Every finding on record at U-City Forest Manor

Based on observation and interview, the facility failed to ensure facility staff used proper hand hygiene during meal service affecting seven Residents (Residents #54, #2, #47, #25, #29, #26, and #30) and failed to ensure hair restraints were worn properly while handling food in the kitchen. The sample size was 20. The census was 81. Review of the facility's handwashing policy, dated 1/2012, showed:-Policy: Handwashing facilities will be readily accessible and equipped with paper towels and soap. Staff will wash hands frequently as needed throughout the day following proper handwashing procedure;-Procedure: When to wash hands; after touching ears, nose, mouth, hair, etc. Any contact with infected or otherwise unsanitary areas of the body. Hand contact with unclean equipment or work surfaces. Hand contact with soiled clothing or other materials that are soiled. Review of the facility's personal hygiene and appearance policy, dated 1/2012, showed:-Purpose: To ensure a clean and proper uniform appearance consistent with good personal hygiene. To ensure staff are in good health to support food safety and environmental safety goals. To support food safety practices and to maintain compliance with federal, state and local regulations governing food safety;-Policy: Staff shall report to work in clean uniforms according to the facility uniform policy. Hair nets or hair coverings shall be worn while in the kitchen or storage areas. Facial hair shall be covered with a beard cover. 1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed:-Diagnoses included chronic kidney disease, type two diabetes, and unspecified intellectual disabilities;-Cognitively intact. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Diagnoses included end stage renal disease, legal blindness, dementia, and major depressive disorder;-Moderately impaired cognition. 3. Review of Resident #47's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder);-Severe cognitive impairment; 4. Review of Resident #25's quarterly MDS, dated [DATE], showed:-Diagnoses included type two diabetes, major depressive disorder, and anxiety;-Cognitively intact. 5. Review of Resident #29's quarterly MDS, dated [DATE], showed:-Diagnoses included dementia, major depressive disorder, and chronic kidney disease;-Moderately impaired cognition. 6. Review of Resident #26's admission MDS, dated [DATE], showed:-Diagnoses included type two diabetes, acute kidney failure, and acquired absence of right leg above the knee;-Cognitively intact. 7. Review of Resident #30's quarterly MDS, dated [DATE], showed:-Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) affecting right dominant side and type two diabetes;-Severe cognitive impairment. 8. Observation on 3/23/26, of breakfast in the main dining room, showed:-At 8:45 A.M., Certified Nursing Assistant(CNA) E touched Resident #54, patting him/her on the shoulder, went to the serving line to pick up a food tray, and brought the food tray to Resident #2. He/She picked up Resident #2's silverware and used it to cut up the resident's food;-At 8:49 A.M., CNA E took the empty tray that held Resident #2's food back to the serving line to discard it, grabbed a clean coffee cup, poured a cup of coffee, and brought the coffee cup to Resident #2;-At 8:51 A.M., CNA E picked up a clean coffee cup, poured coffee in it, and [NAME] the cup to Resident #47; -At 8:53 A.M., CNA E brought cups of coffee to both Resident #25 and #29 who were both seated together. While speaking to CNA B, CNA E touched CNA B's shirt;-At 8:54 A.M., CNA E brought a cup of coffee to Resident #26;-At 8:57 A.M., CNA E put his/her hands in his/her pocket. He/She then walked over to Resident #47 and repositioned him/her in his/her wheelchair while holding onto the resident. CNA E then turned and patted Resident #30 on the shoulder while speaking with him/her. 9. Observations on 3/23/26 at 8:41 A.M., 8:44 A.M., 8:47 A.M., 8:50 A.M., 8:56 A.M., 9:04 P.M., and 9:12 A.M., of breakfast in the main dining room, showed Dietary Aide F in the kitchen preparing plates at the steam table. His/her hair net was on. Approximately 2 inches of hair was hanging out of the hair net around the front of both sides of his/her face. 10. Observations on 3/25/26 at 12:15 P.M., 12:26 P.M., 12:30 P.M., 12:35 P.M., 12:40 P.M., and 12:45 P.M., of lunch in the main dining room, showed Dietary Aide F in the kitchen preparing plates at the steam table. His/her hair net was on. Approximately 2 inches of hair was hanging out of the hair net around the front of both sides of his/her face. 11. During an interview on 3/26/26 at 1:09 P.M., the Dietary Manager said she would expect staff to sanitize their hands after touching any unclean surface, resident, or themselves. She would expect dietary staff to wear hair restraints properly in order to keep hair out of the food. 12. During an interview on 3/27/26 at 12:44 P.M., the Administrator said she would expect staff to sanitize their hands after touching any unclean surface, a resident, or their clothing. She would expect kitchen staff to have their hair restraints on properly to ensure hair does not get into food.

Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) during care and failed to follow acceptable infection control practices during wound care, medication administration and direct patient care related to hygiene, for three of three residents observed for wound care (Residents #5, #26 and #77). The facility also failed to follow acceptable infection control practices during blood glucose testing. In addition, staff failed to ensure one out of five residents sampled for vaccinations and health screenings had a two-step tuberculosis (TB, infectious lung disease) screening within the 30-day post admission, per facility policy (Resident #49). The sample was 20. The census was 81. Review of the facility's Infection Prevention and Control Program Policies and Procedures, dated August/2018, showed: -The organization has made a commitment to prudent infection prevention and control measures by prompting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. We strive to implement evidence based approaches to infection prevention; -The infection prevention and control program: --Investigates, controls, prevents infection in the organization; --Decides what procedures, such as isolation, should be applied to the individual resident/patient; --Maintains a record of incident and corrective actions related to infections; --Has written procedures as a basis of determination for isolation (transmission based precautions) to help prevent the spread of infection; Review of the facility's Isolation Precautions/EBP policy, dated 4/24, showed: Policy: It is the policy to make every effort to prevent the spread of infection in the facility;--Standard Precautions require the health care worker (HCW) to estimate the degree of risk associated with a given task and plan for appropriate personal protective equipment; --Precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; Procedurep -EBP will be used for any resident who meets the following criteria:- Infection or colonization with a Center for Disease Control & Prevention (CDC_-targeted MDRO when contact precautions do not otherwise apply;-Chronic wounds, such as, pressure ulcer, venous stasis ulcers, diabetic ulcers, unhealed surgical wounds;-Indwelling medical devices, such as, central lines, urinary catheters, feeding tubes, and tracheostomies. -Residents who meet the above criteria, EBP are recommended when performing the following high-contact resident care activities:--Providing hygiene;--Changing briefs or assisting with toileting;--Chronic wound care; - Place EBP sign at entrance to the room for the residents who meet the criteria; --Staff will clean their hands before entering and when leaving the room;--Staff will wear gloves and a gown for high-contact resident care activities;--Do not wear the same gloves and gown for the care of more than one person;--If only one resident in the room requires EBP, place an EBP sign above the bed of the resident who meets the criteria as well as the entrance to the room. 1. Review of Resident #5's medical record, showed: -Diagnoses included gastrostomy tube (g-tube, a tube that is surgically inserted into the abdomen to administer medication and liquid nutrition) and Alzheimer's disease; -An order, dated 10/22/25, levetiracetam (medication used to treat seizures) give 100 milligrams (mgs) via g-tube; -An order, dated 10/16/25, polyethylene glycol (medication used to treat constipation) give 17 grams (gms), via g-tube; -No order for enhance barrier precautions. Review of the resident's care plan, in use at the time of survey, showed it did not address EBP. Observation on 3/25/26 at 8:53 A.M., showed Registered Nurse (RN) Q prepared the resident's medication at the medication cart and entered the resident's room. A PPE supply drawer was located outside the resident's room. The resident had an EBP sign posted on the door and above his/her bed on the wall. RN Q moved the resident's arms away to obtain access to the resident's g-tube. The resident held onto the RN Q's arm. RN Q administered the levetiracetam and polyethylene glycol through the residents g-tube with gloved hands. RN Q did not wear an isolation gown while administering medications. During an interview on 3/25/26 at approximately 9:00 A.M., RN Q said he/she should have worn an isolation gown when administering the resident's medications. EBP should be worn when staff is providing direct care to a resident who has wounds, g-tubes, dialysis ports and urinary catheters 2. Review of Resident #26's medical record, showed: -Diagnoses included diabetes, peripheral vascular disease (PVD, a narrowing of blood vessels in the legs causing decreased circulation); -An order, dated, 3/12/26, wet to dry dressing, clean with wound cleaner, apply Medihoney (an ointment that removes dead tissue) to two wounds on the left foot on right side and on the top middle and a apply a border dressing (a specialized dressing); -No order for EBP. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's wounds or EBP. Observation on 3/23/26 at 6:40 A.M., showed Licensed Practical Nurse (LPN) P gathered supplies off of the treatment cart and entered the resident's room. The resident did not have an EBP sign posted on the door. A PPE supply drawer was not outside the resident's door. The resident was sitting in his/her wheelchair. The LPN removed the resident's left foot dressing dated 3/22/26, with gloved hands. The resident had two small wounds to his/her left foot. LPN P cleansed the resident's foot wounds with wound cleaner and applied Medihoney to the wound beds with gloved hands. LPN P then applied the border gauze that covered both of the resident's wounds. LPN P did not wear an isolation gown during the resident's dressing change. 3. Review of Resident's #77's medical record, showed diagnoses included morbid obesity, bipolar (mood swings), intellectual disability (neurological disability). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/25, showed: -admission date of 7/9/24; -Moderately impaired cognition; -Fully dependent on staff assistance for activities of daily living (ADLs); -Skin conditions, no concerns noted. Review for the resident's care plan, in use during the survey, showed no EBP concerns and no goals or interventions in place to prevent the resident from foreign pathogens. The resident had a right ankle wound and g-tube. Observation on 3/24/26 at 8:04 A.M., showed Certified Nursing Assistant (CNA) T and CNA U entered the resident's room. CNA T and CNA U washed hands and did not put on a gown. There was a PPE caddy outside the door, along with an EBP sign above the bed. The CNAs performed peri care (wash the genital area) and dressed the resident. During an interview on 3/25/26 at 8:37 A.M., CNA U said they did not use PPE (gown). The resident is on EBP for wounds and the g-tube. During an interview on 3/27/26 at 12:20 P.M., the Director of Nursing (DON) said he expected staff to follow policies and procedures of the facility. Residents who are expected to be on EBP included residents with the following: Wound(s), G-tubes, and catheters. He expected staff to use a gown and gloves during invasive tasks or when providing direct care to the resident. There were no orders required for EBP; it is the nurses' best judgment. 4. Review of the facility's Equipment, Supplies, and Cleaning Policy, revised 2/3/21, showed: -If equipment must be used for more than one resident, it will be cleaned and disinfected before use on another resident, according to manufacturer's recommendations using Environmental Protection Agency (EPA)-registered disinfectants; -The facility will ensure healthcare personnel have access to EPA-registered hospital-grade disinfectants to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. Observation on 3/23/26 between 8:47 A.M. and 9:08 A.M of the main dining room, showed LPN I provided blood sugar checks to residents in the dining room. At 8:53 A.M., LPN I used the glucometer to assess a resident's blood sugar level, providing the resident with a small cotton swab and returned to the treatment cart with the glucometer. LPN I did not disinfect the glucometer after removing his/her gloves and performing hand hygiene with alcohol-based hand sanitizer. At 8:57 A.M., LPN I used the glucometer to assess a second resident's blood sugar level, providing the resident with a small cotton swab and returning to the cart with the glucometer. No disinfectant was used on the glucometer after LPN removed his/her gloves and performed hand hygiene. At 9:03 A.M., LPN I used the glucometer to assess a third resident's blood sugar level, providing the resident with a small cotton swab and returning to the cart with the glucometer. No disinfectant was used on the glucometer before it was placed back into the treatment cart by LPN I. During an interview on 3/27/26 at 8:09 A.M., LPN C said glucometers should be cleaned after each resident's blood sugar is assessed. Glucometers are not to be used for multiple residents and should be sanitized with medical equipment disinfectant wipes, preferably those equipped to kill the hepatitis (bloodborne pathogen) virus. This is important to reduce the spread of infection between diabetic residents receiving insulin therapy and blood glucose level assessments at the facility. During an interview on 3/27/26 at 12:11 P.M. the facility Administrator, Director of Nursing, and Assistant Director of Nursing (ADON) said staff are instructed to clean the glucometer between residents with a medical equipment disinfectant wipe sufficient for the equipment's manufacturer's guidelines for cleaning. This is important to reduce the spread of blood-borne infections between residents. 5. Review of the facility's Infection Prevention and Control Program Policies and Procedures, dated August/2018, showed: -Due to recent shortage of serum for screening and testing for tuberculosis for new employees and newly admitted resident(s), CDC has issued the following direction; -The facility will: --Make every effort to obtain the tuberculin skin testing (TST, detects TB infection) supplies including checking with your local health department, all suppliers, etc in a timely manner; --Document all attempts to obtain the TST testing supplies and estimated times of delivery; -Until you can obtain the necessary TST testing supplies: --During the shortage, if supplies are still available, new employees should be administered the one-step TST upon hire, and then defer the second TST until the shortage resolves. If supplies are not available, conduct a symptom screen and document, --All new Admits will be assessed for signs and symptoms of TB upon admission to the building and this assessment documented; -- If the assessment of any employee or resident results in signs and symptoms of possible TB instruct them to see their physician or their local public health department; --Once TST testing supplies become available, all employees or resident(s) who required testing and were not tested, must be tested. The testing tis o be completed within a reasonable time period, usually within 30 days of obtaining the supplies; Tuberculosis Control: General Statement: -Resident and staff TB screening program will be implemented based upon the annual TB risk assessment in accordance with applicable state and local regulations. Review of the resident's #49's medical record, showed: -admission date of 1/6/26; -Moderately impaired cognition; -Independent with ADLs. Review of the resident's Immunizations Consent sheet dated 1/6/26, showed the resident consented to receive the 2-step TB test, however the facility could not provide any documentation related to if the resident did in fact receive the test. During an interview on 3/26/26 at 9:16 AM, the ADON said there is no documentation regarding the 2-step test aside from the consent form. The ADON would need to talk to the admitting nurse and see if he/she remembered. At this point, they would have to say the resident did not receive the TB test. During an interview on 3/27/2026 at 12:20 P.M., the DON said he expected the nurse to follow the facility's policy and protocol related to TB testing. The shift nurse was responsible for administering a TB test to newly admitted residents. The medical doctor would need to be aware if/when a TB test could not be administered within the recommended timeframes of the policy. During an interview on 3/27/2026 at 12:20 P.M., the Regional Nurse said she was unaware of what the policy stated regarding the TB testing.

Based on observation, interview and record review, the facility failed to ensure common areas in the facility were maintained in a clean, comfortable and homelike environment. Concerns were identified with two of 20 sampled residents (Resident #45 and #39), the Memory Care Courtyard and resident hall shower rooms on the 100, 200 and 300 halls. The census was 81.1. Review of the facility's Night Shift Assignment Sheet, undated, showed wheelchairs should be cleaned nightly. 2. Review of the facility's housekeeping cleaning schedule for March of 2026, showed shower rooms on all resident halls were to be cleaned once weekly on Sundays. 3. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 3/9/26, showed:-Diagnoses included depression and schizophrenia (a mental disorder that distorts reality);-The resident uses a wheelchair. Observation on 3/23/26 at 6:20 A.M., 3/25/26 at 9:25 A.M., and 3/27/26 at 10:30 A.M., showed the resident sat in his/her wheelchair in the Memory Care dining room. The resident's wheelchair had a white powdery substance, dust and hair on the wheelchair frame and wheels. 4.Review of the Resident #39's annual MDS, dated [DATE], showed:-Diagnoses included diabetes and bipolar disorder (a mental disorder that cause severe mood swings);-The resident uses a wheelchair. Observation on 3/23/26 at 6:20 A.M. and 3/24/26 at 12:17 P.M., and 3/25/26 at 9:22 A.M., showed the residents sat in his/her wheelchair in the Memory Care dining room. The resident's wheelchair had a thick layer of dust and food particles on the wheelchair frame and wheels. During an interview on 3/26/26 at 10:45 A.M., Licensed Practical Nurse (LPN) L said the night shift was to wipe down and clean the residents' wheelchairs weekly. He/She was not aware of a set schedule but though it might be on the resident shower days that the wheelchairs were to be cleaned. During an interview on 3/27/26 at 12:22 P.M., the Assistant Director of Nursing (ADON) said the resident wheelchairs were expected to be cleaned by nursing staff on the night shift and the staff had not been doing it. 5. Observation on 3/24/26 at 4:15 P.M. and 3/26/26 at 10:45 A.M., of the Memory Care Courtyard showed, an overgrowth of weeds, cigarette butts, dandelions, overgrown grass, piles of leaves near the entrance of the courtyard and two animal traps with weeds growing over them. The windows were covered with dirt, dust and spiderwebs. Observation on 3/25/26 at 1:40 P.M., showed four residents sat in the Memory Care Courtyard smoking with two facility staff members. The courtyard showed an overgrown of weeds, cigarette butts, dandelions, overgrown grass, piles of leaves near the entrance of the courtyard and two animal traps with weeds growing over them. The windows were covered with dirt, dust and spiderwebs. During an interview on 3/24/26 at 12:17 P.M., Certified Medicine Technician (CMT) M and Activities Assistant O said the residents go into the courtyard for activities and to smoke. The courtyard has not been cleaned for several months, and they never saw anyone clean the windows. The residents looked out onto the courtyard during meals or watching television and the courtyard was not in the best shape and could use some work. During an interview on 3/26/26 at 10:45 A.M., the Maintenance Director said he was responsible for maintaining the Memory Care Courtyard and had not cleaned anything in the courtyard since last year. He had not done any type of fall or winter maintenance or cleaning. The animal traps were for when they use to have racoons, and they were trying to trap them. He said the courtyard did need some cleanup work so it would look better for the residents. During an interview on 3/26/26 at 10:47 A.M., the Housekeeping Supervisor said she was new and did not know who cleaned the outside of the windows and said they were very dirty and did need to be washed. The Memory Care Courtyard did not appear to be very homelike with the condition it was in. 6. Observation on 3/23/26 at 5:50 A.M. of the facility's 100 hall shower room, showed what appeared to be excrement on the walls and baseboards near the shower room toilet, and the whirlpool tub filled with packages of incontinence briefs and a soft positioning wedge. A pile of dirty, unmarked clothes and a plastic bag filled with toiletries was observed on a chair near the shower stall. Observation on 3/23/26 at 6:20 A.M. of the facility's 200 hall shower room, showed the room's whirlpool tub filled with packages of briefs, linens, and a soft positioning wedge. A laundry cart was observed blocking access to the toilet stall. Observation on 3/23/26 at 6:41 A.M. of the facility's 300 hall shower room, showed the room's whirlpool tub filled with packages of briefs. A pile of wet towels and a wet chucks pad were observed on the floor of the shower room, a pair of latex gloves and a comb were observed on the floor under the sink, and a pair of wheelchairs blocked entrance to the room's shower stall. Observation on 3/24/26 at 11:03 A.M. of the facility's 200 hall shower room, showed the room's whirlpool tub filled with packages of briefs, linens, and a soft positioning wedge. Two large trash cans and two laundry carts were parked inside the door to the shower room, blocking access to any part of the shower room. Observation on 3/24/26 at 11:11 A.M. of the facility's 100 hall shower room, showed what appeared to be excrement on the walls and baseboards near the shower room toilet, and the whirlpool tub filled with packages of incontinence briefs and a soft positioning wedge. A pile of dirty, unmarked clothes and a plastic bag filled with toiletries was observed on a chair near the shower stall. Observation on 3/25/26 at 8:23 A.M. of the facility's 200 hall shower room, showed the room's whirlpool tub filled with packages of briefs, linens, and a soft positioning wedge. Two large trash cans and two laundry carts were parked inside the door to the shower room, blocking access to any part of the shower room. Observation on 3/23/26 at 8:25 A.M. of the facility's 300 hall shower room, showed the room's whirlpool tub filled with packages of briefs. A pile of wet towels and a wet chucks pad were observed on the floor of the shower room. The toilet appeared to be clogged with excrement and toilet paper. Observation on 3/24/26 at 8:27 A.M. of the facility's 100 hall shower room, showed what appeared to be excrement on the walls and baseboards near the shower room toilet, and the whirlpool tub filled with packages of incontinence briefs and a soft positioning wedge. A pile of dirty, unmarked clothes and a plastic bag filled with toiletries was observed on a chair near the shower stall. 7. During an interview on 3/27/26 at 8:03 A.M., Housekeeping Aide G said housekeeping staff were responsible for cleaning the resident hall shower rooms every day, which could sometimes be made much more difficult when the shower rooms were filled with trash cans, laundry carts, or mechanical lifts. Wheelchairs in the facility were cleaned nightly by nursing staff, and was not the responsibility of the housekeeping staff. During an interview on 3/27/26 at 8:09 A.M., LPN C said resident hall shower rooms were the responsibility of the housekeeping staff and should be cleaned every day. Wheelchairs were cleaned by night shift nursing staff on a routine basis, but anyone could clean a resident's wheelchair if requested or needed. During an interview on 3/27/26 at 8:26 A.M., CNA H said resident hall shower rooms should be cleaned after every resident shower by the staff who used the shower room to care for the resident. The shower rooms were deep cleaned on a routine basis by the housekeeping staff, but CNA H was unsure of which day of the week deep cleaning was done. Wheelchairs could be cleaned by anyone when requested by a resident and were routinely cleaned by the night shift nursing staff. During an interview on 3/27/26 at 12:21 P.M., the facility Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) said housekeeping staff were responsible for deep cleaning resident hall shower rooms once weekly, and nursing staff should clean them after resident use. Wheelchairs were cleaned by night shift nursing or as requested by a resident. The facility maintenance staff was responsible for the memory care courtyard and should ensure the courtyard was maintained in a clean manner and any animal traps were routinely surveilled for activity and/or removal.

Based on interview and record review, the facility failed to ensure six discharged residents had their money returned after discharge within 30 days (Residents #89, #90, #91, #92, #93, and #94), and failed to ensure third party liability (TPL) letters were sent and followed up on to for two residents who expired with balances in their account (Residents #95 and #96). The census was 81. Review of the facility's resident trust policy, undated, showed:-The Business Office Manager(BOM) has the primary responsibility for ensuring that residents' funds held in the trust are kept safe, are properly accounted for, and that all payments from the residents' funds are appropriate and legitimate;-Procedure: discharged /deceased resident accounts need to be refunded to theresident or Medicaid no later than 30 days from date of discharge. 1. Review of Resident #89's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $1,644.00;-No record of funds returned to the resident. 2. Review of Resident #90's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $378.68;-No record of funds returned to the resident. 3. Review of Resident #91's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $60.67;-No record of funds returned to the resident. 4. Review of Resident #92's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $3,016.56;-No record of funds returned to the resident. 5. Review of Resident #93's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $25.97;-No record of funds returned to the resident. 6. Review of Resident #94's resident trust account, showed:-Resident discharged on [DATE];-The account had a balance of $30.00;-No record of funds returned to the resident. 7. Review of Resident #96's resident trust account, showed:-Resident expired on [DATE];-The account had a balance of $.03;-No record of TPL letter being sent. 8. Review of Resident #95's resident trust account, showed:-Resident expired on [DATE];-The account had a balance of $717.45;-No record of TPL letter being sent. During an interview on [DATE] at 1:57 P.M., the BOM said he would expect money to be out of the resident's accounts in the required time frame when they discharged or expired. He did not know the exact timeframe. He said he did not send the TPL letters and that the corporate office sent them out. He did not have proof that the TPL letters were sent. During an interview on [DATE] at 12:53 P.M., the Administrator said she would expect for the facility policy to be followed for resident funds. She would expect the TPL letters to be sent when a resident expired. She would expect resident funds to be returned to Medicaid or to the resident following their discharge within 30 days.

Based on observation and interview, the facility failed to have a system in place to ensure controlled medications were securely stored under two locks for one out of one medication room observed. The facility also failed to label eye drops with an open and expiration date for two out of four medication carts reviewed. The census was 81. Review of the facility's Medication Administration policy, dated [DATE], showed:-Policy: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations;-All drugs classified as a controlled substance will be stored under double locks;-The policy did not address labeling of eye drops. 1.Observation and interview on [DATE] at 10:05 A.M. of the Central Medication Room, showed a refrigerator with no lock. Inside the refrigerator showed 56 vials of Lorazepam (a controlled substance medication used to treat anxiety) 2 milligrams (mgs) per milliliter (ml) not secure in a locked container. The Lorazepam vials expired [DATE]. Registered Nurse (RN) Q said he/she did not know the medication was in the refrigerator because it was not being counted. The Lorazepam should have been secured in a locked box in the refrigerator. During an interview on [DATE] at 12:22 P.M. the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) said once the medication was discontinued or expired, it should be immediately brought to the DON's office so it could be destroyed. The Lorazepam was expected to be secured under two locks. 2.Observation and interview on [DATE] at 8:53 A.M. of the 100 and 400 hall medication cart, showed:-Two bottles of Dorzolamide-Timolol 2%/0.5% (eye medication use to treat high eye pressures), with the manufacturer seal broken, no open date or expiration date;-One bottle of Ciprofloxin 0.3 % eye drops (eye medication used to treat eye infections) with the manufacturer seal broken, no open date or expiration date;-One bottle of Tobramycin 0.3 % eye drops (eye medication used to treat eye infections) with the manufacturer seal broken, no open date or expiration date;-One bottle of Asteline 0.5 % eye drops (eye medication use to treat itching) with the manufacturer seal broken, no open date or expiration date;-One bottle of Brimonidine 0.2 % eye drops (eye medication use to treat high eye pressures) with the manufacturer seal broken, no open date or expiration date;-RN Q said the eye drops should be labeled when opened and with an expiration date to ensure the efficacy of the medications. RN Q was not sure how long the eye drops lasted after they were opened, but thought it was 30 days. 3.Observation and interview on [DATE] at 9:25 A.M. of the Memory Care Certified Medication Technician (CMT) Cart, showed one bottle of Cipro 0.3 % eye drops with the manufacturer seal broken, no open date or expiration date. CMT M said whoever opens the eye drops should label them with the open date and expirations date. Eye drops once opened were good for 30 days. The labeling of eye drops was important because expired eye drops should not be given to the residents. During an interview on [DATE] at 12:22 P.M., the DON and ADON said they expected staff to label eye drops with an open date and an expiration date to ensure the efficacy of the eye medications. Recommendations of when medications expire were based off pharmacy instructions.

Based on observation, interview and record review, the facility failed to implement fall interventions for one resident with frequent falls (Resident #26) and failed to ensure one resident was assessed for safety while smoking (Resident #15). The sample was 20. The census was 81. Review of the facility's Fall Management policy, dated 3/28/25, showed:-Policy: It is the policy of the management company to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions;-Procedure: A fall risk assessment will be completed on all residents upon admission, re-admission, after each fall and quarterly thereafter. Residents identified as high risk will have fall prevention addressed on the plan of care. Review of the facility's Smoking policy, dated 10/21/22, showed:-Purpose: To ensure all residents are safe while smoking;-Procedure: Any resident that expresses an interest in smoking will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision that will be needed to ensure the resident's safety;-Residents who are determined by the care plan team to be able to smoke withoutsupervision may smoke at will in the designated smoking area. Smoking materials will be returned to the nurse's station and will not be kept in the resident's room. The facility will notify the resident of the times throughout the day that independent smoking is allowed;-All residents that are not deemed capable of smoking unsupervised, will be given the opportunity to smoke with supervision at the designated facility smoking times. All smoking supplies for residents that require supervision will be kept at the nurse's stations when not in use. 1. Review of Resident #26's admission Minimum Data Set (MDS), a federally mandated assessment instrument competed by facility staff, dated 12/23/25, showed:-Lower extremity impairment to one side;-Partial to moderate assistance required for transfers;-Diagnoses included diabetes, acute kidney failure, and acquired absence of right leg above the knee. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident admitted to the facility for long term care. Resident requires a baseline care plan identifying care needs, risks, strengths and goals within the first 48 hours;-Goal: Resident will have access to necessary services to promote adjustment to new living environment in the facility;-Approaches: Resident will need to be monitored to prevent falling in new environment. Resident will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury. Resident uses a wheelchair and need safety reminders to use durable medical equipment safely;-The care plan did not address the resident's falls or any fall interventions put in place. Review on 3/23/26, of the facility's facility event summary report, dated 12/23/25 through 3/23/26, showed:-On 12/24/25 at 6:42 P.M, the resident had an unwitnessed fall;-On 1/6/26 at 7:25 A.M., the resident had an unwitnessed fall;-On 1/11/26 at 4:00 A.M., the resident had an unwitnessed fall;-On 1/29/26 at 11:11 A.M., the resident had a witnessed fall;-On 1/29/26 at 12:32 P.M., the resident had a witnessed fall;-On 2/17/26 at 11:40 A.M., the resident had an unwitnessed fall. Review of the resident's fall investigation, dated 2/28/26, showed:-Event information: Resident had an unwitnessed fall in his/her bathroom;-Root cause: Resident left dining area and tried to transfer from wheelchair to toilet in common bathroom. Resident encouraged to ask for assistance;-No new interventions documented. Review the resident's fall investigation, dated 3/14/26, showed:-Event information: Resident had a witnessed fall in his/her bathroom;-Root cause: Resident was trying to transfer him/herself from bed to wheelchair without assistance;-No new interventions documented. Review of the resident's fall investigation, dated 3/19/26, showed:-Event information: Resident had unwitnessed fall in his/her room;-Root cause: Resident had an amputated leg and tried to get out of bed without assistance and into wheelchair. Resident educated on calling for help when wanting to move;-No new interventions documented. Observation on 3/25/26 at 6:47 A.M., showed the resident seated in his/her wheelchair by the left side of his/her bed with eyes closed. The call light not in reach. Observations on 3/26/26 at 6:51 A.M., 7:46 A.M., 9:36 A.M., 9:54 A.M., and 11:08 A.M., showed the resident seated in a wheelchair to the left side of his/her bed, with eyes closed. The call light not in reach, on the ground on the right side of the resident's bed. During an interview on 3/26/26 at 10:52 A.M., the Director of Therapy said the resident is receiving physical therapy, occupational therapy and speech therapy. Her recommendation for the resident is that he/she should be in a wedge wheelchair (tilted wheelchair) with foot pedals to prevent further falls. She expected the resident's call light to be in reach at all times. She expected nursing staff to conduct more frequent rounding on the resident. She expected these interventions to be on the resident's care plan. During an interview on 3/27/26 at 7:28 A.M, Licensed Practical Nurse (LPN) C said the resident has had frequent falls. The resident should have fall interventions put in place. His/Her care plan should include interventions that have been put in place. The Director of Nurses (DON) is responsible for updating the care plan. During an interview on 3/27/26 at 12:50 A.M., the Administrator and DON said they have tried many different interventions but nothing has worked to prevent the resident's falls. They have tried frequent rounding, ensuring the call light is in reach of the resident, and having the resident sit where he/she can be observed. Interventions should be documented on a resident's care plan. Interventions should be in place for the resident due to his/her frequent falls. 2. Review of Resident #15's admission MDS, dated [DATE], showed:-Diagnoses included Huntington's disease (neurodegenerative disorder) and weakness;-Moderately impaired cognition. Review of the resident's electronic medical record, reviewed 3/24/26 at 12:00 P.M., showed no smoking assessment. Observations on 3/25/26 at 1:25 P.M. and 3/26/26 at 8:12 A.M., showed the resident outside smoking. During an interview on 3/27/26 at 7:28 A.M., LPN C said staff should have completed as smoking assessment on the resident upon his/her admission. Completion of a smoking assessment is important to ensure the resident's safety while smoking. During an interview on 3/27/26 at 12:30 P.M., the Administrator and DON said they expected for staff to have completed a smoking assessment on the resident upon admission. 2741631

Based on observation, interview and record review, the facility failed to provide appropriate treatments and assessments for two of two residents sampled for wounds (Residents #88 and #77). The facility failed to administer treatments on a consistent basis and failed to enter an order in the electronic medical record (EMR) for a newly identified wound for Resident #88. The facility failed to accurately document skin assessments for a resident with an ankle wound, so the facility and the Wound Doctor had the correct information to conduct wound follow-up and monitoring (Resident #77). The sample was 20. The census was 81. Review of the facility's Wound Management Policy, dated January 2023, showed:-Policy: Manage resident skin integrity through prevention, assessment and implementations and evaluations of interventions.-Procedure:--The facility is provided with Wound Care Protocols. These are to be utilized to assist in the care and treatment of wounds. This reference tool can be placed in the nursing report books;--The facility will use the Braden Scale (clinical tool to assess a patient's risk of developing pressure injuries) for predicting pressure ulcers (localized injuries to skin and underlying tissue, primarily caused by prolonged pressure, friction, or shear, often on bony prominences) on each resident at admission, weekly for four weeks post admission and readmission, and quarterly thereafter to assess skin breakdown risk. Complete the Braden Scale in its entirety in the electronic medical record to calculate a score;--Residents identified at risk on the Braden Scale will have this addressed on their care plan and will have interventions put in place for preventative measure. High risk or any stage pressure injury will have skin checks daily. All others will have at least a weekly skin check assigned through the Resident Scheduler and documented by the nurse Registered Nurse (RN) or License Practical Nurse (LPN). Interventions: Pressure reducing mattress and/or cushion, be reviewed by dietician and lab values as needed. Residents identified with impaired skin will have a care plan initiated regarding impaired skin integrity;--The facility will assess all residents weekly for current skin conditions;---Any resident that scores very high risk, high risk, or has a pressure injury present will have a skin check documented daily to identify any new or worsened areas;---The daily skin assessment will be documented on the electronic treatment administration (eTAR)record/electronic medication administration record , (eMAR), which is completed as follows:----Observe the skin for the following: Clear, Redness, Open, Pressure, and Skin Tear (CROPS);---The nurse responsible for treatments will review all daily documentation and review any new areas;--All wounds will be reported weekly in the eMAR, using wound management;--It is important that wounds are assessed correctly to differentiate between pressure and non-pressure wounds, and documented within wound management;-- It is the responsibility of the Administrator to review the Pressure Wound Report and Non Pressure Injury Report weekly;--Physician and guardian/family members are called weekly with an update of the current wound conditions. 1. Review of Resident's #88's medical record, showed diagnoses included: Open wound right foot, pressure ulcer-coccyx (tailbone), stroke, hemiplegia (weakness limited movement) and hemiparesis (near total paralysis), dysphagia (difficulty swallowing), severe protein - calorie malnutrition (a critical deficiency in protein intake-often coupled with inadequate caloric consumption), cognitive communication deficit (impaired communication), seizure (abnormal electrical activity in the brain) and peripheral vascular disease (PVD) (ineffective blood flow). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/25, showed:-admission date 4/5/25;-admission weight 104 pound (lbs.);-Cognitively intact;-Dependent assistance required for activities of daily living (ADLs);-No skin concerns. Review for the resident's care plan, in use during survey, showed no problems related to skin, goals to meet or interventions to prevent wounds. Review of the readmission skin observation report, dated 12/07/25 at 5:02 P.M., showed no skin abnormalities noted. Review of the Nurse Practitioners (NP) progress note dated 12/11/25 at 12:16 P.M., showed new open area to right ankle, no redness or swelling noted. New orders for cleanse right ankle with wound cleaner, pat dry and apply Medi honey (antibacterial, and used for treating chronic and acute wound) to the wound bed. Review of the resident's physician order sheets (POS), showed an order, dated 12/11/25, for Medi Honey gel 80% dime size topical (on the skin), instructions cleanse right buttocks with wound cleanser or normal saline and apply Medi honey and dry dressing (DD) daily until healed 7:00 A.M. - 7:00 P.M. Review of the Resident's MAR/TARs dated 12/25 showed no orders for a right ankle wound treatment. Review of the LPN K weekly skin observation report at 1:41 P.M., dated 12/15/25 showed areas of skin concern: Pressure injury, blister or open area, was checked yes, description buttocks. Review of the NP progress note dated 12/18/25, showed, According to nurse the resident has a right buttocks slight excoriation. NP wrote to continue to monitor area. Review of the Director of Nursing's (DON) skin observation report dated 12/23/25 at 1:28 P.M., showed, no abnormalities of the skin. Review of the LPN J's unscheduled skin observation report dated 12/23/25 at 8:30 P.M., showed skin assessment of right hip abrasion and a coccyx wound previously noted. Review of the Medical Doctor's wound report notes dated 12/30/25, showed:-Activate initial phase of treatment to buttocks, wound type moisture associated skin damage (MASD), no measurements, minimal exudate (mass and fluid), serous (clear/serum) drainage, and signs and symptoms of infection were erythema (red) and warm.-Order for Medi honey to open areas (location of open area not noted), zinc oxide (medicated barrier cream) to peri (around) wound, dry clean dressing (DCD), change daily and as needed (PRN), perform on day shift and PRN;-Right hip pressure injury stage 3 (full thickness and depth to subcutaneous tissue), measurements 3 centimeters (cm) length by 1 cm width by 0.2 cm depth, 50% granulation (new tissue growth) and 50% slough (dead tissue near wound); with moderate exudate drainage serosanguineous (bloody and clear serum);-New order for cleanse, pat dry and apply Medi honey to wound base (location of wound not noted) alginate (highly absorbent dressing), DCD daily and PRN every day and PRN;-Follow up at next appointment. Review of the DON's progress note dated 12/31/25 at 1:47 P.M., (recorded as a late entry on 1/5/26 at 4:59 P.M.) showed right buttock/hip stage 3 ulcer/MASD, measurements of 3 cm by 1 cm, edges are approximated, improving slightly, pink in color, appears to have superficial skin healing since edges have pink wound bed;-Family updated. Review of the resident's MAR/TAR dated January 2026, showed: -Order dated 12/7/25, Medi honey gel 80% cleanse right buttock wound cleaner, or Normal Saline (NS, sterile water), apply Medi honey, DD daily until healed;--Missed four out 31 opportunities, for refused or not completed, without progress notes.-Order dated 1/6/26 cleanse wound right hip with Dura Wound Cleanser (DWC, a general wound care product), pat dry, apply silicone faced foam dressing, change daily;--Per documentation, resident refused 1/8/26, 1/12/26 and 1/18/26 without progress note;--On 1/16/26, missed dressing change without a progress note. Review of the Medical Doctor's wound report notes dated 1/6/26, showed:-Wound onset date 12/30/25, buttocks MASD, healing, drainage exudate serous and signs symptoms of erythema and warmness;-Treatment order: Medi honey to open areas zinc oxide per wound DCD, daily and PRN every day and PRN;-Wound onset date 12/30/25, Right hip wound stage 3 declined, related wound status - dressing changes and offloading, measurements 4 cm by 1.5 cm by 0.3 cm 60% granulation and 40% slough;-Treatment order: Consult physical therapy and occupational therapy for wound offloading needs to right lower extremity. Review of the DON's progress note, dated 1/6/26 at 4:49 P.M., showed:-This is a wound note;-Right buttocks MASD, 0.5 cm by 0.5 cm edges approximated, significant improvement from last week, pink in color, appears to have superficial skin healing since edges have pink wound bed;-Right hip, 4.1 cm by 1.5 cm by 0.3 cm, appears stable, pink wound bed, wound edges approximated;-Family updated. Review of the DON's progress note, dated 1/16/26 at 11:14 A.M., showed:-This is a wound note;-Right buttock MASD - healed;-Right hip pressure injury stage 3, measurements were 3.6 by 1.2 cm by 0.1 cm, improved pink wound bed, wound edges approximated;-Family updated and medical doctor updated. Review of the DON's progress note dated 1/23/26 at 12:53 A.M., showed:-This is a wound note;-Right buttock MASD - healed;-Right hip stage 3, 3.6 cm by 1.2 cm by 0.1 cm, improved pink wound bed, wound edges approximated;-Family updated and medical doctor updated. Review of the Medical Doctor's wound report dated 1/27/26, showed:-Onset date 12/30/25, sacrum (tailbone), wound type buttocks, posterior scrotum healing status, declined, minimal exudate with serous drainage and signs and symptoms of infection erythema;-Patient unable to offload,-Other--peri-care (incontinence care) and relative immobility;-Treatment order: Zinc oxide to peri wound, DCD daily and PRN with incontinence, every day and PRN;-Onset wound date 12/30/25, right hip, wound type pressure injury, stage 3 healing type, stable/same, measurements 4.5 cm by 1.0 cm by 0.3 cm, 40% granulation and 60% slough; moderate serosanguineous drainage signs and symptoms of infection purulence (discharging pus, typically indicating a bacterial infection);-Treatment order: Cleanse, pat dry, Medi honey to wound bed (location of wound not noted), alginate with silver (highly absorbent, sterile, antimicrobial wound dressings derived) DCD daily and PRN, every day and PRN. Review of the DON's progress note dated 1/30/26 at 4:54 A.M., showed:-This is a wound note;-Sacral buttock MASD - 4.8 cm by 6.3 cm, stable pink wound bed, wound edges approximated;-Right hip, stage 3, 4.5 cm by 1.0 cm by 0.3 cm, improved pink wound bed, wound edges approximated;-Scrotum MASD, 2 cm by 1.0 cm by 0.1 cm, stable, very superficial;-Family updated. Review of the resident's MAR/TAR dated February 2026, showed: -Order date 3/11/25, barrier cream to applied to resident's peri area (area between the thighs, extending from the pubic bone to tail bone) after each incontinence episode every shift, missed eight out of 42 opportunities;-Order date 11/3/25, apply zinc oxide to buttocks, cleanse with soap and water, pat dry PRN and following each incontinence episode, missed 66 out of 66 opportunities;-Order date 12/11/25, Medi Honey, right buttocks with normal saline or wound cleanser, apply Medi honey and dry dressing daily until healed, missed six times out of 23 opportunities;-Order date 1/6/26, cleanse wound to right hip with DWC, pat dry, apply silicone face foam dressing, change daily once daily, missed six times out of 22 opportunities, without any progress note;-Order date 2/11/26, for cleanse right ankle with wound cleanser, pat dry, apply Medi Honey dime size amount to the wound (location of wound not noted) and cover with dry dressing daily every shift, missed 10 times out of 30 opportunities. Review of the DON's progress note dated 2/6/26 at 4:34 P.M., showed:-This is a wound note;-Sacral buttock MASD - 4.8 cm by 6.3 cm, stable pink wound bed, wound edges approximated, no change from previous week;-Right hip, stage 3, 4.5 cm by 1.0 cm by 0.3 cm, slight decline, pink wound bed, wound edges approximated, no change from last week;-Scrotum MASD, 2 cm by 1.0 cm by 0.1 cm, stable, very superficial;-Family updated. Review of the Medical Doctor's wound report dated 2/10/26, showed:-Resident was away from facility not seen by doctor.Review of the DON's progress note dated 2/11/26 at 10:29 A.M., showed;-The resident had a new wound to his/her ankle and the NP confirmed the resident did not appear to be ill or need to be sent to hospital for evaluation. NP suggested to keep the same treatment as the wound doctor planned. Review of the DON's progress note dated 2/13/26 at 10:43 A.M., showed:-This is a wound note;-Sacral/coccyx buttock MASD - 4.8 cm by 6.3 cm, stable pink wound bed, wound edges approximated, no change from previous week;-Right hip, stage 3, 4.5 cm by 1.0 cm by 0.3 cm, stable, pink wound bed, wound edges approximated, no change from last week;-Scrotum MASD, 2 cm by 1.0 cm by 0.1 cm, stable very superficial;-Right ankle/foot, stage 2 ulcer (a partial-thickness tissues loss), 2 cm by 2 cm by 0.1 cm, stable, wound edges approximated;-Family updated. Review of the Medical Doctor's wound report, dated 2/17/26 with an addendum 2/23/26 showed:-Onset wound 12/30/25, right hip, stage 3 pressure injury, stable, measurements were 4.5 cm by 1.0 cm by 0.3 cm, moderate serosanguineous drainage, signs and symptoms of infections purulence;-Treatment orders: Pat dry, Medi honey to wound base alginate with silver DCD, daily and PRN;-Comments: Wound status not able to assess today, patient was seen and found very lethargic. The vitals were collected by the DON and me while rounding. The resident was given Naloxone (Narcan treats overdoses) resident sent out to local hospital. Review of the resident's census log showed that he/she discharged from the facility at 2:45 P.M., on 2/27/26 without anticipated return. Review of the facility's wound report dated 3/27/26, showed:-Onset of 12/11/25, right buttocks, wound type MASD on 12/11/25, not present on admission open wound for 36 days improving as of 1/6/26;-Onset of 1/20/26, coccyx, wound type MASD, not present on admission, wound 49 days open and stable as of 3/13/26;--Onset of 1/20/26, groin, wound type MASD, not present on admission, wound has been open for 49 days, stable as of 3/13/26. During an interview on 3/27/26 at 7:26, LPN K said last time he/she saw the resident, he/she had a hip, coccyx and possible ankle wound. All residents have standing orders for skin assessments and are care planned for any refusal of treatments. LPN K said the resident was one who had to be approached a couple of times before he/she would do something. The resident did like to smoke and would not do anything if it was smoke break time. LPN K said the resident was understanding of the need to off-load his/her weight for wound treatments. 2. Review of Resident's #77's medical record, showed diagnoses included morbid obesity, bipolar (mood swings), intellectual disability (neurological disability). Review of the resident's annual MDS, dated [DATE], showed:-admission date of 7/9/24;-Moderately impaired cognition;-Full dependence on staff assistance for ADLs;-No skin concerns noted. Review of the resident's care plan, in use during survey, showed no problems related to skin, goals to meet or interventions to prevent wounds. Review of the Braden Scale report predicting pressure sore dated 12/17/25 at 6:24 A.M., showed a score of 11 (indicated the resident is at a high risk for developing a pressure injury). Review of the resident's POS, dated December 2025, showed: -Offload pressure areas (on heels), keep area of concern and surrounding skin dry, elevate extremities every shift 7:00 A.M., -7:00 P.M., and night (NOC) 7:00 P.M., - 7:00 A.M.,-Order dated 12/15/25 showed, cleanse lateral right ankle with normal saline or wound cleanser, pat dry and apply foam dressing every three days, start at 6:00 A.M. Review of the of Wound Specialist's progress note, dated 12/17/25, showed patient not seen, resident away from facility with family. Review of the of Wound Specialist's progress note, dated 12/30/25, showed patient not seen, DON said the right ankle wound healed. Review of the weekly skin observation report form, dated 3/3/26 at 7:27 A.M., showed no abnormalities of the skin present. Review of the weekly skin observation report form, dated 3/17/26 at 7:41 A.M., showed no abnormalities of the skin present. Review of the resident's March 2026 MAR/TAR, showed:-An order dated 12/15/25, cleanse right lateral ankle with normal saline or wound cleanser, pat dry, apply foam dressing every three days:--Documented as completed on 3/3, 3/6, 3/9 and 3/12/26;--On 3/15/26, documented as not administered, other comment;--On 3/18/26, documented as resident refused;--On 3/21/26, documented as resident refused;--On 3/24/26, documented as resident combative, will attempt this evening. Observations on 3/25/26 at 8:04 A.M., showed the resident had a foam dressing on his/her right ankle with a date of 3/9. The resident's heels were on pillows directly under the heels. His/Her left inner heel had a dark circular discoloration, the size of a quarter. During an interview on 03/25/2026 at 8:30 A.M., LPN K said the dressing on the resident's right ankle was dated for 3/9. The orders were for a standard dry dressing, and night shift were scheduled to change the wound. LPN K will go check the ePOS now and clean the wound, along with notifying the Wound Doctor. LPN K checked the computer and said the resident was listed as refused care from 3/9 to 3/25/26 at 8:52 A.M. LPN K was unaware of the wound and staff had not mentioned it in shift report. The wound measured 2 cm by 2 cm. During an interview on 3/25/26 at 8:41 A.M., the DON said there was some discoloration to the left heel, equivalent to the size of a dime. The DON said he is not at liberty to make any clinical decisions related to the stage or type of wound without first a consultation with the Wound Doctor. The Wound Doctor makes all those clinical decisions. Review of the of Wound Specialist's progress note, dated 3/25/26, showed:-Onset wound date 3/25/26, stage 2 pressure injury over right ankle, measurements are 0.5 cm by 1.5 cm by 0.1 cm, moderate serous drainage, no signs or symptoms of infection;-Treatment order: Cleanse wound with NS or sterile water, apply alginate to wound bed, cover with dry clean dressing. Review of the of NP's progress note, dated 3/25/26 at 7:20 A.M., showed the resident has a stage 2 pressure injury, per Wound Doctors' notes, It's very shallow with good granulation tissue, which is a good sign of healing from changes with moderate amount of serous drainage, no signs or symptoms of infection, no foul odor, pain, noticed at the time of dressing change. During an interview on 3/27/26 at 10:09 A.M., the DON said the resident's wound to the right ankle was an abrasion, but he would need to review the entry; this could be a clinical error. Review of the facility's wound report dated 3/27/26 showed the resident has a right ankle abrasion, initial measurements were 3 cm by 2 cm, current are 0.5 cm by 1.5 cm, improving. 3. During an interview on 3/27/26 at 12:20 P.M., the DON said he expected nursing staff to follow facility policies. Assessments were completed weekly, but there were not orders for them. Staff are prompted on the schedule on the EMR. The shift nurses are expected to enter the treatment orders, or the nurse can provide the DON the order to enter in on their behalf. The DON expected nurses to enter a progress note related to treatments being declined by residents. Staff should also notify the Medical Doctor of any new recommendation from the hospital related to wound treatments. All care plans should be updated by the MDS coordinator within 24-48 hours to reflect new changes for the resident. If the resident declines a treatment, staff should try a second approach or allow some time to lapse before documenting a refusal. 274163127417612742276

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #46) received care and services in accordance with professional standards by failing to notify the physician the resident was not wearing thromboembolic deterrent stockings (TEDS) (stockings used to prevent blood clots in the legs). The facility also failed to provide alternative interventions to address the resident's lower leg edema (swelling). The sample size was 20. The census was 81. Review of the facility's Obtaining and Following Physician orders, last revised, July 2017, showed:-Policy: Physician orders will be obtained by licensed personal and followed; If the licensed professional does not in his/her best judgement think that the order is not in the best interest of the resident, he/she has the obligation to further investigate prior to fulfilling the order; If these orders are not followed by any reason, the physician and Director of Nursing (DON) will be promptly notified. Review of Resident #46's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 3/9/26, showed:-Moderate cognitive impairment;-Diagnoses include heart failure and diabetes;-Requires set up from staff for putting on and taking off footwear. Review of the resident's medical record, showed diagnoses included mild intellectual disabilities and borderline intellectual functioning. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident is at risk for dehydration related to diuretic (a medication used to remove excess fluid) for heart failure;-Interventions: TEDS, as ordered. Review of the resident's medication administration record (MAR), dated 2/1 through 2/28/26, showed:-An order, dated 8/8/26, TEDS, apply in A.M. and remove in P.M.;-Documented as not administered on 17 out of 28 opportunities: 7:00 A.M. through 7:00 P.M.;-On 2/23/26 and 2/26/26, 7:00 A.M. through 7:00 P.M. shift documented the reason the TEDS were not administered showed: The resident said the TEDS were too tight. Review of the resident's MAR, dated 3/1 through 3/26/26, showed:-An order, dated 8/8/26, TEDS, apply in A.M. and remove in P.M.;-Documented as not administered for 14 out of 26 opportunities 7:00 A.M. through 7:00 P.M.;-On 3/9/26, 7:00 A.M. through 7:00 P.M. shift documented the reason the TEDS were not administered showed: The resident does not wear TEDS;-On 3/23/26, 7:00 A.M. through 7:00 P.M. shift the documented the reason the TEDS were not administered showed: The resident said the TEDS were too tight. Review of the resident's focused observation assessment, dated 3/23/26 at 11:32 P.M., showed:-Edema present: Blank;-Left leg edema: Blank;-Right leg edema: Blank. During an observation and interview on 3/23/26 at approximately 11:30 A.M., the resident said his/her legs hurt. The resident's lower legs had a moderate amount of edema. The resident said his/her legs felt swollen and heavy and it caused him/her to have discomfort. The resident said he/she was supposed to wear TEDS, but they were too tight. The resident was not wearing TEDS. The resident said staff have not offered an alternative to the stockings to help with his/her edema. Observation and interview on 3/24/26 at approximately 5:00 P.M., showed the resident lay in bed. The resident was crying and said his/her legs were hurting bad. The resident's legs were moderately edematous (swelling with fluid). The resident's left leg was more edematous than the right leg. The resident continued to cry and rubbed his/her legs saying his/her legs were so swollen and hurt. The DON entered the resident's room and assessed the resident. The resident was not wearing TEDS. Review of the resident's progress notes dated 2/26 through 3/24/26, showed:-On 3/24/26 at 5:40 P.M., The DON assessed the resident, bilateral (both) lower extremities were warm to touch. Pedal (foot) pules were withing normal limits. The resident said he/she was having pain to bilateral lower legs and winces in pain when touched. The resident said his/her pain level was 5 out of 10. The physician was called. The resident refused to go to the hospital. Venous doppler (test to check for blood clots in the legs) ordered;-No documentation that the resident's physician was notified that the resident was not wearing TEDS;-No documentation that further recommendations were received for the resident's bilateral leg edema. Observation and interview on 3/25/26 at 8:16 A.M., showed the resident walked into the dining room for breakfast. The resident had moderate edema to both legs. The resident was not wearing TEDS. Certified Medicine Technician (CMT) R said the resident's legs were always swollen. During an observation and interview on 3/27/26 at 8:25 A.M., the resident said his/her legs continued to feel heavy, tight, and uncomfortable. The resident's bilateral legs showed moderate edema. The resident was not wearing TEDS. The resident said he/she was willing to try an alternative to TEDS but the TEDS the staff tried to place on him/she was too tight. During an interview on 3/26/26 at 2:32 P.M., Licensed Practical Nurse (LPN) I said he/she did not know any interventions off the top of his/her head that could help the resident with his/her edema. During an interview on 3/27/26 at 8:39 A.M. Certified Nursing Assistant (CNA) B said the resident's legs were usually swollen and had not seen the resident wear anything on his/her legs to help with the swelling. During an interview on 3/27/26 at 10:28 A.M., LPN C said the resident had not been wearing TEDS. LPN C said the physician should be called and notified the resident had not been wearing TEDS. Alternatives to the resident's edema could be a leg sleeves, elevating his/her legs when sitting, or a bigger size in the TEDS. During an interview on 3/27/26 at 12:22 P.M. the DON said he would expect the physician to be notified the resident was not wearing the TEDS as ordered after a couple of missed times. The Nurse Practitioner (NP) was always in the building and staff should have notified the NP about the resident's leg edema and discomfort. He would have expected staff to obtain alternative orders and interventions to the TEDS.

Based on interview and record review, the facility failed to ensure three of 20 sampled residents received comprehensive care plans specific to their needs while admitted at the facility (Residents #26, #47 and #77). Resident #26's care plan did not include information and interventions for multiple falls in the facility, Resident #47's care plan did not include hospice services, and Resident #77's care plan did not include concerns regarding skin conditions. The census was 81.Review of the facility's Resident Assessment Instrument (RAI) policy, revised, 10/20/22, showed:-Within seven days of the completion of the resident assessment, a comprehensive care plan will be developed. Care plans shall be culturally competent and trauma-informed. This includes interventions that reflect the resident's cultural preferences, values, and practices and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that cause re-traumatization;-The Interdisciplinary Team must develop, review, and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident is readmitted from the hospital, or at least quarterly in conjunction with the required quarterly assessments. 1. Review of Resident #26's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/25, showed:-Diagnoses included diabetes, acute kidney failure, and acquired absence of right leg above the knee;-Cognitively intact. Review of the resident's 5-day MDS, dated [DATE], showed moderately impaired cognition. Review on 3/23/26, of the facility's facility event summary report, dated 12/23/25 through 3/23/26, showed:-On 12/24/25 at 6:42 P.M, the resident had an unwitnessed fall;-On 1/6/26 at 7:25 A.M., the resident had an unwitnessed fall;-On 1/11/26 at 4:00 A.M., the resident had an unwitnessed fall;-On 1/29/26 at 11:11 A.M., the resident had a witnessed fall;-On 1/29/26 at 12:32 P.M., the resident had a witnessed fall;-On 2/17/26 at 11:40 A.M., the resident had an unwitnessed fall;-On 2/28/26 at 5:46 P.M., the resident had a fall;-On 3/14/26 at 12:45 P.M., the resident had a fall;-On 3/19/26 at 4:40 P.M., the resident had an unwitnessed fall. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident admitted to the facility for long term care;-Goal: Resident will have access to necessary services to promote adjustment to new living environment in the facility;-Approach: Safety: Resident will need to be monitored to prevent falling in new environment. Resident will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury. Resident uses a wheelchair and needs safety reminders to use durable medical equipment safely;-The care plan did not address the resident's falls or list any fall interventions put in place. During an interview on 3/27/26 at 7:24 A.M., Certified Nursing Assistant (CNA) B said the resident's care plan should include the resident's falls and fall interventions that have been put in place. This is important because the care plan is how CNAs know how to care for the resident. During an interview on 3/27/26 at 7:28 A.M., Licensed Practical Nurse (LPN) C said the resident's care plan needed to be updated. He/She expected the resident's care plan to indicate the resident's fall risk and interventions used to prevent falls. The Director of Nursing was responsible for updating the care plans. During an interview on 3/27/26 at 12:39 P.M., the Administrator and Director of Nursing (DON) said they expected the care plan to be updated to include the resident's falls and interventions that have been put in place to prevent future falls. 2. Review of Resident #47's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder);-Severe cognitive impairment. Review on 3/23/26, of the resident's electronic medical record (EMR), showed the resident started receiving hospice services on 10/8/25. Review of the resident's care plan, in use at the time of the survey, showed no indication of the resident being placed on hospice or interventions related to hospice care. During an interview on 3/27/26 at 7:28 A.M., LPN C said he/she expected the resident's care plan to indicate that the resident is receiving hospice services. During an interview on 3/27/26 at 12:39 P.M., the Administrator and DON said they expected the care plan to be updated to reflect that the resident is receiving hospice services. 3. Review of Resident's #77's medical record, showed diagnoses included morbid obesity, bipolar (mood swings), intellectual disability (neurological disability). Review of the resident's annual MDS, dated [DATE], showed:-admission date of 7/9/24;-Moderately impaired cognition;-Full dependence on staff assistance for activities of daily living (ADLs);-No skin concerns noted. Review of the Braden Scale report predicting pressure sores, dated 12/17/25 at 6:24 A.M., showed a score of 11 (indicated the resident is at a high risk for developing a pressure injury). Review of the resident's physician's orders sheet (POS), dated December 2025, showed: -Offload pressure areas (on heels), keep area of concern and surrounding skin dry, elevate extremities every shift 7:00 A.M., -7:00 P.M., and night (NOC) 7:00 P.M., - 7:00 A.M.,-Order dated 12/15/25 showed, cleanse lateral right ankle with normal saline or wound cleanser, pat dry and apply foam dressing every three days, start at 6:00 A.M. Observations on 3/25/26 at 8:04 A.M., showed the resident had a foam dressing on his/her right ankle with a date of 3/9. The resident's heels were on pillows directly under the heels. His/Her left inner heel had a dark circular discoloration, the size of a quarter. Review of the of Wound Specialist's progress note, dated 3/25/26, showed:-Onset wound date 3/25/26, stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure injury over right ankle, measurements are 0.5 centimeters (cm) by 1.5 cm by 0.1 cm, moderate serous (clear or slightly yellow drainage drainage), no signs or symptoms of infection;-Treatment order: Cleanse wound with normal saline or sterile water, apply alginate (absorbent wound dressing) to wound bed, cover with dry clean dressing. Review of the resident's care plan, in use during survey, showed no problems related to skin, goals to meet or interventions to prevent wounds. During an interview on 3/27/26 at 12:20 P.M., the DON said he expected nursing staff to follow facility policies. All care plans should be updated by the MDS coordinator within 24-48 hours to reflect new changes for the resident. 4. During an interview on 3/27/26 at 8:26 A.M., CNA H said care plans are important because they help facility nursing staff provide care personalized to each resident. 5. During an interview on 3/27/26 at 8:09 A.M., LPN C said each resident should have a care plan completed upon admission personalized to each resident's specific care needs. Care plans should include personal preferences, psychosocial care needs, interest in activities, and other resident care needs. 6. During an interview on 3/27/26 at 12:21 P.M., the facility Administrator, DON, and Assistant Director of Nursing (ADON) said all residents should have a comprehensive care plan completed within 14 days after admission to the facility. Care plans are important as they provide nursing staff personalized care information specific to each resident's needs.

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents had a baseline care plan created within 48 hours of admission (Resident #15). The census was 81. Review of the facility's Baseline Care Plan policy, dated 8/2017, showed:-Policy: The facility will develop and implement a baseline plan of care for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care. The baseline care plan will include the minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and will identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary;-Procedure: The baseline plan of care will be developed within 48 hours of resident's admission and will include the minimum healthcare information necessary to properly care for the resident including, but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/19/26, showed:-Diagnoses included Huntington's disease (neurodegenerative disorder that causes progressive brain cell decay) and weakness;-Moderately impaired cognition. Review on 3/24/26, of the resident's electronic medical record (EMR), showed:-The resident did not have a baseline care plan. Observation and interview on 3/26/26 at 9:48 A.M., showed Certified Nursing Assistant (CNA) D pulled up the resident's page on the tablet where he/she charted. He/She clicked on resident care plan and a box popped up indicating the resident did not have a care plan. He/She said the resident should have a care plan so staff would know how to care for him/her. During an interview on 3/27/26 at 7:28 A.M., Licensed Practical Nurse (LPN) C reviewed the resident's EMR and confirmed the resident did not have a care plan. He/She would expect the resident to have a baseline care plan completed within 48 hours of admission to ensure staff knew how to care for the resident. During an interview on 3/27/26 at 12:39 P.M., the Administrator and Director of Nursing (DON) said they would expect for the resident to have had a care plan created upon 48 hours of his/her admission. They would expect for the resident to have a care plan to ensure the resident was properly cared for.

Based on interview and record review, the facility failed to ensure the resident's Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) accurately reflected the resident's status of having a life expectancy of less than six months when they received hospice services (a service provided when a resident has a condition indicating a life expectancy of less than six months as certified by the hospice physician) for two of eight residents identified by the facility as receiving hospice services (Residents #47 and #69). The census was 81. 1. Review of Resident #47's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder);-Severe cognitive impairment;-Section J (health conditions) was marked as no for having a life expectancy of six months or less. Review of the 60-day physician recertification of terminal illness, dated 2/6/26, reviewed on 3/26/26 at 12:30 P.M., showed:-Certification statement: I certify that this patient is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. 2. Review of Resident #69's comprehensive MDS, dated [DATE], showed:-Diagnoses included dementia, chronic kidney disease, type two diabetes, and muscle weakness;-Severe cognitive impairment;-Section J was marked as no for having a life expectancy of six months or less;-Section O (special procedures) was marked as yes for hospice. Review of the resident's hospice order, dated 2/12/26, reviewed on 3/26/26 at 12:30 P.M., showed:-Order description: the medical director/hospice physician listed above certifies that the patient's prognosis is six months or less if the disease runs its normal course. During an interview on 3/27/26 at 12:45 P.M., the Administrator and Regional Director of Clinical Services said they would expect the MDS assessments to be accurate. They would expect the MDS section J to indicate that both residents had a life expectancy of six months or less.

Based on observation, interview, and record review, the facility failed to provide routine dental care to meet the needs of one resident (Resident #10). The sample was 20. The census was 81.Review of facility's Dental Examination and Assessment policy, last revised, July 2014, showed:-Policy: Each resident shall undergo a dental assessment by facility nurses as part of the Nursing assessment process upon admission;-Policy interpretation: Prior to, or within 90 days after admission, the resident shall undergo a dental examination; Dental examinations will be made b the resident's personal dental dentist or by the facility's consulting dentist; Records of dental care provided shall be made a part of the resident's medical record; Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed:-Moderate cognitive impairment;-Requires set up and clean up assistance from staff for oral hygiene. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident requires assistance with activities of daily living related to poor follow through and decreased task initiation;-Approach: The resident requires set up, supervision, and verbal cures for oral care. Review of the medical record, showed the resident's diagnoses included: Nicotine dependence to cigarettes, anxiety, bipolar disease (a mental disorder that causes extreme mood swings), and adult failure to thrive. Review of the resident's physician order sheets, dated March 2026, showed no order for the resident to see the dentist. Review of the resident's observation detail list report focused observation, dated 3/10/26, showed:-Oral cavity assessment: Blank. Review of the facility's dentist consult list, showed the resident not listed for the 1/7/26 and 2/25/26 dental visits. Observation and interview on 3/25/26 at approximately 9:30 A.M., showed the resident began speaking and was noted to have halitosis (bad breath). The resident said he/she had not seen a dentist in a very long time. When the resident smiled, the resident had multiple teeth that were dark brown and black. Some of the resident's teeth were chipped and missing. The resident said he/she would try to see a dentist if he/she could. The resident said he/she did not know where his/her toothbrush was, and he/she has smoked cigarettes for over 30 years. During an interview on 3/27/26 at 8:39 A.M., Certified Nursing Assistant (CNA) B said he/she has provided care to the resident. CNA B did not notice the resident had issues with his/her teeth or had halitosis. The resident required reminders about personal hygiene. During an interview on 3/27/26 at 12:22 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they would expect all residents to have their oral cavity inspected routinely and as needed. If a resident is in need of dental care, the nurse is expected to let the Social Services Director know that the resident needs to be placed on the dentist list.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach for two residents (Resident #26 and Resident #5). The sample size was 20. The census was 81. Review of the facility's Answering the Call Light policy, last revised, July 2014, showed:-Purpose: The purpose of this procedure is to respond to the resident's requests and needs;-General guidelines: When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure these residents are checked on frequently. 1. Review of Resident #26's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/25, showed:-Diagnoses included type two diabetes, acute kidney failure, and acquired absence of right leg above the knee;-Cognitively intact. Review of the resident's 5-day MDS, dated [DATE], showed:-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Resident admitted to the facility for long term care. Resident requires a baseline care plan identifying care needs, risks, strengths and goals within the first 48 hours;-Goal: Resident will have access to necessary services to promote adjustment to new living environment in the facility;-Approach: Safety: Resident will need to be monitored to prevent falling in new environment. Resident will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury. Resident uses a wheelchair and needs safety reminders to use durable medical equipment safely;-The care plan did not address the resident's falls or any fall interventions put in place. Review of the facility's facility event summary report, dated 12/23/25 through 3/23/26, reviewed on 3/23/26, showed:-On 12/24/25 at 6:42 P.M, the resident had an unwitnessed fall;-On 1/6/26 at 7:25 A.M., the resident had an unwitnessed fall;-On 1/11/26 at 4:00 A.M., the resident had an unwitnessed fall;-On 1/29/26 at 11:11 A.M., the resident had a witnessed fall;-On 1/29/26 at 12:32 P.M., the resident had a witnessed fall;-On 2/17/26 at 11:40 A.M., the resident had an unwitnessed fall;-On 2/28/26 at 5:46 P.M., the resident had a fall;-On 3/14/26 at 12:45 P.M., the resident had a fall;-On 3/19/26 at 4:40 P.M., the resident had an unwitnessed fall. Observation on 3/25/26 at 6:47 A.M., showed the resident sat in his/her wheelchair by the door on the left side of his/her bed. The resident was asleep. The call light was out of reach. Observations on 3/26/26 at 6:51 A.M., 7:46 A.M., 9:36 A.M., 9:54 A.M., and 11:08 A.M., showed the resident in his/her room. He/She sat in his/her wheelchair next to the left side of the bed, by the door. The resident was asleep. The resident's call light was out of reach, on the ground on the right side of the resident's bed. Observation on 3/27/26 at 10:00 A.M., showed the resident in his/her room. He/She sat in his/her wheelchair by the door on the left side of the bed. The resident was asleep. The call light was out of reach, on the ground under the resident's bed. During an interview on 3/27/26 at 6:29 A.M., Licensed Practical Nurse (LPN) A said he/she would have expected the call light to always be within reach of the resident. He/She said the resident fell frequently and liked to sleep in his/her wheelchair. During an interview on 3/26/26 at 10:52 A.M., the Director of Therapy said the resident was receiving physical therapy, occupational therapy, and speech therapy. Her recommendation for the resident was he/she should have been in a wedge wheelchair (tilted wheelchair) with foot pedals to prevent further falls. She expected the resident's call light to be in reach at all times. She also expected nursing staff to conduct more frequent rounding on the resident. 2. Review of the Resident #5's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for dehydration:-Intervention: Keep call light within reach while the resident is in their room and remind the resident to call for assistance when needed;-Focus: The resident is at risk for increased complaints of pain due to contractures, skin integrity issues and hospice care;-Intervention: Have call light within reach while the resident is in their room. Review of the resident's medical record, showed diagnoses included Alzheimer's disease and dementia. Observation on 3/25/26 at 8:53 A.M. and 10:07 A.M., showed the resident lay in bed. The resident was unable to communicate, and all four extremities were contracted. The resident's call light was positioned at the foot of the resident's bed, out of the resident's reach. Observation on 3/26/26 at 6:30 A.M., 8:55 A.M. and 10:58 A.M., showed the resident lay in bed. The resident was unable to communicate, and all four extremities were contracted. The resident's call light was on the floor under the resident's bed, out of the resident's reach. During an interview on 3/27/26 at 10:28 A.M., LPN C said the resident's call light should be positioned within the resident's reach even though he/she could not use the call light. During an interview on 3/27/26 at 8:39 A.M., Certified Nursing Assistant (CNA) B said the call light should be within the resident reach no matter what the residents cognition status was. If the resident could not use the light, then frequent rounding was to be completed. 3. During an interview on 3/27/26 at 12:46 P.M., the Administrator and Director of Nursing (DON) said they would have expected call lights to be in reach of all residents at all times while they were in their rooms no matter what their cognition status was. After providing care, staff should ensure residents had their call light before exiting the room. They would have expected a resident who had frequent falls to have their call light within reach.

Based on observation, interview and record review, the facility staff failed to treat residents with dignity while providing care to one resident (Resident #5). The sample size was 20. The census was 81. Review of the facility's Resident Rights policy, last revised 8/31/26, showed: The resident has a right to a dignified existence. The facility must treat each resident with respect and dignity. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed cognitive status not assessed. Review of the resident's medical record, showed diagnoses included Alzheimer's disease, dementia, and gastrostomy tube (G-Tube), a tube that is surgically inserted into the abdomen and is used for medications and liquid nutrition. Observation on 3/25/26 at 8:53 A.M., showed Registered Nurse (RN) Q prepared the resident's medication at the medication cart and entered the resident's room without knocking. The resident lay in bed. RN Q moved the resident's arms away to obtain access to the resident's hygiene g-tube. RN Q did not explain to the resident what care he/she was going to be providing before touching the resident. RN Q did not pull the privacy curtain between the resident and the resident' roommate. RN Q did not close the resident's door. RN Q administered the resident his/her medication through his/her g-tube. The resident's roommate watched RN Q give the resident his/her medication. Multiple staff members walked past the resident's room and residents in wheelchairs propelled past the resident's room and could see directly into the resident's room while RN Q was providing resident care. During an interview on 3/25/26 at 9:16 A.M., RN Q said he/she should have knocked before entering and immediately explained to the resident what he/she was doing. The resident's privacy curtain should have been pulled so the resident's roommate could not directly watch the care RN Q provided. If the curtain wasn't pulled, the resident's door should have been closed while care was being provided. During an interview on 3/27/26 at 8:39 A.M. Certified Nursing Assistant (CNA) C said staff should knock on the door before entering and wait for an answer. Staff should also explain the care they would be providing to the resident, pull the privacy curtain, and close the residents' door before providing care. All residents were to be treated in a respectful and dignified manner. During an interview on 3/27/26 at 12:22 P.M., the Administrator said she would expect all residents to be treated with dignity and respect. The staff were expected to knock before entering the resident's room, explain all care that was going to be provided and pull the privacy curtain before care was provided. If the privacy curtain was not pulled the resident's door was expected to be closed.

Based on observation, interview, and record review, the facility failed to ensure physician's orders for catheter (a thin flexible tube inserted into the body to drain fluids (usually urine) or inject fluids/medication) care was obtained for one of one resident sampled with a catheter (Resident #2). The census was 81. Review of the facility's Catheter Care policy, dated 7/2017, showed:-Purpose: the purpose of this procedure is to prevent catheter-associated urinary tract infections;-Maintain an accurate record of the resident's daily output, per facility policy and procedure;-Observe the resident for complications associated with urinary catheters. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/26, showed:-Diagnoses included end stage renal disease, legal blindness, dementia, and major depressive disorder;-Moderately impaired cognition. Review of the resident's care plan, in use at the time of the survey, showed:-Problem: the resident has a suprapubic (a hollow tube inserted into the bladder through a small temporary abdominal incision to drain urine when the urethra cannot be used) catheter;-Goal: will be monitored and treated for: obstruction, signs of infection, dislodgment ofcatheter, bowel perforation, or trauma secondary to catheter manipulation throughnext review date;-Approaches: document urinary output every shift and as needed. Record the amount, type, color, and odor. Review on 3/24/26 at 9:51 A.M., of the resident's physician orders summary (POS), dated 3/2026, showed no physician orders for catheter care, catheter maintenance, or catheter observation. Observation on 3/24/26 at12:02 P.M., showed the resident sat on the side of his/her bed awake. The resident pulled up his/her pant leg to expose his/her catheter. The bag and tubing were undated. During an interview on 3/27/26 at 7:28 A.M., Licensed Practical Nurse (LPN) C said the resident should have physician's orders for catheter care. He/She said normally there were orders for monitoring for side affects and for tubing change frequency. During an interview on 3/27/26 at 12:42 P.M., the Administrator and Director of Nursing (DON) said there should be physician orders for catheter care. They would expect the order to include monitoring for catheter concerns and monitoring for urine input and output.

Based on observation, interview, and record review, the facility failed to ensure staff maintained the head of the bed in an elevated position during gastrostomy tube (g-tube, a tube surgically inserted into the abdomen used for liquid nutrition, fluids, and medications) feeding for one resident (Resident #5). This deficient practice had the potential to place the resident at risk for complications, including aspiration (choking). The sample was 20. The census was 81. Review of the facility's Tube Feeding, Bolus (large amount given at one time) policy, revised 3/28/25, showed:-Policy: It is the policy that residents' nutritional needs will be met by a tube feeding, when oral consumption is not possible and the resident consents;-Maintain the head of the resident's bed at a minimum of 30 degrees. Review of the facility's Tube Feeding, Open System policy, dated 3/28/25, showed the policy did not address the position of the head of the bed while tube feeding is infusing. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/19/26, showed:-Dependent on staff for assistance with eating;-Diagnoses included Alzheimer's disease, dementia, and malnutrition;-Use of feeding tube. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is at risk for dehydration, secondary to tube feeding;-Intervention: Keep head of bed elevated while in bed. Review of the resident's physician order sheets (POS), dated March 2026, showed;-An order, dated 10/17/25, for Jevity 1.5 cal (a type of liquid nutrition) at 45 milliliters (ml) per hour and water flush 150 ml every four hours through g-tube;-An order, dated 10/17/25, to elevate the head of bed 30 degrees while receiving continuous tube feeding. Observations on 3/23/26 at 11:45 A.M. and 12:00 P.M., on 3/24/26 at 12:01 P.M., and on 3/25/26 at 8:55 A.M., showed the resident lay in bed with tube feeding pump on and connected to the resident. The head of the resident's bed positioned at approximately 10 degrees. Observations on 3/26/26 at 6:30 A.M., 8:55 A.M., and 10:58 A.M., showed the resident lay in bed with tube feeding pump on and connected to the resident and the head of the resident's bed flat. During an interview on 3/27/26 at 8:39 A.M., Certified Nursing Assistant (CNA) B said the resident's head of bed should be elevated 30 to 45 degrees while receiving tube feeding to prevent aspiration. During an interview on 3/27/26 at 10:28 A.M., Licensed Practical Nurse (LPN) C said the resident's head of bed should be positioned 45 to 90 degrees while receiving tube feeding to prevent aspiration. During an interview on 3/27/26 at 12:22 P.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said the resident's head of bed is expected to be at 45 degrees while receiving tube feeding to prevent aspiration.

Based on observation and record review the facility failed to provide or obtain laboratory services to meet the needs of one resident (Resident #53). The sample was 20. The census was 81.Review of the facility's Laboratory Reports policy, last revised, July 2014, showed:-Policy: All lab reports will be reviewed by a nurse and reported to the physician as necessary;-Procedure: The night nurse will follow-up nightly through chart audit to ensure all labs have been performed as ordered, physician has been notified of results and reports are filed in the resident's record; If the nurse determines that a lab report has not been received, the nurse will obtain the lab results and notify the physician. Review of the facility's Obtaining and Following Physician orders, last revised, July 2017, showed:-Policy: Physician orders will be obtained by licensed personal and followed; If these orders are not followed by any reason, the physician and Director of Nursing (DON) will be promptly notified;-Procedure: If there is a new order, write the new order on the physician order sheet or entered into the electronic health record (EHR). Review of Resident #53's, quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed diagnoses include seizure disorder, anxiety and traumatic brain dysfunction. Review of the resident's progress notes on 2/13/26 at 11:46 A.M., showed at 8:00 A.M., the nurse assistant came to the nurses' station and said the resident was slumped over to the right side and unresponsive while out on a smoke break. The resident was sitting up and conscious and the resident was provided a wheelchair and escorted back into the building, The resident did not have facial drooping, weakness of the arms and legs. Both hand grips were equal in strength. The resident was slightly confused and could only answer yes and no questions. The resident was showing signs and symptoms of seizure activity, by decrease responsiveness. No complaints of pain or injury. The resident then stood up and walked to breakfast. Seizure precautions in place and will be monitored. The physician was notified and ordered a complete blood count (CBC), a blood test that measures cell circulating in the body, comprehensive metabolic panel (CMP), a blood test that checks electrolytes and organ function in the body, and a Keppra (a medication used to treat seizures) level. Review of the resident's physician order sheets (POS), dated February and March 2026, showed no physician orders for a CBC, CMP, or Keppra level. During an interview on 3/36/26 at 2:50 P.M., Licensed Practical Nurse (LPN) L said he/she did not see any physician orders for lab work for the resident. LPN L said once the lab orders were obtained by the physician, then an order should be placed in the resident's physician orders. The nurse is then to enter the lab request in the lab portal. The lab came all days of the week. During an interview on 3/27/26 at 8:39 A.M., the DON and the Administrator said the resident's labs were not done. The nurse that entered the progress notes about the labs was new and did not inform nursing management of any concerns about obtaining labs. During an interview on 3/27/26 at 12:22 P.M., the DON said he would expect the staff to place physician orders in the resident's medical record. Lab requests were expected to be entered into the lab portal. If the nurse didn't know how and could not log into the lab portal, he would have expected the staff to notify him.

Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse when Restorative Aide/Certified Nursing Assistant (CNA) E grabbed the resident's right arm from behind him/her to put the arm on his/her lap. The resident was non-verbal and provided several non-verbal actions of refusal when Restorative Aide/CNA E pried the resident's fingers off the wheelchair (WC) wheel and pulled the arm forward so forcefully that it nearly caused the resident to fall forward out of the chair (Resident #34). The sample size was 20. The census was 81. Review of the facility's Abuse policy, dated September 2022, showed: Definitions:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with the resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or service that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled using technology. Nursing home staff are prohibited from taking or using photographs or recording in any manner that would demean or humiliate a resident. This would include using any type of equipment (cameras, smart phones, and other electronic devices to take, keep or distribute photographs and recordings on social media). Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm.-Procedures for Prevention:--Orientation and Training of Employees: During the orientation of new employees, the facility will cover at least the following topics;--A. Sensitivity to resident's rights and resident needs;--H. Nurses aides must have received initial and annual abuse prevention training;-Internal Reporting Requirement and Identifications of Allegations:--Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. All resident, visitors, volunteer, family members or other are encouraged to report their concerns, suspected may be made without fear of retaliation. The administrator has a responsibility to ensure that retaliation is prevented and prohibited. Notice of employee rights regarding non-retaliation for reporting the suspicion of a crime are posted in areas of the facility conspicuous to staff. Anonymous report will also be thoroughly investigated;--Internal investigation of abuse, neglect or misappropriation allegations and response;---All incidents will be documented, whether abuse occurred, was alleged or suspected;---Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. Review of Resident #34's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/24/25, showed:-Severely impaired cognition;-Mood: Resident rarely feels isolated, and no behaviors marked;-Resident is fully dependent on assistance from staff for all activities of daily living (ADLs);-Weight 213 pounds (lbs.). Review of the resident's care plan, in use at the time of survey, showed:-Problem: Communication, the resident has impaired cognitive function/decision making skills related to unspecified intellectual disability with unclear speech. Often repeats words or phrases heard by others.-Goal: Will remain safe, and needs to be anticipated and met through next review date;-Approach: Explain any procedure being done prior to carrying out task, provide ques and reorientation as needed, provide simple choices, use alternative forms of communication (pictures, communications board, etc.) as needed. Observation on 03/24/26 at 12:47 P.M., showed the resident was positioned at the nurse's desk. The resident had his/her arm positioned on the back of the wheelchair and the lower part of his/her arm looped around the handlebar of the WC. Restorative Aide/CNA E stood to the right of the resident and kept grabbing at the resident's right arm to move it forward. The resident made non-verbal actions towards the staff by moving his/her arm away from Restorative aide/CNA E. The resident propelled him/herself forward a little bit and grabbed onto the WC wheel. Restorative Aide/CNA E pried the resident's fingers off the wheel of the chair. Restorative Aide/CNA E grabbed the resident's arm. Restorative Aide/CNA E held the resident's right arm in his/her right hand. Restorative Aide/CNA E's left hand was placed behind the resident's right arm triceps (above the elbow) area. Restorative Aide/CNA E forcefully jerked the resident's right arm forward, to the point the resident lost balance in a seated position and nearly fell forward onto the tile. Observation on 03/24/26 at 12:49 P.M., showed Restorative Aide/CNA E wiped the resident's hands off and a red substance was on the washcloth. The resident sat in the wheelchair by the wall around the corner from the dining room entrance. During an interview on 03/24/26 at 12:50 P.M., the resident said staff were rough, and he/she was afraid. Review of the facility's security camera system on 03/24/26 at approximately 1:00 P.M., with the Administrator, Assistant Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) present, showed: The resident was in his/her WC at the nurse's desk. Restorative Aide/CNA E stood parallel to the resident. Restorative Aide/CNA E attempted to reposition the resident's arm. The video showed Restorative Aide/ CNA E tugging and pulling on the resident's arm in a forward motion, so much that the seated resident's entire body went forward, nearly causing the resident to fall out of his/her WC. During an interview on 03/24/26 at 1:06 P.M., after watching the video footage of the incident, the DON said because the resident was propelling forward and then the resident's arm flared outward, Restorative Aide/CNA E should have stopped. The DON said excess force should not occur, and the employee should have reapproached the resident at a later time. During an interview on 03/24/26 at 1:06 P.M., after watching the video footage of the incident, the ADON said the resident was known for resting his/her arm behind the chair. The ADON said she saw the staff member put the resident's arm to the front, and staff placed the resident's arm again to the front because the resident was resisting to put his/her arm where the staff member wanted it. During an interview on 03/24/26 at 1:06 P.M., after watching the video footage of the incident, the Administrator said this resident needs several ques. During an interview on 03/24/26 at 1:06 P.M., after watching the video footage of the incident, the Administrator, DON and ADON said the staff member used excessive force with the resident. Review of the facility's investigation report dated 03/24/26, showed review of the camera footage found the employee was aggressively repositioning the resident multiple times. The resident can be seen refusing any further assistance and the employee became more aggressive. During an interview on 03/24/26 at 1:12 P.M., Restorative Aide/CNA E said the resident does like to sit with his/her arm behind the chair. Restorative Aide/CNA E tried to reposition the resident's arm at the resident's request. Restorative Aide/CNA E said You saw me reposition his/her arm and that's when he/she fell, and I caught the resident. The resident had his/her hand locked on the WC wheel and that's when Restorative Aide/CAN E moved the resident's hand off the wheel. The resident complained his/her arm hurt. Restorative Aide/CNA E saw a red substance on the resident's arm, but it was ketchup from lunch. Restorative Aide/CNA E did not believe he/she was being rough with the positioning of the resident's arm. Earlier in the day, the resident was not himself/herself. The resident had jerky movements, and Restorative Aide/CNA E informed the nurse on shift. During an interview on 03/24/26 at 1:30 P.M., Licensed Practical Nurse (LPN) C said he/she did not recall any abnormal behaviors or unusual body movements when he/she assessed the resident earlier. The resident will comply with directions, but it depends on the resident's mood. The resident always had his/her arm resting behind the WC. LPN C has cared for the resident for three months and never had to reposition his/her arm or heard the resident complain the arm hurt when seated in this position. Restorative Aide/CNA E said the resident almost fell this morning. Restorative Aide/CNA E said the resident would not sit up and looked like he/she could fall out of the WC. When LPN C saw the resident, he/she was without distress in the kitchen. During an interview on 03/26/26 at 8:03 A.M., Laundry Assistant S said he/she passed by and saw Restorative Aide/CNA E yelling and grabbing at the resident. By that time, the resident was resistant and fought to get Restorative Aide/CNA E off him/her. Restorative Aide/CNA E pulled and tugged on the resident, so much that Laundry Assistant S thought the resident must have bruises or some kind of injury. After the incident, Laundry Assistant S tried to speak with the resident, who became withdrawn and sat in a corner. Laundry Assistant S believed the incident affected the resident. Laundry Assistant S never saw Restorative Aide/CNA E behave in this manner previously. Laundry Assistant S could not intervene safely, due to Restorative Aide/CNA E being right up on the resident. During an interview on 03/24/26 at 1:41 P.M., the Administrator said the facility concluded their investigation, and the decision was to terminate Restorative Aide/CNA E for abuse. 2963114

Based on observation, interview and record review, the facility failed to ensure advance directive/code status forms (a legal document, often a Do Not Resuscitate (DNR) order, that tells medical professionals not to perform cardiopulmonary resuscitation (CPR) if the heart or breathing stops) were not documented, updated and/or reviewed annually for three of 20 sampled residents (Residents #7, #15, and #47). The census was 81.Review of the facility's Advance Directive policy, dated [DATE], showed:-Policy statement: Advance directives will be respected in accordance with state law and facility policy;-Policy Interpretation and Implementation;-Upon admission, the resident will be provided with the written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so;-Written information will include a description of the facility's policies to implement advance directives and applicable state law;-Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record;-The Attending Physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan;-The plan of care for each resident will be consistent with his or her documentation treatment preference and/or advance directive;-The interdisciplinary Team will review annually with the resident his/her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual Minimum Data Set ((MDS) a federally mandated assessment instrument completed by facility staff) assessment process. 1. Review of Resident's #7's annual MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included Alzheimer's Disease (impaired memory), hospice care and protein calorie malnutrition (a critical deficiency in protein intake-often coupled with inadequate caloric consumption). Review of the resident's physician's order summary (POS), dated [DATE], showed an order, dated [DATE], for a full code (perform all life saving measures). Review of the resident's hospice binder, showed an order, dated [DATE], for outside the hospital, Do Not Resuscitate (OHDNR). Review of the resident's electronic medical record (EMR), reviewed [DATE] at 9:40 A.M., showed the banner at the top of the resident's home page as DNR. Review of the resident's care plan, in use during the time of the survey, reviewed [DATE] at 9:40 A.M., showed code status was not addressed. During an interview on [DATE] at 8:23 A.M., Licensed Practical Nurse (LPN) L said the full code order should have been changed and/or canceled to reflect the resident's code status in the hospice binder. He/she said code status should have been entered onto the face sheet. LPN L said if he/she could not locate the code status, he/she would start CPR and call 911. 2. Review of Resident #15's admission MDS, dated [DATE], showed:-Moderately impaired cognition;-Diagnoses included Huntington's disease (neurodegenerative disorder causing progressive breakdown of brain nerve cells) and weakness. Review of the resident's physician's order summary (POS), dated 3/2026, reviewed [DATE] at 7:42 A.M., showed the resident did not have an active order for an advanced directive. Review of the resident's electronic medical record (EMR), reviewed [DATE] at 7:00 A.M., showed:-The resident did not have a baseline care plan;-The banner at the top of the resident's home page did not indicate the resident's advanced directive;-In the document section, a full code advanced directive, signed by both the resident and physician on [DATE], was located. Observation and interview on [DATE] at 9:48 A.M., showed Certified Nursing Assistant(CNA) D pulled up the resident's page on the tablet where he/she charted. The main screen did not indicate the resident's advanced directive. He/She said if the code status was not on the main page, he/she would go to the resident's care plan. He/She clicked on resident care plan and a box popped up indicating that the resident did not have a care plan. He/She said he/she would also look at the care plan binder at the nurse's station but was unable to locate it. He/She said the resident's advanced directive should be readily available to all staff to ensure the resident's wishes were followed. During an interview on [DATE] at 6:29 A.M., LPN A said the advanced directive should have been added to the resident's EMR once the signed document was received. The advanced directive should be readily available to all staff so the resident's wishes were followed. 3. Review of Resident #47's quarterly MDS, dated [DATE], showed:-Diagnoses included chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder (mental health condition that includes features of both schizophrenia and a mood disorder);-Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Advanced directive, full code status. Review of the resident's EMR, reviewed on [DATE] at 10:07 A.M., showed:-The banner at the top of the resident's home page indicated the resident's advanced directive as full code;-In the documents section, an advanced directive, signed by the resident on [DATE], indicated a full code advanced directive. Review of the resident's hospice binder, reviewed on [DATE] at 10:35 A.M., showed a do not resuscitate advanced directive, signed by the resident and the physician on [DATE]. During an interview on [DATE] at 6:29 A.M., LPN A said the advanced directive in the resident's EMR should match the advanced directive in the resident's hospice binder. He/She said the old advanced directive should have been removed from the resident's EMR and the updated directive should have been entered. During an interview on [DATE] at 12:20 P.M., the Director of Nursing (DON) said he would have expected the resident(s) code status' to be constant throughout the chart. He said all residents should have a care plan that focuses and had inventions related to code status.

Based on observation, interview and record review, the facility failed to provide a dietary supplement as ordered and failed to increase the dietary supplement as recommended by the dietitian for one of three sampled residents (Resident #1) with weight loss. The census was 74.Review of the facility's policy on Weight Management Program, updated February 2025, showed the following:-Policy: It is the policy of Helia Healthcare to manage resident weight through prevention, assessment and implementation and evaluation of interventions;-Procedure: #12. The Minimum Data Set (MDS)/charge nurse will notify the physician of the resident's current condition and registered dietitian's recommendations, document the physician's order on the physician order sheet and the 24-hour report sheet. #13. The MDS/charge nurse will initiate a Diet Order and Communication form to the Dietary Manager who will chart the change in the dietary progress note and to the MDS Coordinator to update the care plan. Review of Resident #1's care plan, updated 8/5/25, showed the following:-Problem: Nutritional Deficit related to risk of dehydration as evidenced by poor oral intake and weight loss;-Goal: Resident will receive diet and supplements per orders and encouraged to consume 75% of meals through next review date. Review of the resident's progress note, completed by the dietitian, dated 9/11/25, showed the following:-Resident followed due to insidious (gradual, unintentional) weight loss;-Current weight: 101.6, a 1.4 pound in one month, 5.4 pound loss in three months and 10 pound loss in 6 months;-Diet: Regular pureed with nectar thickened liquids. Super cereal (a high-calorie, nutritious, fortified cereal) provided at breakfast, fortified potatoes at lunch. House Shake and Majic cup (a fortified nutritional supplement used to provide extra calories;-Recommend increase Health Shake to three times a day with all meals. Review of the resident's Medication Administration Record (MAR), dated 9/2025, showed the following:-House supplement twice a day with meals;-Staff documented the resident received the supplements on 9/1 through 9/30/25 at 9:00 A.M. and 5:00 P.M. Review of the resident's quarterly MDS, a federally mandated assessment instrument completed by facility staff, dated 9/28/25, showed the following:-Weight: 102 pounds;-Loss of 5% or more in the last 30 days: No;-Mechanically altered diet: Yes. Review of the resident's Physician Order Sheet (POS), dated 10/25, showed the following:-Diagnoses of cerebral palsy (a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination), severe cognitive impairment, severe protein-calorie malnutrition and developmental disorder of speech and language;-House Shake twice a day;-Majic Cup with lunch and dinner. Review of the resident's MAR, dated 10/2025, showed the following:-House supplement twice a day with meals;-Staff documented the resident received the supplements on 10/1 through 10/8/25 at 9:00 A.M. and 10/1 through 10/7/25 at 5:00 P.M. Observation on 10/8/25 at 1:00 P.M., showed the resident sat in his/her geri-chair (large, padded wheelchair) in the feeding assistance area of the dining room. Certified Nurse Aide (CNA) B sat down to feed the resident a lunch of pureed meat, mashed potatoes, vegetables and a thickened glass of juice. No Majic cup or house supplement was on the resident's tray. CNA B said he/she doesn't know the resident well because he/she was new to the facility. Review of the resident's dietary slip on the resident's lunch tray on 10/8/25 at 1:30 P.M., showed the following:-Required oversight with all meals due to diet texture;-Power potatoes;-Majic cup;-Ice cream;-No documentation regarding the house supplement. During an interview on 10/8/25 at 1:38 P.M., Licensed Practical Nurse A said he/she was unaware the resident hadn't received his/her supplements. He/She reviewed the resident's POS at this time which showed the resident was to receive a Majic cup and house supplement with his/her meal. Nurse A said the resident should have received the supplements with his/her meal. He/She was unaware of the dietitian's recommendation to increase the house supplement from twice a day to three times a day with meals. When the dietitian writes a recommendation, it is given to the Assistant Director of Nursing (ADON) who then gives it to the nurses to complete. During an interview on 10/8/25 at 2:30 P.M., the ADON said the dietitian will verbally tell staff of his/her recommendations and email the recommendations to her. The nurse will notify the physician, update the orders and fill out a change in dietary slip to be given to dietary. During an interview on 10/8/25 at 2:35 P.M., the Administrator said she expected staff to complete dietary recommendations. In addition, she expected the resident to receive supplements as ordered. 2628921

Based on interview and record review, the facility failed to provide adequate supervision, by not ensuring staff were within arm's reach of a resident with a diagnosis of dysphasia (trouble swallowing) and a history of choking (Resident #1). On [DATE], the resident choked during lunch while eating alone at a table in the dining room. Staff intervened and were unsuccessful with clearing the resident's airway and performed lifesaving measures until emergency medical staff (EMS) arrived. EMS staff were eventually able to dislodge a large piece of broccoli, a food that was not served on the resident's lunch tray. Resident #1 expired. The sample size was 5. The census was 81. The Administrator was notified on [DATE] at 4:00 P.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Change in Condition policy, revised ,d+[DATE], showed: Definition: -Change in condition is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of activities of daily living (ADL); -Significant change is defined as an improvement or decline in the resident's physical, mental or psychosocial status that effects two or more areas of ADL; Procedure: -The staff person who first notices the change reports resident change in condition immediately to the licensed nurse; -The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or medical condition, this includes: -Accident involving the resident; -Deterioration in health, mental, or psychosocial status; -Need to alter treatment (i.e. need to discontinue an existing form of treatment due to adverse consequences or to commence new form of treatment); -Notification of physician and/or responsible parties shall be documented in the clinical record as well as on the 24-hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record; -All changes of condition must be completely and objectively documented in the clinical chart; -Appropriate follow through from shift to shift is imperative for all residents with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift. Review of the facility's Safety and Supervision of Residents policy, (no date), showed: -Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Procedure: -Our facility-oriented approach to safety risks for groups of residents; -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization; -When accident hazards are identified, the facility shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible; -Employees shall be trained and in-serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents; -The facility shall monitor interventions to mitigate accident hazards in the facility and modify as necessary; -Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff); -The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents; -The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly; -Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment; -The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. Review of the facility's Interdepartmental Notification of Diet (including changes and reports), dated 2001, revised ,d+[DATE], showed: Policy Interpretation and Implementation: Nursing services shall notify the Physician and Dietitian when a nutritional problem (e.g., eating problem) has been identified and shall collaborate with the Dietitian and Physician to initiate an appropriate process of clinical review for causes of the nutritional problem. Review of the facility's Consistency Modified Diets policy, revised ,d+[DATE], showed: -The following diets are modified in texture to promote ease of chewing and swallowing. No two patients/residents are alike; therefore, diets must be individualized based on their chewing/swallowing ability; -Please have your staff Registered Dietitian (RD) and/or Speech Therapist review these diets to assure appropriateness for each patient/resident. Based on individual patient/resident tolerance and community standards, some menu items, including liquids, may need to be altered; -Mechanical Soft: This diet is used for patients/residents with limited chewing ability. Foods menus include ground moist meats, poultry, and fish (without bones), canned fruits and vegetables, well-cooked, soft vegetables, finely chopped fresh fruits and vegetables as tolerated, soft breads and desserts. Recipes with the abbreviation NRV (No Raw Vegetables) at the end indicate they need to be made without raw vegetables. These food and others may or may not be allowed based on individual patient/resident tolerance; -Pureed: This diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like, no coarse textures, raw fruits or vegetables, nuts, etc., are allowed. Any foods that require bolus (the process of breaking down food into a soft, ball-like mass that can be swallowed), controlled manipulation, or mastication (chewing) are excluded. This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close or complete supervision and alternate feeding methods may be required. Thin liquids should be thickened as ordered as this diet was written assuming no modification for liquids (i.e. liquids of regular consistency are modified). Review of the facility's Diet spreadsheet, showed: -[DATE], Dinner: Mechanical Soft - Ground chicken croquet, mashed potatoes, broccoli, cornbread, mixed melon, gravy, margarine, 2% milk, coffee/Tea; -[DATE], Lunch: Mechanical Soft - Ground Cod, potato wedges, cooked cabbage, wheat bread, snickerdoodle cookie, margarine, coffee/tea; -Diet spreadsheet showed no broccoli on [DATE]. Review of Resident #1's Quarterly Review MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), aphasia (a language disorder that affects a person's ability to speak), stroke, Transient Ischemic Attack (TIA, a brief episode of stroke-like symptoms that occurs when blood flow to the brain is temporarily cut off); -Coughing or choking during meals or when swallowing medications, mechanically altered diet, and therapeutic diet. Review of the resident's progress notes, showed: -[DATE] at 1:51 P.M., resident eats in Courtyard dining room. Feeds himself/herself. In a wheelchair, will move about on his/her own; -[DATE] at 12:31 P.M., appetite usually good. Sometimes he/she will try and eat off other residents' plates; -[DATE], while eating dinner, resident begin to choke. Heimlich maneuver and mouth sweep performed. Was able to remove half of the bread stick that was served with dinner. Resident never lost consciousness and was encouraged to cough. Vital signs within normal limit. States it scared him/her; -[DATE] at 11:13 A.M., new verbal order received from Nurse Practitioner. Speech Therapy (ST) evaluation and treat related to choking incident. Review of the resident's physician order sheet, showed: -Received and started: [DATE], ST evaluation and treat as indicated. Resident evaluation and treatment completed at this time. Resident to receive ST services 3 times a week for two weeks for oral dysphagia; -Start date: [DATE], ST evaluate and treat related to choking incident; -Start date: [DATE], ST evaluate and treat as needed; -Start date: [DATE], thin liquids with mechanical soft diet. NO BREAD. Review of the resident's ST treatment encounter note, dated [DATE], showed: -Dysphagia therapy: 30 minutes; -Swallowing evaluation: 30 minutes; -Resident referred to ST services per nursing staff based on choking incident [DATE]. Resident choked on a breadstick and the Heimlich maneuver was performed with mouth sweep. Reported that staff was able to remove half of a bread stick that was served with dinner. Resident never lost consciousness and was encouraged to cough. Resident has oral dysphagia, staff training is necessary at this time, assessment of current diet, and safe swallowing strategies required. Resident demonstrates unsafe swallowing with large bites, poor attention to task, and attempts to communicate with food in his/her oral cavity. Review of the resident's ST notes, dated [DATE], showed resident challenged with safe swallowing compensatory strategies and ST discussed safety risks associated with aspiration/choking, etc. Resident stated, I need to slow down. Nursing and nursing aides on unit are aware of resident complex needs and cues needed regarding rate of intake and amount of meal consumed when discussed. Resident followed compensatory strategies with 60% accuracy independently and 100% with moderate/maximum verbal cues. Review of the resident's progress notes, showed: -[DATE] at 12:43 P.M., resident eats very fast and does not chew food up. Gulps liquids. He/She has to be redirected frequently at meals. New order per physician for speech to evaluate and treat as needed; -[DATE] at 1:25 P.M., resident is a mechanical soft diet. Received whole slice of pizza for lunch meal and began to choke on pizza. Most of pizza cut up for resident to eat. New order added to diet for no bread. Diet slip made out and given to dietary staff. Review of the care plan, showed staff did not address the resident's choking incident on [DATE]. Review of a ST note, dated [DATE], showed resident was reported to have had increased difficulty consuming pizza over the weekend, additional choking episode. Resident orders are mechanical soft without bread. ST to continue monitoring for signs and symptoms of aspiration/choking of mechanical soft. Resident may need downgrade to puree. Continue with plan of care. Review of the ST discharge recommendations, dated [DATE], included: -Supervision: Close supervision; -Recommendations: To facilitate optimal cognitive-communicative performance, the following strategies are recommended: Training in use of concrete, one step directions by speaker to increase comprehension; -Solids: Soft/Ground/Chopped textures; -Strategies: To facilitate safety and efficiency, it is recommended the resident use the following strategies and/or maneuvers during oral intake: General swallow techniques/precautions, bolus size modifications, rate modification and alternation of liquids/solids upright posture during meals. Review of the resident's care plan, showed staff did not address any of the ST discharge recommendations. Review of the resident's progress notes, showed: -[DATE], at 12:36 P.M., the resident has been on a regular mechanical soft diet with thin liquids. He/She had a choking incident on [DATE] on a bread stick, another choking incident on chopped pizza; -[DATE] at 12:40 P.M., edited [DATE] at 2:42 P.M., called to assist resident who was in the dining room eating lunch. Resident was choking. Resident alert and is coughing. Did Heimlich maneuver on resident, but unable to get food out. Resident had baked fish, mashed potatoes, and diced peaches for lunch. Assistant Director of Nursing (ADON) notified and Yankauer suction catheter (a ridged, hollow, plastic, or stainless-steel tube used to remove mucus or saliva from the mouth or throat) to try and remove food without success. 911 called and made dispatcher aware resident was choking while eating lunch and had food lodged in throat. Made dispatch aware Heimlich was used several times without success. Also used Yankauer suctioning catheter without success. Made dispatch aware the resident was alert and still responding, but food was still lodged in his/her throat. Dispatch stated they had already dispatched paramedics. Resident remains sitting up in wheelchair. After approximately ,d+[DATE] minutes resident became very anxious. Taking very shallow breaths. Had Certified Nurse Assistant (CNA) run up front to make ADON aware and if 911 was here to have them hurry to resident. Licensed Practical Nurse (LPN) C and Certified Medication Technician (CMT) assisted resident to floor to start using Ambu bag (bag valve mask, a handheld device that provides positive pressure ventilation to patients who are not breathing or not breathing adequately) when paramedics x2 came in and we were instructed by them to get resident up to bed. Paramedic attempted to check airway, unable and asked that the resident be laid back on the floor. Resident assisted back on floor and no pulse palpated and Cardiopulmonary Resuscitation (CPR, an emergency life saving procedure that is done when someone's breathing or heartbeat has stopped) started. Paramedic again went to check airway and removed food. Removed a very large piece of unchewed broccoli that was not on resident's plate. Even after broccoli was removed CPR was continued with resident being suctioned. Resident was assisted with CPR continued to stretcher and leave of absence (LOA) to hospital. ADON made aware resident choked on broccoli that wasn't on his/her plate. The resident had to have taken it from someone else. Notified physician and emergency contact. Review of the resident's hospital Death Summary, dated [DATE] at 3:05 P.M., showed: -Past medical history significant for CVA (stroke) with residual dysarthria (a motor speech disorder that makes it difficult to speak clearly), and left sided weakness, and vascular dementia (a condition that affects the brain's ability to think, remember, and behave, caused by damage to blood vessels from reduced blood flow). He/She presented to emergency department for evaluation of choking status post (s/p) cardiac arrest (occurs when the heart suddenly stops beating, preventing blood from flowing to the brain and other vital organs) and return of spontaneous circulation (ROSC). Per EMS, patient choked on broccoli at lunch in the nursing home. Nursing home staff called EMS and started Heimlich maneuver which EMS continued on arrival. The resident subsequently went into cardiac arrest for which he/she received CPR for thirty-two minutes, two doses of epinephrine (a hormone and medication that plays a key role in the body's fight-or-flight response) and was intubated ( insert a tube into a person or a body part, especially the trachea for ventilation) with subsequent removal of the obstructing piece of broccoli in the field. Antibiotics were initiated for aspiration pneumonia; -As per family wishes, he/she was transitioned to comfort only with plan for terminal extubation (removal of tube from a patient's throat and windpipe); -At 4:38 P.M., the resident was pronounced (dead). During interviews on [DATE] at 1:28 P.M. and [DATE] at 9:04 A.M., the Speech Therapist said she knew the resident. He/She was on a mechanical soft diet, nectar thick liquids, and no bread. She said the resident wasn't compliant with his/her diet. The resident coughed when he/she ate things outside of his/her diet and would aspirate as well. Mechanical soft was the most appropriate diet for the resident. The resident had a history of choking. She talked to the nurses and aides about the resident needing extra help with feeding. She would sit with the resident at the assist table, cue him/her to slow down. As she was providing cues, she would educate staff at that time. Nursing provided staff with their own education, from a nursing standpoint. She defined close supervision as being arm's length away. She expected staff to be arm's length away from the resident when eating. A staff member would need to be with him/her. The resident needed to be at the assist table and couldn't be at a table without staff. If the resident was seated at the assist table, there would have been someone sitting at the table with him/her during the meal. She didn't know the resident sat at a separate table to keep him/her from taking food from other residents' plates. She said she remembered him/her choking on a breadstick and he/she sometimes took food from other residents' plates. After the breadstick choking incident, she talked to the kitchen staff about what was appropriate for mechanical soft diet. She wasn't aware the resident had gotten a whole slice of pizza. She said pizza was appropriate for mechanical soft diet, because it had sauce on it, but should have been cut up into bite sizes. The resident had swallowing issue, but he/she could chew. The resident needed a lot of cues to slow down at meals. She said the resident was impulsive and would wheel himself/herself up to other residents' trays and take their food. The Speech Therapist said staff had to make sure the resident's food was cut up appropriately, the resident was to be under supervision and was not allowed to eat in his/her room. Broccoli was acceptable for mechanical soft diet as long as it was the right size and right consistency of softness. She was told kitchen staff would get specific training on diets by someone to show what appropriate consistency, right size, right texture, and how to thicken liquids. The training the kitchen staff received would be passed on to the nursing staff so they could recognize when residents were not getting appropriate food texture, size, and/or consistency of food. During a telephone interview on [DATE] at 10:02 A.M., CNA A said meal set up for residents included passing the tray, taking off the plastic, placing silverware and drinks on the table in front of the resident. Some residents needed help with eating, and some didn't. If a resident needed help eating, the resident got his/her tray last. The tray was supposed to come from dietary in the right diet food texture for the resident. Dietary knew what the residents were supposed to have. He/She knew the resident and was worked with the resident on the last day CNA A was at the facility. The resident was on a mechanical soft diet. Sometimes you had to tell the resident to slow down. The resident didn't sit by other residents and was at a separate table from the other residents. The resident had to be at a table by himself/herself, because he/she would take food off the other residents' plate. The resident didn't eat in his/her room at all. CNA A didn't deliver the resident's tray that day, but was the one who caught him/her choking. CNA A said the resident got baked fish, broccoli, cauliflower, peaches, and mashed potatoes. The resident had no broccoli on his/her plate and CNA A said he/she wasn't sure if the resident ever had broccoli on his/her plate, because when CNA A cleaned up there wasn't any broccoli remnants on the resident's plate. That day, the resident had to be told several times to go back to his/her table. CNA A said he/she turned around and saw the resident choking and told him/her to spit out the food and called the nurse because the resident was choking. When CNA A saw the resident coughing, the resident had mashed potatoes, fish, and peaches in his/her mouth, all at once. He/She told the resident to spit it out and said, You ate all of that at one time? The CMT and nurse came. The CMT put a spoon down the resident's throat to make him/her spit up/vomit. The nurse started the Heimlich maneuver. Someone went to get the suction. The nurse sent him/her to see if the ambulance had arrived. The nurse was suctioning the resident. EMS put a camera down the resident's throat. They saw broccoli and pulled it out. The resident was still unresponsive. He/She thought the resident was already dead. CNA A said that was the first time he/she knew the resident didn't chew the food up. He/She didn't know the resident was just swallowing the food. He/She had teeth, so CNA A didn't know. There were no special instructions for staff to do after the resident's mealtime. Staff would check on the resident after meals. He/She didn't know the resident's care plan said to check him/her for pocketing food in his/her mouth. CNA A said pocketing was when a resident put food in his/her pocket to eat later. The Diet Spreadsheet dated [DATE], showed coleslaw for regular diets and cooked cabbage for mechanical soft diets. There was no documentation of what the substitution for cabbage was. CNA A mentioned broccoli as a vegetable the resident may have gotten, but said there was no sign of broccoli on his/her plate, so he/she wasn't sure. During a telephone interview on [DATE] at 11:13 A.M., LPN C said he/she was called by the Certified Medication Technician (CMT) or CNA and was told the resident was choking, but able to talk. The resident was sitting at a table by himself/herself. He/She did the Heimlich several times and swept the resident's mouth but he/she was biting down, so was difficult to do. LPN C sent the aide to get the Assistant Director of Nursing (ADON). He/She was still doing the Heimlich on the resident. LPN C said he/she looked down at the resident's plate and saw baked fish, mashed potatoes, and diced peaches. They tried to suction the resident with a Yankauer. The resident was alert and still talking. He/She called 911 after they couldn't get the food out of the resident's throat and was still doing the Heimlich. They took the resident to his/her room and continued the Heimlich and suctioning. The resident made some kind of noise and LPN C thought that was when the food went down his/her throat. He/She couldn't breathe. The resident was laid on the floor and CPR was started. They had just gotten the resident to the floor when one of the paramedics said to get the resident onto his/her bed. The paramedic was trying to get a tube down the resident's throat, but couldn't do it with the resident on his/her bed. The resident was moved back to the floor. The paramedics were still trying to get an airway. The resident was suctioned again, because a lot of mucus was coming out. Paramedics had a scope with a camera to look into the resident's mouth. Forceps were used to pull broccoli out. Afterwards, the paramedic was able to get the tube down the resident's throat. When the Fire Department came, they put the chest compression machine on the resident. The paramedics continued CPR while putting the resident on the stretcher. LPN C said he/she had no idea where the resident got broccoli from. LPN C said the CNA (CNA A) said he/she usually passed the resident's meal tray but didn't that day. LPN C asked the CNA if the resident had broccoli on his/her plate and the CNA said no. It was a nice size piece of broccoli, and it was hard. It would have been something he/she would have had to cut up. LPN C said he/she didn't know how the resident was even able to swallow it whole like that. It's mainly the same staff working back in the Courtyard dining area, so they know what diets residents have and the diets are on the mealtime cards that come with the trays. LPN C said he/she was aware the resident pocketed and held food in his/her mouth. He/She told Dietary about the breadstick the resident choked on. He/She was able to get the bread out, but told Dietary not to send the resident bread. LPN C said close supervision was for the ones you knew had problems with swallowing and needed to be watched. He/She said staff were to be in proximity as possible. While staff did other things, they just looked over to check on the resident as best they could. Normally there was a nurse, two CNAs and a CMT. LPN C said he/she was aware the resident was supposed to take small bites during meals. He/She would assist another resident during mealtime, but would tell the resident to slow down and take a drink. He/She said the resident ate like someone was going to snatch his/her food, so the resident always had to be redirected. The resident always ate in the dining room. LPN C said all of the swallow strategies and close level of supervision should have been on the resident's care plan. During a interview on [DATE] at 11:42 A.M., LPN B said he/she knew the resident and he/she was a fast eater. The resident used to cough, but ST started working with him/her. LPN B said he/she tried to keep the resident within his/her line of sight when the resident ate, because he/she ate fast. The resident ate in the dining room. LPN B said the only instructions after meals was the resident was not allowed to get in bed right after his/her meal. LPN B wasn't working the day the resident choked on broccoli. LPN B had seen the resident hold food in his/her mouth before, but it had been quite some time ago. LPN B said nursing would let the CNAs know about diet changes, but didn't know if the information was in the CNA's system. He/She said the diet change was care planned. Once the diet was changed, the order was given to dietary, and a new meal ticket was generated. He/She didn't know pocketing/holding food in mouth was in the resident's care plan. During and interview on [DATE] at 11:58 A.M., the Assistant Administrator said the facility didn't complete an investigation related to the resident's choking incident. She said the resident expired on [DATE]. She said close supervision was staff being within the vicinity of the resident to watch and oversee. Staff should have been close enough to observe and assist. The Assistant Administrator and ADON both said they were not aware of the ST's mealtime strategies and/or close supervision discharge recommendations. The ADON said the resident was in a secure area, so he/she always had direct supervision in the dining room. She was aware the resident would take food from other resident's plates and had to be redirected back to his/her table. She wasn't aware of the resident sitting at his/her own separate table. As she helped ST recommendations through the facility's regular communication process, she would have expected staff to follow the recommendations. During an interview on [DATE] at 3:59 P.M., both the Administrator and ADON said they expected staff to know what pocketing food was. They expected staff check the resident's mouth for pocketing/holding food in his/her mouth. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00245954

Based on observation, interview and record review, the facility failed to have systems in place to identify pressure ulcers and notify appropriate nursing staff of the pressure ulcers in a timely manner, failed to address, assess and monitor pressure ulcers, failed to document and initiate physician ordered treatments for pressure ulcers in a timely manner, and failed to complete treatments as ordered, for two of three residents assessed as high risk for pressure ulcers (Residents #10 and #11). The facility census was 81. Review of the facility Pressure Ulcer/Skin Breakdown - Clinical Protocol policy, dated 2001 and revised on 4/2008, showed: Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcer(s); 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates (wound drainage) or necrotic (dead) tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; e. All active diagnoses; 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics) presence of necrotic tissue, status of wound bed, etc.) of an ulcer; 5. The physician will help identify and define any complications related to pressure ulcers; Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown, for example, medical comorbidities such as diabetes (low blood sugar) or [CONDITION(S)] (the heart is too weak to pump blood efficiently), overall medical instability, cancer or [CONDITION(S)] (infection) causing a catabolic state (the breaking down molecules), and macerate (to make soft due to moisture) or friable skin (easily crumbled/brittle); 2. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing an existing wound; Treatment Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleaning and debridement (tissue removal) approaches (occlusive, absorbent, etc.), and application of topical agents; 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatments, etc.; a. Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional interventions clearly prevent or heal pressure ulcers; b. Beyond trying to maintain a stable weight and providing approximately 1.2 - 1.5 gram/kilogram protein daily, there are no routine pressure ulcer-specific nutritional measures for those with or at risk for developing a pressure ulcer; c. Any nutritional supplementation should be based on realistic appraisal of an individual's current nutritional status and minimizing any medications and conditions that may be affecting appetite and weight; 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors, for example: a. Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic; b. Healing or Prevention Possible: Healing may be delayed or may occur only partially; wounds may occur despite appropriate preventative efforts; c. Healing or Prevention Unlikely: The resident is likely to decline or die because of his/her overall medical instability; wounds reflect the individual's overall medical instability; an existing wound is unlikely to improve significantly; additional wounds are likely to occur despite preventative efforts; 4. As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, the impact of end-stage heart disease or because the resident or family declines artificial nutrition and hydration; a. Advance directives may limit the scope, intensity, duration, and selection of various wound-related or adjunctive treatments such as a choice to forego artificial nutrition and hydration; Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds; 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions; a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified; b. Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident or substitute decision-maker. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/27/21, showed: -admitted [DATE]; -Brief Interview for Mental Status (BIMs, a screening for cognitive status) score: 15 of 15, which indicates intact cognition; -Extensive assistance of one person required for bed mobility; -Total dependence of two persons required for dressing, toilet use, personal hygiene and bathing; -Total dependence of two (+) persons required for transfers; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk to develop pressure ulcers?: Yes; -Unhealed pressure ulcers?: No. Review of the resident's current care plan, located in the electronic medical record (EMR), showed: -Limited physical mobility related to weakness and uses a hoyer lift (a machine used to transfer a resident that is unable to bear weight) for all transfers; -Will remain free of complications related to immobility, including skin-breakdown; -Monitor/document/report skin-breakdown; -Impaired cognitive function/dementia or impaired thought processes related to dementia; -Will be able to communicate basic needs on a daily basis; -Functional bladder and bowel incontinence related to dementia, impaired mobility, physical limitations and is at risk for skin breakdown; -Will remain free from skin-breakdown due to incontinence and incontinence brief use; -Clean peri-area (genitalia/buttocks) with each incontinence episode; -Check every two hours as required for incontinence; -The care plan did not address the pressure ulcer identified in the progress notes on 9/28/21, as a problem with a goal and interventions. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Start 2/24/21, No End Date: Skin assessment, record findings in assessments every evening shift every seven days for assessments; -Start 3/16/21, No End Date: Clean buttock area with soap and water, pat dry. Apply [MEDICATION(S)]-oxide 20% (an ointment primarily used as a preventative to prevent moisture related skin-breakdown) to buttock area after each incontinent episode; -10/15/21, No End Date: [MEDICATION(S)] wound/burn dressing gel (wound dressing). Apply to sacrum (between the lower back and upper buttocks, also referred to as coccyx/sacral) topically one time a day for wound. Cleanse sacrum area, pat dry, apply [MEDICATION(S)] and cover with dry dressing. Review of the resident's treatment administration record (TAR), dated 9/1/21 through 9/31/21, showed: -3/16/21: Clean buttock area with soap and water, pat dry and apply [MEDICATION(S)]-oxide 20% to buttock area after each incontinent episode every shift. The order was not modified or updated to identify a pressure ulcer on the resident's sacrum; -No new treatment was documented related to the resident's sacrum. Review of the resident's Skin Monitoring: Comprehensive CNA (certified nurse aide) Shower Review form (shower sheets, completed by CNAs after each resident shower and used to identify skin issues and co-signed by a nurse), dated 9/15, 9/18, 9/22, 9/25, and 9/29/21 showed CNAs circled decubitus (pressure ulcer) and drew a dark circle on the sacrum area of an anatomical figure located on the form. Review showed none of the shower sheets were co-signed by a nurse. During a telephone interview on 11/17/21 at 3:20 P.M., CNA E said he/she completed the shower sheets for 9/15 and 9/29/21. The resident had skin-breakdown on his/her bottom. It looked cracked and open. He/she would not have circled decubitus had there not been something abnormal. He/she took the shower sheets to the nurse's station and told the nurse. He/she could not recall the nurse on duty at the time and he/she did not know if the nurse went to assess the resident's bottom or not. Review of the resident's progress notes in the EMR, showed: -9/15 through 9/27/21: No documentation regarding a pressure ulcer; -9/28/21 at 2:21 P.M.: Informed by aide of resident having a wound to backside. Once in the room noted resident having wound to coccyx. Measurements 8.0 centimeter (cm) by 4.0 cm. Resident already has treatment order for clean buttock area with soap and water, pat dry. Also, apply [MEDICATION(S)] to buttock area after each incontinent episode. Treatment order was implemented. Physician notified. Assistant Director of Nurses (ADON) notified. Resident will be seen by wound doctor. Will make evening nurse aware. Review showed the resident's progress note, dated 9/28/21, did not provide a full assessment of the identified pressure ulcer (stage, exudate/drainage, or tissue type, etc.) other than the measurements. Review of the resident's wound care company's progress notes, dated 10/4/21 (the resident's first visit by the wound care company physician), showed: -Subjective: Resident is being evaluated for chronic ulcerations. Resident is a poor historian. Unknown how long resident has had the wound. Resident reports no new complaints in regards to the wounds; -Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). May also present as an intact or open/ruptured blister)); -Wound Status: First Visit; -Pre-debridement Measurement: Length 6.4 cm by Width 4.0 cm by Depth 0.1 cm; -Exposure: Subcutaneous (directly under the skin): -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous (thin/watery); -Surrounding Skin: Intact; -Debridement (removal of tissue): Indication for debridement: Reduce devitalized (dead) tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional (debridement by non-surgical means); -Description of Tissue Removed: Slough, biofilm (a thin film of [MEDICATION(S)]); -Instrument Used: 4x4s (gauze pads that adhere and remove some of the dead tissue when removed); -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing (used to absorb exudate); -Change Dressing: Every 24 hours and PRN (as needed); Plan: resident and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Review of the resident's TAR, dated 10/1/21 through 10/31/21, showed: -3/16/21: Clean buttock area with soap and water, pat dry and apply [MEDICATION(S)]-oxide 20% to buttock area after each incontinent episode every shift; -10/15/21 (11 days after the order was written by the wound care physician on 10/4/21): [MEDICATION(S)] wound/burn dressing gel. Apply to sacrum topically one time a day at 9:00 A.M. Cleanse sacrum area, pat dry, apply [MEDICATION(S)] and cover with dry dressing; -Review of the TAR, showed no nurse's initials or code number (Initials indicate a treatment was completed as ordered. If a treatment cannot be completed a code number should be documented in place of the initial which indicates the reason the treatment could not be completed) on 10/16, 10/17, 10/19, 10/24 and 10/29/21, showing the [MEDICATION(S)] treatment had been completed. Review of the resident's wound care company's progress notes, dated 10/11/21, showed: -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (tissue damage underneath the skin)); -Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage III; -Wound Status: Worse; -Pre-debridement Measurement: 4.0 cm by 4.0 cm by 0.3 cm; -Exposure: Subcutaneous: -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Excisional (completed surgically); -Description of Tissue Removed: Devitalized and nonviable tissue; -Instrument Used: Curette (surgical instrument); -Post-Debridement Appearance: Healthy bleeding tissue; -Post-Debridement Measurements: 4.1 cm by 4.1 cm by 0.5 cm; -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing; -Change Dressing: Every 24 hours and PRN; Plan: resident and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Review of the resident's wound care company's progress notes, dated 10/18/21, showed: Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage III; -Wound Status: Static (little or no change); -Pre-debridement Measurement: 4.0 cm by 4.0 cm by 0.3 cm; -Exposure: Subcutaneous: -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Excisional; -Description of Tissue Removed: Devitalized and nonviable tissue; -Instrument Used: Curette; -Post-Debridement Appearance: Healthy bleeding tissue; -Post-Debridement Measurements: 4.1 cm by 4.1 cm by 0.4 cm; -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing; -Change Dressing: Every 24 hours and PRN; Plan: resident and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Review of the resident's wound care company's progress notes, dated 10/25/21, showed: Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage III; -Wound Status: Improving; -Pre-debridement Measurement: 3.5 cm by 3.5 cm by 0.2 cm; -Exposure: Subcutaneous: -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Excisional; -Description of Tissue Removed: Devitalized and nonviable tissue; -Instrument Used: Curette; -Post-Debridement Appearance: Healthy bleeding tissue; -Post-Debridement Measurements: 3.6 cm by 3.6 cm by 0.3 cm; -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing; -Change Dressing: Every 24 hours and PRN; -Plan: resident and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Review of the resident's TAR, dated 11/1/21 through 11/30/21, showed: -3/16/21: Clean buttock area with soap and water, pat dry and apply [MEDICATION(S)]-oxide 20% to buttock area after each incontinent episode every shift; -10/15/21: [MEDICATION(S)] wound/burn dressing gel. Apply to sacrum topically one time a day at 9:00 A.M. to wound. Cleanse sacrum area, pat dry, apply [MEDICATION(S)] and cover with dry dressing. Review of the resident's wound care company's progress notes, dated 11/1/21, showed: Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage III; -Wound Status: Improving; -Pre-debridement Measurement: 3.3 cm by 3.7 cm by 0.2 cm; -Exposure: Subcutaneous: -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Excisional; -Description of Tissue Removed: Devitalized and nonviable tissue; -Instrument Used: Curette; -Post-Debridement Appearance: Healthy bleeding tissue; -Post-Debridement Measurements: 3.3 cm by 3.7 cm by 0.4 cm; -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing; -Change Dressing: Every 24 hours and PRN; -Plan: resident and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Review of the resident's wound care company's progress notes, dated 11/15/21, showed: Wound Location: Sacrum; -Wound Type: Pressure Ulcer Stage III; -Wound Status: Overall static; -Pre-debridement Measurement: 3.8 cm by 3.5 cm by 0.2 cm; -Exposure: Subcutaneous: -Tissue Type: Sloughy; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Maceration (softening of the skin due to moisture); -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Excisional; -Description of Tissue Removed: Devitalized and nonviable tissue; -Instrument Used: Curette; -Post-Debridement Appearance: Healthy bleeding tissue; -Post-Debridement Measurements: 3.8 cm by 3.6 cm by 0.3 cm; -Dressing Order: Cleanse wound with wound cleanser, [MEDICATION(S)] gel, silicone border dressing; -Change Dressing: Every 24 hours and PRN; -Plan: Patient and staff advised on signs and symptoms of infection and instructed to call wound team with any new concerns or change in status. Observation of the resident on 11/16/21 at 10:46 A.M., showed the resident lay in bed as Nurses C and F assisted the resident onto his/her side. There was no dressing on the resident's sacrum. Nurse C said he/she worked yesterday and applied the treatment. It is not unusual for the resident's dressing to get wet and come off. Nurse F said if that happens, staff should let the nurse know so a new dressing can be applied. Nurses C and F did not know how long the dressing had been off. During an interview on 11/16/21 at 3:00 P.M., the ADON said she was notified of the resident's sacrum pressure ulcer on 9/28/21. They called the wound care physician and received an order to use the 3/16/21 order for [MEDICATION(S)], cleanse and pat dry until the wound care physician saw the resident on 10/4/21. That order should have been re-written by the charge nurse to note the pressure ulcer. On 10/4/21, she was aware the wound care physician wrote a new order for [MEDICATION(S)], but she was not aware until today the charge nurse had not initiated the treatment on the POS or TAR until 10/15/21. The treatment should have started on 10/4/21, and the old order for [MEDICATION(S)] had it been added, should have been discontinued. During a telephone interview on 11/22/21 at 11:50 A.M., the wound care company physician said on the day he is at the facility, he makes out an informal list containing his notes that includes any new treatment he orders. He e-mails the list to the facility prior to leaving so they have that information. After a day or two, he will e-mail the facility his formal report that includes his full assessment. He was not aware his orders for [MEDICATION(S)] from 10/4/21 and 10/11/21, had not been initiated by the facility until 10/15/21. The resident's primary problems for healing are offloading pressure and incontinence, but he could not rule out that the delay in starting the new treatment played a role in the resident's pressure ulcer deteriorating from a Stage II pressure on 10/4/21 to a Stage III pressure ulcer on 10/11/21. During a telephone interview on 11/22/21, the ADON said the order dated 3/16/21, for [MEDICATION(S)]-oxide, was a long standing order for preventative purposes. Once the resident developed a pressure ulcer the physician should have been notified and if that treatment was still warranted the order should have identified the new pressure ulcer. She had reviewed the resident's wound care company progress notes and compared them to the resident's TARs. She spoke to the nurse that was responsible to enter the wound care physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . That nurse told her he/she thought he/she had entered the [MEDICATION(S)] treatment order into their EMR, but she (ADON) searched the EMR and could not find the order the nurse said he/she had entered. Without the order in the EMR (POS and TAR), the nurses would not know the resident had a new order for the sacrum pressure ulcer. She expects nurses to co-sign shower sheets and assess the resident any time a new pressure area is noted. If there is an area she expects the nurse to notify the physician and document any new orders. Adding a problem for the pressure ulcer to the care plan was not in the policy. 2. Review of Resident #11's annual MDS, dated [DATE], showed: -admitted [DATE]; -BIMs score: 12 of 15, a score of 8-12 indicates moderately impaired cognition; -Extensive assistance of one person required for bed mobility, dressing and bathing; -Total dependence of one person required for toileting and personal hygiene; -Total dependence of two (+) persons required for transfers; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk for developing pressure ulcers?: Yes; -Unhealed pressure ulcers?: No. Review of the resident's care plan, located in the EMR, showed: Problem: -The resident has actual skin integrity breakdown to bilateral thighs and bilateral axilla (area under the arms) related to pressure; Interventions: -Avoid scratching and keep hands and body parts from excessive moisture; -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Keep skin clean and dry; -Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Weekly treatment documentation to include measurement of each area of skin breakdown, type of tissue and exudate and any other notable changes or observations; -Wound care per orders. Cleanse and pat dry, apply triple antibiotic ointment (TAO) to wound beds and cover with non adherent dressing and secure with tape. Change daily and PRN until healed or re-evaluated; Problem: -The resident has activities of daily living self-care deficits related to limited mobility; Interventions: -The resident is able to wash upper body with assistance; -The resident requires assistance of one staff with bathing and showering; -The resident uses bed rails to maximize independence with turning and repositioning in bed; -The resident requires mechanical stand-up lift with two staff for transfers; Problem: -The resident has limited physical mobility related to left sided weakness from a stroke; Interventions: -The resident uses a wheelchair for locomotion; Problem: -The resident has impaired cognitive function/dementia or impaired thought processes. Review of the resident's progress notes, showed: -9/4/21 (Saturday) at 6:16 A.M.: A CNA summoned the nurse to the resident's room. Upon arrival, the resident had a small 1.5 cm by 0.5 cm open area on the right posterior (back) thigh and a 1.0 cm by 0.5 cm open area on the left posterior thigh. Both areas cleansed with wound cleanser, [MEDICATION(S)] applied, covered with a hydrophillic (moisture retaining) dressing. Resident's physician has been faxed. Awaiting a response. Review showed no documentation that the physician's office responded to the fax; -9/4/21 at 7:37 A.M.: Skin issue. Pressure ulcer/injury. Skin issue location: right posterior thigh. Stage II - partial thickness skin loss. Length 1.5 cm by width 0.5 cm. Depth - beefy. Wound bed: granulation (healing). Peri-wound (skin surrounding the pressure ulcer) within normal limits. No odor, drainage, tunneling or undermining. Skin issue. Pressure/injury. Skin issue location: left posterior thigh. Pressure ulcer stage II. Partial thickness loss. Length 1.0 cm by width 0.5 cm. No wound odor, tunneling or undermining; -9/5/21 at 2:54 P.M.: Skin location #1. Left posterior thigh. Pressure ulcer injury. Wound exudate: Serosanguineous - thin, watery, pale, red/pink drainage. Peri-wound normal. Dressing saturation: none. No wound odor, tunneling or undermining. Treatment schedule every 3 days. Pressure ulcer staging: Stage II. Skin tissue: Painful. The progress note did not show a measurement for the left posterior thigh and did not show any information regarding the right posterior thigh; -9/13/21 at 1:20 P.M. and completed by a Nurse Practitioner: Resident being seen for an acute visit. Resident states he/she has two areas on his/her legs that are sore and his/her groin is really red. Open areas noted to bilateral posterior thighs. Nursing staff to apply TAO and non-adherent dressing and secure with paper tape daily until healed; -9/14/21 at 5:30 A.M.: Resident sent to a local hospital due to a fall; -9/14/21 at 3:09 A.M.: Resident returned to the facility; -9/15/21 at 10:33 A.M.: Report from local hospital. Right posterior thigh 2.0 cm by 1.0 cm. Wound exudate - none. Peri-wound - [CONDITION(S)] (red). Tissue - painful. Left posterior thigh 2.0 cm by 1.0 cm. Exudate - sanguineous, peri-wound - [CONDITION(S)]. Tissue - painful; -Review of the progress notes showed no other documentation regarding the resident's left and right posterior thigh wounds until 10/4/21. Review of the resident's POS located in the EMR, showed: -No treatment order for the left or right posterior thigh from 9/4/21 through 9/12/21; -Start 9/14/21, End 11/13/21: Bilateral posterior thighs - cleanse site and pat dry. Apply TAO and non-adherent dressing and secure with paper tape daily until healed; -Start 10/7/21, End 11/13/21: Right axilla - cleanse with normal saline (salt water solution), apply TAO, Xeroform (a sterile non-adherent dressing) and cover with a dry dressing daily until healed; -Start 10/14/21, End 11/13/21: Left and right chest - collagen matrix-silver sheet 4x4 (an advance wound care dressing, that maintains a moist wound environment, and creates ideal conditions for healing) two times a day for wound. Clean right and left chest wall under arm area with normal saline, apply collagen then cover with border gauze; -Start 10/14/21, End 11/13/21: Right and left posterior thighs - collagen matrix-silver sheet 4x4 two times a day for wound. Clean right and left posterior thighs with normal saline, apply collagen then cover with border gauze. Review of the resident's TAR, dated 9/1/21 through 9/30/21, showed: -No treatment order for the right or left posterior thigh from 9/4/21 through 9/14/21; -Start 9/14/21 End 11/13/21: Right and left posterior thighs. Cleanse and pat dry. Apply TAO and non-adherent dressing and secure with paper tape daily until healed; -Review of the TAR showed no nurse's initials on 9/22 and 9/29/21. Review of the resident's wound care company's progress notes, completed by a physician, dated 10/4/21 (the first visit by the wound care company physician), showed: Subjective: Resident is being evaluated for ulcerations. Resident is a poor historian, reporting 3-4 weeks duration; Wound Location: Left chest wall; -Wound Type: Pressure Ulcer Stage II; -Wound Status: First Visit; -Pre-debridement Measurement: 8.0 cm by 1.0 cm by 0.1 cm; -Exposure: Subcutaneous: -Tissue Type: Granulating (healthy tissue); -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Signs of infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough, biofilm; -Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser, collagen pad, silicone border dressing; -Change Dressing: Every 12 hours and PRN; Wound Location: Right chest wall; -Wound Type: Pressure Ulcer Stage II; -Wound Status: First Visit; -Pre-debridement Measurement: 8.5 cm by 2.9 cm by 0.1 cm; -Exposure: Subcutaneous: -Tissue Type: Granulating; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Signs of infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough, biofilm; -Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser, collagen pad, silicone border dressing; -Change Dressing: Every 12 hours and PRN; Wound Location: Left Posterior Thigh Cluster; -Wound Type: Pressure Ulcer Stage II; -Wound Status: First Visit; -Pre-debridement Measurement: 28.5 cm by 4.5 cm by 0.1 cm; -Exposure: Subcutaneous: -Tissue Type: Granulating; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Signs of infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough, biofilm; -Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser, collagen pad, silicone border dressing; -Change Dressing: Every 12 hours and PRN; Wound Location: Right Posterior Thigh; -Wound Type: Pressure Ulcer Stage II; -Wound Status: First Visit; -Pre-debridement Measurement: 8.5 cm by 2.9 cm by 0.2 cm; -Exposure: Subcutaneous: -Tissue Type: Granulating; -Exudate Amount: Moderate; -Exudate Color: Serous; -Surrounding Skin: Intact; -Signs of infection: None; -Debridement: Indication for debridement: Reduce devitalized tissue, decrease risk of infection, and promote wound healing; -Type of Debridement: Nonexcisional; -Description of Tissue Removed: Slough, biofilm; -Instrument Used: 4x4s; -Dressing Order: Cleanse wound with wound cleanser, collagen pad, silicone border dressing; -Change Dressing: Every 12 hours and PRN; Plan: -Pa

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for one resident. The facility failed to assess, monitor and notify the physician of a resident's acute change in condition, in order to prevent further deterioration in health for one of 4 sampled residents (Resident #4) who required hospitalization . The census was 81. Review of Resident #4's most recent quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 5/1/20, showed the following: -Severe cognitive impairment; -Independent with bed mobility, transfers and eating. Required supervision with dressing and ambulation; -[DIAGNOSES REDACTED]. Review of the resident's laboratory tests, dated 7/24/20 and completed on 7/27/20, showed a positive test for COVID-19. Review of the resident's July 2020 physician order [REDACTED]. -An order dated, 1/22/19 for [MEDICATION NAME] (Tylenol, used to treat minor aches, pains and reduce fever) 325 milligrams (mg), give two tablets by mouth, every 6 hours for pain/elevated temperature; -An order dated, 7/28/20 for Hydrochloroquine (Immunosuppressive drug and anti-parasite, which can treat and prevent [DIAGNOSES REDACTED] (mosquito-borne infectious disease) and also treat lupus ([DIAGNOSES REDACTED] disease that attacks tissues and organs) and arthritis) 200 mg to be given twice a day for five days; -An order, dated 7/28/20 for zinc, one tab to be given twice a day for two weeks; -An order, dated 7/28/29 for [MEDICATION NAME] (Z-Pak, antibiotic used to treat various types of infections) as directed; -A standing order for full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of the resident's August 2020 POS, showed an order, dated 8/1/20 for oxygen (O2) at 3-5 liters (L) as needed (PRN) per nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) for shortness of breath. Review of the resident's medical records, showed the following: -A night shift nurse's note on 7/28/20 at 11:45 P.M., showed the resident had a temperature of 99.9 degrees. Resident up at bedside. Isolation observed. No noted distress; -An evening shift nurse's note on 7/29/20 (no time noted), showed the resident's temperature was 98.1 degrees. Resident remains on isolation related to COVID-19. No signs or symptoms of distress noted. No complaint or discomfort; -A day shift nurse's note on 7/30/20 (no time noted), showed the resident's temperature was 98.6 degrees. Resident resting in bed with call light in reach. No signs or symptoms of distress noted. No complaint of discomfort. Resident remains on isolation; -A night shift nurse's note on 7/31/20 (no time noted), showed the resident had a temperature of 98.1 degrees. No complaint of pain/distress. Resting, eyes closed, normal chest rise and fall. Will continue to monitor; -A day shift nurse's note on 8/1/20 (no time noted), showed the resident had a temperature of 99.0 degrees. The resident rested in bed with call light in reach. No pain or discomfort. No signs of distress noted. Resident has poor appetite. Fluids encouraged. Turned and repositioned every two hours; -An evening shift nurse's note on 8/1/20 at 7:00 P.M., showed the resident was sitting up in bed with head of bed raised. No signs or symptoms of distress. Resident has a temperature of 104 degrees. Resident given Tylenol and two cups of water. Oxygen level at 80% on room air (normal is 95-100%). PRN O2 on at 3 liters (L) per nasal cannula. Resident repositioned for comfort. Resident ate 10% of dinner. Physician made aware. At 9:00 P.M., Rechecked resident temperature at 99.0 degrees. Resident resting comfortably. No signs or symptoms of distress. Oxygen level at 90 on 3 L of O2; -No nurse's notes for 8/2/20; -Review of the 24 hour nurse sheet for 8/2/20, showed on the day shift, the resident had a temperature of 98.1 degrees and oxygen level was 96%. On the evening shift, the resident's temperature was 98.1 degrees and oxygen level was 97%; -A day shift note on 8/3/20 (no time noted), showed the resident appeared lethargic and his/her temperature was 103 degrees. The resident was given Tylenol and two cups of water. His/her temperature went down to 99.3 degrees. The resident required assistance with eating. Remains on O2 at 3 L; -An evening shift note on 8/3/20 (no time noted), showed the resident rested in bed with no signs or symptoms of distress. Resident's appetite is poor; liquids encouraged. Tylenol given for low grade temperature and remains on O2 at 3 L. He/she requires assistance with eating and activities of daily living (ADLs, self-care activities) and remains on isolation; -No documentation staff notified the physician regarding the 8/3/20 onset of lethargy or poor appetite; -A nurse's note, dated 8/4/20 at 6:00 A.M., showed the resident resting quietly. Monitored vital signs closely. Skin temperature is consistent with (undecipherable word) tissue. No diaphoresis (sweating) noted or complaint of pain. Offered small sips of water throughout night. No signs or symptoms of acute distress noted; -A day shift nurse's note on 8/4/20 (no time noted), showed the resident appears lethargic and is unable to state name when nurse asked. Responded to touch and was moaning. His/her temperature was 104 degrees, unable to obtain blood pressure. Two cups of water and Tylenol given. Physician made aware and gave order to send the resident to the hospital. The resident left via ambulance at 1:30 P.M. Review of the August 2020 Medication Administration Record [REDACTED]. Further review of the resident's nurse's note, dated 8/5/20 at 5:00 P.M., showed the hospital called with an update on the resident's condition. The resident was currently sedated, intubated (procedure used when someone is unable to breathe on their own. A tube is placed down the throat and into their windpipe to make it easier to get air into and out of the lungs) and on a ventilator (a machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently). Temperature is 104.2 degrees. A gastrostomy tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) was placed for feeding. Review of the residents COVID-19 Nursing Care Plan, dated 8/11/20, showed the following: -Problem: COVID-19 Infection: Resident requires care and isolation precautions specifically related to the COVID-19 infection; -Goal: Resident will not experience any signs and symptoms of the COVID-19 infection following completion of medications ordered by medical doctor; -Approaches included: Allow resident to get plenty of rest; encourage resident to consume extra amounts of fluids daily; have oxygen available as ordered and whenever needed for shortness of breath; listen to lung sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds; monitor vital signs and notify resident's doctor of those out of range; observe for effectiveness of medications; observe for fever, wheezing, aching all over, diarrhea and inform physician when seen; observe for emergency warning signs (i.e., trouble breathing, persistent pain or pressure in chest, any new confusion or inability to arouse and if lips or face is blue in color). Notify physician and ensure resident gets medical attention immediately. Review of e-mail correspondence from the administrator on 9/28/20 at 12:21 P.M., showed there were no additional screenings, assessments or documentation for the resident. During an interview on 9/28/20 at 9:34 A.M., Certified Nurse Aide (CNA) A said he/she was familiar with the resident. Prior to the resident getting COVID-19, he/she was ambulatory and would wander into other residents' rooms. The resident had high temperatures and was slouched over in bed for four days prior to being sent to the hospital. The resident staying in bed was not normal for him/her, and the resident looked ill. CNA A was trained to look for changes in residents such as fever or loss of appetite. CNA A notified the nurse when he/she noticed these changes in the resident. During an interview on 9/28/20 at 9:52 A.M., Licensed Practical Nurse (LPN) B said he/she was told by the CNAs the resident was able to do more for him/herself before he/she got sick. The resident ended up being a full staff assist for ADLs and eating. The resident did not need O2 prior to testing positive for COVID-19. LPN B could not remember if he/she worked on 8/3/20. When LPN B started work on 8/4/20 around 7:00 A.M., he/she had not received any information regarding the resident having a change in condition from the nurse going off duty. Nurses are expected to keep a close eye on COVID-19 positive residents, which included doing a full set of vitals every shift and screening for fever, cough or issues with breathing. The screenings should be documented on a form. Certified medical technicians (CMT) also documented vitals. The resident was very lethargic and had a poor appetite with a pretty high fever. The resident responded to touch and her name, but was out of it. The LPN could not get the resident's temperature to go below 99 degrees, so he/she notified the physician, and sent the resident to the hospital. Review of correspondence from the Director of Nursing (DON), dated 9/25/20, showed on each day the resident was noted to have a temperature greater than 100.4 degrees, the resident was administered Tylenol (all are properly documented). The only reason to send a resident out due to having an abnormal temperature would be if interventions were not effective or if other adverse symptoms occurred. The resident was sent to the hospital on [DATE] due to his/her change of condition outside of the common symptom of a temperature because this resident was found to be lethargic. Being lethargic was an abnormal and significant change that was reported; therefore the nurse obtained orders to send this resident out to the hospital for further evaluation and treatment. Review of the facility's Acute Condition Changes-Clinical Protocol, undated, showed the following: -Assessment and Recognition: The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia; -In addition, the nurse shall assess and document the following baseline information: -Vital signs; -Neurological status; -Current level of pain, and any recent changes in pain level; -Level of consciousness; -Cognitive and emotional status; -Resident's age and sex; -Onset, duration, severity; -Recent labs; -History of psychiatric disturbances, mental illness, depression, etc.; -All active diagnoses; and -All current medications; -Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse; -The physician and nursing staff will review the details of any recent hospitalization and will identify complications and problems that occurred during the hospital stay that may indicate instability or the risk of having additional complications; for example, acute [MEDICAL CONDITION] or [MEDICAL CONDITION] in someone with advanced [MEDICAL CONDITION] who is receiving corticosteroids (mimics the effects of hormones to treat a number of diseases) after a prolonged, complicated, recent hospitalization ; -The physician will help identify medications and medication combinations that are associated with adverse consequences that could cause significant changes in condition; -Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison; -Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status; -The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less); -The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status; -The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response; -The nurse and physician will discuss and evaluate the situation; -The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms; - Treatment/Management: -The physician will help identify and authorize appropriate treatments; -The physician and staff will identify relevant resident/patient wishes, including advance directives and orders related to life-sustaining treatments (POLST); -If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. During an interview on 9/25/20 at 11:06 A.M., a representative for the resident's physician said the physician expected staff to screen residents who are COVID-19 positive every shift, or a minimum of twice a day. The physician's office was contacted when the resident showed a change in condition outside of an increased temperature. A change in condition would include lethargy, loss of appetite, and change in respiratory health or not drinking. The physician was first notified of the resident's lethargy on 8/4/20. A temperature can be managed in-house and is a part of the disease process. As soon as the physician was aware of the resident's lethargy, he gave an order to send the resident to the hospital. During interviews on 9/24/20 at 11:45 A.M. and on 9/28/20 at 2:25 P.M., the DON, said she started at the facility on 8/4/20. She expected staff to screen COVID-19 positive residents every shift. The screening should include symptoms such as temperature and O2 saturation and should be documented. If a resident had an increase in shortness of breath, fever not relieved with Tylenol, chest pain, decreased O2 saturation, change in blood pressure, more lethargic or anything out of the resident's normal, staff should notify the physician. She was aware nursing staff did not consistently document and had conducted an in-service on this. She could not determine why staff did not document on the resident on 8/2/20. Staff were required to document at least once a shift. She would expect the nurse to document administration and effectiveness of the PRN Tylenol on the MAR. MO 748

Based on observation, interview and record review, the facility failed to properly contain COVID-19 by not developing policies and procedures and not following current standards of practice regarding the control of infection transmission. When staff first identified residents as having COVID-19, the facility had no dedicated area for the treatment of [REDACTED]. Three residents who tested positive for COVID-19 and resided on the memory care unit had roommates who were either negative for COVID-19 or had an unknown COVID-19 status (Residents #5, #6, #9, #10, #7 and #8 ). Staff placed the positive residents on transmission based precautions, but left them in the same room with their roommate, putting the roommates at risk from [MEDICAL CONDITION], from 8/4/20 when the first positive test results came back until after informed by the state survey team on 8/5/20 of the failure. The facility failed to have a current, trained staff member designated as their infection preventionist. A resident known by staff to be positive for COVID-19 (Resident #5) was observed to sit in the television area with an unmasked resident negative for COVID-19 (Resident #13), and staff failed to immediately redirect the positive resident to his/her room. Staff failed to appropriately mark a positive resident's room (Resident #11) to identify the resident's COVID status. Staff failed to wear proper personal protective equipment (PPE) and failed to properly dispose of used PPE when caring for residents positive for COVID-19. Furthermore, staff failed to properly wear facemasks while preparing food, have sufficient biohazard waste containers available for staff and to properly store them (Residents #1, #2, #3, #4 and #12). The resident sample size was 13. The census was 90. The administrator was notified on 8/7/20 at 2:20 P.M., of an Immediate Jeopardy (IJ) which began on 8/4/20. The IJ was removed on 8/7/20, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control and Prevention (CDC) Preparing for COVID 19 in Nursing Homes guidelines, updated 6/25/20, showed the following: -Given their congregate nature and resident population served (older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and health care personnel (HCP); -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use; -Have a plan for how residents in the facility who develop COVID-19 will be handled: -Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated; -The facility is to provide supplies necessary to adhere to recommended infection prevention and control practices. The facility should position a trash can near the exit, inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room; -Environmental Cleaning and Disinfection: Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas. -If extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohort in the same area of the facility and these residents are not known to have any co-infections; -Reinforce adherence to standard IPC measures including hand hygiene and selection and correct use of PPE. Have HCP demonstrate competency with putting on and removing PPE and monitor adherence by observing their resident care activities; -HCP should wear a facemask at all times while they are in the facility; -Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room. Review of the facility's hand hygiene policy, dated August 2020, included the following information: -This facility considers hand hygiene the primary means to prevent the spread of infections; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -After removing gloves; -Before and after entering isolation precaution settings; -Hand hygiene is the final step after removing and disposing of personal protective equipment; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1. Review of the facility's list of COVID-19 positive residents, dated 8/5/20, showed the following: -Total of ten residents tested positive for COVID-19 as of 8/5/20; -Residents #1, #2, #3, #4, #5 #7, #10, #11 and #12 were included on the list of residents who tested positive for COVID-19. Upon entrance to the facility on [DATE] at 7:15 A.M., the business office manager (BOM) said there were positive residents on the 400 hall and also on the secured unit, which included the 300 and 500 halls. The residents on the secured unit would not be moved due to risk of elopement. At 7:48 A.M., the BOM said the red tape at the resident's room door meant the room had a positive resident. Yellow tape meant the resident had been exposed or was under quarantine. Observations of the secured unit on 8/5/20 at 7:45 A.M., 8:50 A.M., and 10:10 A.M., showed the facility failed to post signs at the entrance to the 300 hall or 500 hall to inform staff or visitors they were entering a COVID-19 positive area or to don the appropriate PPE. Observation of rooms, showed two rooms with red tape and one room with yellow tape on the 300 hall and one room with red tape on the 500 hall. Observations of the 400 hall on 8/5/20 at 8:00 A.M. and 10:20 A.M., showed the facility failed to designate an area for COVID-19 positive residents. The facility identified 6 residents who tested positive on the 400 hall and 10 negative residents remained on the 400 hall. The facility failed to post signs to inform staff or visitors they were entering a COVID-19 positive area or to don the appropriate PPE. Review of Resident #5's medical record, showed the following: -Admission face sheet, showed an admission date of [DATE] and a readmission date of [DATE]; -[DIAGNOSES REDACTED]. -A laboratory test, dated 7/31/20 and completed on 8/3/20, showed positive test result for COVID-19. Review of Resident #6's medical record, showed the following: -Admission face sheet, showed an admission date of [DATE] and a readmission date of [DATE]; -[DIAGNOSES REDACTED]. -No documentation of COVID-19 test or results. Observations on 8/5/20 at 8:47 A.M. and 10:20 A.M., showed resident #5 and #6 resided in the same room. Staff placed red tape around the exterior of the doorframe to indicate a positive resident. Staff failed to separate the positive resident from the negative/unknown status resident. During an interview on 8/6/20 at 12:30 P.M., the administrator verified Resident #5 tested positive for COVID-19 and the facility received the resident's test result late on 8/3/20. The administrator received the notification regarding the test results between 10:00 A.M. and 11:00 A.M. on 8/4/20. She notified the Assistant Director of Nursing (ADON) on 8/4/20 about Resident #5's positive test result and informed the ADON that Resident #5 needed be transferred to a room with another positive COVID-19 resident. The administrator said Resident #5 resided with Resident #6, who is negative for COVID-19 at the time Resident #5's test result showed positive for COVID-19. She expected nursing staff to have moved Resident #5 as she instructed on 8/4/20. She verified both Resident #5 and Resident #6 still resided in the same room on 8/5/20 at the time of the observation. The administrator said housekeeping staff deep cleaned/sanitized the room on 8/5/20. She said Resident #6 remained in the room, quarantined and monitored by nursing staff for signs/symptoms of COVID-19. Observations on 8/7/20 at 6:50 A.M., showed the following: -Resident #5 in a different room with another resident the facility identified as positive. Staff placed red tape around the exterior of the doorframe; -Resident #6 remained in his/her original room. The red tape was removed from around the doorframe. Staff failed to place yellow tape around the exterior of the doorframe to indicate the resident had been exposed. During an interview on 8/7/20 at 8:13 A.M., the administrator said she could not locate test results for Resident #6. There must have been an oversight and the resident was not tested . The COVID status of the resident was unknown. 2. Review of Resident #13's medical record, showed the following: -An admission face sheet, showed an admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test dated 7/31/20, completed on 8/3/20, showed negative test result for COVID-19. Observations of the secured unit on 8/7/20, showed from 6:54 A.M. until 7:05 A.M., Resident #5 sat in his/her wheelchair wearing a facemask in the TV area across from the nurses' station. Resident #13 lay in a geri-chair (reclining wheeled chair) in the TV room adjacent from Resident #5, approximately 6 feet apart from each other. Resident #13 did not wear a facemask. Nurse J sat at the nurses' station facing the two residents. Nurse J identified the two residents and verified Resident #5 was positive and Resident #13 was negative for COVID. At 6:57 A.M., Certified Nurse Aide (CNA) G arrived at the nurses' station and asked why Resident #5 was out of his/her room. Nurse J said Resident #5 missed his/her transportation to an appointment and was placed in the TV room by his/her roommate. CNA G said the resident should not be out of his/her room. Both staff members walked away from the nurses' station. Residents #5 and #13 remained in the TV area. At 7:05 A.M., CNA G, who wore two surgical masks, donned gloves and wheeled Resident #5 into his/her room. CNA G then exited the room without doffing the gloves or closing the door. CNA G failed to properly don an N95, goggles, hair covering and gown prior to entering the room. CNA G failed to doff the gloves inside the room before exiting. A sign posted on the resident's door, showed, Presumed COVID-19 positive, before entering room, please put on N95 (respiratory) mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. Observation inside the room, showed no biohazard waste barrels. During an interview on 8/7/20 at 11:26 A.M., CNA G said he/she worked with both positive and negative residents on the same shift. Red tape indicated a positive resident, yellow tape indicated a resident who was being observed and no tape meant the resident was negative. He/she has been educated on what PPE to wear into red rooms, which included head cover, goggles, N95 mask, shoe covers, gown and gloves, which go over the sleeves of the gown. When finished with the PPE, everything should be removed and discarded in the contamination can, except goggles and masks. Hands should be washed before coming out of the room. Doors to red and yellow rooms should remain closed at all times. If going into a yellow room, staff only have to wear masks, goggles and gloves. During an interview at 8/7/20 at 9:32 A.M., the the Director of Nursing (DON), said staff should have immediately moved Resident #5 to his/her room, and the door should be closed at all times to contain [MEDICAL CONDITION]. Staff should wear appropriate PPE for their protection and gloves should always be changed to prevent further spread of [MEDICAL CONDITION]. Housekeeping and everyone was responsible to make sure the biohazard barrels were inside resident rooms. They discovered on 8/5/20, they did not have enough barrels and have ordered more. 3. Review of Resident #9's medical record, showed the following: -An admission face sheet with an admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test dated 7/31/20, completed on 8/3/20, showed negative test result for COVID-19. Review of Resident #10's medical record, showed the following: -An admission face sheet with an admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test dated 7/31/20, completed on 8/3/20, showed positive test result for COVID-19. Observations on 8/5/20 at 7:49 A.M. and 9:45 A.M., showed Resident #9 and #10 resided in the same room. Staff placed red tape around the exterior of the doorframe to indicate a positive resident. Staff failed to separate the positive resident from the negative resident. Observations on 8/7/20 at 6:49 A.M. and 9:45 A.M., showed the following: -Resident #10 moved to a different room with another resident the facility identified as positive. Staff placed red tape around the exterior of the doorframe; -Resident #9 remained in his/her original room. The red tape was removed from around the doorframe. Staff failed to place yellow tape around the exterior of the doorframe to indicate the resident had been exposed. Further observations on 8/7/20 at 6:50 A.M., showed Resident #10 walked away from the nurses' station and did not wear a facemask. The resident stopped the surveyor and grabbed his/her shirt and commented on it. The resident then continued to walk down the hall towards his/her room. At 7:05 A.M., CNA G brought the resident's roommate into the room and left without closing the door. At 7:07 A.M., Resident #10 walked out of the room and started to walk down the hall. CNA F stopped and told the resident he/she needed to go back to his/her room. The resident returned to his/her room. CNA F walked away and the door to the room remained open. At 7:13 A.M., the door remained open as several staff passed by. During an interview on 8/7/20 at 7:20 A.M., CNA F said staff were trained to wear PPE into rooms with red tape, which included gown, N95, surgical mask, gloves, hair and shoe coverings. Staff should sanitize hands before donning PPE and after doffing. The door to rooms with red tape should remain closed to keep the germs inside. CNA F then donned gloves and closed the door to Resident #10's room. He/she then walked across the hall to a room with no tape on the exterior of the doorframe and wearing the same gloves, opened the door and went inside. Further observations of the doors with red tape on the secured unit, showed an additional sign which stated: CDC Guidelines: Effective 7/23/20; -Instructions for putting on PPE before entering a red room: -Sanitize hands; -Put on gown; -Put on N-95 mask; -Put on surgical mask; -Put on goggles; -Put on gloves-cover gown cuffs; -Instructions for taking off PPE before leaving a red room: -Remove gloves; -Remove gown; -Place gown and gloves in red trash bag and leave room; -Remove goggles; -Remove face mask; -Wash/sanitize hands; -All staff must follow the above directions step by step. These directions will be posted on outside of Red Room door. 4. Review of Resident #7's medical record, showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/31/20 and completed on 8/2/20, showed positive test result for COVID-19. Review of Resident #8's medical record, showed the following: -An admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/31/20 and completed on 8/3/20, showed negative test result for COVID-19. Observations on 8/5/20 at 7:49 A.M. and 10:10 A.M., showed Resident #7 and #8 resided in the same room. Staff placed red tape around the exterior of the doorframe to indicate a positive resident. Staff failed to separate the positive resident from the negative resident. Observations on 8/7/20 at 6:50 A.M. and 9:45 A.M., showed the following: -Resident #7 moved to a different room with another resident the facility identified as positive. Staff placed red tape around the exterior of the doorframe; -Resident #8 remained in his/her original room. Staff failed to place yellow tape around the exterior of the doorframe to indicate the resident had been exposed. During an interview on 8/7/20 at 11:26 A.M., CNA D said when residents were tested positive for COVID-19, they were moved to a single room without another roommate, unless the other roommate is also positive for COVID-19. The residents should be placed on isolation for up to 14 days. The CNA said no positive COVID-19 resident should be placed in a negative resident's room. The positive resident's door should be kept closed at all times and the positive resident should not be allowed to leave their room due to infection control. During an interview on 8/7/20 at 11:00 A.M., Nurse C said all positive COVID-19 residents should be isolated in a private or single room without a roommate unless both residents in the same room are positive. He/she said staff place red tape above and around the positive resident's door to indicate which residents are positive for COVID. When residents were admitted from the hospital, the residents were placed in a room with yellow tape above/around the edges of the door to indicate the resident in the room was on quarantine and should remain on quarantine for 14 days. The positive resident should be maintained on isolation for up to 14 days and/or if asymptomatic and should be retested prior to being taken off of isolation. He/she said every resident and staff member were tested every week at the facility. Nurse C said no positive resident should be in a room with a negative resident. The positive resident's door should be kept closed at all times. Review of the facility's COVID-19 Action Plan, dated 4/6/20, showed the facility failed to address any measures for deterring or containing [MEDICAL CONDITION] among residents. The action plan addressed how employees should be screened/monitored and steps to be taken to keep the employee safe if an employee cared for a resident with symptoms or a positive diagnosis. During an interview on 8/7/20 at 8:44 A.M., MDS Coordinator B (previous DON) said the facility did not have a COVID-19 policy/procedure regarding how to manage residents who test positive for COVID-19 and/or how to contain the residents with COVID-19. The MDS coordinator said he presented the COVID-19 Action Plan to the facility's corporate office for approval and noticed the Action Plan policy did not address how to manage and/or contain residents positive for COVID-19 when he presented the policy. The MDS Coordinator said he brought that to corporate's attention. He verified the facility did not have a policy specific to how to manage and/or prevent the spread of COVID-19 for residents. During an interview on 8/7/20 at 10:06 A.M., the DON said she was not aware there were positive residents on the secured unit prior to the survey team informing her on 8/5/20. She was only aware of positive residents on the 400 unit. She would have expected the residents exposed to positive residents be retested immediately and placed on observation. During interviews on 8/5/20 at 8:05 A.M. and on 8/7/20 at 9:32 A.M., the administrator said they realized the positive residents on the secured unit had remained in the same room as their negative roommates after the state surveyors began asking questions on 8/5/20. The positive residents were moved together on 8/5/20. The negative roommates were being tested today during the facility wide testing, and were on observation. The administrator was not aware there needed to be a designated area for residents who were COVID-19 positive. They had their first positive test result on 7/24/20 and began making room changes. They were in the process of making a COVID-19 hall, but were having difficulty with some residents who did not want to move. They were trying to keep positive residents together. Staff knew which residents were on observation because their rooms were outlined with yellow tape. Staff were inserviced on what the red and yellow tape indicated prior to 8/4/20. The maintenance director was responsible to ensure the correct tape was posted around the doorframes. The administrator said there was not a specific policy in place regarding how to manage residents who tested positive for COVID-19 and/or how to contain the residents with COVID-19. They have had in-services. She began at the facility on 3/2/20, and expected there to be a policy in place before she started. The facility was in the process of being purchased, and she was dealing with the transition. The company that purchased the facility on 5/1/20, was currently reviewing and writing policies for the facility. The facility does not have an Infection Preventionist (IP) currently, but is in the process of hiring a Physician's Assistant (PA) who will be the facility's IP. The administrator said she is currently responsible for tracking all positive COVID-19 cases within the facility. She said the former DON was responsible for tracking all other infections within the facility. The current DON who recently started at the facility, will be responsible for tracking all other infections within the facility. During an interview on 8/10/20 at 12:15 P.M., the social worker for the facility's medical director, said the doctor would have expected staff to move the positive residents out of the same room as negative residents right away. The residents who had been exposed should have been retested immediately. The facility should have followed their policy and procedure. The facility did not have anything in place prior to this. 5. Review of Resident #11's medical record, showed the following: -An admission face sheet, showed an original admission date of [DATE], and a current admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/31/20 and completed dated 8/3/20, showed positive test result for COVID-19. Observations of Resident #11's room on 8/4/20 at 7:50 A.M., 8:47 A.M. and 10:20 A.M., showed a sign posted on the resident's door, Presumed COVID-19 positive, before entering room, please put on N95 (respiratory) mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. Staff placed yellow tape on the exterior of the doorframe. Staff failed to correctly identify the positive status of the resident. During an interview on 8/7/20 at 9:32 A.M., the administrator said she did not know why the tape on Resident #11's was yellow since he/she tested positive on 8/3/20. 6. Observation of the kitchen on 8/5/20 from 7:36 A.M. until 7:38 A.M., showed the dietary manager (DM) walked in, out and throughout the kitchen without a facemask. During an interview at 7:38 A.M., the DM said he expected staff to wear a facemask at all times. He did not have on a facemask because he was cooking. He agreed he should wear a facemask while preparing food. Further observation of the kitchen on 8/5/20 at 9:26 A.M., showed the following: -One dietary aide scrubbed dishes with his/her facemask pulled down to his/her chin with his/her nose and mouth exposed; -Two dietary aides stood next to the food prep table with their masks pulled down under their chins with mouths and noses exposed; -The DM stood inside the kitchen with his mask pulled down under his chin with his mouth and nose exposed. During an interview at 9:27 A.M., the DM said he was responsible for ensuring dietary staff wear masks properly. Observation on 8/7/20 at 7:15 A.M., showed Floor Technician A with his/her facemask underneath his/her chin, buffing the floors next to the nurse's station between the 200 and 300 Halls. At 7:18 A.M., the floor technician positioned his/her facemask over his/her nose and mouth. During an interview at 7:18 A.M., Floor Technician A said he/she should have a facemask at all times that covered his/her nose and mouth. The floor technician said he/she received an in-service at the facility regarding the proper way to wear a facemask, and a facemask should be worn at all times when in the facility. During an interview on 8/7/20 at 9:33 A.M., the administrator and DON said they expected all staff to wear facemasks and should cover their nose/mouth at all times when they are in the building to prevent the spread of the COVID-19 virus. It was not appropriate for staff to wear their facemasks below their chin. 7. During an interview on 8/5/20 at 7:30 A.M., the ADON verified Residents #1, #2, #3 and #4 were in designated positive COVID-19 rooms due to testing positive for COVID-19. He said the red tape above the resident's door indicated the resident was positive for COVID-19. Review of Resident #1's medical record, showed the following: -Admission face sheet with an admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/24/20 and completed on 7/27/20, showed positive test result for COVID-19. Observation of Residents #1's room, at the front of the 400 Hall, showed the following: -On 8/5/20 at 7:49 A.M. and 9:30 A.M., of a sign posted on the resident's door, Presumed COVID-19 positive, before entering room, please put on N95 (respiratory) mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. The two isolation biohazard bins positioned directly outside of the resident's room in the hallway. -On 8/7/20 at 6:52 A.M., the two isolation biohazard bins remained positioned directly outside of the resident's room in the hallway. There was no red isolation bin and/or linen bins inside the resident's room. -The room directly across from Resident #1 was occupied by a non-COVID resident. 8. Review of Resident #2's medical record, showed the following: -Admission face sheet with a readmission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/24/20 and completed 7/27/20, showed positive test result for COVID-19. Observations of Resident #2's room, showed the following: -On 8/5/20 at 7:49 A.M. and 9:30 A.M., a sign posted on the resident's door, Presumed COVID-19 positive, before entering room, please put on N95 mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. The two isolation biohazard bins were positioned directly outside of the resident's room in the hallway. -On 8/7/20 at 6:58 A.M., one bin, marked linen, positioned directly outside of the resident's room and no isolation bins positioned inside of the resident's room. 9. Review of Resident #3's medical record, showed the following: -Admission face sheet with an admission date of [DATE] and readmission date of [DATE]; -[DIAGNOSES REDACTED]. -Hospital COVID-19 test, dated 8/1/20, positive for COVID-19. Review of Resident #4's medical record, showed the following: -Admission face sheet with an admission date of [DATE]; -[DIAGNOSES REDACTED]. -Laboratory test, dated 7/31/20 and completed on 8/3/20, showed positive test result for COVID-19. Observations of Resident #3 and #4's shared room, showed the following: -On 8/5/20 at 7:50 A.M. and 9:30 A.M., a sign posted on the door, Presumed COVID-19 positive, before entering room, please put on N95 mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. The two isolation biohazard bins positioned directly outside of the residents' room in the hallway; -On 8/7/20 at 7:00 A.M., one yellow linen bin positioned directly outside of the residents' room in the hallway; -The room directly across from Resident #3 and #4 occupied by a non-COVID resident. 10. Review of Resident #12's medical record, showed the following: -Admission face sheet with an admission date of [DATE] and readmission date of [DATE]; -Laboratory test result, dated 7/31/20 and completed 8/2/20, showed positive test result for COVID-19. Observation of Resident #12's room, showed the following: -Room located in the middle of the 400 hall; -On 8/7/20 at 6:58 A.M., a sign posted on the resident's room door, Presumed COVID-19 positive, before entering room, please put on N95 mask, disposable mask on top of N95 mask, gloves, gown and goggles. Upon exiting the room, please dispose of disposable masks, gowns, goggles and gloves in the red isolation garbage bin. No isolation biohazard bins located inside of the resident's room. 11. Observations of the 300 hall on 8/5/20 at 7:46 A.M. and 9:05 A.M., showed the following: -rooms [ROOM NUMBERS] with red tape around the doorframe and a small cabinet containing PPE on the outside of the room; -No biohazard waste bins inside or outside of the room. 12. Observations of room [ROOM NUMBER] on 8/5/20 at 7:48 A.M., 8:50 A.M. and 10:20 A.M., showed red tape around the exterior doorframe and two large trash receptacles with lids outside of the room, approximately 6 feet from the doorway of the room. One trash receptacle had a yellow plastic liner and marked linen and the other had a red plastic liner and marked trash. During an interview on 8/5/20 at 10:44 A.M., the DON said she expected the biohazard bins to be positioned inside each of the positive resident's rooms to ensure all PPE used by staff were contained within the resident's room. The biohazard bins should not be positioned outside of the positive COVID-19 resident's room due to infection control. 13. Observation of room [ROOM NUMBER], identified as a COVID-19 positive room with red tape around the exterior of the door frame on 8/5/20 from 8:47 A.M. to 9:03 A.M., showed one resident in a wheelchair wearing a mask and another resident standing beside the bed closest to the door without a mask. Housekeeper E wore a gown, hair covering, surgical mask with tissue visible from inside, gloves and an N95 mask hanging around his/her neck. He/she did not wear eye protection. He/she came out of the room with a trash can and stood at the cleaning cart positioned approximately 4 feet outside of the room. He/she placed the trash can on top of the cart. He/she p (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide appropriate care and services to identify, assess, monitor, treat and aid in the healing of pressure ulcers. Of the four residents the facility identified as having pressure ulcers, two were chosen for the sample and problems were found with both. An additional resident, identified as at risk for developing pressure ulcers, was chosen for the sample. On 9/4/17, facility staff documented bruising on the right buttock. There was no further documentation or skin assessments for the resident until 9/14/17, while at a vascular clinic appointment, the resident complained of buttock pain and was found to have an unstagable pressure ulcer on the right buttock and a Stage III pressure ulcer on the left buttock (#26, #3 and #11). The census was 100. 1. Review of Resident #26's annual Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/20/17, showed the following: -admitted [DATE]; -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS, a brief screen for cognitive impairment) score: 15 of 15 (13-15 cognitively intact); -Understood/understands; -Frequently incontinent of bowel and bladder; -Required total assistance from staff for transfers, dressing, toileting, personal hygiene and bathing; -Required extensive assistance for bed mobility; -No behaviors; -Non-ambulatory; -Determination of Pressure Ulcer Risk: formal assessment instrument/tool and clinical assessment; -At risk for pressure ulcers; -No pressure ulcers. Review of the resident's care plan, dated 7/22/17, showed the following: -Problem: At risk for pressure ulcers related to incontinence and mobility deficit; -Goal: Skin will remain intact; -Approaches: Conduct a systematic skin inspection per facility protocol, pay particular attention to bony prominences. Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry and wrinkle free. Provide incontinence care after each incontinent episode. Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of skin and avoid friction to skin. Report any signs of skin breakdown (sore, tender, red or broken areas). Use moisture barrier product to perineal area. Review of the resident's medical record, showed no Braden scale assessment (for predicting pressure ulcer risk) documented. Review of the resident's social services progress note, dated 8/17/17, showed the social worker documented the resident was feeling ill and was assessed by a physician recently regarding wound treatment. The toes on the resident's left foot were amputated and he/she was assessed at a wound clinic for treatment of [REDACTED]. During an interview on 10/10/17 at 9:20 A.M., the Director of Nurses (DON) said she started working at the facility on 9/25/17. Six residents were assessed by a wound physician that came to the facility on Mondays. There was no facility wound report. The facility keeps copies of the weekly wound physician's reports for each resident assessed. The resident was not assessed by the facility's wound physician, he/she went to a wound clinic weekly for a vascular ulcer on his/her left foot. The DON was not aware the resident had any pressure ulcers, but if so the wound clinic would assess them as well. She expected the wound clinic assessments to be in the resident's medical record. Review of the resident's physician's orders [REDACTED]. -Diagnoses: [REDACTED]. the blood), [MEDICAL CONDITION] (high cholesterol), [MEDICAL CONDITION] disorder and [MEDICAL CONDITION] (nerve pain); -Right leg amputation. Review of the resident's Licensed Nurse Weekly Skin Assessment, dated 9/4/17, showed Nurse A documented bruising on the resident's right buttocks. Review of the resident's medical record, showed no additional documentation, regarding the bruising on the right buttock, assessed on the 9/4/17 Licensed Nurse Weekly Skin Assessment and no treatment orders. Review of the resident's medical record, showed no skin assessments, dated 9/5/17 through 9/13/17 and no documentation regarding any skin issues. Review of the resident's Ambulatory Assessment Inquiry (wound physician assessment) from the wound clinic, dated 9/14/17 at 11:25 A.M., showed the following: -Bilateral ischial (lower portion of hip bone) pressure ulcers; -The right ischium was identified as an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) that measured 5.0 centimeters (cm) by 5.0 cm by unable to determine (UTD). Pain was present, no odor was assessed. The wound bed was covered with slough (yellow or white tissue that adheres to the ulcer in strings or think clumps, or is mucinous), red/purple discoloration and eschar (dead tissue). There was a moderate amount of serosanguineous (a semi-thick reddish fluid) drainage assessed. The wound edges had peripheral tissue [MEDICAL CONDITION] and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture). The periwound (area surrounding the wound) was white/gray pallor, pink and macerated; -The left ischium was identified as a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) that measured 4.0 cm by 4.0 cm by 0.1 cm. Pain was present, no odor was assessed. The wound bed was covered with pink/beefy red tissue, granulation (healthy) tissue and slough. There was a moderate amount of serosanguineous drainage. The wound edges had peripheral tissue [MEDICAL CONDITION] and maceration. The periwound was white/gray pallor, pink and macerated. -This appointment was only scheduled regarding the resident's left foot. This was the first time the pressure ulcers on the resident's left and right ischium were assessed. Review of the resident's POS, dated 9/14/17, showed a new treatment, status [REDACTED]. Review of the resident's medical record, showed no copy of the wound clinic report, dated 9/14/17, or any documentation of an assessment of the pressure ulcers on the resident's right and left ischiums. Review of the resident's nurse's note, dated 9/15/17, showed staff documented the following: -At 6:45 A.M., the resident refused to go to a physician's appointment because his/her buttocks was sore. Staff told the resident a cushion would be placed in his/her wheelchair. The resident continued to refuse to go to [MEDICAL TREATMENT]; -At 11:30 P.M., the wound physician's orders [REDACTED]. Review of the resident's medical record, showed no documentation the resident's buttocks was assessed when he/she complained of buttock pain on 9/15/17. Review of the resident's treatment administration record (TAR), dated 9/15/17 through 9/28/17, showed staff documented the treatment was administered to the resident's buttocks per physician's orders [REDACTED]. Review of the resident's nurse's note, dated 9/18/17, showed staff documented the resident complained of buttocks discomfort. Wound on left and right buttocks. Santyl and dry dressing administered. PRN pain medication administered. Review of the resident's Licensed Nurse Weekly Skin Assessment, dated 9/18/17, showed Nurse A documented a treatment was in place on the resident's left and right buttocks. During an interview on 10/10/17 at 11:50 A.M., the administrator said she was aware the resident had pressure ulcers on his/her sacrum (a triangular-shaped bone at the bottom of the spine). She assessed the pressure ulcer on the morning on 9/19/17. She checked the resident's medical record to ensure there was an appropriate treatment. She did not document an assessment of the pressure ulcer or measure it at that time. She guessed the size was about 5.0 cm by 5.0 cm on the resident's right sacrum and 10.0 cm by 5.0 cm on the resident's left sacrum. The pressure ulcer was identified as an Unstageable pressure ulcer due to the large amount of slough assessed. Review of the resident's Ambulatory Assessment Inquiry (wound physician assessment) from the wound clinic, dated 9/19/17 at 1:39 P.M., showed the following: -The right ischium was identified as an unstageable pressure ulcer that measured 6.4 cm by 3.0 cm by UTD. No pain or odor was assessed. The wound bed was covered with slough. There was a moderate amount of serosanguineous drainage assessed. The wound edges were rolled (rolled down toward the wound bed). The periwound was pink; -The left ischium was identified as a Stage III pressure ulcer that measured 3.5 cm by 4.0 cm by 0.1 cm. No pain and odor was assessed. The wound bed was covered with pink/beefy red tissue and granulation tissue. There was a moderate amount of serosanguineous drainage. The wound edges were rolled. The periwound was pink. Review of the resident's medical record, showed no copy of the wound clinic report, dated 9/19/17, or any documentation of an assessment of the pressure ulcers on the resident's right and left ischiums. Review of the resident's nurse's note, dated 9/21/17 at 4:30 P.M., showed staff documented the resident returned from the wound clinic appointment. A follow up appointment was scheduled for 10/25/17 at 8:00 A.M. Review of the resident's Ambulatory Assessment Inquiry (wound physician assessment) from the wound clinic, dated 9/21/17 at 12:43 P.M., showed no assessment of the pressure ulcers on the bilateral ischiums. Review of the resident's Ambulatory Assessment Inquiry (wound physician assessment) from the wound clinic, dated 9/26/17 at 11:40 A.M., showed the following: -The right ischium was identified as an unstageable pressure ulcer that measured 4.2 cm by 3.8 cm by UTD. Pain was present, no odor was assessed. The wound bed was covered with slough and eschar. There was a moderate amount of serosanguineous drainage assessed. The wound edges were rolled. The periwound was pink and bright red; -The left ischium was identified as a Stage III pressure ulcer that measured 3.5 cm by 4.0 cm by 0.1 cm. No pain or odor was assessed. The wound bed was covered with pink/beefy red tissue and granulation tissue. There was a moderate amount of serosanguineous drainage. The wound edges had peripheral tissue [MEDICAL CONDITION]. The periwound was pink and bright red. Review of the resident's nurse's note, dated 9/26/17 at 6:20 P.M., showed staff documented the resident returned from the wound clinic. A copy of the wound report was placed in the resident's medical record. Review of the resident's medical record, showed no copy of the wound clinic report, dated 9/26/17, or any documentation of an assessment of the pressure ulcers on the resident's right and left ischiums. Review of the resident's nurse's note, dated 9/28/17 at 2:30 P.M., showed staff documented the hospital called and said the resident was admitted for low blood pressure, low blood sugar and [MEDICAL CONDITION] (infection of the blood). Review of the resident's Re-Admission Nursing Evaluation/Data Collection, dated 10/5/17 at 7:30 P.M., showed staff documented his/her skin was warm and dry. There was no head to toe skin assessment documented in the medical record. Review of the resident's nurse's note, dated 10/5/17, showed the following: -At 7:30 P.M., the resident was readmitted to the facility. There was no skin assessment documented; -At 10:30 P.M., the resident refused body assessment at that time, will try again later. Review of the resident's medical record, showed no readmission Braden scale assessment documented and the care plan was not updated. During an interview on 10/17/17 at 8:00 A.M., Nurse Z said he/she worked the evening shift, from 3:00 P.M. through 11:00 P.M., on Tuesday and Thursdays and readmitted the resident on 10/5/17. He/she knew the resident had a wound on his/her left foot but was not aware of the pressure ulcer on the resident's buttocks. The night shift nurse administers treatment so he/she never saw the resident's buttocks. Nurse Z notified the night shift nurse, Nurse BB, that the readmission skin assessment was not completed because the resident refused to lay in bed. Nurse BB told him/her he/she would complete the skin assessment when he/she administered the wound treatment. When a new open area was assessed he/she documents the location of the open area in the resident's nurse's notes and notifies the resident's physician for a treatment order. Nurse Z does not document the measurement of the new open area. He/she documents what he/she observed, for example an open area. He/she would also document the new open area on the nurse report sheet and notify the night shift charge nurse. Nurse Z would document the new open area on a skin assessment form and notify the DON. During an interview on 10/10/17 at 1:10 P.M., Nurse BB said he/she worked the night shift, from 11:00 P.M. on 10/5/17 through 7:00 A.M. on 10/6/17. The resident was readmitted from the hospital earlier that day. The evening shift nurse did not communicate that the head to toe skin assessment was not completed. It was his/her understanding the readmission nursing assessment was completed. During an interview on 10/10/17 at 11:50 A.M., the administrator said when a resident was discharged to the hospital and was out of the facility for over 23 hours, they were considered a full discharge and then re-admission. She expected staff to complete a head to toe skin assessment within four hours of a resident's re-admission to the facility and if the resident refused the skin assessment staff should document that in the resident's medical record and communicate to the next shift nurse that the skin assessment was not completed. It was important to assess and document a head to toe skin assessment upon re-admission so staff know if a pressure ulcer was getting better or worse. The administrator was not aware that no skin assessment was documented when the resident was readmitted to the facility on [DATE]. Review of the resident's POS, dated 10/1/17 through 10/31/17, showed an order dated 9/15/17, to cleanse the resident's bilateral ischiums with saline, cover with silver alginate, gauze and secure with tape every day. Review of the resident's TAR, dated 10/1/17 through 10/31/17, showed staff initialed the treatment as administered to the resident's buttocks on 10/6/17 and 10/9/17. The following dates were blank: 10/5/17, 10/7/17 and 10/8/17. The back of the TAR was blank. Review of the resident's Licensed Nurse Weekly Skin Assessment, dated 10/9/17, showed Nurse A documented a circle drawn on the diagram on the resident's right and left buttocks. Review of the resident's social service progress note, dated 10/9/17, showed the social worker was made aware the resident was telling staff he/she was going to refuse to go to the wound clinic. The social worker documented speaking to the resident and found out the resident was refusing a lot of treatments and care in general. The resident said the appointments were too early in the morning, so the social worker pushed the appointments to later in the day and the resident still refused to go. The social worker documented she educated the resident that wound treatment appointments were important to be compliant with and to follow all physicians' orders. Review of the resident's medical record, dated 10/5/17 through 10/10/17, showed no skin assessment of the bilateral ischium pressure ulcers. During an interview on 10/10/17 at 10:15 A.M., Nurse AA said he/she works the day shift, from 7:00 A.M. through 3:00 P.M., and was assigned to the resident. The resident had two pressure ulcers on his/her buttocks. They started off as blisters that opened. The resident smokes cigarettes a lot and was noncompliant with care. The resident sometimes refuses activities of daily living (ADL) care. He/she had not seen the resident's pressure ulcers in weeks because the night shift nurse administers wound treatments and assesses residents' skin. The skin assessments are documented on the weekly skin assessment form in the resident's medical record. When staff notify him/her of a new open area or skin concern he/she assesses the area immediately, notifies the resident's physician for a treatment order and documents the assessment and new treatment order in the resident's medical record. The facility does not have a wound nurse. A contracted wound company comes to the facility every Monday. Observation on 10/10/17 at 10:30 A.M., showed the resident was asleep on his/her back, on a two tone (pressure reducing) mattress. The resident was laying directly on his/her back. During an interview on 10/10/17 at 10:32 A.M., Certified Nurse Aide (CNA) T said he/she worked 7:00 A.M. through 3:00 P.M., and was assigned to the resident. The resident had skin breakdown on both sides of his/her buttocks. The nurses administer a treatment. The resident did not refuse ADL care from him/her. During an observation and interview on 10/10/17 at 10:45 A.M., showed CNA T entered the resident's room to provide ADL care. CNA T turned the resident onto his/her left side and exposed his/her buttocks. There were two large dressings, dated 10/10/17, on the resident's bilateral ischiums. The dressings were clean, dry and intact. There was a cushion in the resident's wheelchair. The resident was alert and able to make his needs known. He/she did not recall refusing to allow the facility's wound specialist to assess his/her wounds. The resident said he/she goes to the wound clinic once a week for his/her left foot and they look at his/her buttocks as well. The wound clinic treated his/her left foot wound with a hyperbaric chamber (therapy to promote healing by increasing the amount of oxygen in the blood) to heal the wound from the inside out. During an observation and interview on 10/10/17 at 11:30 A.M., the resident was outside in his/her wheelchair smoking a cigarette. He/she likes to lay down throughout the day but staff are not helpful, so he/she stays up. During an interview on 10/10/17 at 1:10 P.M., Nurse BB said he/she works the night shift, from 11:00 P.M. through 7:00 A.M., and was assigned to the resident often. The resident's weekly skin assessments were due every Monday. He/she worked at the facility every other Monday. He/she assessed the resident's skin and documented what he/she assessed on the Licensed Nurse Weekly Skin Assessment. The nurses are not supposed to measure the areas for the weekly skin assessment. He/she was trained to draw a circle and document what the circle was, for example a redness, a bruise or an open area. On 9/15/17 the resident complained of buttocks pain. He/she assessed the resident's buttocks and noted two open areas. Nurse BB called the resident's physician but did not receive a call back. He/she notified the day shift charge nurse of the new areas. He/she was very busy at the end of the shift and thought the day shift nurse would follow through. The resident's wounds on his/her buttocks and left foot were assessed weekly at the wound clinic on Tuesdays. Review of the facility's contracted wound company's report, dated 10/16/17, showed the following: -Right ischium was identified as a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) that measured 5.10 cm by 4.0 cm by 1.10 cm. There was no assessment of the wound bed, wound edges or periwound documented; -Left ischium was identified as an unstageable pressure ulcer that measured 3.40 cm by 5.10 cm by 2.0 cm. There was no assessment of the wound bed, wound edges or periwound documented. During an interview on 11/15/17 at 1:05 P.M., the facility's contracted wound company's nurse practitioner said she initially assessed the resident's right and left ischium on 10/16/17. She did not assess the resident prior to that because the resident was being assessed by a vascular wound clinic weekly. She was not aware the resident had pressure ulcers on his/her bilateral ischiums prior to 10/16/17. Pressure ulcers on the ischium were difficult to heal because the resident sat up in his/her wheelchair all day. A low air loss mattress and a pad in his/her wheelchair would help to relieve the pressure from the ischial pressure ulcers. During an interview on 10/10/17 at 10:00 A.M., the social worker said the resident was refusing to go to [MEDICAL TREATMENT]. She spoke to the resident who told her all he/she wanted to do was smoke cigarettes. She educated the resident often about following all physicians' orders and being compliant with physicians' orders, but the resident continued to refuse. The social worker thought the noncompliance was documented on the resident's care plan and if it was not, it should have been. The social worker was not aware the resident had skin issues other than the vascular ulcer on his/her left foot. She did not know if the resident was compliant with pressure ulcer treatments. During an interview on 10/10/17 at 9:20 A.M., the DON said the resident was noncompliant with care. He/she was alert and able to make his/her needs known. When the resident refused care she expected staff to document what the resident refused and why, in the nurse's notes. The noncompliance with care should also be documented on the resident's care plan and the resident's physician should be notified as well. CNAs were expected to keep staff updated when they observe an open area. She expected CNAs to notify the charge nurse and/or her so staff would add the resident to the facility's wound specialist list and notify the resident's physician. She was a wound nurse in the past and said she would assess new wounds within 24 hours. During an interview on 10/10/17 at 1:50 P.M., the resident's wound clinic's clinical nurse leader said the wound clinic specialized in vascular wounds. On 9/14/17 the resident refused to allow the wound physician to assess the vascular ulcer on his/her left foot. The wound physician asked why and the resident told him because my butt hurts. The wound clinic staff assisted the resident to lay down and assessed the resident's buttocks. The resident's right ischium was an unstageable pressure ulcer that measured 5.0 cm by 5.0 cm and the left ischium was a Stage III pressure ulcer that measured 4.0 cm by 4.0 cm by 0.1 cm. The wound clinic was not aware the resident had pressure ulcers on his/her ischiums. During an interview on 10/17/17 at 9:00 A.M., the wound clinic's physician said he/she expected the facility to follow all the wound policies. A licensed nurse should assess all residents' skin thoroughly every week. When there was a pressure ulcer assessed, a licensed nurse should document the assessment in the resident's medical record. The assessment should include the size, stage of the pressure ulcer, type and amount of drainage and what the wound bed looks like. The thorough weekly skin assessment was important for the facility to know if the pressure ulcer was getting better or worse. The facility should have notified the wound clinic of the pressure ulcers on the resident's ischiums so they could have assessed them sooner. He assumed the resident had a low air loss mattress at the facility because it would help to relieve pressure. Additional interventions like the low air loss mattress should have been implemented as soon as the licensed nurse assessed the pressure ulcers. During an interview on 10/10/17 at 1:40 P.M., the DON said when the nurse administered a treatment she expected the nurse to initial the TAR. When there were blank boxes on a resident's TAR, she could only assume the treatment was not documented, and it was not administered. During an interview on 10/10/17 at 11:50 P.M., the administrator said she recalled the resident complained of buttocks pain early September 2017. She put a cushion in the resident's wheelchair but the resident did not like the cushion in the wheelchair so he/she threw it out of the wheelchair. She expected the MDS coordinator to update the resident's care plan, including new pressure ulcer interventions. She also expected staff to follow the facility's wound management policy. When a new skin concern was assessed, the charge nurse was expected to document the assessment on a Wound Communication Sheet. Staff are to document what they see on the Wound Communication Sheet and then draw a circle where the area of concern is on the diagram of a human body. The administrator found that was the easiest way to simplify assessing a new wound because not all nurses measure wounds properly. The DON assesses new wounds within 24 hours of receiving the Wound Communication Form. The resident refused to be assessed by the facility's contracted wound company. The facility's wound specialist came to the facility on Mondays, but changed the day since the resident had another appointment that day. The wound physician came to the facility on Thursday one week, but the resident continued to refuse to allow the wound physician to assess him/her. Review of the resident's medical record, showed no Wound Communication Forms. During an interview on 10/10/17 at 12:40 P.M., the administrator said the system is broken, there is no communication between the nurses and administration. We cannot do anything about a new open area or skin concern if we do not know about it. 2. Review of the facility's Wound Management Policy and Procedure, updated 2016, showed the following: -Policy: risk assessment is a central component of the wound prevention program and of clinical practice, which is aimed at identifying residents susceptible to pressure ulcers in order to target appropriate interventions and prevent pressure ulcer development. It is the policy of the facility to identify residents with activity and mobility limitations that put these individuals at risk for pressure ulcer development as well as identification of any alterations in skin integrity; -Procedure: The admitting nurse will complete a Braden scale assessment as soon as possible upon admission or readmission to the facility, but not to exceed eight hours after admission, to assess and identify residents at risk for developing pressure ulcers. The Braden scale assessment will be repeated quarterly and with significant change in status, as determined by resident acuity by a licensed nurse. The admitting nurse will perform a comprehensive skin assessment to evaluate any alternations to intact skin upon admission or readmission. The documentation should include at a minimum: interview of resident or family history of skin alterations. Physical evaluation to include identification of: skin alterations present on admission, skin discolorations and any evidence of scarring on pressure points, signs/symptoms/[DIAGNOSES REDACTED]. -The admitting nurse will document all alterations to intact skin on the admission skin assessment sheet as well as in the resident's nurse's notes. The documentation should include at a minimum: location of wound, length, width, depth measurements documented in centimeters (Note: perpendicular measurements of the greatest extent of length and width of the ulceration should be performed with length being from head to toe), direction and length of tunneling and undermining, appearance of the wound base, type and percentage of tissue in wound, drainage amount and characteristics, including color, consistency and odor, appearance of wound edges, description of the periwound condition or evaluation of the skin adjacent to the wound; presence or absence of new epithelium at wound rim, pain: if present (Note: the nature and frequency should be noted); -The admitting nurse will: assess the resident's clinical condition to and identify residents at risk of developing pressure ulcers. Indicators in clinical condition that may contribute to pressure ulcer development include: bedfast and/ or chair fast status, existing pressure ulcer, poor overall skin condition, decreased perfusion and oxygenation, poor or altered nutritional status, increased skin moisture, increased body temperature, advanced age, sensory perception limitations, hematological issues and poor overall health status and will initiate pressure ulcer prevention protocol precautions for all residents identified to be at risk of developing pressure ulcers; -The DON or designee will perform an audit of the resident's chart within 24 hours of admission to ensure all preventative measures have been initiated properly; -Any resident with a Braden scale score of 17 or below and/or any resident presenting with significant clinical indicators will be considered at risk for the development of pressure ulcers; -Any interventions implemented will be included on the resident's individual plan of care; -The MDS Coordinator or designee will be responsible for updating the Braden scale assessment a minimum of quarterly and with any significant change in condition; -All residents will have a documented weekly head to toe assessment performed by a licensed nurse; -Weekly documentation of the licensed nurse skin assessment will be completed on the weekly skin assessment sheet and place in a binder for the month; -Upon completion of the month, the weekly skin assessment sheet will be filed in the nurses' notes or under the wound tab of the resident's medical record; -The DON or designee will complete a weekly wound report on all identified skin alterations, including pressure ulcers, stasis ulcers, surgical incisions, skin tears and any other skin alterations. The DON will file the weekly wound report in the wound binder. The DON maintains twelve months' worth of wound reports in the wound binder complete dermal sheets on all pressure ulcers, which will be filed in the resident's medical record under the nurses' notes or the wound tab and in the wound binder; -The DON or designee will perform visual audits of every resident's skin by performing a comprehensive skin assessment a minimum of quarterly. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed: -[DIAGNOSES REDACTED]. -Moderate cognitive impairment; -Incontinent of bowel and bladder; -A Stage IV pressure ulcer that measured 0.4 cm long by 1.6 cm wide with slough; -Required total assistance from the staff for transfers, dressing, personal hygiene and bathing. Review of the resident's POS, dated 11/1/17 through 11/30/17, showed: -An order dated 9/28/17, to apply [MEDICATION NAME] 5% ointment (used to treat pain) to affected area once a day; -An order dated 10/5/17, to cleanse the right foot with wound cleanser, apply triple antibiotic ointment (TAO) and [MEDICATION NAME] AG (a non-adherent antimicrobial dressing) 1 inch rope to the right heel, cover with gauze and non-adhesive foam dressing PRN; -No orders for any type of protective boot to the right foot. Review o

Based on observation, interview, and record review, facility staff failed to ensure confused residents on the locked dementia/behavior unit did not have access to hazardous chemicals in one resident's (Resident #6) bathroom, in which staff placed a mop bucket containing floor cleaner. Additionally, staff failed to secure hazardous personal hygiene products out of the reach of confused residents on the locked unit. The facility census was 92. 1. Record review of Resident #6's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/27/15, showed staff assessed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate impairment of cognitive abilities. Additionally, staff did not assess the resident had behaviors or wandered during the assessment period. Record review of the resident's Psychiatric Follow-up Evaluation, dated 5/14/15, showed the mental health professional documented the resident was alert and oriented to him/herself only. Record review of the resident's physician's orders [REDACTED]. During the initial tour on 6/29/15 at 10:03 A.M., the Assistant Director of Nursing (ADON) said the resident's behaviors included disrobing, turning on water faucets and leaving them running, flushing toilets, and urinating on his/her floor. Observations on 6/29/15, showed the resident ambulated independently throughout the locked unit, including his/her bathroom. During this time, the resident repeatedly turned random bathroom faucets on and left them running, and flushed toilets multiple times. Observations on 6/29/15 at 12:40 P.M., 1:15 P.M., and 2:33 P.M., showed a mop bucket with standing liquid sat in the resident's bathroom. During these times, a strong chemical odor permeated from the liquid substance in the bucket. During an interview on 6/29/15 at 1:20 P.M., Certified Nurses Aide (CNA) A said the resident urinates on his/her floor so staff keep the mop bucket in the resident's room at all times so they can clean the floor. During an interview on 6/29/15 at 1:40 P.M., Housekeeper B said staff leave the mop bucket with cleansing solution in the resident's room all the time. Record review of the Material Safety Data Sheet (MSDS) for the chemical (floor cleaner) used in the mop water solution showed if the cleaner is ingested, do not induce vomiting, call the physician, and the person should drink two to three glasses of water. Additionally, review showed the chemical can cause damage to the eyes and skin, and should be kept in a well-ventilated area. The MSDS showed users should wear goggles and gloves when handling the chemical. During an interview on 6/29/15 at 1:55 P.M., the Director of Nursing (DON) said it is never okay to keep a mop and bucket with floor cleaner in a resident's room. During an interview on 6/30/15 at 7:51 A.M., CNA D said the resident knows where his/her room is and where the dining room and bathrooms are located, but CNA D is not sure the resident knows he/she is in a nursing home. 2. Observations on 6/29/15 at 9:15 A.M. and 1:38 P.M., showed the unlocked shower room/bathroom on the locked unit contained a linen cart with four cans of shaving cream with labels stating keep out of reach of children. Additionally, there was one can of spray deodorant with a label stating if swallowed, get medical help or call Poison Control Center right away. Concentrating and inhaling the contents may be harmful or fatal. Observation on 6/29/15 at 9:20 A.M., showed Resident #6 entered the shower room/bathroom, flushed the toilet, turned on the sink faucet, and exited the bathroom. The resident walked quickly from the shower room/bathroom to his/her room, then returned to the shower room/bathroom. The resident flushed the toilet and exited the bathroom. The shower room/bathroom was unlocked and unattended. During an interview on 6/29/15 at 1:15 A.M., CNA A said the shower room/bathroom on the unit is kept unlocked. During an interview on 6/29/15 at 1:55 P.M., the DON said staff should not leave shaving cream, spray deodorant, and soaps in the unlocked shower room/bathroom. During an interview on 6/29/15 at 2:33 P.M., CNA C said staff always keep the shaving cream and spray deodorant on the linen cart in the shower room/bathroom on the locked unit. Additionally, CNA C said the shower room/bathroom door does not lock. During an interview on 6/29/15 at 3:00 P.M., the staffing coordinator said shaving cream and spray deodorant should be kept behind the nurses station on the locked unit. Observations on 6/29/15, showed multiple observations of confused residents wandering throughout the locked unit. *At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, record review, and interviews, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at that time. During the onsite visit, multiple facility residents were reviewed to determine if this went beyond these residents. Additionally, facility staff removed the mop bucket from the resident's room and removed the personal hygiene products from the shower room and placed them in an inaccessible area at the nurses station. They began inservicing staff regarding proper storage and security of chemicals and personal hygiene products, and will continue inservicing until all staff have been inserviced. Facility staff will continue to monitor residents, including confused residents, to ensure the safety of all residents. The quality assurance committee will monitor this process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 7/1/15, the severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, facility staff failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for five residents (Residents #2, #3, #4, #5, and #6) diagnosed with [REDACTED]. The facility census was 92. 1. Record review of Resident #2's active medical record showed: -The resident was admitted to the facility on [DATE]. -The resident's physician documented the resident's [DIAGNOSES REDACTED]. -Staff did not accurately reflect the resident's status on the Minimum Data Set (MDS), a federally mandated assessment instrument, when they did not include a fall. -Staff did not plan measurable objectives, timetables, and interventions specific to the resident's behaviors, use of psychoactive medications, and activities. Additionally, staff did not plan specific non-pharmacological interventions to address and redirect the resident's behaviors. -Staff did not ensure the resident was free of chemical restraints. -Staff administered as needed (PRN) psychoactive medications and did not document specific behaviors the resident exhibited and non-pharmacological interventions attempted prior to giving the PRN medications. -Staff did not re-evaluate the resident for swallowing disorders when the resident repeatedly attempted to drink thin liquids. Observations from 6/29/15-7/1/15, showed the following: -Staff did not provide thorough perineal care to the resident. -Staff failed to provide privacy during care. -Staff did not provide activities and ongoing stimulation to meet the individual needs and preferences of the resident. -Staff did not provide care and services in a dignified manner when staff left briefs labeled with resident's name on top of the nurses station, served the resident's meals on trays, served meals late, and did not serve the resident his/her meal at the same time as his/her tablemates. -Staff did provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. -The facility did not provide adequate staffing to meet the physical, mental, and psychosocial needs of all the residents. 2. Review of Resident #3's active medical record showed: -The resident was admitted to the dementia unit of the facility on 1/6/15 with [DIAGNOSES REDACTED]. -Staff did not accurately assess the resident when they assessed he/she required physical feeding assistance, was continent of bladder, did not receive antipsychotic medication in the last seven days, did not receive antianxiety medication in the last seven days, and did not have a urinary tract infection in the last 30 days. -Staff did not adequately plan care to address the resident's need for assistance with his/her activities of daily living, bladder incontinence, assessed risk for pressure ulcers, and use of psychoactive medications. -Staff did not follow physician's orders [REDACTED]. -Staff did not maintain the resident's most recent 15 months of assessments in his/her active record. -Staff did not document an appropriate indication for the use of an antipsychotic medication, failed to document appropriate monitoring for the use of psychoactive medications, and failed to provide non-pharmacological interventions prior to administering a PRN antianxiety medication. -Staff did not act upon the resident's physician's documented response to the Consultant Pharmacist's monthly pharmacy recommendation review sheet. Observations from 6/29/15-7/1/15 showed the following: -Staff did not provide care in a manner to prevent urinary tract infections [MEDICAL CONDITION] when staff did not adequately cleanse the resident, who had a history of [REDACTED]. -Staff did not provide care and services in a dignified manner when staff left briefs labeled with resident's name on top of the nurses station, served the resident's meals on trays, served meals late, and did not serve the resident his/her meal at the same time as his/her tablemates. -Staff did not provide activities and ongoing stimulation to meet the individual needs and preferences of the resident. -Staff did provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. -The facility did not provide adequate staffing to meet the physical, mental, and psychosocial needs of all the residents. 3. Review of Resident #4's active medical record showed: - He/she was admitted to the facility on [DATE] from a local homeless shelter due to not being able to take care of him/herself. - [DIAGNOSES REDACTED]. - The physician ordered a UA with culture and sensitivity (laboratory test that determines what bacteria or yeast is present and what drug will kill it) on 6/18/15, which staff failed to obtain. Observations from 6/29/15-7/1/15 showed the following: - Staff did not assist the resident with shaving and fingernail care since he/she was admitted to the facility. - Staff did not maintain the resident's dignity by not serving the resident's meals in a timely manner and not serving the resident his/her food at the same time as his/her tablemate, who was served 11 minutes prior to the resident. -Staff did not provide activities and ongoing stimulation to meet the individual needs and preferences of the resident. -The facility did not provide adequate staffing to meet the physical, mental, and psychosocial needs of all the residents. 4. Review of Resident #5's active medical record showed: - He/she was admitted to the facility on [DATE]. - [DIAGNOSES REDACTED]. - Staff did not notify the physician in a timely manner of the resident's change in condition after a recent hospitalization and being newly placed on [MEDICATION NAME] (an antipsychotic medication). - Staff did not ensure the resident was free from chemical restraints, as staff administered [MEDICATION NAME] (antipsychotic medication) to the resident, who did not exhibit medical symptoms that warranted the use of medication. - Staff did not accurately assess the resident's cognitive status on the MDS due to not conducting the Brief Interview for Mental Status (BIMS). - Staff did not develop and revise the resident's care plans to include measurable objectives and timetables and to adequately reflect the his/her current status regarding the use of antianxiety, antidepressant, and antipsychotic medications and staff did not plan care for activities. - Staff did not obtain a UA with culture and sensitivity as ordered and failed to notify the physician of the inability to collect the sample. - Staff failed to maintain the resident's most recent 15 months of assessments in the resident's active record. - Staff did not ensure the resident did not receive an antipsychotic medication unless a specific condition is diagnosed and documented in the clinical record, staff did not ensure the resident received gradual dose reductions as recommended by the pharmacist, and did not ensure staff used PRN psychoactive medications for behaviors appropriately and with proper documentation of the resident's symptoms and the other interventions staff attempted prior to giving the medication. Observations from 6/29/15-7/1/15, showed the following: - Staff did not provide activities and ongoing stimulation in accordance with the resident's assessment. -The facility did not provide adequate staffing to meet the physical, mental, and psychosocial needs of all the residents. 5. Record review of Resident #6's active medical record showed: -The resident was admitted to the facility on [DATE]. -The resident's physician documented the resident's [DIAGNOSES REDACTED]. -Staff did not accurately reflect the resident's status on the MDS when they did not complete the BIMS to determine the resident's cognitive status. -Staff did not plan measurable objectives, timetables, and interventions specific to the residents behaviors, use of psychoactive medications, and activities. Staff did not plan specific non-pharmacological interventions to address and redirect the resident's behaviors. -Staff administered PRN psychoactive medications and did not document specific behaviors the resident exhibited and non-pharmacological interventions attempted prior to giving the PRN medications. Observations from 6/29/15-7/1/15, showed the following: -Staff failed to provide privacy during care. -Staff left a mop bucket that contained chemical floor cleaner accessible to the resident when they left it in the resident's bathroom unattended. Additionally, staff left personal hygiene items that could cause injury and/or illness accessible to residents in the bathroom on the locked unit. Staff also documented the resident turned water faucets on and left them running and repeatedly flushed toilets. -Staff did not provide care and services in a dignified manner when staff left briefs labeled with resident's name on top of the nurses station, served the resident's meals on trays, and served meals late. -Staff did provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. -The facility did not provide adequate staffing to meet the physical, mental, and psychosocial needs of all the residents. 6. During interviews on 6/29/15 at 12:30 P.M. and on 7/1/15 at 9:30 A.M., the administrator said the Quality Assessment and Assurance (QAA) committee was not actively monitoring any areas of concern. The administrator said the QAA committee does not address dementia care. The administrator said she had not read the updated versions of F309 regarding dementia care and F329 regarding the use of unnecessary medications. The administrator said the facility did not utilize a specific training program to train staff on dementia care. During an interview on 6/30/15 at 8:35 A.M., the administrator said she has acted as the MDS/Care Plan Coordinator, in addition to being the administrator, for approximately one year because former staff could not stay caught up. 7. During an interview on 6/30/15 at 4:30 P.M. and on 7/1/15 at 9:30 A.M., the Assistant Director of Nursing (ADON) said she expects staff to administer a PRN psychoactive medication as a last resort. The ADON expects staff to attempt non-pharmacological interventions first such as music therapy, television, snacks, change of environment, and one-to-one care. When staff administer a PRN medication for behaviors, staff should document the rationale for why they administered the medication and the effectiveness. Staff should document this information in the nurse's notes, on the back of the MARs, or on the Behavior Management Record. Staff should document specific information, rather than just documenting effective or redirected. The ADON said she expects staff to notify family and responsible parties of new antipsychotic medications, however staff do not inform them of the risks and benefits of the medications. The ADON said she expected interactions with residents to be individualized for each resident. 8. During an interview on 7/1/15 at 9:40 A.M., the interim Director of Nurses (DON) said she expected all staff to be involved in stimulating residents. 9. During an interview on 7/1/15 at 12:45 P.M., the Activity Director (AD) said all staff are supposed to work on activities and interaction with the residents. The AD said if activities staff are not on the unit, direct care staff could reminisce with the residents or throw a ball with the residents. The AD said the direct care staff have resources on the unit such as coloring books and games that they could use to interact with the residents. The AD said there is not a lot of activity space at the facility, so activities have to be done in between meals. The AD has an assistant who works Monday through Friday for five hours a day, but the assistant leads the activities on the locked unit. The AD said it is difficult to get the rest of the staff involved in getting residents to activities and to get staff to do activities on the weekends and evenings. The AD said the facility needs more activity staff since there is a census of 92 residents. The AD said the residents' activity assessments and notes are kept in his/her office which is locked when he/she is not in the office. 10. During an interview on 7/1/15 at 12:14 P.M., the Medical Director said he expects staff to try to calm the resident down, provide diversional activities, and take him/her to another room. He expects staff to document exactly what behaviors the resident exhibited and what interventions staff attempted before giving the resident a PRN medication. The Medical Director said staff should not administer an antipsychotic medication to a resident for agitation unless he knew more about the situation and the specifics of the resident's behavior.

Based on observation, interview, and record review, facility staff failed to ensure residents do not receive medication in excessive doses, excessive duration, without adequate monitoring, or without adequate indications for its use. Staff failed to ensure residents do not receive antipsychotic medications unless a specific condition is diagnosed and documented in the clinical record, and residents who use antipsychotic medications receive gradual dose reductions and behavioral interventions to ensure the medications are used appropriately for four of five sampled residents (Residents #2, #3, #5, and #6). The facility census was 92. 1. Review of the facility's undated policy titled, Behavior Monitoring System, showed the following: -It is the policy of the facility to monitor resident behavior in a quantitative manner with documentation to illustrate attempts to redirect behavior that may interfere with the resident's ability to function at their optimal level; -Each resident with identified behaviors and/or receiving a hypnotic, an antipsychotic, or an anxiolytic drug either routinely or on an as needed basis, will be flagged on the Certified Nurses Aide (CNA) directive. Nursing staff will be alerted to observe and document episodes of target behaviors as well as interventions used to redirect these behaviors; -A Behavior Management form will be completed for each resident exhibiting behaviors and/or receiving a hypnotic, an antipsychotic, or an anxiolytic either routinely or on an as needed basis; -The licensed nurse completing the admission assessment will initiate these forms as the identified resident is admitted to the facility. The licensed nurse will include target behaviors as well as interventions appropriate for redirection of the resident; -These forms will be kept in a binder at each nurse's station marked Behavior Monitoring; -The Director of Nursing (DON)/designee will replace these forms monthly during change over; -All nursing staff is responsible for documentation in the Behavior Monitoring book as behavior is observed and intervention implemented; -The DON/designee is responsible for reviewing the previous month's behavior records and completing the Behavior Management Monthly Summary. The summary will also ensure each resident's medical record contains adequate documentation to substantiate use/continued use of these medications; -The completed monthly summary will be placed in the consult section of the medical record for review by the consultant psychiatrist/attending physician during rounds; -It is not necessary for staff to also document episodes of behavior in the nurse's notes each time the behavior is observed. 2. Record review of Resident #2's Behavior Management Record, undated, showed staff documented the resident had the following behaviors: -Cursed at staff; -Cursed at other residents; -Self-placement on floor. Record review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] (an anti-psychotic medication that includes a Black Box Warning stating there is an increased risk of mortality in elderly patients with dementia-related [MEDICAL CONDITION]) 2 milligrams (mg) by mouth every four hours as needed (PRN) for agitation; -[MEDICATION NAME] (an anti-anxiety medication) 1 mg by mouth every eight hours PRN for anxiety; -[MEDICATION NAME] (an anti-psychotic medication) 200 mg by mouth at bedtime; -[MEDICATION NAME] 1 mg intramuscularly injection every eight hours PRN for anxiety. Further Review of the POS [REDACTED]. Record review of the resident's nurses notes, dated 3/9/15, showed staff documented the resident cursed at another resident. Staff asked Resident #2 to leave the other resident alone and not curse at him/her. Staff documented Resident #2 continued this behavior and said he/she was going to beat his/her ass if the other resident did not move. Staff documented they had to move Resident #2 away, and he/she continued to curse and try to hit staff. Staff documented the resident was given the PRN [MEDICATION NAME]. Staff did not document specific non-pharmacological interventions attempted prior to giving the PRN [MEDICATION NAME]. Record review of the resident's POS, dated 4/1/15-4/30/15, showed the resident's physician directed staff to administer the following medications: [REDACTED] -[MEDICATION NAME] 2 mg by mouth every four hours as needed PRN for agitation; -[MEDICATION NAME] 1 mg by mouth every eight hours PRN for anxiety; -[MEDICATION NAME] 200 mg by mouth at bedtime; -[MEDICATION NAME] 1 mg intramuscularly injection every eight hours PRN for anxiety. Record review of the resident's nurses notes, dated 4/8/15, showed staff documented the resident was constantly having verbal altercations with other residents and going up to them. Staff documented the resident was redirected several times, then the Certified Medication Technician (CMT) was instructed to give the resident the PRN [MEDICATION NAME]. Staff did not document specific non-pharmacological interventions attempted prior to giving the PRN [MEDICATION NAME]. Record review of the resident's comprehensive plan of care, last updated 4/16/15, showed staff were instructed to: -Reassure and console resident as allows; -Encourage resident to vent feelings as needed; -Allow choices in care as able to safely make; -Do not argue with resident when he/she is agitated; -Explain to resident when behavior is inappropriate and disruptive to others; -Observe for stressors that agitate resident and remove as able; -Encourage group and diversional activities of interest; -Administer medications as ordered; -Remove from public areas for short periods only if disruptive/abusive to others and not easily redirected. Further review of the resident's comprehensive plan of care, showed staff did not plan measurable objectives, timetables, and interventions specific to the resident's behaviors and use of psychoactive medications. Additionally, staff did not plan specific non-pharmacological interventions to address and redirect the resident's behaviors. Record review of the resident's nurses notes, dated 4/29/15, showed staff documented they administered the resident's [MEDICATION NAME] due to the resident screaming because he/she wanted to see the money lady (the person in the facility who manages the residents' funds). Staff did not document the reason the resident could not talk to the staff member requested, nor did they document non-pharmacological interventions used to calm the resident before they administered the [MEDICATION NAME]. Record review of the resident's POS, dated 6/1/15-6/30/15, showed the resident's physician directed staff to administer the following medications: [REDACTED] -[MEDICATION NAME] 2 mg by mouth every four hours as needed PRN for agitation; -[MEDICATION NAME] 1 mg by mouth every eight hours PRN for anxiety; -[MEDICATION NAME] 200 mg by mouth at bedtime; -[MEDICATION NAME] 1 mg intramuscularly injection every eight hours PRN for anxiety. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 6/24/15, showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Did not exhibit any physical or verbal behavioral symptoms directed toward others; -Rejected care on one to three days during the assessment period; -Received antipsychotic medications seven days out of the last seven days; -Received antidepressant medications seven days out of the last seven days; -[DIAGNOSES REDACTED]. Record review of the resident's Medication Administration Record [REDACTED]agitation on 6/5, 6/11, 6/12, 6/24, and 6/27. Record review of the resident's nurses notes and Behavior Management Record, showed staff did not document the specific behaviors the resident was exhibiting on 6/5, 6/11, 6/12, 6/24, and 6/27. Additionally, staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME]. During an interview on 6/30/15 at 4:35 P.M., Licensed Practical Nurse (LPN) E said he/she is not aware of the 4/29/15 incident in which staff administered [MEDICATION NAME] to the resident when he/she was screaming because he/she wanted to see the money lady. LPN E said the resident likes attention and is easily redirected when staff sit and talk with the resident. LPN E said staff should have tried different redirection approaches before giving the resident [MEDICATION NAME], and staff should have documented that in the nurses notes and on the Behavior Management Form. During an interview on 7/1/15 at 9:30 A.M., the Assistant Director of Nurses (ADON) said she is not aware of the 4/29/15 incident, but staff should have let the resident speak to the money lady. She expects staff to try non-pharmacological interventions, like redirection, before giving medication. Additionally, the ADON said she expects staff to document in detail in the nurses notes the resident's specific behaviors, what interventions were tried, what medication was given, and results of the medication. 3. Review of Resident #3's admission history and physical, dated 1/14/15, showed: -Chief complaint - Elderly resident with a history of dementia; -[DIAGNOSES REDACTED]. Review of the resident's Behavior Management Record, undated, showed the following: -Behaviors identified: Anxiety, leaving locked unit, agitation, packing bags by unit door; -Approaches utilized: Talk with resident, explain the dangers of leaving alone, allow to express fears; -Documentation showed staff made only three entries on the Behavior Management Record, on 1/26/15, 2/3/15, and 3/18/15. -Review of the resident's medical record showed physician's orders [REDACTED]. -[MEDICATION NAME] ([MEDICATION NAME] - an antipsychotic medication) 0.5 mg, 1 by mouth at bedtime; -[MEDICATION NAME] ([MEDICATION NAME] - an antianxiety medication) 0.5 mg, 1 by mouth every six hours PRN agitation. Review of Mosby's 2014 Nursing Drug Reference, showed the following for [MEDICATION NAME]: -Black box warning - increased mortality in elderly patients with dementia-related [MEDICAL CONDITION]; -Common side effects included [MEDICAL CONDITION], agitation, anxiety, nausea, anorexia and constipation. Review of Mosby's 2014 Nursing Drug Reference, showed common side effects for [MEDICATION NAME] included dizziness, drowsiness, orthostatic [MEDICAL CONDITION] and blurred vision. Review of the resident's plan of care, dated 1/6/15, showed staff did not plan care to include measurable objectives, timetables, and interventions specific to the resident's behaviors and use of psychoactive medications. Staff did not plan specific non-pharmacological interventions to address and redirect the resident's behaviors. The resident's care plan showed the resident was at risk for falls related to poor balance, unsteady gait and poor safety awareness and the interventions listed included medication as ordered but did not state what type of medications were ordered. The plan directed staff to observe for side effects of medication and report if noted. The intervention did not state which medication(s) could cause such side effects and did not direct staff on which staff were to report side effects and to who. Review in the resident's medical record, of a Note to Attending Physician/Prescriber, completed by the facility's Consultant Pharmacist, printed date 2/10/15, showed the pharmacist requested from the resident's physician, a justification for the use of the antipsychotic [MEDICATION NAME] 0.5 mg po q HS. Additionally, review showed since [DIAGNOSES REDACTED]. The form requested the physician checkmark a box showing: -Symptoms are identified as being due [MEDICAL CONDITIONS]; -Behavior symptoms present a danger to the resident or to others; -Symptoms are significant enough that the resident is experiencing inconsolable crying, significant decline in function, difficulty receiving care. Review of the form showed staff received and documented a telephone order from the physician, dated 2/24/15, that the [DIAGNOSES REDACTED]. Further review showed staff did not checkmark a box and did not document that they received further information to document the symptoms present that warranted the need for the antipsychotic medication. Review of a psychiatrist note, dated 2/11/15, showed the history of present illness as dementia. The note showed [MEDICATION NAME] was started last visit due to psychotic symptoms. The physician noted since then, the resident denied any psychotic symptoms and has been calm and cooperative with staff. Review of a psychiatrist note, dated 3/9/15, showed at the resident's last appointment, symptoms of [MEDICAL CONDITION] had improved and since then, denies any issues or concerns. Review showed staff received a physician's orders [REDACTED]. Staff did not document an adequate indication for the use of [MEDICATION NAME]. During an interview on 6/30/15 at 3:10 P.M., the Consultant Pharmacist said for the recommendations that require both a [DIAGNOSES REDACTED].#2 (appropriate indication for the medication) to attempt to get staff to address this with residents' physicians. Review of the resident's MAR, dated January 1-28, 2015, showed staff documented administration of the resident's PRN [MEDICATION NAME] on 1/23 for anxiety-redirection and talking is ineffective, on 1/24 for agitation-redirected, 1/27 for agitation, and 1/28 for agitation-redirection non-effective. Review of the resident's Behavior Management Record and nurse's notes showed staff did not document the behaviors the resident exhibited on 1/23, 1/24, 1/27 or 1/28. Additionally, staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME] on 1/28. Review of the resident's MAR, dated February 1-28, 2015, showed staff documented administration of the resident's PRN [MEDICATION NAME] on 2/15 for agitation-looking for children and trying to leave and on 2/25 for agitation-taking off clothes. Review of the resident's Behavior Management Record and nurse's notes showed staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME]. Review of the resident's MAR, dated March 1-31, 2015, showed staff documented administration of the resident's PRN [MEDICATION NAME] on 3/18 and 3/23 for agitation. Review of the resident's Behavior Management Record showed on 3/18/15, staff documented the resident exhibited anxiety and agitation. They documented reason for the behavior was a verbal altercation with a resident. Staff noted they talked with the resident and allowed him/her to express fears. The resident response documented was quiet. Staff did not document on the Behavior Management Record that they administered PRN [MEDICATION NAME]. Further review of the Behavior Management Record and nurse's notes showed staff did not document the behaviors the resident exhibited on 3/23. Additionally, staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME]. Review of the resident's MAR, dated May 1-31, 2015, showed staff documented administration of the resident's PR [MEDICATION NAME] on 5/9/15 for agitation. Review of the resident's Behavior Management Record and nurse's notes showed staff did not document the behaviors the resident exhibited on 5/9. Additionally, staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME]. Review of the resident's MAR, dated June 1-30, 2015, showed staff documented administration of the resident's PRN [MEDICATION NAME] on 6/5, 6/7 and 6/26. Review of the resident's Behavior Management Record and nurse's notes, showed staff did not document the behaviors the resident exhibited on 6/5, 6/7 or 6/26. Additionally, staff did not document they attempted any non-pharmacological interventions prior to giving the resident the PRN [MEDICATION NAME]. During an interview on 7/1/15 at 8:10 A.M., CNA A said the resident gets upset at times and paces the floor. The CNA said when the resident exhibits these behaviors, staff redirect the resident, talk to the resident and ask him/her what is wrong. The CNA said it helps calm the resident a lot if staff talk to him/her. During an interview on 7/1/15 at 8:25 A.M., CNA C said the resident sometimes tells other residents to shut up and be quiet. The CNA said when the resident exhibits this type of behavior, staff tries to redirect him/her, and tries to make him/her laugh. The CNA said it usually helps calm the resident if staff talk to him/her. Review of the resident's nurse's notes showed on 2/24/15, staff documented, 11-7 nurse states resident is not sleeping at night. Review of the resident's POS showed: -An order, original date, 2/24/15 which directed staff to administer to the resident [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]-an H-1 blocker [MEDICATION NAME], also used for nighttime sedation) 25 mg capsule, one po (by mouth) q HS (at bedtime). Review of the Centers for Medicare and Medicaid Services (CMS) guidelines, as written in the State Operations Manual (SOM) showed the following information: -H-1 blocker [MEDICATION NAME] have strong [MEDICATION NAME] properties (block the passage of impulses through the parasympathetic nerves, which are responsible for involuntary movement of muscles in the gastrointestinal tract, lungs, urinary tract, and other parts of the body) and are not considered medications of choice in older individuals; -H-1 blocker [MEDICATION NAME] should be used in the smallest possible dosage for the shortest possible duration, especially in individuals who are susceptible to [MEDICATION NAME] side effects; -H-1 blocker [MEDICATION NAME] may cause excessive sedation, confusion, cognitive impairment, distress, dry mouth, constipation, [MEDICAL CONDITION]. These may lead to other adverse consequences such as falls. Review in the resident's medical record, of a Note to Attending Physician/Prescriber, completed by the facility's Consultant Pharmacist, printed date 5/13/15, showed the pharmacist documented, Please clarify the reason for the use of the following: [MEDICATION NAME] 25 mg po qHS. Review showed the resident's physician documented a checkmark in the box stating he/she agreed with the request and wrote PRN (as needed) [MEDICAL CONDITION]. Review of the resident's POS, dated May, 2015, showed facility staff added a [DIAGNOSES REDACTED]. [REDACTED]. Review of the resident's MARs for May, 2015 and June, 2015 showed staff did not change the physician's orders [REDACTED]. on a daily basis in May and June. During an interview on 6/30/15 at 3:10 P.M., the facility's Consultant Pharmacist said, there are better choices for a resident's [MEDICAL CONDITION] than [MEDICATION NAME] due to it's potential side effects. The Consultant Pharmacist said in May, he/she asked staff to obtain a [DIAGNOSES REDACTED]. The Consultant Pharmacist said in June, he/she noted to staff that the physician had indicated to change the medication to PRN on the recommendation sheet. The Consultant Pharmacist said he/she had a note to check the order during her July visit to ensure the order was changed to PRN, and to see if staff were using the [MEDICATION NAME] for the resident. During an interview on 7/1/15 at 9:40 A.M., the ADON said there are other medications than [MEDICATION NAME] she would rather see ordered for [MEDICAL CONDITION] for a resident. The ADON said she would question the order. The ADON said she was not aware that the Consultant Pharmacist had noted on his/her monthly staff report that the resident's physician had written an order for [REDACTED]. During an interview on 7/1/15 at 12:15 P.M., the facility's Medical Director said he/she would usually order a different medication than [MEDICATION NAME] for [MEDICAL CONDITION] for an elderly resident due to [MEDICATION NAME]'s side effects. 4. Review of Resident #5's POS, dated January 2015, showed the following orders: - [MEDICATION NAME] (antianxiety medication) 0.5 mg twice daily (ordered 10/29/14); - [MEDICATION NAME] (antianxiety/antidepressant medication) 60 mg every morning (ordered 11/18/14). Review of the Consultant Pharmacist Note to the Attending Physician/Prescriber, dated 1/8/15, showed the pharmacist documented the resident's [MEDICATION NAME] is due for a dose evaluation in an attempt to establish the lowest effective dose per regulations. The pharmacist documented a note to the physician asking if a trial reduction to 0.25 mg twice daily would be appropriate. Review showed the physician replied on 1/14/15, disagree, needs [MEDICATION NAME] ([MEDICATION NAME]) according to staff. Review showed the physician did not give rationale for continuing the medication, including evidence that the physician evaluated the resident's target symptoms and the effect of the medication on the severity, frequency, and other characteristics of the symptoms, any changes in the resident's function during the previous quarter, and whether the resident experienced any medication-related adverse consequences during the previous quarter. Review of the resident's Consultant Pharmacist Note to the Attending Physician/Prescriber, dated 3/11/15, showed the pharmacist documented that she recommended a gradual dose reduction for the [MEDICATION NAME] to 40 mg daily. Review showed the physician responded on 3/17/15 at 1:30 P.M., disagree. Review showed the physician did not give rationale for continuing the medication, including evidence that the physician evaluated the resident's target symptoms and the effect of the medication on the severity, frequency, and other characteristics of the symptoms, any changes in the resident's function during the previous quarter, and whether the resident experienced any medication-related adverse consequences during the previous quarter. During an interview on 6/30/15 at 3:10 P.M., the Consultant Pharmacist said: - She reviews the Monthly Summary, Behavior Management Monthly Summary, MARs, nurse's notes, PRN medication usage, and physician's notes to try to get information to determine if a gradual dose reduction is needed for a resident, in addition to making her own observations of the residents. - She requests a gradual dose reduction if she is unable to find the information showing why a gradual dose reduction is not indicated. Review of the resident's comprehensive MDS, dated [DATE], showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - No behaviors; - [DIAGNOSES REDACTED]. - Received antidepressant and antianxiety medications over the last seven days. Review of the resident's plan of care, dated 3/1/14, showed staff documented the resident has restlessness, fatigue, [MEDICAL CONDITION], and irritability due to generalized anxiety disorder. Review showed the plan of care directed staff to: - Encourage resident to ventilate feelings; give positive, realistic feedback; - Touch, e.g. hug, back rub, hold hand, stroke forehead; - Diversionary activities; - Spiritual support, e.g. inspirational reading, prayer, music as desired/accepted by resident; - Medicate as ordered; - Monitor and record response. Review of the resident's plan of care, dated 3/1/14, showed the care plan did not address what diversionary activities worked for the resident when he/she experienced anxiety. Review of the resident's POS, dated April 2015, showed: - [MEDICATION NAME] (antianxiety medication) 0.50 mg twice daily. Review of the resident's nurse's notes, dated 4/15/15 at 3:30 P.M., showed staff documented the resident said he/she wanted to go to the hospital, but not now. The resident made this statement after taking a shower. The resident did not have any distress or pain. Review of the nurse's notes, dated 4/15/15 at 4:15 P.M., showed staff documented they obtained a new order from the psychiatrist for [MEDICATION NAME] (antipsychotic medication) 2.5 mg by mouth every 12 hours as needed for agitation. Review of the resident's Medication Administration Record [REDACTED].M. Review of the MAR indicated [REDACTED]. Review of the resident's Behavior Management Record showed staff did not document any information to show the resident exhibited agitation or other behaviors on 4/15/15. Review showed staff did not document the use of [MEDICATION NAME] for agitation on 4/15/15. Review of the resident's nurse's notes, dated 4/16/15 at 6:00 A.M., showed staff documented the resident was difficult to arouse when staff entered the resident's room to check his/her blood sugar. Staff documented they would continue to monitor the resident. During an interview on 6/30/15 at 3:10 P.M., the Consultant Pharmacist said the difficulty to arouse the resident the morning after he/she received [MEDICATION NAME] could have been related to the [MEDICATION NAME] due to it having a 24-48 hour half-life (the amount of time it takes for the body to get rid of half the dose of medication). Additionally, the Consultant Pharmacist said staff did not document enough information in the resident's medical record to show the resident's specific behaviors and why staff administered the antipsychotic medication. During an interview on 6/30/15 at 4:30 P.M., the ADON said: - The former DON is the staff member who obtained the order from the resident's physician for [MEDICATION NAME] and administered it to the resident. - The resident swore at staff and was verbally antagonizing toward staff and the resident's sibling (also a resident at the facility) around the time the former DON administered the [MEDICATION NAME]. - The ADON did not expect staff to administer an antipsychotic medication or an as needed psychoactive medication for verbally antagonizing behavior, and expected staff to use medications as a last resort for behaviors. Review of the resident's POS, dated 5/15/15, showed the resident returned to the facility after a 10-day psychiatric hospitalization . Review showed the resident returned with the following order: - [MEDICATION NAME] 0.5 mg- one tablet by mouth three times daily as needed for anxiety (ordered 5/15/15). Review of the resident's MAR, dated 5/15/15 through 5/31/15, showed staff documented they administered [MEDICATION NAME] as follows: - 5/20/15 at 9:00 A.M.- resident agitated/anxiety; result- effective; - 5/21/15 at 2:00 P.M.- resident anxiety; result- effective; - 5/22/15 administered once (unknown time); staff did not document the reason administered, nor the effect of the medication; - 5/23/15 administered once (unknown time); staff did not document the reason administered, nor the effect of the medication; - 5/24/15 administered once (unknown time); staff did not document the reason administered, nor the effect of the medication; - 5/26/15 at 1:00 P.M. for anxiety; no results documented. Review of the resident's MAR, dated 5/15/15 through 5/31/15, showed staff did not document an appropriate reason or description for giving the medication to the resident. Additionally, staff did not document an appropriate description of the result of the medication on the resident. Review of the resident's nurse's notes, dated 5/15/15 through 5/31/15, showed staff did not document any specific reasons for the use of the [MEDICATION NAME] for anxiety. Review of the resident's Behavior Management Monthly Summary, dated May 2015, showed staff documented: - No unusual behavior for the resident this month; - No previous reduction attempts for [MEDICATION NAME] and [MEDICATION NAME] (medications taken prior to hospitalization on [DATE]); - No PRN (as needed) medications used; - No interventions used; - No adverse reactions or symptoms; - Seen by psychiatrist in April 2015. Review of the resident's MAR, dated June 2015, showed staff documented they administered [MEDICATION NAME] as follows: - 6/1/15 at 2:00 A.M., staff did not document the reason administered, nor the effect of the medication; - 6/3//15 at 6:00 P.M., staff did not document the reason administered, nor the effect of the medication; - 6/5/15 at 2:00 P.M. for agitation; result- effective; - 6/5/15 at 9:00 P.M., staff did not document the reason administered, nor the effect of the medication; - 6/6/15 at 2:00 P.M. for agitation; result-effective; - 6/7/15 at 1:00 P.M. for agitation; result- effective; - 6/9/15 at 9:00 P.M., staff did not document the reason administered, nor the effect of the medication; - 6/16/15 at 2:00 P.M. for agitation; result- effective; - 6/20/15 at 9:00 P.M. for agitation; result- effective. Review of the resident's nurse's notes, dated 6/1/15 through 6/20/15, showed staff did not document any specific reasons for the use of the [MEDICATION NAME] for anxiety. Review of the resident's ongoing Behavior Management Record showed staff documented the physician ordered the following for behavior management: - [MEDICATION NAME] 0.5 mg twice daily (ordered 10/29/14); - [MEDICATION NAME] 60 mg in the morning (ordered 11/18/14). Review of the resident's Behavior Management Record, showed staff did not update the record with the resident's current medications. Additionally, staff did not document any information to show the resident has ever received PRN medications for behaviors at the facility. 5. Record review of Resident #6's Behavior Management Record, undated, showed staff documented the resident had the following behaviors: -Cursed loudly; -Spit on the floor; -Paced fast, ran into residents; -Came out of room naked. Record review of the resident's active medical record, showed the resident's physician directed staff to administer the following medications: [REDACTED] -[MEDICATION NAME] intramuscularly injection every 14 days (ordered 9/12/12); -[MEDICATION NAME] (an anti psychotic medication) 3 mg by mouth twice daily (ordered 4/17/14); -[MEDICATION NAME] 5 mg by mouth every four hours PRN agitation (ordered 3/12/14); -[MEDICATION NAME] 2 mg by mouth every four hours PRN anxiety (ordered 1/2/15). Record review of the resident's comprehensive plan of care, last updated 11/1/14, showed staff were instructed to: -Encourage and allow as much independence as is safe; -Provide a safe environment at all times; -Administer medication as needed; -Monitor for side effects of medications; -Redirect and keep resident calm. Additionally, staff documented in the comprehensive plan of care that the resident smears feces, counts to self, and paces. Fur

Based on interview and record review, facility staff failed to ensure residents were free from chemical restraints. Staff administered psychoactive medications to two residents (Residents #2 and #5) out of five sampled residents, who did not exhibit medical symptoms that warranted the use of medication. The facility census was 92. 1. Record review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/24/14, showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Did not exhibit any physical or verbal behavioral symptoms directed toward others; -Rejected care on one to three days during the assessment period; -Received antipsychotic medications seven days out of the last seven days; -Received antidepressant medications seven days out of the last seven days. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's comprehensive plan of care, last updated 4/16/15, showed staff were instructed to: -Reassure and console resident as allows; -Encourage resident to vent feelings as needed; -Allow choices in care as able to safely make; -Do not argue with resident when he/she is agitated; -Explain to resident when behavior is inappropriate and disruptive to others; -Observe for stressors that agitate resident and remove as able; -Encourage group and diversional activities of interest; -Administer medications as ordered; -Remove from public areas for short periods only if disruptive/abusive to others and not easily redirected. Further review of the resident's comprehensive plan of care, showed staff were not instructed when to administer PRN medications. Record review of the resident's nurses notes, dated 4/29/15, showed staff documented they administered the resident's [MEDICATION NAME] due to the resident screaming because he/she wanted to see the money lady (the person in the facility who manages the residents' funds). Staff did not document the reason the resident could not talk to the staff member requested, nor did they document non-pharmacological interventions used to calm the resident before they administered the [MEDICATION NAME]. Record review of the resident's Behavior Management Record, showed staff did not document any information regarding the resident's behavior and interventions attempted on 4/29/15. During an interview on 6/30/15 at 4:35 P.M., Licensed Practical Nurse (LPN) E said he/she is not aware of the 4/29/15 incident in which staff administered [MEDICATION NAME] to the resident when he/she was screaming because he/she wanted to see the money lady. LPN E said the resident likes attention and is easily redirected when staff sit and talk with the resident. LPN E said staff should have tried different redirection approaches before giving the resident [MEDICATION NAME], and staff should have documented that in the nurses notes and on the Behavior Management Form. During an interview on 7/1/15 at 9:30 A.M., the Assistant Director of Nurses (ADON) said she is not aware of the 4/29/15 incident, but staff should have let the resident speak to the money lady. 2. Review of Resident #5's comprehensive MDS, dated [DATE], showed staff assessed the resident as: - Severely impaired cognitive skills for daily decision making; - No behaviors; - Has little interest/pleasure in doing things; - Required limited assistance of one staff member with transfers, ambulation, dressing, eating, and personal hygiene; - diagnosed with [REDACTED]. - Received antianxiety and antidepressant medications daily. Review of the resident's plan of care, dated 3/1/14 and updated 8/29/14, showed staff documented the resident has restlessness, fatigue, [MEDICAL CONDITION], and irritability due to generalized anxiety disorder. The plan directed staff to: - Encourage to ventilate feelings; give positive, realistic feedback; - Touch, e.g. hug, back rub, hold hand, stroke forehead; - Diversionary activities; - Spiritual support, e.g. inspirational reading, prayer, music as desired/accepted by resident; - Medicate as ordered; - Monitor and record response. Review of the resident's POS, dated April 2015, showed: - [MEDICATION NAME] (antianxiety medication) 0.50 milligrams (mg) twice daily. Review of the resident's nurse's notes, dated 4/15/15 at 3:30 P.M., showed staff documented the resident said he/she wanted to go to the hospital, but not now. The resident made this statement after taking a shower. The resident did not have any distress or pain. Review of the nurse's notes, dated 4/15/15 at 4:15 P.M., showed staff documented they obtained a new order from the psychiatrist for [MEDICATION NAME] (antipsychotic medication) 2.5 mg by mouth every 12 hours as needed for agitation. Review of the resident's Medication Administration Record [REDACTED].M. Review of the MAR indicated [REDACTED]. Review of the resident's Behavior Management Record showed staff did not document any information to show the resident exhibited agitation or other behaviors on 4/15/15. Review showed staff did not document the use of [MEDICATION NAME] for agitation on 4/15/15. Review of the resident's nurse's notes, dated 4/16/15 at 6:00 A.M., showed staff documented the resident was difficult to arouse when staff entered the resident's room to check his/her blood sugar. Staff documented they would continue to monitor the resident. During an interview on 6/30/15 at 3:10 P.M., the Consultant Pharmacist said the difficulty to arouse the resident the morning after he/she received [MEDICATION NAME] could have been related to the [MEDICATION NAME] due to it having a 24-48 hour half-life (the amount of time it takes for the body to get rid of half the dose of medication). Additionally, the Consultant Pharmacist said staff did not document enough information in the resident's medical record to show the resident's specific behaviors and why staff administered the antipsychotic medication. During an interview on 6/30/15 at 4:30 P.M., the ADON said: - The former Director of Nursing (DON) is the staff member who obtained the order from the resident's physician for [MEDICATION NAME] and administered it to the resident. - The resident swore at staff and was verbally antagonizing toward staff and the resident's sibling (also a resident at the facility) around the time the former DON administered the [MEDICATION NAME]. - The ADON did not expect staff to administer an antipsychotic medication or an as needed psychoactive medication for verbally antagonizing behavior, and expected staff to use medications as a last resort for behaviors. 3. During an interview on 6/30/5 at 3:10 P.M., the Consultant Pharmacist said a chemical restraint is administering a psychoactive medication without attempting non-pharmacological interventions and is typically used for staff convenience. 4. During an interview on 6/30/15 at 4:30 P.M., the ADON said: - Staff are expected to document behaviors on the Behavior Management Record or in the nurse's notes. - Staff should document the rationale for administering an as needed psychoactive medication and the effect of the medication on the resident on the back of the MAR, in the nurse's notes, or on the Behavior Management Record. - Staff should document specific interventions attempted prior to administering a medication for behaviors. 5. During an interview on 7/1/15 at 9:30 A.M., the ADON said she expects staff to try non-pharmacological interventions, such as redirection, before giving medication. Additionally, the ADON said she expects staff to document in detail in the nurses notes the resident's specific behaviors, what interventions were tried, what medication was given, and results of the medication. 6. During an interview on 7/1/15 at 12:14 P.M., the Medical Director said he expects staff to try to calm the resident down, provide diversional activities, and take him/her to another room. He expects staff to document exactly what behaviors the resident exhibited and what interventions staff attempted prior before giving the resident PRN medications. The Medical Director said staff should not administer an antipsychotic medication to a resident for agitation unless he knew more about the situation and the specifics of the resident's behavior.

Based on observation, interview and record review, the facility failed to assess a resident who complained of chest pain and later expired (Resident #11), failed to obtain an arterial Doppler flow study to determine treatment for [REDACTED].#2) and failed to remove sutures from a resident's [MEDICAL CONDITION] for over a month (Resident #16). The total sample was 15. The census was 90. 1. Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Limited assistance required of staff with activities of daily living (ADL's); -Occasionally incontinent of bowel and bladder; -No short/long term memory problems; -Able to make own decisions. Review of the care plan, used during the survey, updated [DATE], showed the following the facility identified the following problems: -Paralysis/weakness on one side secondary to stroke; -High blood sugar with a need for control; -Assist with ADL's due to tremors, muscular rigidity, "pill-rolling" (a circular movement or tremor of the tips of the thumb and the index finger when brought together) secondary to [MEDICAL CONDITION]; -Need for control of hypertension (high blood pressure); -Poor short and long-term memory recall; -Limited movement secondary to inflammation of the joints; -Verbalized symptoms of depression and wishes to isolate self; -Sometimes anxious and upset when being redirected by staff. Staff identified the following interventions: -Keep medication administered on time; -Create a diversion when resident becomes upset; -Approach resident in a calm manner when redirecting him/her; -Involve resident in supervised task, helping out at mealtimes; -Give as needed anxiety medication as a last result or if attempt to calm is unsuccessful; -Involve family in interventions, accepting suggestions. Review of the physician order [REDACTED]. Review of the residents record, showed no results for the EKG ordered on [DATE]. Review of the POS [REDACTED] -[DIAGNOSES REDACTED]. -Emergency orders: Full Code (in the event of cardiac or respiratory arrest, life-saving measures are to be performed); -No order for EKG on [DATE]. Review of the nurse's note, dated [DATE] at 2:15 P.M., showed an EKG was obtained per physician's orders [REDACTED]. Further review of the nurse's notes, showed no results of an EKG obtained [DATE]. Review of the EKG requisition, dated [DATE], showed the following: -Service date: [DATE]; -Priority: Routine; -Ordered by: Nurse A; -Reason: 786.59 (other chest pain). Review of the EKG, dated [DATE] at 2:18 P.M., showed the following: -Sinus [MEDICAL CONDITION] (slow heartbeat); -Flat or negative T wave; -Abnormal rhythm EKG. Further review of the EKG requisition, dated [DATE], showed the following: -Arrival date and time: [DATE] at 2:01 P.M.; -Clinical note: EKG copy given to Nurse R. Review of the nurse's notes, showed no documentation the physician was notified of the EKG results. Review of the nurse's note, dated [DATE] at 10:50 P.M., showed the resident's roommate notified staff that he/she was speaking with the resident around 9:35 P.M. The roommate stated the resident stopped talking and he/she continued to observe the resident. The roommate noticed the resident appeared to not be breathing. The roommate notified Nurse A and asked him/her to come check on the resident. During the assessment the resident was found unresponsive to verbal and tactile (touch) stimulation. There was no pulse, no blood pressure present, no rise or fall of the chest and no breath sounds. 911 was called and cardiopulmonary resuscitation (CPR) started until the arrival of the emergency medical technician (EMT, ambulance technician). EKG leads were placed on the resident by the EMT. The EKG showed the resident was asystole (flatline, no cardiac electrical activity). Review of the resident's EMS Report, dated [DATE], showed the following: -Type of service: Emergency with lights and sirens; -Dispatch time: 11:03 P.M.; -Arrived at scene: 11:06 P.M.; -At patient: 11:07 P.M.; -Vital signs at 11:08 P.M.: Blood pressure: none, Pulse: none, Respirations: none; -Treatment: Cardiac monitoring; -Primary complaint: Cardiac/respiratory arrest; -Impression: Obvious death; -[MEDICAL CONDITION]: Prior to EMS arrival; -Resuscitation attempted: No signs of life; -Monitored rhythm: Asystole; -Narrative: Patient was laying supine on bed with CPR board and CPR being performed for approximately 10 minutes prior to arrival. Nursing staff stated they made rounds approximately 40 minutes prior to CPR. At that time CPR was terminated per fire crew. The patient was cool to touch, had no signs of life, pupils were dilated and unresponsive to light, asystole was observed in all EKG leads, time of death 11:13 P.M. During an interview on [DATE] at 7:34 A.M., Nurse A said he/she worked the courtyard unit during the evening shift on [DATE]. He/she left the courtyard unit at approximately 10:30 P.M., to go to the nurse's station to wait on the next shift. Resident #11's roommate asked Nurse A if he/she could check on Resident #11 because they were talking and Resident #11 stopped talking. Nurse A said he/she entered the room and could tell the resident had expired. He/she put oxygen on the resident, checked for a pulse at his/her neck and wrist, obtained the crash cart (equipped with CPR supplies), placed a back board beneath him/her and began chest compressions. Nurse A said he/she took turns performing chest compressions with Nurse I, while Certified Nurse Assistant (CNA) K operated the ambu (device used to provide air during CPR) bag. Nurse A said Nurse L told him/her the resident was not feeling well before nurse L left the facility but did not provide any specific information. Nurse A said he/she did not go assess the resident. He/she said this was the first time he/she had seen the resident that shift. He/she said CPR is performed until the EMT arrives and it does not matter if the resident is cold because they cannot pronounce the death of a resident. When asked who was delegated to call 911, Nurse A said he/she could not recall if he/she called or if he/she had asked another staff member. He/she said CNA M was told to go to the door to escort the ambulance staff to the resident. Review of Nurse A's employee file, showed a CPR certification card issued ,[DATE] and expired on ,[DATE]. He/she did not have a current CPR certification. Review of Nurse I's employee file, showed a CPR certification card issued on ,[DATE] and expired on ,[DATE]. He/she did not have a current CPR certification. Review of CNA K's employee file, showed no documentation of CPR certification. A review of the staffing schedule, dated [DATE], showed 12 staff members on duty during the 3:00 P.M. to 11:00 P.M. shift. Of those 12, there was one CNA with a current CPR certification. He/she was not involved in the CPR performed on the resident. During an interview on [DATE] at 8:22 A.M., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) said the nurses and management are required to have CPR certification, the CNA's are not. They said staff who are not CPR certified can not be actively involved in a code. Non-certified CPR staff can only be the "runner" during a code situation. Review of the facility's policy on Cardiopulmonary Resuscitation, showed instructions from the Nursing Procedures Manual, dated ,[DATE]. There was no updated policy. During an interview on [DATE] at 11:59 A.M., Resident #12, who was Resident #11's roommate, said his/her roommate kept complaining of constipation. Resident #12 said he/she was just walking over and checking on him/her, but he/she was sleeping. He/she said nobody came into the room until he/she went to the nurse's station to tell the nurses to come and check on his/her roommate because he/she was having pain. Resident #12 said he/she went to the desk several times and the last time the nurse came, but Resident #11 had passed away in his/her sleep. Resident #12 said he/she just thought his/her roommate was asleep. He/she and Resident #11 had been roommates for a while. He/she said nobody was checking on his/her roommate but him/her. Resident #12 said he/she kept getting up and walking over to his/her roommates bed and he/she was sleep. Resident #12 remained in the room when the nurses entered the room. He/she said they did not pull the privacy curtain. He/she repeated his/her roommate passed away in his/her sleep. Resident #12 did not remember seeing a cart in the room. He/she said nobody was touching his/her roommate. During an interview on [DATE] at 4:30 P.M., CNA K said at about 10:30 P.M., Resident #11's roommate came out of the room and said he/she thought Resident #11 was dead. At that time, Nurse A went into the room. Resident #11 did not have a pulse. He/she said Nurse I came into the room. Nurse A and Nurse I started the chest compressions and he/she did the ambu bag. He/she said another CNA from night shift was sent outside to wait for the ambulance because the front doors are locked at night. CNA K said he/she was not assigned to the resident and was not aware of his/her complaints that evening. Nurse A paged for CNA P, but he/she had left for the night, which is why CNA K helped. He/she said Nurse A came up the hall with the crash cart and Nurse I was coming in for the night shift. CNA K said he/she did operate the ambu bag. He/she removed it from the crash cart. CNA K said he/she is not CPR certified, but has two premature children and took a class at children's hospital four times. During an interview on [DATE] at 4:50 P.M., CNA P said he/she had left the facility early that night. He/she said at about 3:30 P.M. or 4:00 P.M., Resident #11 started complaining of chest pain. CNA P said he/she told Nurse L. He/she went back to the resident's room at about 5:30 P.M. The resident wanted to eat dinner in his/her room. CNA P said at 7:30 P.M., the resident still had not eaten. He/she checked him/her and he/she was not wet. CNA P last saw the resident at 10:00 P.M. He/she left the facility around 10:30 P.M. CNA P did not know if Nurse L checked on the resident but he/she said he/she would. CNA P said the resident complained of chest pain early in the shift and kept saying he/she was still hurting. CNA P told Nurse L every time. He/she said the resident's roommate never said anything to him/her about Resident #11 that evening. During an interview on [DATE] at 5:05 P.M., Nurse L said Resident #12, the roommate said Resident #11 was not feeling well and wanted a 7-Up soda. He/she gave the resident the soda. He/she checked on the resident about an hour later. When he/she left the facility around 10:00 P.M., the resident was alive. Nurse L said the roommate told him/her the resident was not feeling well around 7:00 P.M. He/she denies staff telling him/her anything prior to 7:00 P.M. He/she said the resident complained of being nauseated. Nurse L said he/she asked the resident if anything hurt and he/she said he/she was just nauseated. He/she said the resident denied any complaints of pain and he/she did not obtain any vital signs. He/she could not remember if he/she documented anything. Nurse L said he/she checked on the resident again around 8:00 P.M. and 10:00 P.M., prior to leaving for the night and he/she was alive. He/she does rounds prior to leaving and it may have been a little before 10:00 P.M. Nurse L said he/she vaguely remembers the resident not eating dinner and not wanting to go to the dining room. Nurse L said he/she did not assess the resident because he/she only complained of being nauseated and just wanted a 7-Up soda, so he/she bought and gave him/her a 7-Up. He/she did not document anything. During an interview on [DATE] at 12:15 P.M., CNA CC said he/she was not the CNA assigned to the resident. It was his/her second day at the facility on the evening shift. He/she was walking past the resident's room and the call light was on. At that time, the roommate said Resident #11 needed help turning. He/she assisted the resident onto his/her side. He/she said the resident wanted to turn onto his/her stomach but he/she was not comfortable placing the resident onto his/her stomach. He/she said the resident was heavy to turn but he/she was alert and talking. He/she said the resident complained that his/her stomach was hurting and he/she was having chest pain. CNA CC said he/she went to the desk and notified Nurse A. He/she said Nurse A waved his/her hand at CNA CC saying the resident is always complaining. CNA CC said there were other staff at the desk. He/she said Nurse A never got up from the desk. Nurse A did not get up from the nurse's station until Resident #11's roommate asked if someone could come and check on the resident because he/she did not think the resident was breathing. He/she did not remember the exact time, but the roommate came to the nurse's station about a hour later. He/she said they took the crash cart to the resident's room, but none of the supplies were on it because they kept running around looking for stuff. He/she said the crash cart was there but the resident was cold. There was an ambu bag but he/she was not sure if that was one of the missing items on the crash cart. He/she said Nurse A told an unknown CNA to stand at the front of the facility and let him/her known when the ambulance arrives so that he/she could "fake like" he/she was performing CPR. CNA CC said the unknown CNA called Nurse A on his/her cell phone when the ambulance arrived at the facility. He/she said the roommate remained in the room the entire time. During an interview on [DATE] at 6:50 A.M., CNA M said he/she worked the night shift. When he/she arrived at the facility a little after 11:00 P.M., the resident was already deceased . The resident was on his/her assignment for the night. He/she said when he/she entered the resident's room, he/she was laying on a board. There was not a crash cart in the room and there were no staff members in the room. CNA M said the evening CNA had left for the night. CNA M said he/she asked Nurse A if he/she could clean the resident up because the board was still beneath him/her and he/she was uncovered. He/she could not remember if the ambulance was still at the facility or if the crash cart was outside of the room when he/she arrived. CNA M said he/she was not involved in the code and would not call a nurse to notify him/her that the ambulance has arrived so he/she could pretend to perform CPR. During an interview on [DATE] at 7:05 A.M., Nurse I said he/she arrived for the night shift between 10:45 P.M. and 11:00 P.M. He/she said Nurse A was at the nurse's station when he/she told him/her that he/she needed some help. Nurse I said he/she went into the resident's room. He/she had expired. When asked what did that mean. He/she said the resident's eyes were closed and he/she did not have a pulse. He/she said that is when he/she went to get the crash cart. Nurse I said he/she performed the compressions, while CNA K operated the ambu bag. He/she said the first ambu bag did not work. It would not inflate. He/she had to get another ambu bag from the cart, but did not have to search for supplies. Nurse I said someone did leave the room to get the back board to place beneath the resident. He/she said Nurse A did not assist with the CPR, he/she called 911 and was at the desk getting the paperwork together. Nurse I was not sure who was sent to the door to wait for the ambulance. He/she said sending someone to the door to wait for the ambulance was standard practice. Nurse I said the ambulance arrived quickly and placed the EKG leads on the resident. He/she said CPR continued until the ambulance arrived and instructed him/her to stop. Nurse I said he/she has not been CPR certified since [DATE]. He/she said CPR certification is not required. During an interview on [DATE] at 12:45 P.M., the ADON said staff call and notify him or the DON when a resident codes. The ADON or the DON then notifies the Administrator. During an interview on [DATE] at 12:40 P.M., CNA F said Nurse A called him/her and said the resident coded. CNA F said he/she notified the DON and Administrator. The ADON said staff are encouraged to be CPR certified and do not think any staff are required to be CPR certified, but the facility offers the class. During an interview on [DATE] at 1:35 P.M., the ADON said staff should have notified the physician of the resident's abnormal EKG results. During an interview on [DATE] at 10:19 A.M. Nurse Practitioner B said she could not recall facility staff notifying her of the resident's complaints of chest or abdominal pain. She did not recall ordering an EKG on [DATE] and is unaware of why staff obtained an EKG. She said staff did not notify her of the EKG results. If staff would have reported the EKG results to her, she would have notified the physician. During an interview on [DATE] at 12:05 P.M., the DON said he had no idea whose handwriting was on the EKG results, dated [DATE]. The fax time stamp on the top of the page is [DATE] at 8:59 A.M. He said he is assuming the EKG, dated [DATE], is the EKG the physician ordered on [DATE], since these are the only results. During an interview on [DATE] at 12:21 P.M., X-ray Company Staff T said the EKG was ordered by Nurse A on [DATE] at 10:06 A.M. He/she said there were no other EKG results for the resident. During an interview on [DATE] at 12:40 P.M., X-ray Company Staff U said a pink copy of the EKG was given to Nurse R after the EKG was obtained. He/she frequently visits the facility. Nurse R is the nurse who is always at the center desk (the nurse's station outside of the locked unit). He/she said the authorized signature is obtained when he/she arrives at the facility, but the staff could sign it ahead of time. X-ray Company Staff U said he/she is confident he/she obtained the signature while he/she was at the facility, but without a time stamp next to the signature he/she does not know. He/she did not remember anything about the resident the day the EKG was performed. During an interview on [DATE] at 11:33 A.M. and 12:57 P.M., Nurse R said he/she worked the day shift on [DATE] and remembered the resident having an EKG. He/she did not remember who ordered the EKG that was obtained on ,[DATE], the resident did not complain of chest pain. He/she could not remember who gave him/her report when he/she started his/her shift. Nurse R said the X-ray company provided the facility staff with a requisition to sign when they arrive to provide the service. Nurse R said the EKG results were not given to him/her, but he/she does not remember. The company arrived around 3:00 P.M. He/she was not given the results because he/she had left the facility before the EKG was complete. Nurse R said if the resident would have complained of chest pain he/she would have got the resident "the hell out of there and would have written a nurse's note". He/she said if his/her signature is on the requisition then he/she must have been there that day, but does not remember getting the results. Further review of the EKG requisition, dated [DATE], showed Nurse R's signature on the authorized signature line. During an interview on [DATE] at 1:40 P.M., Nurse S said he/she remembered the resident. He/she said the last time he/she saw the resident was the morning he/she died . Nurse S was the night shift nurse the night of ,[DATE] into the morning of [DATE]. He/she gave the resident his/her morning medications. Nurse S said the resident was alert, pleasant and had no complaints. He/she was not aware of the EKG. During an interview on [DATE] at 8:53 A.M., CNA X said he/she worked evening shift on [DATE]. He/she worked as a certified medication technician (CMT) that day and was not aware of the resident voicing any complaints. He/she administered medications to the resident during and afternoon and night medication pass. During the afternoon medication pass the resident did not seem like his/herself, he/she seemed a little tired. CNA X reported his/her observation of the resident to Nurse L. He/she is unaware of what happened after he/she talked with Nurse L. CNA X said the resident looked okay during the night medication pass. He/she was not in the room during the code. CNA X said he/she has a current CPR certification. Review of the Medication Administration Record [REDACTED].M., 6:00 P.M., 9:00 P.M. and 10:00 P.M. on [DATE]. CNA X's initials were written in the time slots to show the administration of the medications. During an interview on [DATE] at 9:44 A.M. Nurse A said he/she did not remember who ordered the EKG on [DATE] or the reason. He/she only works on Friday, Saturday, Sunday, Tuesday and Thursday. He/she said if the test was ordered on Monday, he/she was not at the facility unless he/she picked up an extra shift, but he/she does not remember. Nurse A said the evening the resident passed away he/she did not see the resident until he/she was already expired. He/she remembers the roommate coming to the desk and saying something, but does not remember what he/she said. Nurse A thinks the roommate said something about checking on his/her roommate, but does not remember. He/she does not remember who was at the desk with him/her, but thinks it was Nurse L. He/she was not working at the desk during that time. He/she stopped by the desk for a moment. During an interview on [DATE] at 10:19 A.M., Nurse Practitioner B said she was surprised to hear the resident died . Review of the death certificate, showed the resident expired from [MEDICAL CONDITION]. 2. Review of Resident #2's significant change MDS, dated [DATE], and quarterly review, dated [DATE], showed the following: -Originally admitted to the facility on [DATE], and readmitted from a local hospital on [DATE]; -[DIAGNOSES REDACTED]. -Alert with confusion; -No behaviors; -No pressure ulcers or wounds; -Required maximum assistance from staff for dressing, hygiene and bathing. Review of the resident's re-admission sheet, dated [DATE], showed no reddened areas on his/her skin or ulcers. Review of the resident's nurses notes, dated [DATE] (no time), showed the resident's left heel had a fluid filled intact blister. No measurements or further description documented. Review of the resident's POS, dated ,[DATE] through ,[DATE], showed an order dated [DATE], for staff to apply skin prep (a barrier) to the fluid filled blister on the left heel and cover with a dry dressing until healed. An order dated [DATE], for staff to apply skin prep to both heels every shift. Review of the resident's POS, dated ,[DATE] through ,[DATE], showed an order dated [DATE], for staff to cleanse the left heel wound with wound cleanser, apply Santyl Ointment (a debriedment ointment), apply Vaseline gauze to the open red area only. Cover with a dry dressing and wrap with gauze wrap every day and as needed. Review of the resident's Wound Solutions notes located in the resident's record, showed the following: -[DATE] - Left heel diabetic wound - 6.5 centimeters (cm) long by 5.2 cm wide by 0.1 cm deep. Wound base fully covered with black eschar (a hard cover of dead or dying tissue) 100%. No odor or drainage. -[DATE] - Left heel diabetic wound - 6.6 cm long by 4.70 cm wide by 0.1 cm deep. Wound base fully covered with black eschar 100%. No odor or drainage. -[DATE] - Left heel diabetic wound - 6.6 cm long by 4.7 cm wide by 0.1 cm deep. Wound base fully covered with black eschar 100%. No odor or drainage. -[DATE] - Left heel diabetic wound - 5 cm long by 5.4 cm wide by 0.1 cm deep. Wound base fully covered with black eschar 100%. -[DATE] - Left heel diabetic wound - 5.9 cm long by 4.7 cm wide by 0.1 cm deep. Wound base fully covered with black eschar 100%. Obtain bilateral lower extremity arterial Doppler flow study and ABIs (ankle brachial index, a simple vascular study commonly used to diagnose [MEDICAL CONDITION] by comparing the ratio of the blood pressure in the lower legs to the blood pressure in the arms to evaluate flow). [DATE] - Left heel diabetic wound - 2.5 cm long by 2 cm wide by 0.1 cm deep. Wound base fully covered with black eschar 100%. Obtain bilateral lower extremity arterial Doppler and ABIs. -[DATE] - Left heel diabetic wound - 2.5 cm long by 2 cm wide by 0.10 cm deep. Wound base 60% red and 40% black eschar. Cleanse wound with wound cleanser. Apply skin prep to black eschar. Apply Vaseline gauze to the open red area only. Cover with a dry dressing, secure with gauze wrap daily and as needed. Obtain a previously performed arterial Doppler and ABIs. -[DATE] - Missed visit, the resident was not available in the facility. -[DATE] - Left heel diabetic wound - 5.1 cm long by 4.4 cm wide by 0.2 cm deep. Wound base 60% red and 40% black eschar. No odor. Scant amount serous (clear watery fluid) drainage. Obtain a previously performed arterial Doppler and ABIs. -[DATE] - Left heel diabetic wound - 4.1 cm long by 3.5 cm wide by 0.2 cm deep. Wound base 50% red, 10% yellow (slough, dead or dying tissue) and 40% black eschar. No odor and scant amount serous drainage. Obtain a previously performed arterial Doppler and ABIs. -[DATE] - Left heel diabetic wound - 4.0 cm long by 3.4 cm wide by 0.3 cm deep. Wound base 50% red, 10% yellow and 40% black eschar. No odor and scant amount serous drainage. Please obtain bilateral arterial Doppler and ABIs. -[DATE] - Left heel diabetic wound - 3.8 cm long by 3.4 cm wide by 0.2 cm deep. Wound base 50% red, 10% yellow and 40% black eschar. No odor and scant amount serous drainage. Please obtain bilateral arterial Doppler and ABIs to evaluate flow. -[DATE] - Left heel diabetic wound - 3.7 cm long by 2.8 cm wide by 0.6 cm deep. No odor and scant amount serous drainage. Please obtain bilateral arterial Doppler and ABIs to evaluate flow. -[DATE] - Left heel diabetic wound - 3.5 cm long by 2.7 cm wide by 0.7 cm deep. No odor and scant amount serous drainage. Please obtain bilateral arterial Doppler and ABIs to evaluate flow. -[DATE] - Left heel diabetic wound - 3.5 cm long by 2.2 cm wide by 0.2 cm deep. No odor and scant amount serous drainage. Please obtain bilateral arterial Doppler and ABIs to evaluate flow. Review of the resident's care plan updated on [DATE], and in use during the survey, showed no information to address the diabetic wound on the resident's left heel. Review of the resident's POS, dated ,[DATE] through ,[DATE], showed an order dated [DATE], for staff to obtain arterial Doppler on lower extremities including ABIs. Review of the bilateral arterial Doppler flow study dated [DATE], showed the following: -Right lower extremity - severe plaque noted; -Left lower extremity - severe plaque noted; -Multilevel significant [MEDICAL CONDITION] disease (a buildup of plaque in the lining of the artery walls causing them to thicken and harden). Severe [MEDICAL CONDITION] ([MEDICAL CONDITION], a buildup of plaque in the arteries) bilateral lower extremities. Observation on [DATE] at 10:15 A.M., showed the resident sat in a recliner in his/her room. Nurse C washed his/her hands, put on gloves and removed the dressing from the resident's left heel. The resident's left heel had an unstageable ulcer that measured approximately 4 cm long by 4 cm wide. The wound base contained 50% red granulated tissue, 10% yellow slough and 40% black eschar without any odor. Nurse C cleaned, treated and covered the ulcer with a dressing. During an interview on [DATE] at 8:30 A.M., the DON said the Nurse Practitioner (NP) saw and measured the resident's wound every Friday, would document everything on the wound report on the computer and he would print the report the next Monday and place it in the resident's medical record. He did not look for any orders or recommendations on the report. The bilateral arterial Doppler flow study with ABIs was not done, because the NP did not write an order on the POS. If the NP wanted the test done, she should have written the order on the POS when in the facility. He did not clarify anything with the NP. The arterial Doppler flow study with ABIs was done on [DATE], because the Wound Solutions physician saw the resident on [DATE], and wrote the order on the POS. During an interview on [DATE] at 10:15 A.M., the Wound Solutions Physician said she needed to know the arterial Doppler flow study with ABI results to determine if the resident's heel could be debrided (removal of the eschar with a sharp instrument) in the facility, or if he/she needed to be seen by a vascular surgeon. 3. Review of Resident #16's annual MDS dated [DATE], showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. -BIMS score of 15 out of a possible 15 (no cognitive impairment); -No behaviors exhibited; -Required limited assistance from staff for bed mobility, transfers, dressing, hygiene and bathing; -No falls since prior assessment. Review of the resident's nurse's notes dated [DATE] at 9:40 A.M., showed the resident slid out of his/her geri-chair onto the floor and hit the right side of his/her forehead. A small amount of blood was noted and the doctor was notified. At 10:25 A.M., the resident was taken to the emergency room for examination. Per the nurse's note, at 3:30 P.M. on [DATE]: "Resident returned at this time with", the note ends mid-sentence and there is no further documentation in the nurse's note for that day. Review of the resident's nurse's note dated [DATE] at 10:00 A.M., showed the resident had six sutures to the right side of his/her forehead, dry and intact. Review of the resident's discharge instructions from the emergency department dated [DATE] at 12:00 P.M., showed orders for the resident to have an appointment with his/her doctor for follow-up care in ,[DATE] days and to have sutures removed in seven days ([DATE]). Review of the resident's medical chart from [DATE] through [DATE], showed no record of the resident being seen for follow-up care by his/her doctor or the removal of the sutures. During an interview on [DATE] at 7:40 A.M., Nurse A said that documentation for physician follow-up care would be in the nurse's notes of the resident's medical chart. Nurse A said the resident could either be sent out to have the sutures removed or the DON could remove them. The date for removal, per discharge order, would be [DATE]. Nurse A reviewed the nurse's notes with the surveyor and could not locate documentation of the sutures being removed. Observation on [DATE] at 8:55 A.M., showed the surveyor went with the DON to examine the resident's forehead. At that time, he verified the sutures were still in place. The DON then checked the resident's chart for the removal date listed on the order. He said he would call the resident's doctor to verify if the sutures should be removed. During an interview on [DATE] at 9:15 A.M., the Administrator said she was unaware of the resident's fall and injury. During an interview on [DATE] at 9:32 A.M., the DON said the facility nurse practitioner would come out today to take out the sutures. He said he was not comfortable removing the sutures himself. Review of the resident's care plan, dated [DATE], showed the following hand written entries on the first page of the care plan that identified visual function as the problem: - Written in-between entries dated [DATE] and [DATE], "(Late note) [DATE] just informed res fell , sent out, sutures."; -"[DATE] Sutures to be removed by N.P. Nurse has been fired." During an interview on [DATE] at 10:16 A.M., Nurse Practitioner B verified that he/she removed the sutures from the resident's forehead on [DATE]. He/she said they expected for orders to be followed and the s

Based on interview and record review, facility staff failed to transfer residents with proper use of a gait belt (a safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) to prevent accidental injuries or falls and failed to adequately investigate the circumstances that resulted in the fall for one of 14 sampled residents (Resident #7). The census was 81. 1. Review of Resident #7's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/9/10, showed the following: -Short term memory loss; -Stroke, [DIAGNOSES REDACTED]/hemiparesis (paralysis of one side of the body), unsteady gait; -Extensive assistance required for bed mobility, transfer, walking, dressing, toilet use and personal hygiene. Review of the resident's care plan, updated 6/10, showed the following: -One person extensive assistance for transfers with a gait belt; -Late effect of a stroke with left sided hemiparesis; -At risk for falls related to falls in the past 180 days. Review of the fall risk assessment dated [DATE], showed under gait/balance, the resident could not perform the function. The resident received a score of 12 (a score of 10 or above represented a high risk for falling) for the complete fall risk assessment. Review of nurse's notes dated 7/4/10 at 5:35 P.M., showed Certified Nurse Aide (CNA) H called the nurse to the resident's room. The CNA said when he/she transferred the resident from bed to a wheelchair, the resident grabbed the wheelchair. That caused the resident to fall face down onto the floor. The resident's nose bled and a hematoma (a collection of blood under the skin) noted in the middle of his/her forehead. At 6:25 P.M., an ambulance arrived to transport the resident to the hospital. Review of the incident report dated 7/4/10, showed the following: -Type of incident: fall; -The resident was injured and seen in the emergency room ; -Attached statement by CNA H, showed while transferring the resident in his/her wheelchair, the CNA stood the resident. The resident started to lean to the side. CNA H tried to put the resident in his/her chair but the resident fell . It happened so fast. Review of the hospital emergency department records dated 7/5/10, showed the following: -Facial fracture; -Nasal bones- closed fracture; -Frontal sinus fracture; -Head injury. Further review of the resident's care plan did not show any update since 6/10. During an interview on 9/27/10 at 12:50 P.M., CNA H said he/she began to transfer the resident from the bed to the wheelchair. He/she stood the resident by holding the resident under his/her arms. The resident leaned to one side and he/she tried to pull the resident upright, but the resident fell . He/she had not used a gait belt for the transfer. A gait belt should have been used when transferring the resident. He/she did not have a gait belt with him/her at that time. Review of the facility's transfer, one-person pivot transfer from bed to chair policy, dated 11/07, showed the following: -Purpose: To safely transfer a resident from one location to another; decrease potential for resident and/or staff injury; -Equipment: bed, chair and gait belt; -Never transfer a resident by lifting him/her under the arms. This can cause nerve damage, fractures and shoulder dislocation. -Apply gait belt to resident; -Stand in front of resident with feet about 18 inches apart; -Place hands underneath the gait belt, assist resident to stand and pivot toward the chair. During an interview with the Director of Nursing (DON) and corporate administrator on 9/27/10 at approximately 1:00 P.M., the DON said CNA H wrote a statement that described what occurred when the resident fell (on 7/4/10). The CNA's statement was attached to the incident report provided to the surveyor. All the information about the fall was included in that report. Staff should use a gait belt for all transfers. The corporate Administrator said she did not ask CNA H if a gait belt was used during the transfer and did not know the CNA did not use a gait belt. During an interview on 10/1/10 at 12:20 P.M., the corporate administrator said the nurses have meetings five days per week and the CNA's are notified of any changes in resident care needs and care plans are available to staff at the nurses station. During an interview on 10/1/10 at 12:26 P.M., the DON said after she was made aware by the surveyor (on 9/27/10), she had started inservicing staff on proper transfers, including CNA H.