident #16's pressure ulcer with "bone exposed." A progress note, dated 03/10/12, identified pain of a "10" and facility staff provided a non-medication intervention of "repositioning." Observation showed the resident experienced pain while seated in her wheelchair and again during treatment to the pressure ulcer. The facility failed to notify Resident #16's physician regarding her increased pain related to the Stage IV pressure ulcer and failed to administer her PRN pain medication when she experienced pain. - Review of Resident #6's medical record occurred on March 13-15, 2012. [DIAGNOSES REDACTED]. On 03/13/12, the resident fell and sustained abrasions to her left knee and left wrist, as well as hitting her head on the floor. Observation on on 03/13/12 at 4:03 p.m. showed a CNA (#21) assisted Resident #6 to use the bathroom. Observation showed a bruise to the resident's left eye, and abrasions to the left wrist. A nurse (#22) entered the room to assess the resident's bruise. The nurse asked the resident if she was having any pain related to her fall. The resident did not respond verbally and made unintelligible noises while rocking back and forth in her wheelchair. The nurse asked Resident #6 if she would like a Tylenol, and the resident stated, "Yes!" The nurse then stated, "Ok, I'll see about getting you some Tylenol," and left the room. Resident #6's medical record contained physician's orders for Tylenol 500 mg every six hours, and [MEDICATION NAME] 200 mg twice per day as needed (prn). The medical record did not contain an order for [REDACTED]. Review of Resident #6's MAR identified the nurse failed to administer any type of [MEDICATION NAME] until 6:00 p.m. (two hours later), at which time she provided the resident her scheduled Tylenol. Record review identified facility staff failed to assess Resident #6's nonverbal indicators of pain. During an interview on the afternoon of 03/15/12, an administrative nursing staff member (#7) indicated the nurse should have followed up with the resident's request for pain medication. 2. Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 4 sampled resident (Resident #14) identified with contractures. Failure to ensure facility staff placed a cloth pad (as ordered by the provider) to Resident #14's left hand may delay in the healing of the resident's wound. Findings include: Review of Resident #14's medical record occurred on all days of the survey. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated intact cognition, extensive assistance of one for personal hygiene and limited range of motion of upper and lower extremity on one side of her body. Physician's orders, dated 03/12/12, stated, "Clean q (every) shift-cloth pad L (left) hand. [MEDICATION NAME] BID (twice daily) (paint wounds till healed)." The current care plan listed the problem "SKIN INTEGRITY . . . Monitor Skin-left hand in the inside knuckle in the two middle fingers Two times daily. . ." The care guide and care plan failed to address the wound care ordered per physician. Observation on 03/13/12 at 2:10 p.m. showed a nursing staff member (#5) assessing Resident #14's left hand wounds. The nurse (#5) noted two areas on the inside of the resident's left hand, one measuring 0.5 centimeters (cm) x 0.5 cm and the other wound measuring 0.5 cm x 0.8 cm. Observations on 03/14/12 at 09:40 a.m. and 03/15/12 at 8:10 a.m. and 10:30 a.m. showed Resident #14 without a cloth in her left hand. During an interview on 03/15/12 at 11:25 a.m., a nursing administrative staff member (#2) stated she would expect staff to follow physician's orders regarding the left hand wounds.