Every finding on record at Trinity Manor

The facility had a census of 40 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve food in a sanitary manner for the 40 residents who received meals from the facility kitchen. Findings included: - On 01/21/25 at 07:48 AM, observation in the facility kitchen revealed: A refrigerator with an opened, partially used, undated plastic quart container of macaroni salad, undated, opened, and partially used bags of diced ham, and pre-cooked chicken pieces. The walk-in freezer had three boxes of food stored on the floor. On 01/22/25 at 10:45 AM, observation in the facility kitchen revealed the utensil drawers below the coffee maker had a piece of wrinkled paper towel, a brownish drip in a teaspoon, and a small amount of dried food particles. The drawers under a make table had plastic bins for scoops and ladles with dried food and spills in the bins. The walk-in freezer stall had two boxes of food on the floor. The kitchen had one of six fluorescent light covers with a large number of cracks. On 01/21/25 at 07:48 AM, Dietary Staff (DS) CC verified the bags of opened foods and salad should have been dated when opened. She verified food boxes should not be stored on the floor. On 01/22/25 at 10:48 AM, Dietary Staff (DS) BB verified the drawers needed cleaning and stated they had not included drawer cleaning on the schedule. She verified food boxes should not be stored on the floor in the freezer and stated the vendor delivered the foods on Thursdays (four days earlier). She stated maintenance had problems finding covers to fit these lights. The facility's Cleaning Rotation policy, dated 2011, stated drawers would be cleaned weekly. The facility's Food Storage policy, dated 2011, stated staff were to store deliveries as soon as they were inspected. The facility's Labeling/Dating Food policy, dated 2011, stated all foods stored would be properly re-dated with the date the item was opened and shall be used by the safe food storage guidelines. The facility failed to store, prepare, and serve food in a sanitary manner for the 40 residents who received meals from the facility kitchen.

The facility had a census of 40 residents. Based on observation, record review and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by legionella) which placed the residents at risk of contracting infectious processes. Findings included: - On 01/22/25 at 04:50 PM, Administrative Staff A reported the facility lacked a waterborne pathogen/Legionella program. The facility's Legionella Water Management Program dated 08/2023, documented as part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The purpose of the water management program is used to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionella disease. The facility failed to implement a water management program and manage waterborne pathogens placing the residents who reside in the facility at risk for contracting Legionella pneumonia.

The facility had a census of 40 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure two of five residents reviewed during the medication administration pass remained free of medication errors for Resident (R) 19 and R21. This placed the residents at risk for adverse reactions from the medication. Findings included: - R19's Electronic Health Record (EHR) revealed diagnoses of dysphagia (swallowing difficulty), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R19's Annual Minimum Data Set (MDS), dated [DATE], recorded R19 had a Brief Interview for Mental Status score of 00 that indicated she had severely impaired cognition. The MDS recorded she required extensive assistance of two staff with activities of daily living (ADLs). R19's Care Plan, dated 12/31/24, recorded R19 required extensive assistance with most activities of daily living (ADL) care. R19's Care Plan documented the resident received a regular diet with pureed (a paste or thick liquid suspension usually made from cooked food ground finely) texture, and nectar thick consistency. The care plan documented to administer medication as ordered and observing for side effects. The Physician Order, dated 12/02/24, directed the staff to administer Protonix (reduce the amount of acid in the stomach) DR (delayed release) 40 milligram (mg), administer one, tablet one time a day for maintenance therapy. On 01/22/25 at 08:00 AM, License Nurse (LN) G crushed R19's morning medications including the Protonix, and placed the medications in a plastic medication cup then poured the pills in a plastic medication bag and crushed the medication. LN G next placed the crushed medication in the plastic medication cup and added applesauce. Continued observation revealed LN G administered the crushed medication to the resident. On 01/23/25 at 09:20 AM, LN G stated she administered R19 medications crushed because the resident had a hard time swallowing the pill whole. LN G verified that delayed-release medications should not be crushed and she would speak with the director of nursing to get another route of administration for the resident. On 01/23/25 at 09:25 AM, Administrative Nurse D verified that the extended-release medication should not be crushed and said it should be administered whole due to its extended release. Administrative Nurse D said she would have an in-service with the nurse regarding the proper route of medication. Medlineplus.gov directed that delayed-release and extended-release tablets should be taken whole; do not split, chew, or crush them. The facility's Crushing Medication policy, undated, documented medications shall be crushed only when appropriate and safe to do so, consistent with physician orders. The medical director and director of nursing, in conjunction with the consulting pharmacist, shall identify appropriate indications and procedures for crushing medications. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric-coated medications. That attending physician or consultant pharmacist must identify an alternative and/or dose form, or the attending physician must document (or provide the nurses with clinical pertinent reason to document) why crushing the medication would not adversely affect the resident; or when such medication is administered, the facility staff will observe the resident for pertinent adverse effects. Crushing each medication separately and administering each with food is considered best practice. Issues related to safety, needs preference, medication schedule, and functional ability will determine the most resident-centered approach. The facility failed to ensure R19 remained free from medication errors when staff crushed a delayed-release medication prior to administration. This placed the resident at risk for adverse reactions from the medication. - R21's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (dysphagia (swallowing difficulty), and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R21's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R21 had a Brief Interview for Mental Status score of 00 that indicated she had severely impaired cognition. The MDS recorded she required extensive assistance of one to two staff with activities of daily living (ADLs). R21's Care Plan, dated 01/03/25, recorded R21 required one to two assistance with most activities of daily living (ADL) care. R21s Care Plan documented the resident received a Low Concentrated Sweet (LCS) diet with pureed (a paste or thick liquid suspension usually made from cooked food ground finely) texture, and thin liquids. The care plan documented to administer medication as ordered and observe for side effects. The MDS recorded staff would monitor for and report any difficulty chewing/swallowing and report to speech therapy as needed. The Physician Order, dated 01/07/25, directed the staff to administer Oxybutynin XL ER (extended-releaseextended release) 10 milligram (mg), administer one, tablet one time a day for overactive bladder. On 01/22/25 at 07:30 AM observation revealed License Nurse (LN) G crushed R21's morning medications including the Oxybutynin, and Oxybutynin and placed the medications in a plastic medication cup then poured the pills into a plastic medication bag and crushed the medication. LNG then placed the crushed medication back in the plastic medication cup and added applesauce. Continued observation revealed LN G administered the crushed medication to the resident. On 01/23/25 at 09:20 AM, LN G stated she administered R21 medications crushed because she had a hard time swallowing the pill whole. LN G verified extended-release medications should not be crushed and she would speak with the director of nursing to get another route of administration. On 01/23/25 at 09:25 AM, Administrative Nurse D verified the extended-release medication should not be crushed and said it should be administered whole due to the extended release of the medication. Administrative Nurse D said she would have an in-service with the nurse regarding proper route of medication. Medlineplus.gov directed that delayed-release and extended-release tablets should be taken whole; do not split, chew, or crush them. The facility's Crushing Medication policy, undated, documented medications shall be crushed only when appropriate and safe to do so, consistent with physician orders. The medical director and director of nursing, in conjunction with the consulting pharmacist, shall identify appropriate indications and procedures for crushing medications. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long-acting or enteric-coated medications. That attending physician or consultant pharmacist must identify an alternative and/or dose form, or the attending physician must document (or provide the nurses with clinically pertinent reason to document) why crushing the medication would not adversely affect the resident; or when such medication is administered, the facility staff will observe the resident for pertinent adverse effects. Crushing each medication separately and administering each with food is considered best practice. Issues related to safety, needs preference, medication schedule, and functional ability will determine the most resident-centered approach. The facility failed to ensure R21 remained free from medication errors when staff crushed an extended-release medication prior to administration. This placed the resident at risk for adverse reactions from the medication.

The facility census totaled 41 residents with one resident sampled for accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and ensure a safe and secure environment as free from accident hazards as possible when Housekeeping/Laundry Staff C failed to report a malfunctioning basement door. About six weeks later, on 07/01/24, cognitively impaired Resident (R)1 opened the same malfunctioning, key coded basement door and fell down seven steps to the landing, in her wheelchair. R1 sustained major injuries including a lump to the back of her head and three fractured ribs. This deficient practice placed R1 in immediate jeopardy and at risk for personal injury. (R1) Findings included: - R1's electronic medical record (EMR) included the following diagnoses that included cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and cognitive impairment (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS documented the resident wandered daily. The Behavioral Symptoms Care Area Assessment (CAA) dated 03/27/24 revealed R1 wandered around the facility and went into other residents rooms due to her confusion. The Quarterly MDS dated [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS documented the resident wandered daily. R1' s Care Plan revised 02/23/24, revealed R1 required a wheelchair for mobility. Staff were to monitor the resident and document/report to R1's physician of any changes in cognitive function, specifically changes in decision making ability, memory, recall, general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. R1 was at risk for falls related to confusion, muscle weakness, and cerebral infarction. The Care Plan included a 06/16/24 revision for staff to encourage the resident to remain in the common area until staff could assist her to bed. On 07/01/24 at 11:15 AM, a fall note revealed Licensed Nurse (LN) B was looking for R1 when a housekeeper notified the nurse the resident fell down the stairs. Upon entering the staircase, the resident was on the landing of the basement stairs on the floor with her wheelchair near her. The resident had her shoes on and a stack of kitchen napkins beside her. LN B asked the resident if she hit her head and R1 stated yes. Three staff assisted R1 into her wheelchair. When asked what she was doing R1 reported, I was walking down the stairs. Staff transported R1 upstairs via a basement elevator. R1 could follow commands and answer most questions. R1 had a bump to the back, left side of her head. R1 reported pain to her upper left back and stated it hurts when staff palpated (touched) her head. LN B provided Tylenol (pain medication), 650 milligrams (mg), as needed (PRN) at 11:23 PM. Review of the facility investigation dated 07/01/24, revealed R1 went through a door with a keylock and fell down the basement stairs (7 stairs). R1 told staff she was walking down the stairs and lost her balance and fell . The resident had a bump to the back, left side of her head and pain to her left upper back. No other injuries found. Staff initiated neuro checks (an assessment to monitor for neurological functions, motor and sensory response and level of consciousness). Staff notified R1's physician and the physician advised staff to apply an ice pack to the affected area. Immediately after the accident, the resident had complaints of pain and the staff administered PRN Tylenol. Later in the day, (untimed) the resident complained of left-sided pain. The nursing staff contacted the physician a second time and received orders for an X-ray of her ribs to the left side. The X-ray revealed three minimally displaced fractures of the left fifth, sixth, and seventh ribs. The Progress Notes dated 07/01/24 at 04:18 PM, revealed the resident complained of pain to her left ribs when staff transferred her from a recliner to a wheelchair. Staff contacted Physician F's office to request an X-ray. On 07/02/2024 at 02:04 PM, the x-ray results revealed R1 ha Minimally displaced fractures of the posterior left 5th, 6th, and 7th ribs. The witness statement by Housekeeping Staff C revealed on 07/02/24 Housekeeping Staff C reported the [malfunctioning basement door] door was not completely shut. The statement revealed if staff let it shut slowly, the door would not latch. Housekeeping Staff C documented it was approximately a month and a half ago, the door did not latch effectively. Housekeeping Staff C documented she told another housekeeper about it but did not report it to maintenance because she did not feel the door was broken, but it was just not latching. Review of the maintenance door logs from 06/03/24 through 07/18/24 showed no malfunction of the doors or the locks. Observation on 07/15/24 at 11:45 AM, revealed the resident in her wheelchair and able to propel her wheelchair without assistance. Observation on 07/15/24 at 01:40 PM, revealed the resident sat in a recliner in the commons area with the TV on. Observation on 07/15/24 at 02:40 PM, revealed Certified Nurse Aide (CNA) D transferred R1 from a recliner in the commons area to a wheelchair. R1 wheeled herself independently to her room with staff walking beside her. Once in her room, CNA D assisted the resident to the toilet. R1 could stand while she held onto the grab bar to transfer to the toilet. On 07/15/24 at 11:10 AM, Administrative Staff A stated staff were not sure how the resident got the door open. Administrative Staff A reported she knew laundry staff noted the door was not all the way latched about six weeks prior to the incident and did not know if the resident just shook the door handle until it opened or how she opened the door. Administrative Staff A stated the resident was confused but told staff she was walking down the stairs and lost her balance, so staff do not know how she got out the door. Her wheelchair was on the landing next to her when a housekeeping staff saw her on the floor. On 07/15/24 at 11:20 AM, Maintenance Staff H reported the door had a manual lock on it, but it worked fine when he checked the doors. He reported he checked all doors and door locks to make sure they were functioning and documented those on a daily log. He reported the whole locking mechanism was changed and switched it to an electronic lock pad to assure it did not open except with the code. On 07/15/24 at 01:30 PM, Licensed Nurse B reported she did not know how the resident got the door open. LN B said the door had a keypad on it and if a person did not have the code, it should not open. She reported it was about lunch time and the resident had been outside at an activity and as she was coming back in, R1 went through the dining room and picked up a big stack of napkins. LN B saw R1 go by the nurses' station holding onto the napkins. LN B said she watched her go by and was going to finish her charting and then take the resident to the dining room for lunch, but when she looked down the hall, she could not find R1, so she went to look for her. LN B said she looked on in every room, including the chapel and the restrooms, and had all the aides looking as well. LN B said Housekeeping Staff C took LN B to the basement door and LN B saw the resident on the landing of the stairs, going to the basement. LN B said her wheelchair was upright and next to the resident. LN B did range of motion (ROM) and asked R1 if she hit her head the resident reported yes, she hit her head. LN B said R1 had a bump to the back of her head. Several CNAs lifted the resident back into her wheelchair and staff carried her in her wheelchair down the stairs to the basement, then brought her upstairs in the elevator. LN B said she notified Administrative Nurse G, faxed the physician, then put an ice pack on the resident's head. The resident was placed in recliner in the commons area and was there a couple of hours. Staff then went to take her to the bathroom and when they transferred R1, the resident complained of pain in her left side by her ribs. LN B said she notified the physician for an order to get an x ray of her ribs. The physician ordered the X-ray the next day, which revealed three rib fractures. The physician ordered Tramadol (pain pill) and ice for pain. LN B said the maintenance department changed the locks on the door so it could not come open again and said the door is heavy and difficult for staff to open. On 07/15/24 at 02:30 PM, CNA D said they did know how R1 could open the heavy door. CNA D said a housekeeping staff saw R1 and notified the nurse. Review of the undated facility Maintenance policy for doors, documented all doors were to be checked daily for proper function and documented on the door log. On 07/15/24 at 05:20 PM, the IJ template was provided to Administrative Staff A and notified the facility of the failure to ensure a safe and secure environment as free from accident hazards as possible when a housekeeping/laundry staff failed to report a malfunctioning basement door, and about six weeks later, on 07/01/24, cognitively impaired R1 opened the key coded basement door and fell down seven steps to the landing, in her wheelchair and sustained major injuries that included a lump to the back of her head and three fractured ribs, placed the resident in immediate jeopardy. The immediate jeopardy was determined to first exist on 07/01/24. The facility identified and implemented the following corrective actions, completed on 07/03/24: 1. Doorknob/lock changed, and door closure changed on 07/02/24. 2. All staff received education on Reporting malfunction or equipment not working appropriately immediately to Administration Team. 3. Charge Nurses received education If there is a substantial fall (stairwell, out of transportation vehicle, fall face first out of wheelchair) and Director of Nursing/ Assistant Director of Nursing is present in the building, notify them and have them assess, too; if not present and another Charge Nurse present in the facility have the assess, also. If a resident sustains a substantial fall notify physician via phone, not a fax. 4. The Medical Director notified on 07/03/24. 5. Staff members who have not had education will be educated prior to working their next assigned shift. 6. An ad-hoc QAA meeting held to review this area of concern and the action plan created to ensure system is corrected and sustained 07/03/24. The surveyor verified the above implemented and completed corrective actions while onsite 07/15/24. Due to corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe environment as free of accident hazards as possible, when Social Services Designee (SSD) C failed to ensure the lap belt was snug on Resident (R)1 prior to transport in the facility van while traveling on the highway. R1 fell out of the wheelchair onto the floor of the facility van, landing on his knees. SSD C failed to notify 911 or activate EMS for assistance. SSD C assisted R1 to lay on the floor of the van and then drove R1 back to the facility (approximately 20 miles), unsecured, and laying on the floor of the wheelchair van. Upon arrival to the facility R1 required emergency medical transport to a local hospital for evaluation and treatment of a left femur (thigh bone) fracture (broken bone). This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR) documented R1 had diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one side of the body) following cerebrovascular disease (CVA or stroke - a sudden death of brain cells due to the lack of oxygen caused by impaired blood flow to the brain), end stage renal disease (ESRD - a terminal disease of the kidneys due to irreversible damage), dependence on renal dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to - a treatment procedure that is usually performed three to four times per week), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin) and disorders of bone density (disorders of altered bone density), and osteopenia (loss of bone density which weakens the bone). The 05/18/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance of two staff for all cares except eating, which was independent. R1 had no falls in the facility since admission. The 05/18/23 Falls Care Area Assessment (CAA) documented R1 was at increased potential for falls related to the requirement of a full body mechanical lift, incontinence (loss of bowel or bladder function), use of psychotropic medications (classes of medications that affect the mind, mood or mental processes), and hemiplegia. The 11/08/23 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. R1 required the assistance of two or more staff for all cares except eating, which was independent. The MDS documented no falls since admission. The Care Plan documented R1 was at risk for falls related to hemiplegia, history of CVA, chronic diffuse osteopenia, muscle weakness, bone demineralization, and history of a fall prior to admission that resulted in a femur fracture. The Care Plan lacked interventions specific to the mitigation of fall risk during transportation in facility owned vehicles. The Care Plan documented an intervention on 02/01/24 at 10:00 AM for R1 to have a pummel cushion (a cushion added to a wheelchair seat to prevent sliding) in place and to add use of vehicle's factory installed shoulder/lap seat belt for all transportations. The Fall Risk Score Assessments revealed the following for R1: 1. On 11/02/23, a fall score of 16, which indicated high risk for falls. 2. On 01/29/24, a fall score of 19 which indicated high risk for falls. The Progress Notes documented the following: On 02/01/24 at 06:45 AM, SSD C was providing transportation in the facility van when a small herd of deer crossed the road in front of the vehicle. SSD C swerved the vehicle to miss the deer and heard R1 yell her name. SSD C stopped the vehicle on the side of the road and saw R1 on his knees on the floor with the seatbelt intact on the wheelchair. On 02/01/24 at 07:36 AM, Licensed Nurse (LN) D documented at approximately 07:00 AM, SSD C reported to her that SSD C swerved to avoid hitting deer on the road and R1 fell out of his wheelchair. SSD C laid R1 down on the floor of the van and drove the resident back to the facility. R1 complained of left leg pain. LN D assessed R1 for injuries and called 911 to activate EMS (Emergency Medical Services) at 07:06 AM and R1 was transported to the ED (Emergency Department) for further evaluation of his injuries. On 02/01/24 at 12:00 PM, Administrative Nurse B informed LN D that R1 was going to be returning to the facility via EMS with a left leg splint (a rigid device used to prevent motion of a joint or the ends of a fractured bone) due to a distal femur fracture and R1 was not a candidate for surgery. On 02/01/24 at 12:45 PM, R1 returned to the facility via EMS from the ED and R1 complained of pain to his left leg and required pain medication. Review of the facility's undated investigation revealed on 02/01/24 at 06:45 AM, R1 was being transported to an appointment out of town in the facility van. The van traveled on the highway approximately 20 miles from the facility when a herd of deer crossed the highway. SSD C performed an emergency stop and swerve to avoid colliding with the deer and heard R1 call her name. R1 was observed by SSD C to have slipped out of his seatbelt and was on his knees on the floor. SSD C observed the seat belt and other safety belts were still in their proper position/placements. SSD C then assisted the resident off his knees and into a laying position on the floor of the van and returned to the facility. Upon the return to the facility, LN D assessed R1 and called 911 to activate EMS to transport R1 to the ED for further evaluation of his injuries. The ED staff assessed R1 and diagnosed a left distal femur fracture with slight displacement and placed a left leg splint due to R1 not being a candidate for surgical repair and opioid (a class of medications for severe pain) medication for pain management. On 02/07/24 at 09:41 AM, R1 observed laying in his bed on his left side. The resident wore a left leg splint. R1 stated that some deer ran out in front of the facility owned transport van and SSD C slammed on the brakes and swerved to avoid the deer. R1 stated that he slid out of his wheelchair and landed on his knees on the floor of the transport van. R1 further stated that he did not think the seatbelt was appropriately fastened to the wheelchair and only recalled use of the lap belt. On 02/07/24 at 10:45 AM, SSD C stated when staff transport residents in the van, a resident is wheeled into the transport van, there are four hook straps that secure the wheelchair to the van floor, then a seatbelt is placed through the arms of the wheelchair and positioned as low as possible on the resident's abdomen/pelvis. Further stated that at the time of the incident, deer were beginning to cross the roadway and she performed an emergency braking maneuver and swerved to the right to avoid the collision with the wildlife. Stated after the incident, the resident called out her name and she pulled completely off the road to the right to assess what had happened. R1 knelt on the floor of the transport van with the wheelchair and the seatbelt still fastened/secured to the van. She assisted R1 to a laying position while telling the resident that she was going to call 911. Once R1 was laying on the floor of the transport van with the wheelchair and seatbelts moved out of the way, she transported the resident back to the facility without the resident being secured in any way. Confirmed that she failed to call 911 from the side of the road, and that she failed to call the licensed nurse on duty for instructions. On 02/07/24 at 10:50 AM, Transportation Aide E revealed when staff propel a resident into the transportation van, the wheelchair should be secured to the transportation van with four hook straps then a seatbelt is snugly placed as low as possible across the resident's abdomen/pelvis. In the event a resident fell from the wheelchair, staff were to check the resident for injuries, then call 911 to activate EMS for further assistance. On 02/07/24 at 11:15 AM, Licensed Nurse D revealed that on 02/01/24 at approximately 07:00 AM, SSD C revealed an incident occurred to R1 in the transport van and R1 had been injured. 911 was called to activate EMS response for further assistance. R1 was laying on the floor of the transport van on his right side. On 02/07/24 at 11:30 AM, Certified Nurse Aide (CNA) F revealed when a resident was wheeled into the transportation van, the wheelchair should be secured with four hook straps and then a lap belt snugly placed as low as possible around the resident's abdomen/pelvis. In the event of a resident falling from the wheelchair, staff were to check the resident to make sure they were OK and then call 911 to activate EMS for further assistance, then call the charge nurse and/or Administrative Nurse B. On 02/07/24 at 11:42 AM, Administrative Nurse B revealed in the event of an incident in the transportation van, the expectation is for staff to call 911 to activate EMS to evaluate the resident for injuries. Further stated that she was unsure of what the policy directed in that situation. Further confirmed R1 was transported unsecured on the floor of the transportation van approximately 20 miles back to the facility. On-the-spot reeducation was provided to SSD C. On 02/07/24 at 12:00 PM, Administrative Staff A revealed in the event of an incident in the transportation van, the expectation is that staff should not move the resident and call 911 to activate EMS to evaluate the resident for injuries. Further, confirmed that SSD C did not follow procedure to call 911 to activate EMS. The facility's undated Assessing Falls and Their Causes policy lacked guidance related to incidents that occurred during transport to and from the facility in facility owned vehicles. On 02/07/24 at 03:43 PM, Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ when SSD C failed to ensure the lap belt was snug on R1 prior to transport in the facility van while traveling on the highway. R1 fell out of the wheelchair onto the floor of the facility van, landing on his knees. SSD C failed to notify 911 or activate EMS for assistance. SSD C assisted R1 to lay on the floor of the van and then drove R1 back to the facility (approximately 20 miles), unsecured, and laying on the floor of the wheelchair van. Upon arrival to the facility R1 required emergency medical transport to a local hospital for evaluation and treatment of a left femur fracture. This deficient practice placed R1 in immediate jeopardy. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on 02/01/24: The facility implemented education for all transportation staff on the proper securing methods for securing residents into transportation vans and the use of the new seatbelt that was initiated on 02/01/24 at 01:00 PM and completed on 02/05/24 at 02:00 PM. The facility implemented education for all transportation staff on the need to call 911 to activate EMS response during an emergency event during transportation, initiated on 02/01/24 at 01:00 PM, and completed on 02/05/24 at 02:00 PM. The facility completed on-the-spot education to SSD C on the necessity of calling 911 to activate EMS response during any emergent event initiated on 02/01/24 at 11:00 AM and completed on 02/01/24 at 11:00 AM. The facility updated R1's care plan to include the use of a pummel cushion and use of transportation van's factory installed shoulder/lap belt for all resident transports initiated on 02/01/24 at 10:00 AM and completed on 02/01/24 at 10:00 AM. The facility ordered shoulder straps that attach to the resident's wheelchair for added protection in addition to implementation of a seatbelt device that allows for integration of the transportation van's factory installed shoulder/lap belt and was initiated on 02/02/24 at 01:00 PM and completed on 02/02/24 at 01:00 PM. Due to the correction measures implemented by the facility prior to the onsite complaint investigation on 02/07/24, the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.

The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food storage to prevent the spread of food borne illness to the residents of the facility. Findings included: - On 02/07/03 at 07:52 AM initial tour of the kitchen with Dietary Staff CC revealed the following concerns: In the main refrigerator: 1. A large bag of shredded cheese, open and undated. 2. A container of sliced tomatoes, lacked preparation or expiration date. 3. A large bag of shredded lettuce, open and undated. 4. A small bag of shredded lettuce, open and undated. On 02/08/23 at 12:15 PM, Dietary Staff BB, stated staff should label food products in the refrigerators and freezers with an opened (or prepared) date and expiration dates. The revised 06/1997 facility's policy for Storage of food and non-food items revealed all opened food items would be labeled with contents and dated. Further documented that cheese should be tightly wrapped. The facility failed to store food under sanitary conditions for the residents in the facility. This created the potential for the spread of food borne illnesses to the residents of the facility.

The facility census totaled 43 residents with 12 residents included in the sample and two residents reviewed for hospitalization . Based on observation, interview, and record review the facility failed to send a copy of the facility- initiated hospitalization transfer/discharge notice to the Office of the State Long- Term Care Ombudsman for Residents (R)40 and R 34. Findings included: - R 40's signed physician orders dated 12/25/22, revealed the following diagnoses: alcohol dependence, in remission (consumption of alcohol in large quantities on a routine basis), atrial fibrillation (rapid irregular heartbeat), history of falling, unsteadiness on feet, and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The resident required extensive assistance of staff with transfers and ambulation. The resident had falls prior to admission with no fracture, and no falls since admission. The Significant change in status MDS dated [DATE], revealed a BIMS of seven, indicating severe cognitive impairment. The resident required extensive assist of two staff with transfers and ambulation. The resident had falls prior to admission with no falls since admission. The Care Plan dated 10/12/22, revealed the resident was at risk for falls. On 10/26/22, the care plan updated to include the resident was noncompliant with calling for assistance with transfers and has been transferring himself. The 12/19/22 care plan update included the resident was to be evaluated and treated, by therapy, as per physician orders, once the resident returned from the hospital. The care plan update on 01/28/23 included anti-rollback bars placed on the resident's wheelchair. Review of the physician orders dated 12/19/22, revealed the resident fell , and required hospitalization . On 12/30/22, the resident readmitted to the facility following surgery to repair his fractured right hip. Review of R40's Medical Record lacked evidence of a written notification of the facility-initiated hospitalization s transfer/discharges to the Office of the State Long-Term Care Ombudsman (Ombudsman). On 02/09/23 at 08:52 AM, Social Service Staff X stated she did not know staff were to notify the Ombudsman of hospitalization s. On 02/09/23 at 08:45 AM, Administrative Nurse D revealed she was unaware of the social service process with transfers/discharge. On 02/09/23 at 09:02 AM, Administrative Staff A stated she was aware of the requirement. and confirmed she would expect that staff notify the Ombudsman with transfers. The facility's policy for Transfer or Discharge Notice revised 12/2016, documented a notice would be given as soon as practicable but before the transfer or discharge when a resident required an immediate transfer or discharge for urgent medical needs. A copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. The facility failed to send a copy of the facility- initiated hospitalization transfer/discharge notice to the ombudsman for residents (R)40, as required. 41302 - Review of Resident (R)34's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on 12/07/22 and returned to the facility on [DATE]. Furthermore, the resident discharged to the hospital again on 12/20/22 and returned to the facility on [DATE]. Review of R34's Medical Record lacked evidence of a written notification of the facility-initiated hospitalization s transfer/discharges to the Office of the State Long-Term Care Ombudsman (Ombudsman). On 02/09/23 at 08:52 AM, Social Service staff X confirmed she did not send a notice to the Office of the State Long Term Care Ombudsman when a resident discharged to the hospital and was unaware of the need to notify the State Long Term Care Ombudsman. On 02/09/23 at 09:00 AM, Administrative Nurse D stated she did not know social service staff X's procedure for Ombudsman notifications. On 02/09/23 at 09:02 AM, Administrative Staff A confirmed no notice was sent to the Office of the State Long-Term Care Ombudsman when residents transferred to a hospital. She stated she was aware that a notice was required and would have expected it to be completed. The facility's policy for Transfer or Discharge Notice revised 12/2016, documented a notice would be given as soon as practicable but before the transfer or discharge when a resident required an immediate transfer or discharge for urgent medical needs. A copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. The facility failed to notify/ send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman of the reason for the transfers for R34's required hospitalization s.

The facility census totaled 43 residents, with 12 sampled, including five residents for unnecessary medications. Based on interview and record review, the facility failed to ensure adequate monitoring for one of the five residents reviewed, regarding Zoloft (antidepressant- class of medications used to treat mood disorders and relieve symptoms of depression) and a lab for diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) for Resident (R) 21, by not decreasing the dose of this medication as ordered and not having the lab results available for review. These failures placed the resident at risk for adverse effects related to medication use. Findings Included: - The 02/07/23 Electronic Health Record (EHR) documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness) and diabetes mellitus. The 12/23/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The assessment documented the use of an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and an antidepressant medication daily for R21. The 10/04/22 Quarterly MDS documented a staff assessment which indicated severely impaired cognition. The assessment documented the use of an antipsychotic and an antidepressant daily for R21. The Physicians Orders documented an order dated 06/24/21 for Zoloft, 100 milligrams, (mg) a day, that changed to 50 mg once daily, on 02/24/22. An order dated 10/01/22 for Levemir (a long-acting insulin used to treat high blood sugar levels) 30 units subcutaneous at bedtime, that changed from 20 units. Review of the monthly Pharmacy Medication Record Review (MRR) for January 2022 through January 2023 documented a gradual dose reduction (GDR) recommendation on 01/19/22 to decrease the dose of Zoloft to 50 mg daily to help reduce the risk of adverse effects (including increased risk of bleeding and suicidal thoughts and behaviors). The provider signed the recommendation in agreement on 01/21/22, the recommendation was not implemented for R21 until 02/24/22 (a total of 34 days after signed by the provider). A recommendation on 08/17/22 a need for a current hemoglobin A1C (HbA1c, a blood test that shows the average blood sugar level over the past two to three months). On 02/08/23 at 03:25 PM, Certified Medication Aide (CMA) R confirmed R21 took Zoloft daily. On 02/09/23 at 09:11 AM, Administrative Nurse D confirmed she was responsible for completion of the MRR's and that the recommendations for R21 had not been processed appropriately. She stated R21 was in the hospital at the time of the GDR (01/19/22), so she put the recommendation on hold. Administrative Nurse D stated at the time of R21's return to the facility the admitting nurse then put in the old order, and Administrative Nurse D changed it following the 02/23/22 recommendation by the consultant pharmacist. Administrative Nurse D stated the HbA1c had been drawn on 08/24/22 but had not been scanned in for review until 09/27/22, following the consultant pharmacist recommendation. The facility's Medication Regimen Review Policy and Procedure policy revised 05/2019 documented the goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The facility failed to adequately monitor medication use for R21, by the failure to decrease the Zoloft when recommended and ordered by the physician and for not having available for review in a timely manner the HbA1c, for the monitoring of blood sugar levels to possibly reduce the adverse effects for R21.

The facility reported a census of 32 residents. Based on interview and record review the facility failed to employ a Certified Dietary Manager (CDM). Findings Include: - On 07/13/21 at 11:50 AM Dietary Staff (DS) J confirmed she was not a CDM. She stated that her plan was to attend courses as soon as she could get registered, explaining that since Covid-19 it was difficult to register for classes. On 07/14/21 at 01:39 PM Administrative staff A stated DS J the had taken the courses but had not tested , also that the registered dietician had found out recently that DS J could still test, even though courses were taken in the mid 1990's. Stated she was aware they were to have a CDM and confirmed that they do not currently. The facility failed to provide a policy on required dietary staff when requested on 07/15/21. The facility failed to employ a CDM in the allotted time.

The facility reported a census of 32 residents, with one central kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary by the staff's failure to date and reseal opened food items, failure to discard expired food items, and failure to use gloves appropriately in the kitchen. Findings included: - On [DATE] at 08:24 AM, during the initial tour of the main kitchen, the following was observed: In the walk-in refrigerator, noted one crate with 17 molded tomatoes, one bag of broccoli florets, one bag of carrots, and one bag of vegetable medley all opened and not dated, one eight ounce (oz) boost breeze (liquid nourishment) with a use-by date of [DATE], three eight oz boost breeze with a use-by date of [DATE], one eight oz ensure plus (liquid nourishment) with a use-by date of [DATE]. In the refrigerator, noted one 24 oz container of cottage cheese expired on [DATE], one bag of sliced ham, and one bag of 22 hot dogs opened and not dated. During an interview on [DATE] at 09:03 AM, Dietary Staff (DS) J removed all items and verified that all items opened should be dated and resealed and facility staff should be observing all expiration dates. DS J expected the staff to follow the policy and reseal and date all opened items and expected all expired items be removed from use. DS J stated that it was all the staff's responsibility to check expiration dates. On [DATE] at 11:17 AM, during a follow-up visit to the central kitchen, Dietary Staff K was observed using gloved hands to place silverware into napkins while touching the food tray cart, the handle of the two shelf serving cart, and then touching the tops of the silverware while wearing the same gloves. During an interview on [DATE] at 11:50 AM, DS J stated she has made sure to educate all kitchen staff on infection control and glove use and watched them for competencies. She expected staff to change gloves after touching external objects such as the face, hair, doorknobs, etc. She did not know that Dietary Staff K did not know the proper way to wear gloves. She also stated that Dietary Staff K usually worked in transportation and was helping in the kitchen for other dietary staffs vacations. Review of facility's Labeling/ Dating Foods (Date Marking) policy dated 2011 documented once opened food will be re-dated with a use-by date according to current safe food storage guidelines. The facility failed to store foods safely and sanitary and that dietary staff followed appropriate glove usage.

The facility census totaled 32 residents, with three residents reviewed for beneficiary notices. Based on record review and interview, the facility failed to notify Resident (R)183 in advance of Medicare Part A (skilled) services ending on 05/06/21 per the Centers for Medicaid/Medicare Services (CMS) regulation. Findings included: - Review of R183's Notice of Medicare Non-coverage (NOMNAC) documented her Medicare Part A skilled services last covered day was 05/06/21, and the resident had signed the form. Review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage, (SNFABN) documented the form was not provided to R183 because the Social Services Director (SSD) was new and still learning the forms that were required. An interview with SSD D on 07/12/21 at 04:30 PM revealed she provided all residents with the NOMNAC at the end of skilled services but only provided the SNFABN to residents who remained in the facility after skilled services. She did not provide the SNFABN to residents who discharged from the facility after completing skilled services. SSD D stated R183 remained in the facility for six weeks after completing skilled services before being discharged and that she was unaware that R183 should have received the SNFABN. An interview with Administrator A on 07/14/21 at 05:01 PM revealed that all residents were to receive the NOMNAC and SNFABN at the completion of skilled services. She also stated that R183 did not receive the SNFABN because the SSD was new and still learning what forms were needed. Review of the Form CMS- dated for 2018 documented SNFs are to issue the SNFABN to all beneficiaries so s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. The facility failed to provide R183 written notification of the SNFABN before the end of the Medicare Part A stay.

The facility reported a census of 32 residents with 12 residents included in the sample. Based on interview and record review the facility failed to prevent the misappropriation of resident's property, when the facility utilized Resident (R)133's government issued stimulus check to pay for facility charges on the resident's account without R133's consent. Findings included: - Review of the R133 personal funds revealed a deposit of $1200.00 from a government issued stimulus check. Further review revealed the facility used R133's stimulus check to make a payment to the facility, towards his account. Review of R133's record revealed no evidence of resident consent for the transaction. Interview with Business office staff C on 7/14/21 at 03:01 PM revealed R133 would not sign the check they had sent to him at the other facility where lived prior to admission to the current facility. The funds were placed back into R133's account and Business office staff C wrote a check from the account to the facility to apply the amount of the stimulus check to the account. Interview with Administrative Staff A on 07/14/21 at 03:53 PM revealed when the stimulus checks arrived the money went directly into the resident's funds. The facility policy Abuse, Neglect and Exploitation Prevention Policy and Procedure dated 08/16/19 revealed the facility prohibits the abuse, mistreatment, neglect and/or exploitation of residents. The policy defined the misappropriation of resident's property as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility failed to prevent the misappropriation of residents' property, when the facility utilized the resident's government issued stimulus check to pay for the facility charges on the resident's account without R133's consent.

The facility reported a census of 32 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to address the consultant pharmacist's recommendations for Resident (R)2. Findings included: - Review of R2's Physician's Orders in the Electronic Medical Record (EMR) dated 07/26/21 included a diagnosis of major depressive disorder (major mood disorder). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA), dated 08/04/20, documented that the resident had a potential for issues related to [CONDITION(S)] medications and that pharmacy reviews were to be completed quarterly and as needed. Review of the 04/07/21 Quarterly MDS documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics and antidepressants. Review of the 06/29/21 Care Plan documented staff was to monitor R2 for [CONDITION(S)] medication side effects as well as possible dose reduction of [CONDITION(S)] medication. Review of the Medication Regimen Review (MRR) and Gradual Dose Reduction (GDR) regarding R2 documented the following: On the 04/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) tablet, one tablet by mouth (PO) every night, be decreased to 10mg PO every night. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 10/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) tablet, one tablet by mouth (PO) every night, be considered for a decrease. In addition, the consultant pharmacist also recommended that [MEDICATION(S)] (an antipsychotic medication) 60mg tablet, one tablet PO every day, be considered for a decrease. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 12/2020 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) tablet, one tablet by mouth (PO) every night, be considered for a decrease. In addition, the consultant pharmacist also recommended that [MEDICATION(S)] (an antipsychotic medication) 60mg tablet, one tablet PO every day, be considered for a decrease. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 02/2021 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) tablet, one tablet by mouth (PO) every night, be considered for a decrease. The consultant pharmacist also recommended that [MEDICATION(S)] (an antipsychotic medication) 60mg tablet, one tablet PO every day, be considered for a decrease. The facility faxed the recommendation to the provider, but the facility failed to follow up on this recommendation. On the 04/2021 MRR and GDR, the consultant pharmacist recommended that [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) tablet, one tablet by mouth (PO) every night, be considered for a decrease. The facility faxed the recommendation to the provider, with a response to decrease the [MEDICATION(S)] to 40mg PO every day and to keep the [MEDICATION(S)] at the same dosage. Review of the 10/2020 through 03/2021 Monthly Medication Review documented that the provider printed the medication/order list and signed each one. An interview with Pharmacist E on 07/19/21 at 09:51 AM revealed he completed a GDR every two months to allow the provider to respond. He expected the provider to see the GDR, agree or disagree [with explanation], and then sign the form before faxing back to the facility. Pharmacist E stated he would send the GDR every two months until he received an acceptable signed response from the provider and stated that a printed monthly medication/order review signed by the provider is not an acceptable response to a GDR. Pharmacist E stated that he follows the appendix PP of the state regulations, which required a signature from the provider. He also stated that R2 was on [MEDICATION(S)] for at least one year before it was addressed and reduced by the provider. An interview with Administrative Nurse B on 07/14/21 at 02:30 PM revealed that she would resend the fax after one week with no response after the GDR is faxed to the provider. If there were no response after the third attempt, she would call the office about completing the GDR. Administrative Nurse B stated that some of the providers that work with the facility would not complete the MRR/GDRs. Instead, the providers would print out the medication/order list each month, make changes, sign, and fax it back to the facility to respond to the pharmacist recommendations. Review of the 04/2007 Tapering Medications and Gradual Drug Dose Reduction documented that the physician was to review antipsychotic medications for gradual dose reductions periodically. Within the first year of a new antipsychotic medication for a resident, the practitioner was to attempt a GDR two separate quarters and then at least annually. The facility failed to follow up on the consultant pharmacist recommendations for R2 timely.

The facility reported a census of 32 residents, with 12 sampled and five reviewed for unnecessary medications. Based on interviews and record review, the facility failed to adequately follow the physicians' diabetic orders and document appropriately for Resident (R)2. Findings included: - Review of R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R2 received insulin (mediation that regulates the amount of glucose in the blood) seven out of a seven-day observation period. Review of the Care Area Assessment (CAA) dated 08/04/20 documented no applicable CAAs triggered. A review of the Quarterly MDS dated [DATE], documented a BIMS score of 13, indicating intact cognition. R2 received insulin seven out of a seven-day observation period. Review of the 06/29/21 Care Plan documented staff was to administer medications as ordered, monitor R2 for signs and symptoms of [CONDITION(S)] (high blood sugar levels), complete blood glucose (BG; blood sugar), and to notify the provider if the BG was above or below prescribed parameters. Review of the Electronic Health Records (EHR) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 02/19/21: [MEDICATION(S)] Kwikpen (long -acting insulin to reduce BG levels) 20 units SQ (into the belly fat) at bedtime for DM 03/01/21: NovoLOG [MEDICATION(S)] (fast -acting insulin to reduce BG levels) 15 units SQ every 4 hours as needed (PRN) for BG greater than 300 milligram/deciliter (mg/dl). 06/04/21: [MEDICATION(S)] Extended -Release (medication to help reduce BG) 2 milligrams (mg) subcutaneous (SQ; into the belly fat) once a day on Fridays for DM 06/18/21: accucheck (BG check) three times a day related to DM, no need to notify provider unless BG is greater than or equal to 450 mg/dl, or is 70 mg/dl or less. 06/19/21: accucheck (BG check) one time a day every Tuesday, Thursday, Saturday, and Sunday for DM 06/21/21: accucheck one time a day every Monday, Wednesday, and Friday for DM 06/18/21: accucheck three times a day related to DM, no need to notify provider unless BG is greater than or equal to 450, or is 70 or less 06/04/21: [MEDICATION(S)] Extended Release (medication to help reduce BG) 2 milligrams (mg) subcutaneous (SQ; into the belly fat) once a day on Fridays for DM 03/01/21: NovoLOG [MEDICATION(S)] (fast acting insulin) 15 units SQ every 4 hours as needed (PRN) for BG greater than 300 02/19/21: [MEDICATION(S)] Kwikpen (long acting insulin) 20 units SQ at bedtime for DM Review of the 04/2021 through 07/2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Certified Medication Aide (CMA) I on 07/14/21 at 09:38 AM revealed R2's BG was checked four times a day, and she would notify the nurse on duty of any BG greater than 250 mg/dl and obtain a second BG check if required. An interview with CMA H on 07/14/21 at 02:18 PM revealed R2's BG was checked four times a day and with a parameter of 350 to notify the nurse. After notifying the nurse, CMA H would obtain a second BG check two hours after the high reading. The nurse would notify the provider if the BG remained elevated and gives the insulin to the resident. An interview with License Nurse (LN) G on 07/14/21 at 09:00 AM revealed that LN staff would notify the provider the provider would be notifiefd for all BGs greater than 450. If R2's BG was greater than 300 mg/dl, the LN would give 15 units of NovoLOG insulin every four hours until the BG was less than 300 mg/dl. An interview with Administrative Nurse B on 07/14/21 at 02:30 PM revealed that she expected staff to give the NovoLOG [MEDICATION(S)] PRN when R2's BG was greater than 300 mg/dl. An interview with Pharmacist E on 07/19/21 at 09:51 AM revealed that he would look at the emar to monitor BG but that [Administrative Nurse B] was to monitor as well. Pharmacist E expected staff to monitor R2's BG four times a day and after every dose of PRN NovoLOG given. If the BG was greater than 300 mg/dl, the facility staff should have administered the PRN NovoLOG should have been given each time. He also stated that if the insulin was not documented in the emar as having been given, there would be no way to know that the BG was treated. Review of the 04/2019 Administering Medications policy documented that all staff was to administer medications were to be administered in accordance with prescriber orders. The facility failed to adequately follow the physicians' diabetic orders and document appropriately for R2.

The facility reported a census of 32 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to adequately ensure gradual dose reductions (GDR's) were attempted for Resident (R) 2. Findings included: - Review of R2's Physician's Orders in the Electronic Medical Record (EMR) dated 07/26/21 included a diagnosis of major depressive disorder (major mood disorder). A review of the Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics (class of medications used to treat [CONDITION(S)] and other mental and emotional conditions) and antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression). Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA), dated 08/04/20, documented that the resident had a potential for issues related to [CONDITION(S)] medications and that pharmacy reviews were to be completed quarterly and as needed. Review of the 04/07/21 Quarterly MDS documented R2 received scheduled pain medication, as well as seven out of the seven-day observation period of antipsychotics and antidepressants. Review of the 06/29/21 Care Plan documented staff was to monitor R2 for [CONDITION(S)] medication side effects as well as possible dose reduction of [CONDITION(S)] medication. Review of the Electronic Health Records (EHR) Physician Orders documented an order for [MEDICATION(S)] (antidepressant medication) 25 milligram (mg) capsule, staff would give one capsule by mouth at bedtime started on 10/08/19. R2 also had an order for [MEDICATION(S)] (an antipsychotic medication) 40mg tablet that staff would give one tablet by mouth every day started on 04/13/21. Review of 01/2021 through 06/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented appropriate documentation of administrations of medications and monitoring of behaviors. Review of the GDRs from 10/2020 through 02/2021 documented Pharmacist E completed a GDR request for [MEDICATION(S)] and [MEDICATION(S)] every two months with no reduction in dosage or reasonable explanation for continuing the dosage. [MEDICATION(S)] did not have a dosage reduction until the 04/2021 GDR request by Pharmacist E. [MEDICATION(S)] did not have a dosage reduction or reasonable explanation for continuing the dosage. An interview with Pharmacist E on 07/19/21 at 09:51AM revealed he completed a GDR every two months to allow the provider to respond. He expected the provider to see the GDR, either agree or disagree [with explanation], and then sign the form, before faxing back to the facility. Pharmacist E stated he would send the GDR every two months until he received an acceptable signed response from the provider and stated that a printed monthly medication/order review signed by the provider is not an acceptable response to a GDR. Review of the 04/2007 Tapering Medications and Gradual Drug Dose Reduction documented that the physician was to review antipsychotic medications for gradual dose reductions periodically. Within the first year of a new antipsychotic medication for a resident, the practitioner was to attempt a GDR two separate quarters and then at least annually. The facility failed to ensure GDRs were attempted for R2.

The facility census totaled 32 residents with three residents included in the sample. Based on interview and record review, the facility failed to ensure staff provided cognitively impaired, physically dependent Resident (R) 4 with toileting assistance in a timely manner, when facility staff neglected to remove a bedpan placed under R4 for over 10 hours. Findings included: - Review of R4's History and Physical dated 11/07/20 included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed R4 had a brief interview for mental status (BIMS) score of one, indicating severely impaired cognition. She was able to make herself understood and could sometimes understand others. She was totally dependent on two staff members for bed mobility and toilet use. R4 had moisture associated skin damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, [MEDICATION(S)], or saliva) and the facility had implemented a pressure reduction device for her bed, repositioning, and topical ointments. Review of the 11/16/20 Pressure Ulcer Care Area Assessment (CAA) revealed R4 was at risk for the development of pressure ulcers related to incontinence and decreased mobility. Review of the 11/16/20 Cognitive Loss/Dementia CAA revealed she had no communication issues and could make her needs known. The Care Plan, last revised on 12/07/20, advised staff to turn and reposition R4 frequently, apply creams and ointments as ordered, ensure her call light was within reach, and she required two staff members to assist with toileting. Review of the transferring facility's Patient Health Summary, dated 11/10/20 revealed R4 as alert and orientated. Review of the Admission/Readmission Evaluation Bundle dated 11/10/20 revealed R4 had redness noted to both buttocks, groin, and abdominal folds. Review of the Skilled Progress Note dated 12/03/20, revealed staff were continuing treatments to bilateral (both) buttocks for MASD and repositioned every two hours and as needed (PRN). Review of a Facility Reported Incident included a signed notarized witness statement from Licensed Nurse (LN) B, dated 12/04/20, which revealed on 12/03/20 at approximately 08:30 PM, R4 was placed onto a bedpan. LN B wrote the Certified Nurse Aides (CNAs) were advised R4 was on the bedpan. Review of a signed, notarized witness statement from CNA C, dated 12/04/20, revealed she was notified R4 was on the bedpan, however, she continued to assist other residents with cares until shift change. She wrote that R4 never activated her call light, which R4 would usually activate to request for assistance with the bedpan, water, or repositioning. Review of a signed notarized witness statement from CNA D, dated 12/04/20, revealed she arrived to her shift and was not advised R4 was on the bedpan. Per CNA D statement, they checked on the resident around 12:30 AM, 02:00 AM, and 04:52 AM and R4's call light was clipped onto the top of the blankets and R4 denied needing any assistance. Review of a signed notarized witness statement from Administrative Staff G, dated 12/04/20, revealed R4's family approached her reporting R4 had been on the bedpan since 08:00 PM the night before. They rolled R4 over and found a bedpan underneath R4. LN staff E then performed a nursing assessment. Review of a Skin Observation Tool dated 12/04/20 revealed blanchable redness to bilateral buttocks. During an interview with LN E on 03/12/21 at 09:56 AM it was reported she was not the staff member who found R4 on the bedpan; however, she was the LN who performed the assessment. LN E denied any skin integrity changes for R4 after being on the bedpan, that she recalled. She reported R4 admitted to the facility with MASD and there was no worsening to her skin condition from R4 being on the bedpan for an extended amount of time. Interview with Administrative Nurse F and Administrative Staff G on 03/12/21 at 02:18 PM revealed R4 could call for assistance when needed and would often refuse to allow staff to reposition her during checks. They reported there was increased redness to the bilateral buttocks for several hours, but it had dissipated by the end of the afternoon and there was no outcome to the resident being left on the bedpan. They had identified the problem as a communication issue amongst the staff and had implemented training to all staff that if a resident was assisted onto a bedpan, the staff member who placed the bedpan was the one to ensure they removed the resident from the bedpan. Review of the undated Abuse, Neglect, and Exploitation Prevention Policy and Procedure revealed neglect was defined as the failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Review of the undated policy entitled Activities of Daily Living (ADLs) Support revealed that residents unable to carry out ADLs would receive the services necessary to maintain personal hygiene. The facility failed to ensure staff did not neglect R4 by the failure of staff to remove a bedpan from under R4 for over 10 hours. The facility identified the staff's lack of communication as the causal factor as to why the staff left R4 on the bedpan for an extended amount of time. The facility then determined an educational intervention for staff to follow: if a staff member placed a resident on a bedpan, they were required to remove them from the bedpan. The facility achieved substantial compliance on 12/07/20 when most staff had completed the training; therefore, the deficiency was determined to be past non-compliance.

The facility had a census of 47 residents. The sample included 15 residents with four reviewed for pressure ulcers (PU-localized injury to the skin and/or underlying tissue as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to provide services, including pressure relief, nutrition, and infection treatment, to prevent the development or worsening of facility acquired pressure ulcers for two of four sampled residents. Resident (R) 28 developed a blister on his heel which worsened into a Stage 3 (full thickness tissue loss) pressure ulcer with infection and R32 developed a Stage 3 pressure ulcer on his coccyx (small triangular bone at the base of the spine). Findings included: - R28's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The MDS documented the resident was independent with eating, required extensive assistance of one staff with hygiene, dressing, locomotion, transfers, extensive assistance of two staff with bed mobility, toilet use, walking, and total staff assistance with bathing. The MDS documented the resident used a walker and a wheelchair for mobility, experienced occasional mild pain, and weighed 119 pounds. The MDS documented the resident was at risk for pressure ulcers, no current skin issues, and no pressure ulcer preventions in place. The Significant Change MDS, dated [DATE], documented the resident weighed 127 pounds, had one Stage 3 pressure ulcer, and a foot infection. The MDS documented the resident used a pressure relieving device in the chair and bed, received nutrition interventions to manage skin issues, pressure ulcer care, dressing to foot, and antibiotics. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 07/08/19, documented the resident required staff assistance to complete ADLs. The Nutrition CAA, dated 07/08/19, documented the resident received a therapeutic diet and staff monitored the resident's weight and intake. The CAA documented the registered dietician (RD) evaluated the resident as needed, reviewed labs as ordered, and notified the physician as needed. The PU CAA, dated 07/08/19, documented the resident had impaired mobility, weakness, incontinence, and at risk for skin breakdown. The CAA directed staff to assist the resident with all mobility, positioning, incontinent cares, and assess skin weekly and as needed. The PU CAA, dated 08/29/19, documented the resident had a Stage 3 wound to his heel with recent infection. The CAA directed staff to assist the resident with all mobility, positioning, incontinent care, and assess skin weekly. The Skin Care Plan, dated 07/01/19, documented the resident was at risk for skin breakdown due to decreased mobility. The 07/02/19 update documented skin breakdown to the resident's coccyx and directed staff to apply cream or ointments as ordered, check and change the resident for incontinence upon awakening, before and after meals, at bedtime, and as needed. The care plan directed staff to perform weekly skin observations, monitor labs, and ensure a pressure reduction cushion in the resident's wheelchair. The care plan directed staff to provide the resident incontinence care after each episode, refer to registered dietitian as indicated, and if skin breakdown occurred, notify the physician, and promptly implement treatment. The 07/19/19 update directed staff to administer the resident 2 Cal (high density nutritional drink), 120 milliliters (ml), three times per day and Prostat (high density protein drink), twice daily. The 08/07/19 update directed staff to apply heel protectors to the resident's feet at all times and a pressure reduction cushion to the resident's wheelchair (intervention placed after coccyx re-opened and new open blister on heel). The 08/28/19 update directed staff to place an air mattress on the resident's bed and a heel float cushion when in bed (intervention placed three weeks after PU developed). The 09/12/19 update directed staff to provide the resident a regular diet, liberalized, with mechanical soft texture and thin consistency. The Physician Order, dated 07/01/19, directed staff to perform diabetic foot checks on the resident every Saturday and weekly skin observations. The Wound Assessment, dated 07/02/19, documented a Stage 2 (partial thickness loss of skin or a blister) PU to coccyx upon admission. The Braden Scale assessment, dated 07/03/19, documented a score of 17 indicating low risk for pressure ulcers. The RD Assessment, dated 07/16/19, documented the resident's estimated daily needs as 1580 calories, 63-82 grams of protein, and 1500 cubic centimeters (cc) of fluid. The assessment documented the resident's nutrition risk factors included a history of weight loss, recent fracture, [MEDICAL TREATMENT], and poor appetite. The assessment documented the resident received a regular diet, recently liberalized from renal due to the resident's poor intake of 0-25% and frequent refusals. The assessment documented the resident's coccyx redness on skin review, recommended starting supplements by adding 120 ml 2 Cal, TID (three times per day) providing 720 kcal and 30 grams protein. The physician's orders [REDACTED]. The Wound Assessment Tool, dated 08/07/19, documented the resident had a Stage 2 PU on his coccyx, acquired 08/07/19, scab intact, and measured 0.4 centimeters (cm) x 0.1 cm. The note documented treatment included skin prep every shift until resolved. Resolved by 08/13/19. The 08/07/19 at 04:52 PM, nurse's note documented the resident had an opened blister on his right heel, staff cleansed the area and applied a bordered foam dressing. The note documented the resident to wear egg crate foam heel protectors at all times. The 08/07/19 fax to the physician documented the resident had a 0.4 cm x 0.1 cm scabbed shearing area to coccyx and an opened blister to his right heel measuring 3.0 cm x 5.0 cm. The 08/08/19 physician visit notes lacked mention of the right heel open blister. The 08/09/19 at 03:24 PM, RD progress note recorded considering skin concerns and continued [MEDICAL TREATMENT], suggested adding 30 ml Prostat BID. The 08/16/19 at 01:21 PM, nurse's note documented the Interdisciplinary Team (IDT) met to review new skin concerns of a worsened opened blister on the resident's right heel, culture obtained, and staff were awaiting the physician response. The physician's orders [REDACTED]. The Wound Assessment, dated 08/20/19, documented a small amount serosanguinous drainage (semi-thick reddish drainage), 4.3 cm x 5.2 cm x 0.1, progress stalled. The Wound Assessment, dated 08/27/19, documented unstable eschar (dead tissue) developed in the right heel wound with a small amount serosanguinous drainage, with odor, and measured 3.5 cm, x 6.0 x 0. The note documented the wound worsened, the wound care consultant viewed and recommended a blood flow study for lower extremities and possible wound clinic services On 08/30/19 at 11:21 AM, the IDT met to review new skin concerns of opened blister to the resident's right heel, worse with unstable eschar forming. RD recommended Prostat 30 ml BID, staff were waiting on the physician's reply. An air mattress and heel float cushion were added to the resident's bed. The Wound Assessment, dated 09/03/19, documented the resident's Stage 3 right heel PU with 50% necrosis (dead tissue) or slough (dead tissue, usually cream or yellow in color), moderate amount serosanguinous drainage, no odor, and measured 3.5 cm x 6.0 x 0.2 cm with irregular edges. The Physician Visit Note, dated 09/03/19, documented nursing requested an evaluation of the resident's right heel wound. The resident finished the course of [MEDICATION NAME] on 08/07/19, the wound had not healed and needed to be debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), no [MEDICAL CONDITION] in the resident's feet, and very good dorsalis pedis (artery in the foot) pulse. The Physician Orders, dated 09/03/19, directed staff to administer 30 cc Prostat BID for wound healing, multivitamin with minerals daily for skin integrity, (23 days after recommended by RD) and refer to wound care. The 09/05/19 at 02:32 PM, nurse's note documented a wound culture obtained from the right heel due to odor and drainage as ordered by the physician. The right heel Wound Culture Report, dated 09/05/19, documented heavy growth of bacteria and organisms. The 09/08/19 at 02:15 PM, nurse's note documented the final wound culture results were sent to the physician to review and the facility had no reply from the physician. The Wound Assessment, dated 09/10/19, documented the right heel wound measured 3.5 cm x 6.0 cm x 0 cm. The Wound Clinic Note, dated 09/10/19, documented staff removed minimal necrosis from around the edges, applied [MEDICATION NAME] (antimicrobial wound gel) to the wound bed, covered with non-adherent pad and secured with [MEDICATION NAME] tape. The wound clinic note documented there were no significant changes. The Wound Assessment, dated 09/17/19, documented the right heel wound measured 3.0 cm x 5.5 cm x 0 cm. The Wound Clinic Note, dated 09/19/19, documented staff removed a small amount of necrosis, eschar soft, minimal dark yellow drainage on old dressing, and no maceration (skin looks lighter in color and wrinkly, it may feel soft, wet, or soggy to the touch) surrounding wound this visit. The note documented edges of eschar able to be removed with minimal bleeding, mild odor to wound. The Wound Clinic Note, dated 09/21/19, documented staff removed small amount of necrotic tissue prior to resident saying that's enough due to pain. The wound measured 5.2 cm x 2.5 cm and unknown depth, minimal dark yellow drainage, foul odor, eschar, and associated pain. The note documented the wound displayed necrotic tissue, infection, with increased redness surrounding the wound bed. The Wound Assessment, dated 09/24/19, documented the right heel wound measured 3.0 cm x 4.0 cm x 0 cm. The Physician Visit Note, dated 09/24/19, documented the physician previously assessed the resident's right heel wound, referred to the wound clinic, and the resident saw the specialist today. The note documented the wound looked red and was hot to touch. The physician ordered to continue wound care. The Wound Clinic Note, dated 09/24/19, documented the resident reported the wound very tender. The Wound Clinic Note, dated 09/26/19, documented staff removed a small amount of necrotic tissue, but stopped due to the resident's pain. The note documented the wound's surrounding tissue not as red or warm, but very dry, no gel or honey reapplied after the physician visit. The Wound Clinic Note, dated 10/01/19, documented staff removed slough, and the wound measured 3.2 cm x 4.7 cm x 0 cm, worse. The Wound Clinic Note, dated 10/01/19, documented staff removed the dressing with blood and other drainage leaking out and onto the resident's sock, moderate amount of necrotic tissue and dead skin removed from inferior aspect of the wound. The note documented the resident reported pain with any touching of the wound, wound deeper and open with moderate amount of thick, bloody drainage. The Wound Clinic Note, dated 10/07/19, documented the resident reported mild pain until someone did something to his foot and a minimal amount of thick dark necrosis was debrided from lateral aspect of wound. The Wound Assessment, dated 10/08/19,documented the resident's right heel measured 4.9 cm x 5.0 cm x 0 cm, worse due to debridement. The Wound Clinic Note, dated 10/09/19, documented unstageable pressure ulcer to the resident's right heel, minimal amount of thick dark necrosis debrided from inner aspect of the wound. The note documented the wound measured 3.8 cm x 3.2 cm, unable to determine depth with minimal dark yellow drainage, foul odor, 90% eschar, and increased redness surrounding the wound. The 09/05/019 wound culture positive for [DIAGNOSES REDACTED] pneumoniae (bacteria that can cause different types of healthcare-associated infections, including bloodstream infections, wound or surgical site infections), pseudomonas aeruginosa (a multidrug resistant bacteria), [MEDICATION NAME] faecalis (can cause life-threatening infections) and Bacteroides ovatus (bacteria that are a common cause of infections.). The Physician Visit Note, dated 10/09/19, for wound follow up on a wound culture from 09/05/19, documented a non-healing right heel wound, and directed staff to start the resident on [MEDICATION NAME] as empiric (given without knowledge of the cause or nature of the disorder and based on experience rather than logic. Sometimes urgency dictates empirical treatment, as when a dangerous infection by an unknown organism is treated with a broad-spectrum antibiotic while the results of bacterial culture and other tests are awaited) therapy. The physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. On 10/08/19 at 08:13 AM, observation revealed an air mattress on the resident's bed. The resident independently ate and drank 100% of breakfast in the dining room consisting of ground sausage, scrambled eggs, cinnamon roll, Malt-O-Meal, 120 cc dark juice, 120 cc water, and 200 cc coffee. Observation revealed both the resident's feet encased in large foam boots, and he sat in a wheelchair with a 3 inch seat cushion. On 10/08/19 at 02:58 PM, observation revealed Administrative Nurse D observed the right foot/heel, wound drainage showed through the gauze wrapping. Observation revealed Administrative Nurse D cleaned her hands, gloved, and removed the soiled wound dressing, containing a moderate amount of serosanguinous drainage. Administrative Nurse D changed gloves, cleansed the wound with wound cleanser twice, removed gloves, and applied new gloves. Observation revealed the wound mostly eschar in the middle with some tissue visible around the center, measured 3 cm x 4.2 cm, Administrative Nurse D applied [MEDICATION NAME] with a sterile Q Tip, 4 x 4 dry gauze, and wrapped the foot with gauze. On 10/8/19 at 04:55 PM, Administrative Nurse D stated the resident went to the wound clinic after the culture and no further follow up. Administrative Nurse D stated she contacted the physician today and he wanted to re-evaluate the wound. On 10/09/19 at 11:00 AM, Certified Medication Aide (CMA) R stated she administered the 2 Cal and Prostat, but occasionally the resident refused. CMA R stated she tried to give the supplements within the specified window of medication pass and had not reported anything to the nurse as it was only occasionally. On 10/09/19 at 11:15 AM, Administrative Nurse [NAME] verified the facility sent the 09/05/19 wound culture reports to the physician on two separate days and did not receive a response. On 10/10/19 at 08:40 AM, Administrative Nurse D verified the wound culture results were faxed on Sunday 09/08/19, not passed on report to weekday nurse, and the physician did not respond. Administrative Nurse D stated the resident had an appointment with the physician on 09/26/19, the physician documented the wound was red, hot to touch, but did not order a new treatment. Administrative Nurse D stated on 10/09/19 staff called the physician to check if the resident needed an antibiotic and changed the scheduled times for the supplements to ensure the resident received them. Administrative Nurse D stated staff should have given the supplements upon return from [MEDICAL TREATMENT], and 2 Cal started for weight loss, his weight had stabilized, so staff were not concerned, and had not informed the physician. Administrative Nurse D stated nursing staff notified the RD, she replied with recommendations, staff fax recommendations to the physician, and waited for the physician to respond. Administrative Nurse D stated if nursing staff push for a response the physician will not respond and becomes upset with the facility. The facility's Pressure Ulcer Risk Assessment policy, dated (MONTH) 2013, instructed staff to assess the special needs of the resident, review the risk assessment tool, ensure the resident drinks plenty of fluids and eats a well-balanced diet. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Because an at risk resident can develop a pressure ulcer within 2-6 hours, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The facility failed to provide services in a timely manner to prevent the development or worsening of a facility acquired pressure ulcer, including pressure relief, nutrition, and infection treatment for [REDACTED]. - R32's physician's orders [REDACTED]. The Quarterly MDS, dated [DATE], documented the resident had no pressure, venous, or arterial ulcers. The MDS documented a pressure reducing mattress and cushion in his chair. The Significant Change MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe impairment. The MDS documented the resident required total assistance of two staff with toileting and bathing, extensive assistance of two staff with bed mobility, transfers, dressing, personal hygiene, and supervision with eating. The MDS documented the resident used a wheelchair for mobility, had one Stage 3 pressure ulcer, and pressure reducing devices in his chair and bed. The Pressure Ulcer Care Area Assessment (CAA), dated 07/07/19, documented the resident currently had a Stage 3 pressure ulcer to his coccyx (small triangular bone at the base of the spine) and staff assisted the resident with all mobility, positioning, and incontinent cares. The CAA documented the staff administered the resident's dietary supplements as ordered, performed weekly skin assessments and the resident had a pressure reducing device to his wheelchair. The Comprehensive Care Plan initiated on 01/09/19, documented the resident had skin breakdown related to urinary incontinence, impaired mobility, [MEDICAL CONDITION], and hypertension. The care plan instructed staff to encourage good nutrition and hydration, promote protein-based food items to help with skin integrity, and caution during transfers. The Comprehensive Care Plan, dated 09/09/19 instructed staff to encourage good nutrition and promote protein based food items to help with skin integrity. The care plan directed staff to apply heel protectors to the resident at all times when in bed, ensure air mattress in place on the resident's bed, and use caution during transfers and bed mobility to prevent the resident from striking his arms, legs, and hands against any sharp or hard surfaces. The care plan documented the resident received Prosource (protein supplement) three times a day and Two Cal (protein supplement) 120 milliliters (ml) three times a day. The Weekly Wound Tool dated 06/27/19, documented a new Stage 2 pressure ulcer to R32's coccyx measuring 1.0 centimeter (cm) by 0.5 cm by 0.2 cm. The Wound Tool documented a treatment order for duoderm (dressing that provides a waterproof barrier and creates an optimal moist wound healing environment) change every three days, and avoid pressure to the area as much as possible. The Nutrition Note, dated 06/28/19, recommended Prosource twice a day for wound healing. The Interdisciplinary Team (IDT) note, dated 07/05/19, documented the team met to review the new Stage 2 pressure ulcer to the resident's coccyx. The note documented staff treated the wound with a [MEDICATION NAME] foam dressing (a gel-forming dressing that promotes wound healing), change every other day and turned the resident frequently. The note documented the wound stalled since initial assessment. The 07/24/19 fax to R32's physician, documented the wound measurements of 4.5 cm x 3.5 cm x 0.1 cm. The Wound Tool documented a treatment of [REDACTED]. The Registered Dietician (RD) note, dated 08/05/19, documented the RD recommended to add [MEDICATION NAME] (dietary supplement to aid wound healing), one packet, mixed with the beverage of choice, twice daily. The Nutrition Note, dated 08/05/19, recommended Two Cal three times a day and [MEDICATION NAME] twice a day for poor wound healing. The 09/03/19 fax to R32's physician recommended protein alternatives, such as boiled eggs and cottage cheese to the residents' meals due to wound concerns. The Nutrition Note, dated 09/19/19, recommended a liberalized diet due to skin integrity and Juven (dietary supplement for wound healing) one packet with eight ounces of water twice a day, for wound healing. The Weekly Pressure Wound Dashboard, dated 10/1/19, documented R32's coccyx wound measured 1.2 cm x 0.9 cm x 1.5 cm with tunneling (channels that extend from the wound bed into the surrounding tissue or muscle) 3.0 cm at six o'clock, 0.5 cm at 12 o'clock, and 0.4 cm at three o'clock, based on clock face position identification. The Weekly Pressure Wound Dashboard, dated 10/8/19, documented R32's coccyx wound measured 1.0 cm x 0.8 cm x 1.0 cm with tunneling of 3.0 cm at six o'clock, 2.0 cm at 12 o'clock, and 1.0 cm at three o'clock, based on clock face position identification. On 10/09/19 at 07:32 AM, observation revealed Licensed Nurse (LN) G entered R32's room, washed hands, applied gloves, removed and discarded the used dressing from R32's coccyx into a lined trash receptacle. LN G opened one sealed packet of Calcium Alginate (biodegradable dressing derived from seaweed that promotes wound healing), applied triple antibiotic ointment to the dressing, and let sit in the packaging. LN G cleaned the wound area with saline wound spray and patted dry with a clean padding. LN G applied the Calcium Alginate dressing to the open wound and used a clean cotton tipped applicator to press the dressing into the undermined (a pocket that forms beneath the wound edges) areas of the wound. LN G removed gloves, applied hand sanitizer, and applied a new pair of gloves, and opened a package of bordered dressing. LN G dated and secured the dressing to the resident's coccyx and applied pressure to seal. On 10/09/19 at 08:05 AM, observation revealed the resident sat in his wheelchair in the dining room for breakfast with no pressure relieving cushion in wheelchair, served scrambled eggs, oat cereal, two links of pork sausage, 120 ml of orange juice, and 120 ml of milk. On 10/09/19 at 09:15 AM, observation revealed the resident sat in his wheelchair in the north common room area with no pressure relieving cushion in wheelchair, watching television. On 10/09/19 at 09:32 AM, observation revealed the Certified Nurse Aide (CNA) N and CNA P entered the resident's room with a mechanical lift (lift to assist with resident transfer), washed hands and applied gloves. CNA N attached the straps of the sling lift to the mechanical lift and raised the resident (no pressure relief cushion observed in the resident's wheelchair). CNA N maneuvered the resident over his bed, with resident instruction to avoid the overhead trapeze, and lowered the lift. CNA N and CNA P positioned the resident to remove the sling lift, placed a body pillow behind the resident's back for support, and covered the resident, air mattress in place on the resident's bed, CNA P placed the call light and both removed their gloves. On 10/09/19 at 07:57, LN G confirmed the resident had not been to the wound clinic for wound care, but a consultant wound nurse managed the resident's wound care. Staff completed the treatment daily and as needed for soiling. On 10/09/19 at 11:52 AM, Administrative Nurse D stated staff discovered a pea-sized wound on 06/27/19, and the resident refused to lay down, at times. Administrative Nurse D confirmed the resident had not been educated on the importance of pressure reduction to promote healing. On 10/10/19, the surveyor attempted to call the primary care physicians three times, messages left, with no response or return call. On 10/10/19 at 09:47 AM, Administrative Nurse D and Administrative Nurse [NAME] verified the decline in the resident's coccyx wound. Administrative Nurse D stated the wound consultant nurse provided instruction to the administrative nurses and provided a skills check off for the current clinical nursing staff on dressing changes. Administrative Nurse D confirmed the need for the staff to reposition the resident, provide pressure-relieving cushions to seated surfaces, and revise the care plan as needed. The facility's Pressure Ulcer Risk Assessment policy, dated September/2013, documented the facility would assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown, and immediately report any signs of developing or worsening pressure ulcers to the supervisor. The facility failed to provide care and treatment to prevent the development or worsening of a pressure ulcer for R32, placing the resident at risk for further skin deterioration and physical decline.

The facility had a census of 47 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to review and revise the care plan for Resident (R) 7 for therapy recommendations, R28 and R32 for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and R37 for fluid restriction. Findings included: - R7's physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a severely impaired cognition. The MDS documented the resident required extensive assistance of one or two staff for bed mobility, transfers, dressing, toilet use, personal hygiene, bathing, and eating. The MDS documented the resident used a wheelchair with one staff assistance for mobility. The Activities of Daily Living (ADLs) Care Plan, dated 09/22/19, documented R7 unable to propel self around the facility and instructed staff to encourage the resident to use adaptive equipment (walker, wheelchair, splint, etc). The Occupational Therapy (OT) Treatment Notes, from 07/02/19 to 08/13/19, documented staff were trained to approach R7 from the right during feeding and other self-care tasks to decrease her left side lean, improve postural control, and increase proper alignment in her wheelchair. On 10/07/19 at 12:18 PM, observation revealed R7 sat in her wheelchair in the dining room, no foot pedals or support for bilateral lower extremities, staff sat on the left side of the resident and assisted her with eating. On 10/09/19 at 08:09 AM, observation revealed Certified Nurse Aide (CNA) M propelled R7 to the dining room with bilateral lower extremities, in tennis shoes, sliding on the floor in front of her. CNA M continually instructed the resident to pick up her feet. On 10/09/19 at 01:59 PM, Consultant (C) GG, stated R7 was assessed for positioning in her wheelchair and staff were instructed to assist the resident from the right side with eating. On 10/10/19 at 09:07 AM, CNA N and Certified Medication Aide (CMA) R, stated staff had no specific instructions for assisting the resident with eating. On 10/10/19 at 08:44 AM, Administrative Nurse D and Administrative Nurse [NAME] stated OT had evaluated the resident for positioning and an email had been sent to staff in July, to update them on assisting the resident from the right side to eat. Administrative D confirmed the OT recommendations should have been followed. The facility's undated Care Planning policy documented the Care Planning Interdisciplinary Team was responsible for the development of an individualized and comprehensive care plan for each resident. Care plans may be revised and/or updated quarterly, annually, and with significant changes in condition or other changes as needed. The facility failed to review and revise the care plan for R7, placing the residents at risk for inconsistent care and physical decline. - R32's physician's orders [REDACTED]. The Quarterly MDS, dated [DATE], documented the resident had no pressure, venous, or arterial ulcers. The MDS documented a pressure reducing mattress and cushion in his chair. The Significant Change MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe impairment. The MDS documented the resident required total assistance of two staff with toileting and bathing, extensive assistance of two staff with bed mobility, transfers, dressing, personal hygiene, and supervision with one staff assistance for eating. The MDS documented the resident used a wheelchair for mobility, one Stage 3 pressure ulcer, pressure reducing devices in his chair and bed. The Pressure Ulcer Care Area Assessment (CAA), dated 07/07/19, documented the resident currently had a Stage 3 pressure ulcer to his coccyx (small triangular bone at the base of the spine) and staff assisted the resident with all mobility, positioning, and incontinent cares. The CAA documented the staff administered the resident's dietary supplements as ordered, performed weekly skin assessments and the resident had a pressure reducing device to his wheelchair. The Comprehensive Care Plandated 01/09/19, documented the resident had skin breakdown related to urinary incontinence, impaired mobility, [MEDICAL CONDITION], and hypertension. The care plan instructed staff to encourage good nutrition and hydration, promote protein-based food items to help with skin integrity, and caution during transfers. The Comprehensive Care Plan, dated 09/09/19 instructed staff to encourage good nutrition and promote protein based food items to help with skin integrity. The care plan directed staff to apply heel protectors to the resident at all times when in bed, ensure an air mattress was in place on the resident's bed, and use caution during transfers and bed mobility to prevent the resident from striking his arms, legs, and hands against any sharp or hard surfaces. The care plan documented the resident received Prosource (protein supplement) three times a day and Two Cal (proteins supplement) 120 milliliters (ml) three times a day. The Weekly Wound Tool dated 06/27/19, documented a new Stage 2 pressure ulcer to R32's coccyx measuring 1.0 centimeter (cm) by 0.5 cm by 0.2 cm. The Wound Tool documented a treatment order for Duoderm (dressing that provides a waterproof barrier and creates an optimal moist wound healing environment) change every three days, and avoid pressure to the area as much as possible. The Nutrition Note, dated 06/28/19, recommended Prosource twice a day for wound healing. The Interdisciplinary Team (IDT) note, dated 07/05/19, documented the team met to review the new Stage 2 pressure ulcer to the resident's coccyx. The not documented staff treated the wound with a [MEDICATION NAME] foam dressing (a gel-forming dressing that promotes wound healing), change every other day and turned the resident frequently. The note documented the wound stalled since initial assessment. The 07/24/19 fax to R32's physician, documented the wound measurements of 4.5 cm x 3.5 cm x 0.1 cm. The Wound Tool documented a treatment of [REDACTED]. The Registered Dietician (RD) note, dated 08/ 05/19, documented the RD recommended to add [MEDICATION NAME] (dietary supplement to aid wound healing), one packet, mixed with the beverage of choice, twice daily. The Nutrition Note , dated 08/05/19, recommended Two Cal (nutritional supplement for wound healing three times a day and [MEDICATION NAME] twice a day for poor wound healing. The 09/03/19 fax to R32's physician recommended protein alternatives, such as boiled eggs and cottage cheese to the residents' meals due to wound concerns. The Nutrition Note, dated 09/19/19, recommended a liberalized diet due to skin integrity and Juven (dietary supplement) one packet with eight ounces of water twice a day, for wound healing. The Weekly Pressure Wound Dashboard, dated 10/01/19, documented R32's coccyx wound measured 1.2 cm x 0.9 cm x 1.5 cm with tunneling (channels that extend from the wound bed into the surrounding tissue or muscle) 3.0 cm at six o'clock, 0.5 cm at 12 o'clock, and 0.4 cm at three o'clock, based on clock face position identification. The Weekly Pressure Wound Dashboard, dated 10/8/19, documented R32's coccyx wound measured 1.0 cm x 0.8 cm x 1.0 cm with tunneling of 3.0 cm at six o'clock, 2.0 cm at 12 o'clock, and 1.0 cm at three o'clock, based on clock face position identification. On 10/09/19 at 07:32 AM, observation revealed Licensed Nurse (LN) G entered R32's room, washed hands, applied gloves, removed and discarded the used dressing from R32's coccyx into a lined trash receptacle. LN G opened one sealed packet of Calcium Alginate (biodegradable dressing derived from seaweed that promotes wound healing), applied triple antibiotic ointment to the dressing, and let sit in the packaging. LN G cleaned the wound area with saline wound spray and patted dry with a clean padding. LN G applied the Calcium Alginate dressing to the open wound and used a clean cotton tipped applicator to press the dressing into the undermined (a pocket that forms beneath the wound edges) areas of the wound. LN G removed gloves, applied hand sanitizer, and applied a new pair of gloves, and opened a package of bordered dressing. LN G dated and secured the dressing to the resident's coccyx and applied pressure to seal. On 10/09/19 at 08:05 AM, observation revealed the resident sat in his wheelchair in the dining room for breakfast, with no pressure relieving cushion in wheelchair, served scrambled eggs, oat cereal, two links of pork sausage, 120 ml of orange juice, and 120 ml of milk. On 10/09/19 at 09:15 AM, observation revealed the resident sat in his wheelchair in the north common room area with no pressure relieving cushion in wheelchair, watching television. On 10/09/19 at 09:32 AM, observation revealed Certified Nurse Aide (CNA) N and CNA P entered the resident's room with a mechanical lift (lift to assist with resident transfer), washed hands and applied gloves. CNA N attached the straps of the sling lift to the mechanical lift and raised the resident (no pressure relief cushion observed in the resident's wheelchair). CNA N maneuvered the resident over his bed, with resident instruction to avoid the overhead trapeze, and lowered the lift. CNA N and CNA P positioned the resident to remove the sling lift, placed a body pillow behind the resident's back for support, and covered the resident, air mattress in place on the resident's bed. CNA P placed the call light in resident's reach, and both CNAs removed their gloves. On 10/09/19 at 07:57 AM, LN G confirmed the resident had not been to the wound clinic for wound care, but a consultant wound nurse managed the resident's wound care. Staff completed the treatment daily and as needed for soiling. On 10/09/19 at 11:52 AM, Administrative Nurse D stated staff discovered a pea-sized wound on 06/27/19, and the resident refused to lay down, at times. Administrative Nurse D confirmed the resident had not been educated on the importance of pressure reduction to promote healing. On 10/10/19 the surveyor attempted to call the primary care physicians three times, messages left, with no response or return call. On 10/10/19 at 09:47 AM, Administrative Nurse D and Administrative Nurse [NAME] verified the decline in the resident's coccyx wound. Administrative Nurse D stated the wound consultant nurse provided instruction to the administrative nurses and provided a skills check off for the current clinical nursing staff on dressing changes. Administrative Nurse D confirmed the need for the staff to reposition the resident, provide pressure-relieving cushions to seated surfaces, and revise the care plan as needed. The facility's undated Care Planning policy documented the Care Planning Interdisciplinary Team was responsible for the development of an individualized and comprehensive care plan for each resident. Care plans may be revised and/or updated quarterly, annually, and with significant changes in condition or other changes as needed. The facility failed to review and revise the care plans for R32, placing the residents at risk for inconsistent care and physical decline. - R28's Admission MDS, dated [DATE] , documented the resident had a BIMS score of seven, indicating severely impaired cognition. The MDS documented the resident was independent with eating, required extensive assistance of one staff with hygiene, dressing, locomotion, transfers, extensive assistance of two staff with bed mobility, toilet use, walking, and total staff assistance with bathing. The MDS documented the resident used a walker and a wheelchair for mobility, experienced occasional mild pain, and weighed 119 pounds. The MDS documented the resident was at risk for pressure ulcers, no current skin issues, and no pressure ulcer preventions in place. The Significant Change MDS, dated [DATE], documented the resident weighed 127 pounds, had one Stage 3 pressure ulcer, and a foot infection. The MDS documented the resident used a pressure relieving device in the chair and bed, received nutrition interventions to manage skin issues, pressure ulcer care, dressing to foot, and antibiotics. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 07/08/19, documented the resident required staff assistance to complete ADLs. The Nutrition CAA, dated 07/08/19, documented the resident received a therapeutic diet and staff monitored the resident's weight and intake. The CAA documented the registered dietician (RD) evaluated the resident as needed, reviewed labs as ordered, and notified the physician as needed. The PU CAA, dated 07/08/19, documented the resident had impaired mobility, weakness, incontinence, and at risk for skin breakdown. The CAA directed staff to assist the resident with all mobility, positioning, incontinent cares, and assess skin weekly and as needed. The PU CAA, dated 08/29/19, documented the resident had a Stage 3 wound to his heel with recent infection. The CAA directed staff to assist the resident with all mobility, positioning, incontinent care, and assess skin weekly. The Skin Care Plan, dated 07/01/19, documented the resident was at risk for skin breakdown due to decreased mobility. The 07/02/19 update documented skin breakdown to the resident's coccyx and directed staff to apply cream or ointments as ordered, check and change the resident for incontinence upon awakening, before and after meals, at bedtime, and as needed. The care plan directed staff to perform weekly skin observations, monitor labs, and ensure a pressure reduction cushion in the resident's wheelchair. The care plan directed staff to provide the resident incontinence care after each episode, refer to registered dietitian as indicated, and if skin breakdown occurred, notify the physician, and promptly implement treatment. The 07/19/19 update directed staff to administer the resident 2 Cal (high density nutritional drink), 120 milliliters (ml), three times per day and Prostat (high density protein drink), twice daily. The 08/07/19 update directed staff to apply heel protectors to the resident's feet at all times and a pressure reduction cushion to the resident's wheelchair (intervention placed after coccyx re-opened and new open blister on heel). The 08/28/19 update directed staff to place an air mattress on the resident's bed and a heel float cushion when in bed (intervention placed three weeks after PU developed). The 09/12/19 update directed staff to provide the resident a regular diet, liberalized, with mechanical soft texture and thin consistency. The Physician Order, dated 07/01/19, directed staff to perform diabetic foot checks on the resident every Saturday and weekly skin observations. The Wound Assessment, dated 07/02/19, documented a Stage 2 (partial thickness loss of skin or a blister) PU to coccyx upon admission. The Braden Scale assessment, dated 07/03/19, documented a score of 17 indicating low risk for pressure ulcers. The RD Assessment, dated 07/16/19, documented the resident's estimated daily needs as 1580 calories, 63-82 grams of protein, and 1500 cubic centimeters (cc) of fluid. The assessment documented the resident's nutrition risk factors included a history of weight loss, recent fracture, [MEDICAL TREATMENT], and poor appetite. The assessment documented the resident received a regular diet, recently liberalized from renal due to the resident's poor intake of 0-25% and frequent refusals. The assessment documented the resident's coccyx redness on skin review, recommended starting supplements by adding 120 ml 2 Cal, TID (three times per day) providing 720 kcal and 30 grams protein. The physician's orders [REDACTED]. The Wound Assessment Tool, dated 08/07/19, documented the resident had a Stage 2 PU on his coccyx, acquired 08/07/19, scab intact, and measured 0.4 centimeters (cm) x 0.1 cm. The note documented treatment included skin prep every shift until resolved. Resolved by 08/13/19. The 08/07/19 at 04:52 PM, nurse's note documented the resident had an opened blister on his right heel, staff cleansed the area and applied a bordered foam dressing. The note documented the resident to wear egg crate foam heel protectors at all times. The 08/07/19 fax to the physician documented the resident had a 0.4 cm x 0.1 cm scabbed shearing area to coccyx and an opened blister to his right heel measuring 3.0 cm x 5.0 cm. The 08/08/19 physician visit notes lacked mention of the right heel open blister. The 08/09/19 at 03:24 PM, RD progress note recorded considering skin concerns and continued [MEDICAL TREATMENT], suggested adding 30 ml Prostat BID. The 08/16/19 at 01:21 PM, nurse's note documented the Interdisciplinary Team (IDT) met to review new skin concerns of a worsened opened blister on the resident's right heel, culture obtained, and staff were awaiting the physician response. The physician's orders [REDACTED]. The Wound Assessment, dated 08/20/19, documented a small amount serosanguinous drainage (semi-thick reddish drainage), 4.3 cm x 5.2 cm x 0.1, progress stalled. The Wound Assessment, dated 08/27/19, documented unstable eschar (dead tissue) developed in the right heel wound with a small amount serosanguinous drainage, with odor, and measured 3.5 cm, x 6.0 x 0. The note documented the wound worsened, the wound care consultant viewed and recommended a blood flow study for lower extremities and possible wound clinic services On 08/30/19 at 11:21 AM, the IDT met to review new skin concerns of opened blister to the resident's right heel, worse with unstable eschar forming. RD recommended Prostat 30 ml BID, staff were waiting on the physician's reply. An air mattress and heel float cushion were added to the resident's bed. The Wound Assessment, dated 09/03/19, documented the resident's Stage 3 right heel PU with 50% necrosis (dead tissue) or slough (dead tissue, usually cream or yellow in color), moderate amount serosanguinous drainage, no odor, and measured 3.5 cm x 6.0 x 0.2 cm with irregular edges. The Physician Visit Note, dated 09/03/19, documented nursing requested an evaluation of the resident's right heel wound. The resident finished the course of [MEDICATION NAME] on 08/07/19, the wound had not healed and needed to be debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), no [MEDICAL CONDITION] in the resident's feet, and very good dorsalis pedis (artery in the foot) pulse. The Physician Orders, dated 09/03/19, directed staff to administer 30 cc Prostat BID for wound healing, multivitamin with minerals daily for skin integrity, (23 days after recommended by RD) and refer to wound care. The 09/05/19 at 02:32 PM, nurse's note documented a wound culture obtained from the right heel due to odor and drainage as ordered by the physician. The right heel Wound Culture Report, dated 09/05/19, documented heavy growth of bacteria and organisms. The 09/08/19 at 02:15 PM, nurse's note documented the final wound culture results were sent to the physician to review and the facility had no reply from the physician. The Wound Assessment, dated 09/10/19, documented the right heel wound measured 3.5 cm x 6.0 cm x 0 cm. The Wound Clinic Note, dated 09/10/19, documented staff removed minimal necrosis from around the edges, applied [MEDICATION NAME] (antimicrobial wound gel) to the wound bed, covered with non-adherent pad and secured with [MEDICATION NAME] tape. The wound clinic note documented there were no significant changes. The Wound Assessment , dated 09/17/19, documented the right heel wound measured 3.0 cm x 5.5 cm x 0 cm. The Wound Clinic Note, dated 09/19/19, documented staff removed a small amount of necrosis, eschar soft, minimal dark yellow drainage on old dressing, and no maceration (skin looks lighter in color and wrinkly, it may feel soft, wet, or soggy to the touch) surrounding wound this visit. The note documented edges of eschar able to be removed with minimal bleeding, mild odor to wound. The Wound Clinic Note, dated 09/21/19, documented staff removed small amount of necrotic tissue prior to resident saying that's enough due to pain. The wound measured 5.2 cm x 2.5 cm and unknown depth, minimal dark yellow drainage, foul odor, eschar, and associated pain. The note documented the wound displayed necrotic tissue, infection, with increased redness surrounding the wound bed. The Wound Assessment, dated 09/24/19, documented the right heel wound measured 3.0 cm x 4.0 cm x 0 cm. The Physician Visit Note, dated 09/24/19, documented the physician previously assessed the resident's right heel wound, referred to the wound clinic, and the resident saw the specialist today. The note documented the wound looked red and was hot to touch. The physician ordered to continue wound care. The Wound Clinic Note, 09/24/19, documented the resident reported the wound very tender. The Wound Clinic Note, dated 09/26/19, documented staff removed a small amount of necrotic tissue, but stopped due to the resident's pain. The note documented the wound's surrounding tissue not as red or warm, but very dry, no gel or honey reapplied after the physician visit. The Wound Clinic Note, dated 10/01/19, documented staff removed slough, and the wound measured 3.2 cm x 4.7 cm x 0 cm, worse. The Wound Clinic Note, dated 10/01/19, documented staff removed the dressing with blood and other drainage leaking out and onto the resident's sock, moderate amount of necrotic tissue and dead skin removed from inferior aspect of the wound. The note documented the resident reported pain with any touching of the wound, wound deeper and open with moderate amount of thick, bloody drainage. The Wound Clinic Note, dated 10/07/19, documented the resident reported mild pain until someone did something to his foot and a minimal amount of thick dark necrosis was debrided from lateral aspect of wound. The Wound Assessment, dated 10/08/19,documented the resident's right heel measured 4.9 cm x 5.0 cm x 0 cm, worse due to debridement. The Wound Clinic Note, dated 10/09/19, documented unstageable pressure ulcer to the resident's right heel, minimal amount of thick dark necrosis debrided from inner aspect of the wound. The note documented the wound measured 3.8 cm x 3.2 cm, unable to determine depth with minimal dark yellow drainage, foul odor, 90% eschar, and increased redness surrounding the wound. The 09/05/019 wound culture positive for [DIAGNOSES REDACTED] pneumoniae (bacteria that can cause different types of healthcare-associated infections, including bloodstream infections, wound or surgical site infections), pseudomonas aeruginosa (a multidrug resistant bacteria), [MEDICATION NAME] faecalis (can cause life-threatening infections) and Bacteroides ovatus (bacteria that are a common cause of infections.). The Physician Visit Note, dated 10/09/19, for wound follow up on a wound culture from 09/05/19, documented a non-healing right heel wound, and directed staff to start the resident on [MEDICATION NAME] as empiric (given without knowledge of the cause or nature of the disorder and based on experience rather than logic. Sometimes urgency dictates empirical treatment, as when a dangerous infection by an unknown organism is treated with a broad-spectrum antibiotic while the results of bacterial culture and other tests are awaited) therapy. The physician's orders [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. On 10/08/19 at 08:13 AM, observation revealed an air mattress on the resident's bed. The resident independently ate and drank 100% of breakfast in the dining room consisting of ground sausage, scrambled eggs, cinnamon roll, Malt-O-Meal, 120 cc dark juice, 120 cc water, and 200 cc coffee. Observation revealed both the resident's feet encased in large foam boots, and he sat in a wheelchair with a 3 inch seat cushion. On 10/08/19 at 02:58 PM, observation revealed Administrative Nurse D observed the right foot/heel, wound drainage showed through the gauze wrapping. Observation revealed Administrative Nurse D cleaned her hands, gloved, and removed the soiled wound dressing, which contained a moderate amount of serosanguinous drainage. Administrative Nurse D changed gloves, cleansed the wound with wound cleanser twice, removed gloves, and applied new gloves. Observation revealed the wound mostly eschar in the middle with some tissue visible around the center, measured 3 cm x 4.2 cm, Administrative Nurse D applied [MEDICATION NAME] with a sterile Q Tip, 4 x 4 dry gauze, and wrapped the foot with gauze. On 10/8/19 at 04:55 PM, Administrative Nurse D stated the resident went to the wound clinic after the culture and no further follow up. Administrative Nurse D stated she contacted the physician today and he wanted to re-evaluate the wound. On 10/09/19 at 11:00 AM, Certified Medication Aide (CMA) R stated she administered the 2 Cal and Prostat, but occasionally the resident refused. CMA R stated she tried to give the supplements within the specified window of medication pass and had not reported anything to the nurse as it was only occasional. On 10/9/19 at 11:15 AM, Administrative Nurse [NAME] verified the facility sent the 09/05/19 wound culture reports to the physician on two separate days and did not receive a response. On 10/10/19 at 08:40 AM, Administrative Nurse D verified the wound culture results were faxed on Sunday 09/08/19, not passed on report to weekday nurse, and the physician did not respond. Administrative Nurse D stated the resident had an appointment with the physician on 09/26/19, the physician documented the wound was red, hot to touch, but did not order a new treatment. Administrative Nurse D stated on 10/09/19 staff called the physician to check if the resident needed an antibiotic and changed the scheduled times for the supplements to ensure the resident received them. Administrative Nurse D stated staff should have given the supplements upon return from [MEDICAL TREATMENT], and started 2 Cal for weight loss, his weight had stabilized, so staff were not concerned, and had not informed the physician. She verified the care plan had not been updated in a timely manner to reflect the new pressure ulcer on the right heel. Administrative Nurse D stated nursing staff notified the RD, she replied with recommendations, staff fax recommendations to the physician, and waited for the physician to respond. Administrative Nurse D stated if nursing staff push for a response the physician will not respond and becomes upset with the facility. The facility's undated Care Planning policy recorded the facility's Care Planning Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. The policy recorded care plans may be revised and or updated quarterly, annually, and with significant change in condition or other changes as needed. The facility failed to review and revise the care plan in a timely manner to reflect R28's facility acquired pressure ulcer on his right heel, placing the resident at risk for inappropriate care. - R37's Physician order [REDACTED]. The Admission MDS, dated [DATE], documented the resident independent with eating. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/06/19, documented the resident incontinent of urine and directed staff to assist the resident with toileting and incontinent cares. The Comprehensive Care Plan, dated 09/06/19, documented the resident independent with eating, instructed staff to explain and reinforce the importance of maintaining the physician ordered diet, and encourage the resident to comply with the diet. The care plan instructed staff to monitor/document/report as needed any sign or symptom of acute [MEDICAL CONDITION] (urine output < 400 milliliter (ml) in 24 hours), and signs and symptoms of [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). The care plan lacked direction to staff on fluid restriction breakdown amounts for dietary and nursing staff. The Physician Order, dated 09/25/19, instructed staff to place the resident on fluid restriction. The order instructed staff to provide the resident with one and one half liters (L) of fluid in 24 hours, consisting of 250 ml every meal, 30 ml with medication pass, and 120 ml in his room every shift. The Fluid Restriction Sheets from 09/25/19 to 10/08/19 documented the residents fluid intake from meals and medication pass but lacked documentation of the fluid the resident received in his room. On 10/08/19 at 11:56 AM, observation revealed staff served the resident regular consistency 120 cubic centimeter (cc) of supplement, 120 cc ice water, and 120 cc of orange juice. Continued observation at 12:07 PM revealed staff served the resident shrimp fajita bowl, jello cake, and mandarin oranges, and rice, and the resident independently ate his meal. Continued observation at 12:35 PM revealed the resident consumed 100% of his fluids and 50% of his meal. On 10/10/19 at 08:00 AM, CNA O stated the aides do not keep track of the residents fluid intake in his room, there used to be a place in the computer but it is not there anymore, so the aide told the CMA and she documented it with the meal and medication pass fluids. On 10/10/19 at 08:06 AM, CMA S stated she did not document the resident's fluid intake from his room, the nurse aide was to document in the computer. CMA S displayed the nurse aide documentation section on the computer and verified there was not a place for the nurse aide to document the resident's fluid intake in his room. On 10/10/19 at 12:09 PM, Administrative Nurse D verified the resident's care plan lacked instructions to staff regarding how to divide the one and one half L

The facility had a census of 47 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to provide and maintain proper wheelchair positioning and alignment for two of two sampled Resident (R) 7 and R18. Findings included: - R7's physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. The MDS documented the resident required extensive assistance of one or two staff for bed mobility, transfers, dressing, toilet use, personal hygiene, bathing, and eating. The MDS documented the resident used a wheelchair with one staff assistance for mobility. The care plan, dated 09/22/19, documented R7 unable to propel self around the facility and instructed staff to encourage the resident to use adaptive equipment (walker, wheelchair, splint, etc). The Occupational Therapy (OT) Treatment Notes, from 07/02/19 to 08/13/19, documented staff were trained to approach R7 from the right during feeding and other self-care tasks to decrease her left side lean, improve postural control, and increase proper alignment in her wheelchair. On 10/07/19 at 12:18 PM, observation revealed R7 sat in her wheelchair in the dining room, no foot pedals or support for bilateral lower extremities, the staff sat on the left side of the resident and assisted her with eating. On 10/09/19 at 08:09 AM, observation revealed Certified Nurse Aide (CNA) M propelled R7 to the dining room with bilateral lower extremities, in tennis shoes, sliding on the floor in front of her. CNA M continually instructed the resident to pick up her feet. On 10/09/19 at 01:59 PM, Consultant (C) GG, stated R7 was assessed for positioning in her wheelchair and staff were instructed to assist her from the right with eating. On 10/10/19 at 09:07 AM, CNA N and Certified Medication Aide (CMA) R, stated staff had no specific instructions for assisting the resident with eating. On 10/10/19 at 08:44 AM, Administrative Nurse D and Administrative Nurse [NAME] stated OT had evaluated the resident for positioning and an email had been sent to staff in July, to update them on assisting the resident from the right, to eat. Administrative D confirmed the OT recommendations should have been followed. The Repositioning policy, dated (MONTH) 2013, documented the facility would evaluate a resident in the chair for postural alignment, even weight distribution, and maintenance of sitting balance. The facility failed to provide and maintain proper positioning and alignment for R7 placing the resident at risk for physical decline. - R18's POS dated 10/03/19, documented [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) of four, indicating severely impaired cognition. The MDS documented the resident required extensive assistance of two staff for bed mobility, dressing, toilet use, personal hygiene, and transfers. The MDS documented the resident required supervision with staff assistance for eating and locomotion on and off the unit, and used a wheelchair for mobility. The care plan, dated 08/19/19, instructed staff to administer continuous oxygen at 2 liters (L), the resident required assistive devices, encourage the resident to use them, and allow for ample time for tasks. The Physical Therapy Treatment Notes, dated 07/18/19, documented R18 discharged OT following upper extremity exercise, bending to increase balance skills, and increased ability to perform dressing tasks. R18 met core strengthening, range of motion activity, sit to stand, and transfer goals and discharged . On 10/08/19 at 02:00 PM, observation revealed R18 sat in his wheelchair in the north common area, eyes closed, head tilted back, resting on the oxygen tank attached to the back portion of the wheelchair and top band of wheelchair backing, snoring, with buttocks shifted to the front edge of the wheelchair seat. On 10/09/19 at 07:36 AM, observation revealed R18 sat in his wheelchair, head tilted back, rested on the oxygen tank attached to the wheelchair, eyes closed, and CNA M assisted the resident with breakfast. CNA M placed a drinking straw into R18's mouth and instructed him to drink. R18 attempted to drink milk from the cup, using the straw and head tilted to the back of his wheelchair. On 10/10/19 at 08:44 AM, Administrative Nurse D confirmed the position of the resident in his wheelchair was not correct for comfort and expected staff to make attempts to correct. Administrative Nurse D confirmed the residents should be in the proper position for eating and drinking. The Repositioning policy, dated (MONTH) 2013, documented the facility would evaluate a resident in the chair for postural alignment, even weight distribution, and maintenance of sitting balance. The facility failed to provide and maintain accurate positioning and alignment for R18, placing the resident at risk for physical decline

The facility had a census of 47 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to accurately record fluid intake amounts for one of one resident reviewed for [MEDICAL TREATMENT] (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Resident (R)37. Findings included: - R37's Physician order [REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident independent with eating. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/06/19, documented the resident incontinent of urine and directed staff to assist the resident with toileting and incontinent cares. The care plan, dated 09/06/19, documented the resident independent with eating, instructed staff to explain and reinforce the importance of maintaining the physician ordered diet, and encourage the resident to comply with the diet. The care plan instructed staff to monitor/document/report as needed any sign or symptom of acute [MEDICAL CONDITION] (urine output < 400 milliliter (ml) in 24 hours), and signs and symptoms of [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues). The care plan lacked direction to staff on fluid restriction breakdown amounts for dietary and nursing staff. The Physician Order, dated 09/25/19, instructed staff to place the resident on fluid restriction. The order instructed staff to provide the resident with one- and one-half liters (l) of fluid in 24 hours, consisting of 250 ml every meal, 30 ml with medication pass, and 120 ml in his room every shift. The Fluid Restriction Sheets from 09/25/19 to 10/08/19 documented the residents fluid intake from meals and medication pass but lacked documentation of the fluid the resident received in his room. On 10/08/19 at 11:56 AM, observation revealed staff served the resident regular consistency 120 cubic centimeter (cc) of supplement, 120 cc ice water, and 120 cc of orange juice . Continued observation at 12:07 PM revealed staff served the resident shrimp fajita bowl, jello cake, mandarin oranges, and rice, and the resident independently ate his meal. Continued observation at 12:35 PM revealed the resident consumed 100% of his fluids and 50% of his meal. On 10/10/19 at 08:00 AM, Certified Nurse Aide (CNA) O stated the aides do not keep track of the residents fluid intake in his room, there used to be a place in the computer but it is not there anymore, so the aide told the Certified Medication Aide (CMA) and she documented it with the meal and medication pass fluids. On 10/10/19 at 08:06 AM, CMA S stated she did not document the resident's fluid intake from his room, the nurse aide documented in the computer. CMA S displayed the nurse aide documentation section on the computer and verified there was not a place for the nurse aide to document the resident's fluid intake in his room. On 10/10/19 at 12:09 PM, Administrative Nurse D stated the nurse aides should keep track of the resident's fluid intake in his room and should document the amount in the computer. Administrative Nurse D verified the nurse aides were not documenting fluid intake and stated it used to trigger in the computer, but it was not there anymore. Administrative Nurse D stated she tried to activate it again and could not, and she was unaware the aides were not able to document fluid intake for the resident until now. The facility's revised Encouraging and Restricting Fluids policy, dated (MONTH) 2010, documented staff should verify that there is a physician order [REDACTED]. The facility failed to accurately monitor R37's fluid restriction intake, placing the resident at risk of fluid overload.

The facility census totaled 54 residents with 22 sampled for review. Five residents were reviewed for accidents with 2 residents sampled for falls. Based on observation, interview, and record review, the facility failed to transfer resident #41 in a safe manner which resulted in a fall from a sit-to-stand lift. Resident #41 sustained a broken arm as a result of the fall. Findings included: - Review of the resident #41's [DIAGNOSES REDACTED].), other specified disorders of bone density and structure, unspecified (bone density and structure disorder), unspecified nondisplaced fracture of surgical neck of left humerus (bone in upper arm), and subsequent encounter for fracture with routine healing ([MEDICAL CONDITION] of the left upper arm). Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating intact cognition. He/she required extensive assistance of 2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene and walking did not occur. The resident needed supervision and set up for locomotion on unit and supervision of 1 person for locomotion off unit. The resident had functional limitations in range of motion on one side of both upper and lower extremities and required a wheelchair for mobility. Review of the Care Area Assessment (CAA) dated 7/12/18 for Activities of Daily Living (ADL) revealed the resident had [MEDICAL CONDITION] to the left side of his/her body due to a stroke. He/she may be screened by physical therapy (PT) and/or occupational therapy (OT) services for possible increase in ADLs. The CAA identified the resident at risk for incontinence, falls, and pressure ulcers. The Fall CAA dated 7/12/18 related to the resident's fall history and use of antidepressant medications revealed he/she had [MEDICAL CONDITION] to the left side of his/her body due to a stroke. He/she may be screened by PT/OT services for possible increase in ADLs. The resident was at risk for falls. The staff updated the care plan to reflect the resident's risk for falls. The fall risk score documentation on 1/18/18 (prior to the fall on 6/19/18) revealed a high-risk score of 18, and on 1/31/18 the resident had a moderate fall risk score of 12. The fall risk score post fall documented on 6/19/18 revealed a high-risk score of 22. Review of the 9/28/18 Quarterly MDS revealed no changes since the 6/28/18 significant change MDS with the exception of the resident's BIMS of 14, which indicated intact cognition and no pain medication interventions or pain at the time of the assessment. The resident received [MEDICAL TREATMENT] and did not receive services from therapy or from the restorative nursing program. Review of the resident's care plan, revised on 8/24/16, identified the resident had a potential for falls related to muscular weakness of one half of the body, history of [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke - characterized by sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain, wheelchair dependence, and bone loss that causes bone weakness and/or thinning). The care plan identified the resident required a 2-person transfer with a gait belt, dated 9/24/16, and read that all staff was reminded to follow proper transfers and where to find the transfers. A care plan intervention initiated on 6/22/18 identified that staff were not to transfer the resident with a sit-to-stand lift due to safety concerns. A care plan revision on 8/24/16 revealed the resident had an alteration in ADL status due to a contracture of the left hand and left side [MEDICAL CONDITION]. An intervention last revised on 3/29/16, recorded the resident needed staff assistance with ADLs and transferring. A new intervention for transfers, initiated on 7/24/18 (no revision date) indicated to use a slide board with 2 staff from wheelchair to bed and from bed to wheelchair. Upon review of the Kardex (a communication document for direct care nursing staff used to communicate pertinent resident information to provide proper care to residents) transfer communication instructed staff to remove heel protectors and place non-skid socks on the resident prior to transfers (undated). The Safety section of the Kardex, directed the direct care staff to remove his/her heel protectors and to place proper footwear on resident for transfers (1/18/18), and to use non-skid socks and non-skid strips on floor in front of bed (2/2/17). Under the Resident Care section of the Kardex, direct care staff were only informed that the resident needed staff assistance with ADLs and transferring with no further details or instructions. The Kardex did not include resident #41's transfer status details until it was added on 10/24/18. Therapy notes from 6/21/16 referred to resident #41 scooting for transfers and the use of a transfer board. The care plan was not updated to reflect appropriate transfer status at the time of the fall, indicating the resident transferred with the assistance of two staff members and a gait belt. The Kardex and care plan lacked instructions or reference on how to transfer the resident prior to the fall on 6/19/18. There was no evidence therapy assessed/evaluated and/or approved a sit-to-stand lift to be safely used for the resident. Review of the Nursing Incident Note regarding the fall on 6/19/18 at 5:40 p.m. revealed when direct care staff used a sit-to-stand lift on the resident he/she became unresponsive during the transfer. A direct care staff member who was present when the resident fell notified the licensed nurse, who entered the resident's room to find him/her lying on his/her back on the floor with bilateral legs extended out. The resident was re-oriented and assisted to his wheelchair. The resident recalled direct care staff helped him/her when he/she was in his/her wheelchair. It was noted the resident had [MEDICAL TREATMENT] (a process of removing excess fluid and waste products from the body) prior to the fall. Review of the vital signs assessment obtained as a result of the fall revealed the following results: a low blood pressure of 83/47 mm/Hg (milliliters of mercury), (a normal blood pressure example is 120/75 mm/Hg), and a low-grade temperature of 99.0 Fahrenheit. According to the Incident Report, injuries observed at the time of the incident were that he/she complained of low back pain, stating it was unrelated to fall and an abrasion and/or skin tear to right or left hand occurred . The resident denied pain or discomfort to any of his/her upper or lower extremities at the time of the fall. Staff assisted the resident up from floor with the assistance of four staff members and a gait belt into the wheelchair. Staff reoriented the resident to situation and he/she was alert and oriented x3. A full set of vital signs at the time of the fall revealed a blood pressure of 83/47 mmHg, pulse of 82 beats per minute, respiratory rate 18 per minute, temperature of 99.0 F., and oxygen saturation of 98% on room air. After the fall, the resident complained of left arm pain for a couple of days after the fall before he/she was seen, and an x-ray was ordered and obtained on 06/21/18 (two days after the fall), providing evidence of a fracture to the bone of the upper arm. The nurse incident note and other documentation in Point Click Care lacked evidence the nursing staff or the direct care staff assessed and documented the resident's vital signs upon returning from [MEDICAL TREATMENT] on the day of the fall and lacked any documentation the staff followed up on the abnormal vital signs on 6/19/18. The incident note lacked documentation regarding the assessment, evaluation, and documentation of the range of motion for resident's extremities to rule out injury. Review of the nurse's note dated 6/19/18 revealed the resident reported left upper extremity pain since the fall but declined an offer to contact the doctor. Review of the nurse's note dated 6/19/18 revealed the resident continued to experience left upper extremity pain but declined an offer to make an appointment with the physician. Review of the nurse's note dated 6/21/18 revealed the resident approved of an appointment to have the left upper extremity examined. An x-ray of the left upper extremity, resulted in the [DIAGNOSES REDACTED]. An observation of the resident on 10/24/18 at 1:15 PM revealed the resident struggled to eat his/her ice cream with use of one upper extremity. The resident had heel protector boots on both feet, the left lower extremity on the left foot pedal and the right lower extremity free from a foot pedal, the resident used to propel him/herself, resident's left upper extremity observed weak, soft, and flaccid, without movement, positioned in his/her lap. The resident only used the right upper extremity to eat. An interview on 10/24/18 at 9:35 AM with direct care staff D revealed he/she received four physical communication documents from PT and/or OT for the resident. Direct care staff D reported only one of the four documents (dated 6/21/16) from PT referred to resident's transfer status (referring to slide board/scoot transfers). An interview on 10/24/18 at 3:53 PM with direct care staff E revealed resident #41 used a transfer board and a gait belt for transfers and a Hoyer lift for shower transfers because the shower chair had arms, and for that reason, staff cannot use the slide board for showers. Staff E denied ever using the sit-to-stand lift on the resident. Staff E reported he/she received report from the prior staff, stated information could be reviewed on the Kardex and Point Click Care (PCC) would sometimes have a message regarding care updates for residents. Staff E stated the resident's left arm was usually sore on his/her [MEDICAL TREATMENT] days. An interview 10/25/18 11:15 AM with direct care staff F revealed resident #41 currently required a two person transfer with a slide board and a gait belt, totally dependent on staff for dressing and changing, can turn self in bed, incontinent of bowel, and used the urinal independently. Direct care staff F denied being present during any of resident #41's falls. Direct care staff F reported the use of grip strips to prevent falls with use of the slide board during transfers because the resident insisted on transferring with his/her heel protectors on both feet. He/she stated that when there was a change in the level of assistance for providing care to a resident, that change was posted on the home page for charting that was used to communicate notices and reminders, updated daily, and there for at least a week. He/she reported that although there was a way to look back on them, he/she did not know how to do that. Direct care staff F reported that he/she would know to use a Hoyer lift by checking the care plan, if the resident could not bear weight with both lower extremities or would do whatever therapy instructed to do. He/she reported that prior to the fall on 6/19/18, he/she approached a staff member from therapy, asked if he/she could use the sit-to-stand lift on resident #41 for shower transfers because the arms of the shower chair prevented slide board transfers, and received verbal permission to use the sit-to-stand lift for transferring in and out of the shower. Direct care staff F also reported that the sit-to-stand lift was routinely used to change resident's brief when incontinent of bowel, and staff would tell resident during this time to let them know if he couldn't hang on or felt like he was going to fall; however, the resident refused to use the sit-to-stand life after the fall on 6/19/18. Direct care staff F also reported that after the fall, the resident had to be changed in bed and only the slide board or the Hoyer lift could be used for transfers. He/she also reported that resident's left arm continues to hurt when lifted and does not want anyone messing with his/her arm. An Interview on 10/25/18 at 11:30 AM with Licensed Nursing Staff G revealed he/she could not provide details regarding the resident's fall history, other than looking up in the chart when the last fall occurred. He/she reported the resident was unable to use his/her left arm. Licensed nursing staff G could not verbalize how resident #41 transferred without reading the Kardex, then could verbalize the resident required two person assistance with use of a gait belt and slide board, and staff placed the Hoyer lift sling underneath him/her in his/her chair on [MEDICAL TREATMENT] days. Licensed nursing staff G ensured direct care staff were able to review up to date transfer status on residents by referring to the Kardex or the Plan of Care. A review of the Kardex and the Plan of Care revealed the transfer status details were not present when the resident fell on [DATE]; however, were added to the Kardex on 10/24/18 (just prior to the interview) and some transfer details were added to the Plan of Care on 7/24/18. An interview on 10/25/18 at 2:54 PM with administrative nursing staff B stated the using the sit-to-stand lift was not appropriate for this resident. On 10/25/18 at 4:10 PM, administrative nursing staff B verified that the comprehensive care plan did not have the specific transfer interventions prior to the fall in on 6/19/18. According to the facility's fall guidelines for assessing falls and their causes (last revised (MONTH) 2010), instructed the nursing staff to review the care plan for any special needs, identify medications and active medical conditions, and assemble equipment and supplies as needed for preparation of assessment and identifying causes. The resident would be assessed in a timely manner for potential causes of falls, including potential for causes related to medication side effects, environmental risk factors, underlying risk factors and functional decline. Once assessment ruled out a significant injury, the resident would be assisted to a more comfortable position before documenting relevant details. Then, the nurse would notify the physician and family in a timely manner regarding the fall. When a fall results in a significant injury or a condition change, nursing staff were to notify the practitioner by phone immediately. When a fall did not result in a significant injury or a condition change, nursing staff were to notify the practitioner routinely by fax or by phone. The nursing staff observed for delayed post-fall complications for 72 hours and documented findings in the resident's electronic health record. An incident report must be completed by the assigned nurse and submitted to the director of nursing services. When determining causes of falls or fall risk, nursing staff should refer to resident-specific evidence including medical history and known functional impairments. The facility failed to ensure staff transferred resident #41 in a safe manner. Resident #41 sustained a fall with a broken arm as a result of an unsafe transfer using a sit-to-stand lift. Resident #41 had paralysis on the left side and lacked the ability to hold on to the lift during transfers.

The facility census totaled 52 residents. The sample included 1 resident reviewed for abuse. Based on interview and record review, the facility failed to have evidence of a thorough investigation and prevent potential further abuse after resident #1 alleged licensed nurse D (of the opposite gender) raped him/her. The facility's failure to suspend the alleged perpetrator (staff D) to protect all the other residents and complete a thorough investigation placed all residents of the same gender as resident #1 in immediate jeopardy. Findings included: - Review of resident #1's history and physical dated 1/5/18 revealed the following Diagnosis: [REDACTED]. Review of the admission (minimum data set) MDS dated [DATE] revealed a (brief interview for mental status) BIMS score of 15 (cognitively intact). The resident made his/her wants and needs known and understood others. The resident had no mood or behaviors identified on the assessment. He/she required total assist of one staff for personal hygiene; and assist of two staff members for bed mobility and transfers. Review of the activities of daily living (ADLs) care area assessment (CAA) dated 1/23/18 revealed he/she admitted to the facility on [DATE] after a brief stay at an acute hospital setting. He/she required ADL assistance related to his/her impaired balance and activity intolerance secondary to generalized muscle weakness, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), acute kidney failure and history of falls. Review of the mood and behavior care plan initiated on 1/13/18 directed staff to administer medications as ordered and monitor for adverse reactions related to medication. The care plan directed the staff to provide the resident with limited to extensive assistance of 1-2 staff for the completion of his/her ADLs. On 1/23/18 at 11:45 a.m. Administrative Nurse B revealed resident #1 reported License Nurse D raped him/her on 1/20/18 during the 2 p.m.-10 p.m. shift. The resident reported the alleged rape to direct care staff E during staff E's scheduled shift from 10 p.m. to 6 a.m. on 1/20/18. Staff B revealed Staff E reported the allegation to licensed nurse C immediately after the start of the 10 p.m. - 6 a.m. shift. Administrative nurse B revealed licensed nurse C contacted him/her on 1/20/18 by text at 11:45 p.m. and he/she called administrative staff A immediately and reported the allegation. Administrative nurse B revealed he/she instructed the staff to write witness statements regarding what the resident reported to them and directed staff C to complete a total body assessment on resident #1 and question the resident about the allegation to find out exactly what happened. Administrative staff B confirmed the alleged perpetrator (AP) (licensed staff D) finished report and stated, I did not touch that resident, when he/she was informed of the allegations. Administrative nurse B confirmed the AP returned to work at 2:00 p.m. on 1/21/18 and administrative staff A directed him/her to work the north hall instead of the south hall (where resident #1 lived) as he/she was scheduled. Interview with licensed nurse D (AP) on 1/23/18 at 2:58 p.m. revealed he/she was never told he/she was suspended or not to come back to work so he/she came back to work on 1/21/18 for the 2-10 p.m. shift. Interview on 1/23/18 at 5:00 p.m. with administrative staff A revealed the AP was not suspended, per facility policy, during the facility investigation and the AP did return to work with residents on 1/21/18 before the facility had contacted the police and completed the investigation of the rape allegation. Interview on 1/24/18 at 8:25 a.m. with licensed nurse C revealed during the 10 p.m. report on 1/20/18 direct care staff E came to the nurse's station and reported resident #1 had reported being raped by the nurse (Licensed Nurse D) working that night. Staff C revealed the AP, staff D, was in the middle of giving him/her report and stated, I never touched (him/her). Staff C notified the nurse on call, administrative nurse B, of the resident's allegation and was instructed to complete a full body assessment on the resident and instructed to have all the staff in the facility write a statement about anything they knew about the incident. Staff C revealed he/she completed a body assessment on the resident and asked the resident if anyone hurt him/her and the resident responded that nurse was always very sexual and he/she bites. Staff C revealed he/she did not find any bruising, abrasions, bite marks, irritation to sexual organs or bleeding. During an interview on 1/24/18 at 8:55 a.m. direct care E revealed he/she assisted the resident back to his/her room where the resident reported to direct care staff E the nurse of the opposite gender raped me again. Direct care staff E revealed he/she toileted the resident prior to putting him/her to bed and did not see any blood or injuries during peri care. Direct care staff E reported the allegation to licensed nurse C immediately and confirmed the AP (licensed nurse D) was still in the facility giving report at the time he/she reported to licensed nurse E. Resident #1 reported to direct care staff E that licensed staff D raped him/her at approximately 10:45 p.m. on 1/20/18. Review of licensed nurse D's time sheet for (MONTH) revealed he/she clocked in on 1/20/18 at 1:50 p.m. and clocked out at 10:54 p.m. and staff D clocked in on 1/21/18 at 1:52 p.m. and clocked out at 10:55 p.m. Review of the facility's undated Abuse, Neglect and Exploitation and Prevention Policy and Procedure revealed the facility prohibited the abuse, mistreatment, neglect, and/or exploitation of residents. Should an incident of suspected resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator or his/her designee, would appoint a member of management to investigate the alleged incident. Employees of the facility who were accused of resident abuse should be immediately suspended pending investigation to protect residents from potential additional abuse and to protect the employee from further allegations in the event he/she was innocent. The facility's failure to conduct a thorough investigation of an allegation of rape, and suspend the AP to protect all residents of the same gender as resident #1 during the investigation placed those residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 1/25/18 with the following actions: 1. All department staff were re-educated on the Abuse, Neglect, and Exploitation (ANE) Policy with emphasis on: identifying types of abuse, protecting resident(s) during ongoing ANE investigations, suspension of accused staff members during entire duration of the investigation, how to conduct an investigation, and reporting guidelines. 1. The facility designated an individual to do random audits for ANE daily for 4 weeks and report any areas of concern to the Quality Assessment and Assurance committee for review and development of an action plan to ensure the system was corrected and sustained. The deficiency remained at a scope and severity of an E after abatement.

The facility census totaled 55 with 16 included in the sample and one reviewed for death. Based on observation, interview, and record review, the facility failed to follow the protocol to initiate CPR (cardiopulmonary resuscitation- a system for giving chest compressions and breaths when someone did not have a pulse and/or respirations) for 1 of 1 residents sampled for death (#28), who had a full code status, indicating he/she wanted lifesaving measures taken if his/her heart stopped or he/she stopped breathing. This failure placed the resident in immediate jeopardy. Findings included: - Review of resident #28 ' s significant change MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 15, indicating no cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility, transfers, and did not walk. The resident experienced shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. The resident did not have a condition or chronic disease that could result in a life expectancy of less than 6 months. Review of the resident ' s ADL (activities of daily living) Functional/Rehabilitation Potential CAA (care area assessment) dated [DATE] revealed the resident admitted for strengthening and to increase endurance. The resident and his/her family member wanted him/her to be able to return home if possible. At the time, the resident required extensive assistance of ,[DATE] staff for safe transfers. The resident was cognitively intact, participated in therapies, and made his/her needs known. Review of resident #28 ' s care plan initiated [DATE] revealed the resident had a full resuscitation code status. Interventions directed staff to: · Call 911 to activate EMS (emergency medical services) if they found the resident unresponsive. · Initiate CPR if staff found him/her not breathing, without a heartbeat, or unresponsive. Review of the nurses' report sheet for the resident's hall dated [DATE] night shift (10 PM-6 AM) revealed it listed resident #28 as a full code. Per the facility's self investigation nurse V said he/she noticed the nurses' report sheet was on the desk. Review of a nursing note dated [DATE] at 10 PM revealed the nurse changed the dressing to the resident's upper left knee. The resident denied pain or discomfort at the time and asked staff to fill his/her ice water pitcher. The resident denied other needs at that time and stated I'll see you tomorrow kid. Review of a nursing note dated [DATE] at 6:37 AM revealed at 5:05 AM, staff reported they suspected the resident passed away. The resident laid on his/her right side at the last bed check and when staff went in around 5 AM, the resident was cold and staff thought he/she passed away. The resident did not have an apical pulse (obtained by listening over the heart with a stethoscope) or breath sounds. Staff nurse E gathered the resident ' s contact information from the electronic medical record and contacted the physician, who gave permission to release the body. Review of a signed witness statement dated [DATE] by direct care staff X revealed at 4 AM he/she checked the resident and watched for a few moments to ensure the resident ' s chest rose and fell so he/she knew the resident was breathing. At 5 AM when he/she went in to complete his/her bed checks, he/she found resident #28 unresponsive and cold to the touch. He/she notified the charge nurse immediately, who came and did not ask if the resident had a full code status. Staff X wrote he/she was too shook up to see if the resident had a full code status. Staff X reported when he/she cleaned up resident #28 his/her back felt warm. Review of a signed witness statement dated [DATE] by direct care staff U revealed at 4 AM, he/she checked the resident and he/she slept at that time. At 5 AM, direct care staff X notified him/her the resident deceased . Staff U then called licensed nurse V, who came and asked if the resident received hospice services. Staff U told him/her no. Staff V went to the other side of the facility and did not do any vitals. Licensed nurse E came then went to assist staff V. Direct care staff X and staff U checked the resident and he/she felt cold and stiff. Review of a signed witness statement dated [DATE] by licensed nurse V (agency nurse) revealed he/she arrived to the facility at 1:40 AM on [DATE] and received report from the night shift nurse at 2 AM. Staff V confirmed he/she received report on all of the residents using the report sheet. Staff V reported receiving orientation showing him/her where to document the remaining vitals for the shift and where to find the medications remaining for the shift. At 5 AM, he/she answered a phone call from a staff member telling him/her to come to the other side of the facility because they thought someone had passed. Staff V walked to the other side of the facility and saw staff E sitting at the nursing station. Staff E pointed him/her in the direction of resident #28 ' s room. A direct care staff was there. Staff V assessed for breath sounds and noted none. The resident ' s pupils did not react to light and he/she was extremely cool to the touch. The direct care staff reported they were in the room last at 3 AM for bed checks and staff repositioned him/her onto his/her side at that time and resident #28 was fine. The direct care staff reported to him/her when they went in at 5 AM, the resident appeared to have passed. Staff V asked staff E where to find the resident ' s contact information and face sheet (summary of important information). Staff E told staff V he/she would get it and then he/she brought it to him/her. Staff V confirmed he/she did not look up the resident ' s face sheet information him/herself, but instead assumed the resident had a DNR (do not resuscitate) status because of the information he/she received from staff E. Staff V contacted the physician and responsible parties. Staff E notified staff V at 5:40 AM or 5:45 AM he/she needed to fill out a statement since the resident had a full code status. Staff V then looked in the electronic medical record and saw the full code status for resident #28. Staff E later notified staff V of the color system on the outside of the residents ' rooms, indicating their status. Review of a signed witness statement dated [DATE] by licensed nurse E revealed at 5:05 AM that morning, he/she just got to the facility and sat down at the nursing station. The statement from staff E indicated he/she was not on duty until 6 AM. Direct care staff U came up to him/her and stated in a conversational tone, You know we lost (resident #28). Staff E asked him/her when it had happened and staff U replied, Just now. Staff E wrote he/she immediately got up and started to go to the resident ' s room to see what he/she could do to help. In the hall, staff E saw the charge nurse, who asked him/her to get the resident ' s contact information from the computer. The charge nurse denied needing any further assistance, so he/she completed the charge nurse ' s request. Review of the facility nursing schedule for [DATE] revealed licensed nurse V ' s first shift in the facility was [DATE] from 2 AM-6 AM. One other nurse worked in the facility at the time of the resident ' s death. The facility failed to provide proof licensed nurse V had any orientation to the facility or their policies and/or procedures for code status and resuscitation. Review of licensed nurse V ' s online training transcript dated [DATE] revealed it lacked training about advanced directives or code status. Review of American Heart Association Basic Life Support for Healthcare Providers Program cards revealed: · Licensed nurse V completed the course on [DATE] with a recommended renewal date of [DATE]. · Direct care staff U completed the course on [DATE] with a recommended renewal date of [DATE]. During an interview with administrative nurse B and administrative staff A on [DATE] at 4:22 PM revealed he/she stated if they found a resident without vital signs, the expectation would be for staff to check the resident ' s code status and then start CPR if the resident was a full code. Staff B reported the facility had completed training on [DATE] with the protocol for unobtainable vitals and the color coded name tags on the doors. Staff B indicated a blue name plate by the door indicated full code status and red indicated DNR code status. Staff B also reported each resident ' s code status could be located in the electronic medical record and staff updated it whenever there was a change. The facility also had a code status notebook at the nursing station, which staff kept up to date routinely. Staff B reported periodically staff completed quizzes during nursing staff meetings to make sure staff knew where to find out someone ' s code status and what to do if they found someone not breathing. Staff A and Staff B reported since resident #28 ' s death, staff went over the unobtainable vitals protocol and added that if staff found a resident cold they needed to go ahead and start CPR. Since the incident staff B also made a more thorough training packet for agency staff, since licensed nurse V was agency staff, to be checked off and completed before they were allowed to work in the facility. On [DATE] at 5:25 PM, staff A confirmed [DATE] was licensed nurse V ' s first shift in the facility and was not employed at the time of the [DATE] training. Interview with administrative staff A on [DATE] at 2:37 PM revealed prior to their first day of employment in the facility, there were 10 online in-service education modules the facility asked for the agency staff to complete. Staff A reported one of those modules covered advanced directives. Staff A reported he/she monitored the online learning modules for completion and coordinated with the staffing agency. Staff A reported for the first shift agency staff worked in the facility, after they arrived for the shift, the nursing staff oriented them to the facility and showed staff where to find things. The agency staff were then expected to complete a check-list with the facility staff that covered where to find each resident ' s code status. Staff were then expected to turn in the completed check-list at the beginning of the next shift. Staff A confirmed agency staff, such as licensed nurse V, did not receive any on-site orientation or training about the facility ' s policies and procedures. Review of the facility protocol for a resident with unobtainable vitals, revised [DATE] revealed if staff found a resident without vital signs, staff were to confirm the resident ' s code status then call necessary staff for assistance if the resident had a status of full code, then initiate CPR. The facility failed to ensure staff followed the facility protocol for initiating CPR for resident #28 after he/she became unresponsive, even though he/she had a full code status. This place the resdient in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when they completed the following measures: Review of advanced directives for all residents to ensure accuracy of DNR (do not resuscitate) status. Initiated re-education/orientation of staff on the systems in place, including the facility Protocol on a Resident with Unobtainable Vital Signs for facility staff and temporary agency staff. Implemented an Agency Check-off list to ensure the facility provided orientation prior to agency staff providing any resident care. Provided the temporary staffing agency with the facility's required Protocols on Residents with Unobtainable Vitals and the mandatory completion of this education for each person they would schedule in the facility. The deficient practice remained at a scope and severity of a G.

The facility identified a census of 56 residents with a sample of 21 residents. Based on observation, record review and interview, the facility failed to implement the written policy and procedures that prohibited neglect of 1 sampled resident #45, with failure to provide CPR (cardiopulmonary resuscitation) on one non-responsive resident with a full code status (every possible measure available will be used to resuscitate them), placing the resident in immediate jeopardy. The resident subsequently expired on [DATE] at 8:07 AM. Findings included: - The physician orders, dated [DATE], documented the resident admitted to the facility on [DATE] with code status of full code. The admission care plan, dated [DATE], lacked any documentation on code status. The admission MDS (minimum data set), dated [DATE], identified no condition or chronic disease that may result in a life expectancy of less than 6 months. The nurses' notes documented the following: On [DATE] at 1:03 AM, the resident slept in the recliner, but usually slept in the bed. On [DATE] at 8:07 AM, staff assisted the resident this morning into the wheelchair, and the resident requested a pain pill. The CMA (certified medication aide) entered the room to administer the pain pill. However, the resident did not respond and the CMA asked this nurse to check on the resident. Upon entering, the resident did not respond to this nurse, no obtainable vital signs and no audible heart or lung sounds. On [DATE] at 8:12 AM, the on call physician called with orders to have the resident's body released to the mortuary. The nurse notified Administrative Nursing Staff D of the resident's death. On [DATE] at 7:19 AM, Direct Care Staff U reported being CPR certified and explained the residents code status could be found by looking at the chart. If the back of the chart contained a red dot, the resident was a DNR (do not resuscitate) code status. Staff U reported that if a staff member found a non-responsive resident, the staff member should call for the nurse and get vital signs, then follow what the nurse instructed, the nurses determined if the resident is DNR or not, and whether to start chest compressions. Staff U confirmed the nurse usually started CPR if the resident was a Full Code. On [DATE] at 7:23 AM, Direct Care Staff R reported not being CPR certified. Staff R confirmed the code status could be found in the kiosk (computer system for the direct care staff), under ADL's (activities of daily living) and if staff found a non-responsive resident, he/she would call for the nurse, then do what the nurse instructed them. On [DATE] at 8:17 AM, Licensed Nursing Staff K confirmed being the nurse on duty the day the resident expired. Staff K explained, that morning a CNA staff assisted the resident up and the resident was okay, but the resident told the CNA staff he/she needed a pain pill, and the CNA staff reported to the nurse the resident was not looking too good. Staff K, reported, at that time, he/she got a pain pill out, went into the resident's room and the resident had already passed away in the wheelchair. On [DATE] at 7:11 AM, Licensed Nursing Staff I reported the resident code status was in the charts and the facility used to put a red dot on the outside of the cover of the chart, but did not do that anymore. Staff I reported that staff have to look in the paper chart due to being unaware of where to find code status in the electronic medical record. Staff reported if the resident was a Full Code, and non-responsive, the procedure would be to check vital signs, if absent, staff would attempt to stir the resident, call for help, start chest compressions and have someone call 911. Staff I reviewed the electronic record and confirmed that the residents' code status documented in this record, as a Full Code. Staff I confirmed staff should have started the code when this resident was found non-responsive. On [DATE] at 7:28 AM, Licensed Nursing Staff J reported being CPR certified. Staff J reported code status was found by looking it up on the computer under orders and in the (CNA electronic charting program), so if staff were down the hall, the kiosk may be a closer place to look. Staff J confirmed if staff found a non-responsive resident that was Full Code, the procedure would be to start CPR, call for help, call the family to find their wishes, call the physician, and staff call 911. On [DATE] at 9:16 AM, Licensed Nursing Staff K confirmed he/she was not aware of the residents code status. Staff K confirmed he/she would have been able to get code status under the dash program in the electronic medical record. Staff K reported this resident did not have a paper chart, and staff did not remember checking the code status. Staff reported he/she did not ask anybody to check code status of the resident. Staff K confirmed it was his/her responsibility to check the code status of the resident. Staff reported he/she did not know why he/she did not initiate CPR on that day. Staff K confirmed that procedure was to call a code and perform CPR for this resident. The protocol would be to take vital signs and start CPR if they are absent. Staff K was unaware if his/her CPR certification was current. Staff K confirmed he/she should have put the resident on the floor, started CPR, called the ambulance to get some paramedics here, and notified the doctor, family and probably the DON (director of nursing). On [DATE] at 10:09 AM, Social Services Staff FF reported that the facility used to look at the spine of the paper chart for a red dot, that meant the resident was a DNR order. Begining in [DATE], staff scanned the DNR or FULL CODE into the electronic medical record and was immediately available to staff. Staff FF reported the resident was a full code from the time of admission. On [DATE] at 10:57 AM, Licensed Nursing Staff I reported when there was a code called in the building, all available nurses in the building go to help and confirmed there was no code called the morning of the resident's death, there should have been though if he/she was a full code. Staff I reported their CPR certification had expired. On [DATE] at 2:06 PM, Administrative Nursing Staff D confirmed that the nurse should have checked the Code Status in the computer under the admission tab, called for help, and had people calling the EMS (emergency medical services) first while he/she checked vitals and started CPR if the resident lacked vital signs. Staff D reported the nurse should have had someone else call the physician and family. Staff D confirmed this nurse failed to follow the facility policy or procedure. Administrative Nursing Staff D confirmed this resident was a full code and should have had CPR performed. The facility failed to provide the requested policy for following procedure on code status. The facility failed to begin CPR on this resident who was a full code status. The resident subsequently expired on [DATE] at 8:07 am. The facility abated the immediate jeopardy, on [DATE] at 6:00 PM by initiating the following: 1.) SSD/Medical Records/Nursing Administration reviewed our 57 residents to assure Proper Advanced Directives are accurate and readily available. Completed by SSD/Medical Records/Nursing Administration on [DATE]. 2.) New code status binders were now available at each nurse's station for nurses to quickly check code status of each resident. Completed on [DATE] by Administrative Nursing Staff D. The Director of Nursing or designee would train each oncoming nurse on usage of new code status binder and proper implementation. Completed on [DATE] and [DATE] by Administrative Nursing Staff D. Effective immediately, the Director of Nursing or designee would ensure that there was at least one staff member on each shift is trained and certified in CPR to ensure 24 hour coverage by a CPR certified staff member. Completed on [DATE] by Administrative Nursing Staff D. Effective immediately, the SSD (social service director) would update the code status binder with code status of any new admission. Completed on [DATE] by Administrative Nursing Staff D. 3.) The Director of Nursing or designee would audit code status book weekly for 4 weeks to ensure code status for each resident is readily available to all staff members. After the 4 week period, the code status book will be audited monthly. Administrative Staff D audited [DATE]. 4.) Administrator or designee would review audits and submit findings to the QA (quality assurance committee) monthly. QA would monitor monthly for compliance. 5.) Director of Nursing or disignee will educate staff on "Protocol on Residents with Unobtainable Vitals (includes "Code Status" Book). Notified all staff of new protocol and will be educated prior to clocking in for their assigned shift. Administrative Nursing Staff D will confirm all staff has been educated. On [DATE] educated 45 nursing staff out of 53 on "Protocol on Residents with Unobtainable Vitals". On [DATE] at 5:00 PM will educate 1 nursing staff and prior to 10:00 PM shift will review protocol with 3 nursing staff, will fax 1 protocol to PRN (as needed) RN on [DATE] to sign. Will review protocol with 1 CMA on [DATE] prior to 10:00 PM clock-in. Prior to 1 aide returning from college and one from medical leave will be educated prior to the first assigned shift. Will review Protocol with 1 LPN on [DATE] prior to clock-in time. Will review protocol on [DATE] with 2 laundry/housekeeping staff prior to clock-in shift. On [DATE], will review protocol with 1 dietary staff prior to clock-in time. On [DATE], will review protocol with 1 housekeeping staff. The Director of Nursing or Designee will review protocol with these staff members. Protocol On Resident With Unobtainable Vitals: 1.) Notify charge nurses promptly. 2.) Confirm "Code Status" (check the Code Status Books at each nurses station). 3.) Call necessary staff for assistance if resident is a "Full Code". CPR is to be started, notify EMS, Primary/On-Call Physician, Family and DON. 4.) Have proper paperwork for EMS for transfer. The facility failed to begin CPR on this resident who was a full code status. The resident subsequently expired on [DATE] at 8:07 am. This deficient practice remains at the scope and severity of a G.

The facility identified a census of 56 residents, with a sample of 21. Based on record review, observation and interviews, the facility failed to provide care and treatment to prevent the development or worsening of pressure ulcers for 2 (#38 and #65) of 3 residents sampled for presure ulcers. Findings included: - The POS (physician's orders [REDACTED].#38 had a [DIAGNOSES REDACTED]. The Significant change Minimum Date Set Version 3.0 ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident's cognition for daily decision making was severely impaired. The resident required extensive two person physical assistance for bed mobility, dressing, and toileting. He/she needed one person physical assistance for feeding and personal hygiene, and was totally dependant for bathing. The resident was not steady when moving from seated to standing, walking, or transferring, had range of motion impairment to both lower extremities, and used a wheel chair for locomotion. He/she was on a toileting program and was frequently incontinent of bowel and bladder. He/she did not have a swallowing disorder and was on a physician prescribed weight-gain regimen. The resident had no stage 1 or greater pressure ulcer (PU) but was at risk for PU, had no unhealed PU, had no venous/arterial ulcers, and no other skin problem. He/she had a pressure reducing device for his/her chair and bed, was on a turning/repositioning program, received nutrition/hydration interventions to manage skin problems, and did not have a dressing to the feet. The Care Area Assessment (CAA) for cognition dated 2/10/14 revealed the resident had increased confusion, lethargy (drowsiness), somnolence (prolonged sleepiness), withdrawal, sedation, agitation, respiratory depression, constipation, pain, irritability, behavior and mental changes. He/she was incontinent of bowel and bladder, was on a toileting schedule where staff took him/her to the bathroom every 1 to 2 hours. He/she was a 2 person assist, did not have skin breakdown at this time, and wore disposable briefs. The resident had impaired mobility and used a wheel chair (w/c) for mobilization with 1 person assist, some days he/she was able to self-propel him/herself in a wheel chair. The resident's current weight was 104 and fluctuated from 107 in September of 2013 to his/her current weight. He/she received 2 Cal nutritional supplement 30 cubic centimeters (cc) four times a day, Carnation Instant Breakfast (CIB) drink twice a day, and all his/her meals were fortified to help with weight loss. The resident could feed him/herself, but needed cueing and assistance due to his/her confusion. The resident received a regular diet and drank 700 cc of fluid in a 24 hour period. Staff reported he/she ate less than 30 percent of meals. The resident did not have skin issues. He/she was at high risk for PU due to his/her incontinence of bowel/bladder and immobility, was chair fast, and needed extensive assistance with his/her activities of daily living (ADLs). The revised care plan dated 12/20/13 revealed the resident had ADL self care deficit with interventions of: required 2 staff members for all transfers, required staff participation to reposition and turn in bed, required skin inspections 2 times per week on bath days. Nursing staff observed for redness, open areas, scratches, cuts, bruises and reported changes to the nurse. Nursing staff cued, encouraged, and assisted the resident to eat and drink. The resident was incontinent of bowel and bladder, and staff toileted and or changed the resident every 2 to 2 1/2 hours. Direct care staff were to report red or open areas to the nurse. The care plan for pressure ulcer development related to immobility and nutritional deficits dated 3/24/14 revealed an area to the left outer ankle measured 1.5 cubic centimeters (cm) x (by) 2 cm, red area on right ankle measured 1 cm x 1 cm skin intact, red area to the right great toe/foot measured 1.4 cm x 1 cm with skin intact. Interventions on 3/2/14 listed an order change to the resident's left outer ankle from AquaceII/Duoderm dressing to [MEDICATION NAME] wet to dry dressing three times a day (TID). Nursing staff requested a complete blood count (CBC) and wound culture from the on call doctor on 3/3/14. Changed dressings to [MEDICATION NAME] dressings TID and start [MEDICATION NAME] 100 mg twice a day (BID) for 2 weeks. Area noted to left outer ankle: cleanse with normal saline (NS), dry, apply spot Duoderm dressing and change every 3 days and as needed until healed, change the resident's position every 2 hours and as needed (PRN). The resident's current plan for wound care included a multivitamin with minerals daily, Vitamin C 500 milligrams (mg) by mouth BID, and protein supplement Prostat 1 serving every morning and at bedtime daily. The physician visited the resident on 2/24/2014 and documented a new [DIAGNOSES REDACTED]. The physician ordered an antibiotic, Keflex 500 mg, by mouth TID and a diuretic, [MEDICATION NAME] 20 mg, by mouth daily. The resident wore heel protectors to his/her feet bilaterally at all times. Nursing staff were to monitor for any red or open areas. Staff preformed Braden assessment (assessment done to determine pressure ulcer risk) quarterly and skin assessment 2 times a week on bath days. Direct care staff reported any areas of concern to the nurse. The resident received a weekly skin check by licensed nurse. The resident had an unopened reddened area to his/her coccyx, over a bony prominence. Staff applied Duoderm dressing for protection, change dressing every 3 days and PRN. Staff treated reddened areas to the right outer ankle and right great toe/foot areas with skin prep (a protective barrier applied to skin) daily, monitored and documented changes daily in the nurse notes. The nursing admission screening/history dated 1/2/14 at 5:21 P.M. revealed the resident was incontinent of bladder, wore a disposable brief, was assisted to toilet every 2 hours and PRN, his/her groin area was red, coccyx was red, treatment ordered was for staff to apply [MEDICATION NAME] cream topically to peri area daily for redness. The resident's skin was intact with no open areas noted. He/she needed assistance for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bathing, did not walk, and used a wheelchair. The skin/wound note dated 2/17/14 at 1:55 P.M. revealed the resident's left outer ankle presented as 0.5 cm x 0.4 cm eschar (dead tissue) area without any exudates noted, the surrounding peri wound bed was bright red in color and no [MEDICAL CONDITION]. Staff cleansed the area with normal saline (NS), gently patted dry and applied a spot Duoderm dressing applied. Staff placed the resident's heel protectors when he/she was in bed. He/she layed on his/her left side per his/her preference. Staff used pillows for positioning every 2 hours and PRN. The physician's orders [REDACTED]. Apply skin prep to reddened areas of right outer ankle and right great toe, and document changes in the nurses notes. The skin/wound note dated 4/1/14 revealed the resident's left outer ankle had 2 areas of eschar. Area A measured 0.4 cm x 0.4 cm. Area B measured 1.6 cm x 1.7 cm (previously measured 1.4 cm x 2.4). Both areas were unstageable due to eschar and the surrounding tissue was red in color with dry skin noted. The resident's left leg was elevated on a pillow with mild [MEDICAL CONDITION] and no exudate (drainage) noted when staff removed the dressing. Staff to continued to treat the area with [MEDICATION NAME] wet to dry dressings TID. Nursing staff monitored areas of concern on the resident's right ankle and right great toe/side of foot. The resident's coccyx was reddened and staff applied Duoderm dressing for protection. Nursing staff would continue with the current treatment and fax the wound assessment to the resident's physician. The registered dietitian note dated 12/23/13 at 1:16 P.M. revealed the resident's oral intake was 25 percent (%) for breakfast, 50% to 75% for lunch, and 0 to 50% of dinner. The resident refused 3 meals in the review period. Staff offered the resident alternatives and he/she did not take the alternatives. The resident received a regular diet with 2-Cal supplement 1 ounce (oz) four times a day (QID). The resident's weight was 106.8 pounds. The resident did not have any new medications or labs in the last 90 days. Calorie needs for the resident were 1535 per day, protein needs were 59 grams (G), and 1455 cc of fluid daily. The resident's oral intake was poor to fair, refused meals, did not take alternate foods when offered, and was on supplements to help with calories and protein needs. The dietitian recommended the addition of meal fortification (increased protein) to the diet order and increase 2 Cal to 2 oz QID. The Braden scale dated 1/2/14 at 5:43 P.M. revealed a score of 15, the resident was at low risk for pressure sores. The Braden scale dated 2/10/14 at 4:56 P.M. revealed a score of 15, the resident was at low risk for pressure sores. The physician order [REDACTED]. Nursing staff cleaned the area with NS, applied [MEDICATION NAME] wet to dry dressing every shift and padded area well with 4 x 4 gauze for protection. The Braden scale dated 3/20/14 8:20 P.M. revealed a score of 13 the resident was at moderate risk to develop pressure sores. The physician's orders [REDACTED]. The lab results dated 12/30/13, 12/31/13, and 1/1/14 revealed the serum total protein was within normal limits. Continuous observation on 4/2/14 revealed: at 7:16 A.M. revealed direct care staff QQ and U transfered the resident to the wheelchair. The resident's left ankle was covered with gauze dressing. Direct care staff U applied the foam boots/heel protectors then placed the resident's feet on foot pedals. The resident sat on a gel filled cushion in the wheel chair. Direct care staff pushed the resident into the hall. At 7:31 A.M. and 7:42 A.M. the resident sat in wheelchair in front of the nurses' station. At 8:02 A.M. the resident sat in wheelchair in front of the nurses' station, leaned to the right in the wheelchair. At 8:11 A.M. staff wheeled the resident to the dining room. Staff served him/her coffee, milk 6 oz, fruit punch juice 4 oz, water 6 oz. The resident drand his/her coffee independently. 8:27 A.M. the resident sat in wheel chair in the dining room, took a few sips of coffee, and sat with his/her eyes closed. 8:30 A.M. the resident's family member arrived. The resident kept eyes open and conversed with his/her family member. At 8:35 A.M. The family member offered water with straw to the resident. The resident's meal included 1/2 bagel, 2 strips of bacon, scrambled eggs, and cream of wheat. At 8:37 A.M. the family member cut and handed bites of the bagel to the resident. The family member stated to the resident that the bagel was too hard and got some toast with jelly. At 9:14 A.M. Direct care staff U assisted the resident with eating. The resident ate 1 piece of toast, 1/2 of cream of wheat, 1/2 of water, all of coffee 1/2 of his/her eggs. Direct care staff U wheeled the resident to the common area for exercises. The resident sat in the wheel chair with eyes opened. At 9:23 A.M. the resident did not participate in exercese, the resident's feet were on the wheel chair foot pedals and did not move legs, he/she continued to lean to the right. At 9:36 A.M. the resident continued to sit in the w/c in activities, did not participate, nor had he/she repositioned him/herself in wheel chair. At 9:49 A.M. direct care staff U wheeled the resident from activities to the common area in front of nurses' desk. At 9:52 A.M. direct care staff QQ offered to lay the resident down in bed. The resident refused and said he/she wanted to watch TV. The staff did not offer to take the resident to the bath room or a change position. At 9:56 A.M. direct care staff U pulled on the right side of the lift sling under the resident, the resident continued to lean to the right and did not change the resident's position. At 10:03 A.M. and 10:16 A.M. the resident sat in wheel chair, leaned to the right with his/her head/neck tilted down. At 10:23 A.M., this writer requested a skin check. The resident was last repositioned at 7:31 A.M. At 10:30 A.M. direct care staff OO assisted by QQ wheeled the resident to his/her room, and using hoyer lift, assisted the resident to bed. The resident was continent, groin area skin was red, and the resident had small bowel movement. A Duoderm dressing was on the right coccyx area dated 3/31/14. Direct care staff applied zinc oxide cream to the resident's groin area, placed the resident's legs on a blue riser pillow, a pillow between the resident's knees, and a pillow beside his/her right side. The resident laid in bed on his/her back, tilted to the left with heels floating when the direct care staff left the room. The resident was not repositioned for a total of 3 hours and 17 minutes. On 4/2/14 at 2:11 P.M. licensed staff K changed the resident's dressing. He/she removed dressing to the left ankle marked 4/2/14 10 P.M. to 6 A.M. It had brown exudate and was stuck to the wound bed which was dark brown, and the resident's foot was swollen. License staff K cleansed the left ankle with NS, applied [MEDICATION NAME] on 2x2 gauze, wrapped with gauze wrap around ankle and marked tape with 4/2/14 2:20 P.M. The resident moaned several times during dressing change. License staff K stated the resident did not have PRN pain medication. The staff placed the foam boot on the left foot. On 4/3/14 at 10:40 A.M. licensed staff I treated the resident's right foot. He/she removed the foam boot and sock from the resident, no dressing noted to the right foot, and toes were slightly red. Licensed staff I used NS and gauze to clean the toes. The resident's second toe was red. License staff I then replaced the resident's sock and foam boot. He/she rolled the resident to the left side. He/she removed the Duoderm from the resident's right buttocks and stated it was not on the coccyx, and the coccyx was reddened. He/she cleansed the area with NS, and patted the area dry. License staff K placed a new Duoderm over the coccyx, signed and dated the dressing. Interview on 4/2/14 revealed the following: At 10:30 A.M. direct care staff OO stated he/she checked the resident's brief when they got him/her up in the morning, after breakfast when they laid him/her down, before lunch, and after lunch. The resident had a dressing on his/her ankle for a bedsore (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) that was open and he/she got it from people not turning the resident. Direct care staff OO stated staff turned the resident every 2 hours and repositioned him/her by moving him/her from wheel chairs to recliners. The resident laid down after breakfast, had foam boots, and heels floated on a pillow. At 2:24 P.M., direct care staff VV stated he/she checked the resident every 2 hours to see if he/she was wet. The resident had boots on ankles, a blue pillow, rolled on his/her side so he/she laid on the right side. The resident often refused his/her snack of crackers from the kitchen. He/she said he/she notified the nurse if the resident's dressing was off or was dirty. He/she said the resident had redness on his/her skin, or a rash. The resident fed him/herself and needed cueing. The resident refused to eat but staff encouraged him/her to take bites. At 4:06 P.M. direct care staff Q stated the resident received Carnation Instant Breakfast (CIB) at 8 P.M. He/she charted the percentage of consumption in the computer. The resident refused to take the CIB if he/she had pain. At 2:00 P.M. license staff K stated staff changed the resident's dressing every shift, but he/she did not have time to do it this morning. At 2:11 P.M. license staff K stated the resident's had an open wound for a month and a half. The resident moaned several times during dressing changes. License staff K stated the resident did not have PRN pain medication. At 2:50 P.M. license staff H stated the nurses were responsible for the aides who were to check residents every 2 hours. He/she went into rooms and checked to see if the aides took the resident to the bathroom and repositioned resident's every 2 hours. Interventions in place for the resident included staff to reposition every 2 hours, foam boots on both feet, a leg raiser (blue pillow), other pillows used for positioning, 2 cal, and CIB twice a day. Staff changed the resident's left outer ankle dressing every shift. The resident had no other wounds or treatments. At 3:41 P.M. dietary staff CC stated the dietary aides made the CIB and shakes. The facility added Beniprotein to fortify the food. The resident did not have protein or supplements on his/her diet card. CIB was not listed. He/she said the resident received a regular diet At 11:04 A.M. license staff I stated he/she did not read the treatment order for the resident's right great toe. He/she usually read the treatment record every morning to see what treatments were due and how to do them. He/she said he/she did not have time to read it this morning. On 4/3/14 at 11:44 A.M. administrative nursing staff F stated the license staff did the resident's treatments. The staff first noted the resident's left foot PU on 2/17/14. He/she expected the nurse to follow orders as written and as often as ordered. All interventions for the resident's PU were on the care plan. He/she said the direct care staff did 2 hour incontinence checks. He/she said nursing should inform dietary of changes in the resident's diet or supplements, supplements were monitored by Certified Medication Aides (CMA's) and the Certified Nurse Aide (CNA's) documented the percent of each meal the resident consumed. On 4/3/14 at 2:48 P.M. dietary staff BB stated the nursing staff brought new dietary orders to the kitchen. The orders hung on the window for a few weeks until the cooks were used to the resident's diet changes. Foods were fortified with high protein powder, and the resident did not receive fortified meals. On 4/7/14 at 1:42 P.M. dietary consultant staff DD stated he/she gave recommendations for a fortified diet to the facility for this resident and nursing staff were to give the recommendation to the resident's physician for an order. Nursing staff informed him/her if his/her recommendations were not approved by the physician, and he/she was not informed that his/her recommendations were not ordered. On 4/7/14 at 1:59 P.M. attempted to call the facility's medical director, and unable to interview him/her at this time. The facility failed to provide a pressure ulcer policy. The facility failed to provide repositioning every 2 hours as care planned for the prevention of pressure ulcer development, failed to follow dietitian recommendations for fortified diet, and failed to provide treatments as ordered for this cognitively impaired, dependent resident with pressure ulcers. - Review of resident #65's closed record revealed the resident admitted to the facility on [DATE]. Review of the resident ' s Significant Change MDS (minimum data set) dated 10/9/13 revealed the resident had a BIMS (brief interview for mental status) score of 13 (cognitively intact). It revealed the resident exhibited no rejection of care. The resident required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had frequent bowel and bladder incontinence, had no pressure ulcers, but was identified as at risk for pressure ulcers. Review of the resident's Significant Change MDS dated [DATE] revealed the resident had a BIMS of 14 (cognitively intact). It revealed the resident exhibited no rejection of care. It revealed the resident required extensive assistance of 2 people for bed mobility, transfers, dressing, toilet use, and personal hygiene and required supervision of 1 person for eating. The assessment also revealed the resident had frequent bowel and bladder incontinence, the resident had risk for pressure ulcers and currently had one stage 2 pressure ulcer. Review of the Pressure Ulcer CAA (Care Area Assessment) dated 10/9/13 revealed the resident did not have any skin breakdown at that time. The resident had impaired mobility related to poor balance and falls. The resident had frequent incontinence and wore briefs, had a pressure relieving mattress on his/her bed and a cushion in his/her wheelchair. Review of the Pressure Ulcer CAA dated 2/7/14 revealed the resident had a Stage 2 (partial thickness loss of the dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcer on his/her coccyx at that time. The resident had impaired mobility related to poor balance and falls, had frequent incontinent episodes and wore briefs. The resident had a pressure relieving mattress on his/her bed and a roho cushion (specialized air cushion) in his/her wheelchair. Physical therapy saw the resident for positioning therapies to help with relief of pressure, and changed to a roho cushion from a gel cushion. The resident received therapy during the day and laid down after meals on his/her side to relieve pressure from his/her buttocks. It also revealed the resident not compliant with staying on his/her side and moved around until lying on his/her back. The resident currently had the pressure ulcer on his/her left buttock, with measurements of 2.7 cm (centimeters) x (by) 3.0 cm, and undetermined depth. It described the main wound bed as covered with slough (dead tissue, usually cream or yellow in color). A culture of the wound came back positive for infection and the resident received [MEDICATION NAME] (an antibiotic) 100 mg (milligrams) twice daily on 2/4/14. The treatment order directed to cleanse with normal saline, pat dry, apply [MEDICATION NAME] and a wet to dry dressing covered with opsite. Review of the resident's care plan with a review date of 1/10/14 revealed, on 8/30/13 staff identified the resident at risk for skin breakdown, and directed staff to report any red or open areas, and monitor skin with pericare and bathing. On 11/26/13 it directed to toilet the resident every 2 hours, the resident had incontinence and wore incontinent products at all times. On 12/18/13 staff added to the care plan for staff to toilet per the schedule, the resident had a pressure relieving cushion to the wheelchair, and directed to encourage the resident to lay down in the A.M and afternoon. The care plan also identified the resident had impairment to his/her skin integrity related to impaired mobility and incontinence. The care plan identified on 12/23/13, the resident had no open areas, " left open to air " . The care plan revealed staff added to the care plan an " area " to the left inner buttock on 1/1/14, physical therapy for wound care and continued with Duoderm dressing added on 1/13/14, and a dressing order change to [MEDICATION NAME] with Silver and [MEDICATION NAME] daily, and a 4 ounce protein snack with skim milk twice daily added on 1/17/14. The care plan also revealed a referral to the wound care clinic added 1/24/14, an order for [REDACTED]. clean and dry, to wash with soap and water, and rinse and dry. It also directed to lie down in bed between meals in the morning and afternoon, attempt to position the resident off of his/her coccyx, and use pillows to aid in positioning. The care plan revealed the resident received a multivitamin with minerals daily, Vitamin C twice daily, a Prostat supplement twice daily, and Vitamin C juice twice daily initiated per the wound protocol. The care plan also directed staff to refer the resident to the wound care center for the coccyx wound. The care plan lacked any direction to staff to use barrier cream to protect the resident ' s skin. Review of a Braden Scale assessment dated [DATE] revealed a score of 21 (high risk for pressure ulcers). The assessment also revealed scores on 9/12/13 of 22, on 9/30/13 of 20, on 10/13/13 of 18, and 11/20/13 of 18, all scores indicating high risk for pressure ulcers. Review of a nurses note dated 8/30/13 revealed the resident admitted to the facility with no skin issues. Another nurses note dated 9/5/13 revealed the skin moist and " breaking down " . A nurses note dated 9/6/13 revealed the skin to the resident ' s coccyx red, and staff applied cream to the area. Review of lab values dated 9/24/13 revealed an [MEDICATION NAME] level of 3.2 (normal 3.5-5.0 gm/dl (grams per deciliter)). The record lacked indication staff addressed the low [MEDICATION NAME] until adding the protein snack and skim milk to the care plan on 1/17/14. Review of a nurse ' s note dated 12/18/13 at 3:00 P.M. revealed an open area on the left inner buttock, with measurements of 0.3 cm by 0.9 cm, with no exudate, and [MEDICATION NAME] tissue present. Review of a physician notification fax dated and signed by physician on 12/19/13 revealed "noted superficial open area on left buttock, asked physician if wanting to use wound protocol and change duoderm dressing every 3 days and PRN (as needed). " It revealed the physician " ok ' d " the treatment. A nurses note dated 12/23/13 at 11:00 A.M. revealed a wound assessment of the left inner buttocks revealed the area presented as red and intact skin, and also " CNAs to use barrier cream. " Review of a facility Wound Assessment Form signed by the physician and dated 1/7/14 revealed 1 wound to the coccyx from friction, no stage noted, with measurements of 2.4 cm by 2 cm. The form also revealed orders to cleanse area with normal saline, apply a Duoderm dressing, change every 3 days and as needed. It directed staff to monitor the dressing daily, toilet the resident per the toileting schedule, encourage the resident to lie down in the morning and afternoon. A Skin/Wound note dated 1/17/14 at 7:50 A.M. revealed staff faxed the physician regarding a wound assessment as ordered, and notified him/her that physical therapy placed a different cushion in the wheelchair. The note revealed staff also asked if dressing change to [MEDICATION NAME] with silver/[MEDICATION NAME] and [MEDICATION NAME] (wound treatments) daily might be an option. Staff requested 4 ounces of a high protein supplement every evening and hour of sleep would be beneficial, and noted staff would await the physician ' s response. A Skin/Wound noted dated 1/27/14 at 1:38 P.M. revealed the left inner buttock presented as a partial thickness stage 2 pressure area measuring 1.9 cm x 3.4 cm with a depth unable to determine. The wound had no exudate present on the previous dressing, slough present over the surface area, and a bright red periwound bed without [MEDICAL CONDITION] present. It revealed staff currently cleansed the area with normal saline, gently patted dry and applied [MEDICATION NAME] with Silver, [MEDICATION NAME] and [MEDICATION NAME] daily and as needed. It also noted an appointment made for a wound care consult at the wound care clinic on 2/13/14. A Skin/Wound note dated 1/29/2014 at 11:28 A.M. revealed the left inner buttock presented as a partial thickness stage 2 pressure area measuring 2.6 cm x 3.4 cm with the depth undetermined. The center of the wound had a circular area showing pink tissue, with slough otherwise throughout the wound, with no exudate noted. It had a hyperpigmented, dark purple periwound bed. The note revealed staff continued to cleanse the area with normal saline, gently pat dry and apply [MEDICATION NAME] Silver with [MEDICATION NAME] and [MEDICATION NAME]. It revealed to be difficult to keep the area clean due to fecal incontinence, and staff obtained an order and completed a wound culture. The resident had an appointment at the wound care clinic in a nearby city. The note revealed staff laid the resident down in bed in the morning between meals and in the afternoon, family almost daily came in after lunch and got him/her back up to push around in a wheelchair. The resident had a ROHO cushion in the wheelchair but continued to slide down so he/she continued to have sacral pressure. The record lacked indication the facility discussed with the family about making a visiting plan or schedule to best promote pressure relief and healing. Review of the resident ' s Nutritional assessment dated [DATE] revealed the resident received a low concentrated sweets, mechanical soft diet. It revealed a change of Prostat supplement, orange juice, vitamin C, and a multivitamin. It also identified open areas to the coccyx, was on a wound protocol, there were no labs to assess at that time. It revealed they planned to add extra protein and calories. A Skin/Wound note dated 2/3/14 at 2:54 p.m. revealed the left inner buttock area presented as an unstageable pressure area measuring 1.0 cm x 1.7 cm with slough covering the wound bed. It had a moderate amount of purulent exudate with a foul odor noted on the previous dressing, and the periwound bed pale in color. It revealed a current treatment to cleanse the area with normal saline, and gently pat dry, apply skin prep to the surrounding tissue, apply [MEDICATION NAME] Silver, [MEDICATION NAME] and [MEDICATION NAME] daily and as needed. The note revealed staff faxed a culture and sensitivity report to the physician and staff currently awaited orders. Review of a signed physician order [REDACTED]. Review of a Wound assessment form dated 2/24/14 revealed a left buttocks pressure wound 1.5 cm x 2.0 cm, no depth, stage 2. Another Wound assessment form dated 3/3/14 revealed a left buttocks pressure wound 2.5 cm x 1.5 cm, unable to determine depth, and unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). During an interview on 4/3/14 at 9:57 a.m., Direct Care staff QQ revealed the resident totally dependent on staff for all cares, transferred with assistance from 2 people, and would sit in his/her wheelchair and also would sit in his/her recliner a lot. Staff QQ reported, the last few days before the resident passed away, the resident started to look and sound really bad and staff kept the resident in bed more. Staff QQ reported the resident incontinent of bowel and bladder at all times through the resident ' s entire stay in the facility, stated the resident had a toileting schedule for every 2 hours, but was always incontinent when staff checked on him/her. Staff QQ reported the resident had a pressure ulcer on his/her bottom, and the nurses did dressing changes daily. Staff QQ stated staff had a schedule to turn the resident every 2 hours, and would also get the resident up for meals if he/she would allow. Staff QQ reported he/she did not remember any pressure relieving devices in place, and he/she did not document the completion of the turning schedules. On 4/3/14 at 10:19 a.m. Licensed Nursing staff J reported the resident needed assistance of 1-2 staff members with ADLs. Staff J reported the resident had a pressure ulcer to his/her bottom but he/she did not have much to do with it since he/she worked during night shifts. Staff J reported staff tried to keep the resident on his/her side, but the resident always " wiggled " back to his/her back, had a cushion in the wheelchair, had him/her on supplements for wounds, and then eventually went to the wound clinic. Staff J reported he/she expected staff to reposition th

The facility had a census of 44 residents with 3 sampled for review. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents sampled for pressure ulcers received necessary treatment and services (timely initiation of physical therapy which included wound assessments, timely repositioning, and use of heel protectors as care planned) to promote healing, prevent infection and prevent new sores from developing. Resident #1 had physician orders [REDACTED]. The facility failed to ensure the initiation of physical therapy for resident #1 until 9/26/13, a delay of 10 days, and the resident developed a stage 4 pressure ulcer on the left elbow due to pressure from a splint device. The facility also failed to provide resident #3, who had a history of [REDACTED]. (#1 and #3) Findings included: - Resident #1's 9/7/13 significant change MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognition. The resident required extensive assistance of 2 persons for bed mobility and transfers. He/she had functional limitations in range of motion on one side of the upper extremities, and used a wheelchair for mobility. The assessment indicated the resident was at risk for pressure ulcer development and used pressure relieving devices for the bed/chair, had a turning/repositioning program, and received nutrition/hydration interventions to promote healing. Resident #1's 10/7/13 significant change MDS assessment revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. The resident required extensive assistance of 2 persons for bed mobility and transfers. He/she had functional limitations in range of motion on one side of the upper extremities, and used a wheelchair for mobility. According to the assessment, the resident was at risk for pressure ulcer development and had a surgical wound with no unhealed pressure ulcers. The resident used pressure relieving devices for the bed/chair, had a turning/repositioning program, and received nutrition/hydration interventions to promote healing. Resident #1's 10/10/13 pressure ulcer CAA (care area assessment) summary revealed the resident recently fell and fractured his/her left elbow on 8/23/13. The resident had surgery on 8/27/13 and had an order that nursing should not remove the splint, but should check neurological status on the fingers and hands. The facility received an order for [REDACTED]. On 10/1/13, physical therapy staff removed the splint and discovered a stage 4 pressure ulcer from where the splint rubbed on his/her elbow. The surgeon saw the resident on 10/2/13 and a performed a surgical closure of the wound on 10/3/13. Cultures done on the day of discovery came back with epidermis methcillin resistant organism (a bacteria resistant to methcillin, an antibiotic). Resident #1's 2/20/13 nursing care plan identified the resident as at risk for skin breakdown with interventions to encourage intake of fluids on all shifts, keep skin clean and dry, offer house nourishment and document amount of intake, and report any red or open areas. A revision on 8/27/13 directed staff to monitor the left arm for tingling, pain, and [MEDICAL CONDITION]. A 9/16/13 revision included physical therapy 2-3 times per week for 6 weeks with range of motion to left elbow as tolerated, range of motion to left wrist, hand, and lower extremities. Splint may be removed for physical therapy only, otherwise, it is to be in place. A revision of the care plan on 10/1/13 directed staff to administer Keflex 500 mg (antibiotic) four times a day until the culture is back and to hold therapy until seen by the physician. An update on 10/2/13 revealed the resident had a stage 4 pressure ulcer to the left elbow with notification of the primary physician, family, and dietician. Instructions for treatment included triple antibiotic ointment, pad, and [MEDICATION NAME] dressing. The entry indicated a culture was done on 10/1/13. An update on 10/2/13 revealed the surgeon saw the resident, scheduled surgical repair of the wound on 10/3/13, and directed staff to not use the splint to the left upper extremity, keep sling in place when ambulatory, and keep the dressing clean and dry. Another revision to the care plan on 10/3/13 referred staff to post operative instructions. On 10/4/13 the care plan indicated the physician ordered [MEDICATION NAME] (antibiotic) twice a day for 10 days. Review of the clinical record revealed the resident sustained [REDACTED]. Discharge instructions following ORIF (open reduction internal fixation- repair of the fracture) on 8/27/13 included incision care to keep the dressing/splint clean/dry and in place. If dressing/splint becomes heavily soiled or wet , contact the surgeon's office. According to a follow-up appointment on 9/4/13, the incision site was healing well with no signs of infection. Instructions directed staff to keep the splint on the left upper extremity clean and dry, use the sling when ambulatory, elevate on pillows when seated, encourage range of motion of fingers and thumb, and follow-up on 9/16/13. Resident #1's 9/16/13 physician's visit record included the following notes stating the stitches were removed and steri-strips applied to the surgical wound. The notes indicated application of a removable long arm posterior splint with instructions for "only" physical therapy to remove, otherwise to be left in place. The record also included orders for physical therapy to provide range of motion to the left elbow as tolerated, range of motion to left wrist and hand, and lower extremities to increase strength. Physical therapy ordered for 2-3 times per week for 6 weeks. Physical therapy evaluation and plan of treatment dated 9/26/13 included the following clinical impression: "Patient showed limited range of motion of left elbow, decrease muscle strength on bilateral lower extremities, and reduced balance. These impairments are likely the cause of (his/her) difficulty with bed mobility, transfer skills, and ambulation. (He/she) will benefit from therapy to improve functional mobility." Patient and caregiver Goals stated, "Patient wants to move (his/her) arm to get stronger. We will start taking the splint off to be able to improve range of motion and strength." Review of the physical therapy notes dated 9/26/13 revealed no evidence that the splint had been removed and the surgical wound assessed by therapy staff. According to the facility's investigation, on 10/1/13 (16 days after the order) physical therapy staff C notified licensed nurse D, administrative nurse B, and administrative staff A of the findings of resident #1's stage 4 pressure ulcer on the left elbow which was tender to touch, measured 2.5 cm (centimeters) by 3 cm with a reddish-brown discharge. Facility staff notified physician E, the resident's primary care physician of the findings and he/she came to the facility to assess the wound and obtained a culture. Physician E ordered an antibiotic and directed staff to notify the surgeon (physician G) for continued treatment. The facility made an appointment for the resident to see physician G on 10/2/13. A progress note written on 10/2/13 by physician E documented an ulcer of the left elbow, 2 cm by 3 cm and obtained a culture of the wound. The note further reported an assessment of a "pressure ulcer" with a plan to culture, start an antibiotic, and consult with the surgeon (physician G). A 10/2/13 progress note from physician assistant F revealed the resident was last seen at the office on 9/16/13. At that visit a well padded removable long arm splint was applied. Orders were issued at that time to begin physical therapy. According to the note, it was expected physical therapy would remove the splint and a skin check would occur at the time of therapy, so no order was given for nursing to remove the splint. The note further stated, "... (the) patient's physical therapy was expected to be started in a timely manner and would occur three times each week. When I was contacted this morning it was my understanding that a physical therapy evaluation was not performed until 9/26/13, ten days after the order was issued. We were never contacted regarding the delay in physical therapy services. When (the) patient was evaluated for physical therapy services, it was my understanding the splint was not removed. Splint has been removed to inspect skin and (a) pressure ulcer was noted on the day of 10/1/13." According to the physical examination on 10/2/13 by physician assistant F, the "area of pressure ulceration noted to the olecranon (bony prominence of the elbow) of the left elbow.... Bone to be visible. No large amount of drainage. No foul smelling odor. No hardware visible...Remainder of incision site is well healed." The plan of treatment included, "irrigation and debridement of ulcer (methods used to clean wounds, removing dead material and flushing the wound to remove organisms and dead cells) with hardware removal and secondary closure". Resident #1's 10/3/13 Operation Rerport identified a preoperative and postoperative [DIAGNOSES REDACTED]. The operation performed was "irrigation and debridement plus removal of K-wires (hardware from previous surgery) and retained suture". The procedure also included excision of necrotic (dead tissue) skin edges and soft tissue. During an observation on 10/23/13 at 5:15 p.m., resident #1 sat in a wheelchair in the living room area. The resident's left elbow had stitches in place with wound well-approximated and no signs of infection. During an interview on 10/23/13 at 5:21 p.m., direct care staff H stated resident #1 used to have a cast with a sling on his/her left arm. During an interview on 10/24/13 at 12:34 p.m., licensed nurse I revealed that when they receive an order for [REDACTED]. An interview on 10/28/13 at 11:52 a.m. with administrative nurse B verified there was a delay in initiation of physical therapy for resident #1 after the resident had an order for [REDACTED]. After the initial surgery on 8/27/13, the resident had a soft splint in place with a sling. According to administrative nurse B, physician assistant F removed the resident stitches on 9/16/13 and ordered physical therapy 2-3 times a week with removal of the splint by physical therapy only. Nurse B stated the orders for physical therapy were given to therapy staff J the next morning, on 9/17/13. Administrative nurse B verified there was a 10 day delay in starting resident #1's physical therapy and the resident's long arm splint remained in place from 9/16/13 - 10/1/13 without any assessment of the surgical wound. He/she confirmed the resident developed a stage 4 pressure ulcer on the left elbow from the splint device. Attempts to call physician assistant F on 10/28/13 at 11:00 a.m. revealed he/she was unavailable for an interview. During an interview on 10/29/13 at 8:21 a.m., physician E stated he/she believed there was "mis-communication" regarding physical therapy and who should have assessed the incision after the stitches were removed. The facility failed to initiate physical therapy services in a timely manner which included skin assessments with the use of a splint device 2-3 times a week by therapy staff. Resident #1 received an order for [REDACTED]. - Resident #3's 7/22/13 quarterly MDS (minimum data set) assessment revealed the resident had a BIMS (brief interview for mental status) score of 8, which indicated moderately impaired cognition. The resident required extensive assistance of 1 person for bed mobility and transfers. He/she had functional limitations in range of motion in on both sides of the lower extremities and used a wheelchair for mobility. The assessment identified the resident as at risk for pressure ulcer development with no unhealed pressure ulcers. The resident had pressure relieving devices in place in the chair/bed and had a turning/repositioning program. Resident #3's 4/18/13 pressure ulcer CAA (care area assessment) summary stated the resident did not have any skin issues at that time, but was at risk due to being frequently incontinent and decreased mobility. Resident #3's 11/21/12 nursing care plan identified the resident as at risk for pressure ulcers and directed staff to monitor for breakdown from oxygen tubing. An update on 2/26/13 identified an area of redness to the resident coccyx with a treatment of [REDACTED]. A 5/30/13 revision to the care plan identified the resident's right heel was red with a blistered areas 2 cm (centimeters) by 2 cm. Interventions included a [MEDICATION NAME] dressing covered with gauze and heel protectors when in bed with heels elevated. (the area healed on 7/26/13) An update on 10/21/13 revealed the resident had a 2 cm open crease on coccyx, treated with [MEDICATION NAME]. A revision on 10/24/13 stated the area on the coccyx had healed and was open to air. Review of wound assessment forms revealed the resident had a history of [REDACTED]. The wound assessment forms also identified a 2 cm superficial shearing type linear wound on the resident's coccyx found on an admission assessment after a hospitalization on [DATE]. According to the record, the coccyx wound healed on 10/24/13. During an observation on 10/24/13 at 9:36 a.m., resident #3 sat in a wheelchair with a pressure relieving cushion in the chair. Further observations at 9:45 a.m., 10:03 a.m., 10:16 a.m., 10:32 a.m., 10:44 a.m., 11:01 a.m., 11:16 a.m., 11:32 a.m. revealed resident #3 remained in the wheelchair without a change of position. At 11:49 a.m., the resident sat in the wheelchair for lunch in the dining room. Further observations at 12:01 p.m., 12:15 p.m., 12:28 p.m., and 12:45 p.m. revealed the resident remained in the dining room eating lunch. At 1:00 p.m. direct care staff K and L transferred resident #3 to bed. Staff K and L failed to place heel protectors on the resident's heels after assisting him/her to bed. By observation, resident #3 remained in the wheelchair without the benefit of a position change for 3 hours and 24 minutes. During an interview on 10/24/13 at 1:36 p.m., direct care staff K stated resident #3 should be repositioned every 2 hours. He/she further stated the resident used to have a sore on his/her right heel and they used heel protectors and put the resident's feet up. An interview with licensed nurse I on 10 24/13 at 12:34 p.m. revealed resident #3 returned from the hospital with an open "slit" on his/her coccyx and treated it with [MEDICATION NAME]. Nurse I stated the resident should be repositioned every 2 to 2 1/2 hours, especially because of the area on his/her coccyx. During an interview on 10/28/13 at 11:52 a.m., administrative nurse B stated resident #3 returned from the hospital on [DATE] with an open area on the coccyx, that healed on 10/24/13. Nurse B further stated the resident should have a change of position every 2 hours and his/her care plan directed staff to place heel protectors when in bed. Nurse B stated that if the resident refused to lay down, then staff should at least assist him/her to stand or shift his/her weight to provide pressure relief. The facility's August 2005 Protective Skin Care policy stated for those residents at risk for impaired skin integrity, the resident will be repositioned at least every two hours during the day and night. The facility failed to provide resident #3, who had a history of [REDACTED].