Every finding on record at Valley Vista for Nursing and Rehabilitation

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to investigate an allegation of abuse and ensure resident safety during the investigation for 1 of 2 residents reviewed for abuse(Resident #7). The facility reported a census of 62 residents.Findings: 1. The Minimum Data Set(MDS)assessment tool, dated 12/11/25, listed diagnoses for Resident #7 which included cerebral palsy(a disorder caused by brain abnormalities and characterized by symptoms including difficulty with movement, muscle tone, and balance), severe intellectual disabilities, and a history of healed traumatic fractures. The MDS stated the resident was dependent on staff for toileting and dressing, required partial to moderate assistance for transfers, and did not walk during the review period. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated June 2023, stated residents had the right to be free from abuse and to be treated with respect and dignity. The policy defined abuse to include involuntary seclusion. The facility would report abuse to the State Agency within 2 hours and complete a timely and thorough investigation. The policy did not specifically address how the facility would protect residents during the investigation. A 12/8/25 Care Plan entry stated Resident #7 liked to spend time in the common area watching tv, listening to music, and people watching. A 12/10/25 Care Plan entry stated Resident #7 had impaired cognitive function and was able to make basic needs known through body language and saying yeah or nah. The February 2026 Documentation Survey Report V2 documented on 2/21/26 during the day shift(6:00 a.m. to 2:00 p.m.), Staff A Certified Nursing Assistant(CNA) provided the resident with assistance including the following activities of daily living: chair to bed transfers, dressing, oral hygiene, personal hygiene, and toilet transfers.On 2/24/26 at 3:42 p.m., Staff E CNA stated that last Saturday(2/21/26) Resident #7 made vocalizations and Staff A CNA placed him in his room and closed the door so she wouldn't have to hear him. She stated she reported this to Staff F Registered Nurse(RN). Staff E stated the resident didn't like being in his room and he was in there 45 minutes to 1 hour. In a follow-up interview on 2/24/26 at 3:49 p.m., Staff E stated that the resident's roommate was also present in the room at the time this happened. On 2/25/26 at 8:14 a.m., Resident #8, resident #7's roommate, stated at times, Resident #7 wanted out of the room and staff shut the door. He stated resident #7 liked to be in the common area.On 2/25/26 at 10:54 a.m., Staff F, Registered Nurse(RN) stated Resident #7 did not like to be in his room. He liked sitting by the nursing station people watching. She stated staff were aware of what he wanted because he would grunt and point. At first, Staff F stated she was not aware of any staff members who placed the resident in his room when he wanted out. Upon further questioning, Staff F stated Staff E, CNA reported to her that Staff A, CNA placed the resident in his room and closed the door. She stated Staff E told her that Resident #7's roommate alerted the call light. Staff E stated that Staff A entered the room and asked the resident what was wrong and he pointed at the door like he wanted to go out. Staff E stated Staff A told the resident that she would be back in a minute and closed the door. Staff F stated she was not sure what day Staff E reported this to her but it was in the last week. Staff F stated she did not feel that this incident occurred on the day Staff E reported it to her, but a couple weeks prior. She stated she reported this to the Director of Nursing(DON) in passing. She stated her expectation was for staff to bring the resident out of his room if this was his wish. On 2/25/26 at 11:32 a.m., Staff A, CNA denied that she closed the door and would not allow the resident out of his room. She stated she was able to determine some of the resident's wishes per his gestures. For example, the resident made a driving motion when he wanted to go somewhere and also pointed and made noises. She stated this last weekend, she did not think she took care of him as she wasn't assigned to his hall. On 2/25/26 at 11:40 a.m., the Director of Nursing(DON) stated she would want staff to report it if someone placed a resident in their room and closed the door against their wishes. She stated no one reported anything of this nature to her. She stated Resident #7 loved to be out in the common area. She stated if someone notified her of this, she would have suspended the staff member while the investigation was pending. On 2/25/26 at 11:50 a.m., the Administrator stated staff should report allegations of abuse to her or the DON. She stated she would separate (the alleged perpetrator) from residents to make sure they were safe. She stated she would complete an investigation and report the allegation to the State Agency. The Administrator stated no one reported to her any concerns related to Staff A. She stated Resident #7 preferred to be out in the common area and agreed that if he gestured that he wanted out of his room, staff should honor his wishes. She stated she would suspend Staff A.On 2/25/26 at 2:28 p.m., the Administrator stated staff should treat residents with kindness and they should be free from abuse. The facility lacked documentation they carried out an investigation or separated residents from Staff A prior to 2/25/26.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 2 residents reviewed for abuse(Resident #7). The facility reported a census of 62 residents.Findings: 1. The Minimum Data Set(MDS)assessment tool, dated 12/11/25, listed diagnoses for Resident #7 which included cerebral palsy(a disorder caused by brain abnormalities and characterized by symptoms including difficulty with movement, muscle tone, and balance), severe intellectual disabilities, and a history of healed traumatic fractures. The MDS stated the resident was dependent on staff for toileting and dressing, required partial to moderate assistance for transfers, and did not walk during the review period. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated June 2023, stated residents had the right to be free from abuse and to be treated with respect and dignity. The policy defined abuse to include involuntary seclusion. The facility would report abuse to the State Agency within 2 hours and complete a timely and thorough investigation. A 12/8/25 Care Plan entry stated Resident #7 liked to spend time in the common area watching tv, listening to music, and people watching. A 12/10/25 Care Plan entry stated Resident #7 had impaired cognitive function and was able to make basic needs known through body language and saying yeah or nah. The February 2026 Documentation Survey Report V2 documented on 2/21/26 during the day shift(6:00 a.m. to 2:00 p.m.), Staff A Certified Nursing Assistant(CNA) provided the resident with assistance including the following activities of daily living: chair to bed transfers, dressing, oral hygiene, personal hygiene, and toilet transfers.On 2/24/26 at 3:42 p.m., Staff E CNA stated that last Saturday(2/21/26) Resident #7 made vocalizations and Staff A CNA placed him in his room and closed the door so she wouldn't have to hear him. She stated she reported this to Staff F Registered Nurse(RN). Staff E stated the resident didn't like being in his room and he was in there 45 minutes to 1 hour. In a follow-up interview on 2/24/26 at 3:49 p.m., Staff E stated that the resident's roommate was also present in the room at the time this happened. On 2/25/26 at 8:14 a.m., Resident #8, resident #7's roommate, stated at times, Resident #7 wanted out of the room and staff shut the door. He stated resident #7 liked to be in the common area.On 2/25/26 at 10:54 a.m., Staff F, Registered Nurse(RN) stated Resident #7 did not like to be in his room. He liked sitting by the nursing station people watching. She stated staff were aware of what he wanted because he would grunt and point. At first, Staff F stated she was not aware of any staff members who placed the resident in his room when he wanted out. Upon further questioning, Staff F stated Staff E, CNA reported to her that Staff A, CNA placed the resident in his room and closed the door. She stated Staff E told her that Resident #7's roommate alerted the call light. Staff E stated that Staff A entered the room and asked the resident what was wrong and he pointed at the door like he wanted to go out. Staff E stated Staff A told the resident that she would be back in a minute and closed the door. Staff F stated she was not sure what day Staff E reported this to her but it was in the last week. Staff F stated she did not feel that this incident occurred on the day Staff E reported it to her, but a couple weeks prior. She stated she reported this to the Director of Nursing(DON) in passing. She stated her expectation was for staff to bring the resident out of his room if this was his wish. On 2/25/26 at 11:32 a.m., Staff A, CNA denied that she closed the door and would not allow the resident out of his room. She stated she was able to determine some of the resident's wishes per his gestures. For example, the resident made a driving motion when he wanted to go somewhere and also pointed and made noises. She stated this last weekend, she did not think she took care of him as she wasn't assigned to his hall. On 2/25/26 at 11:40 a.m., the DON stated she would want staff to report it if someone placed a resident in their room and closed the door against their wishes. She stated no one reported anything of this nature to her. She stated Resident #7 loved to be out in the common area. She stated if someone notified her of this, she would have suspended the staff member while the investigation was pending. On 2/25/26 at 11:50 a.m., the Administrator stated staff should report allegations of abuse to her or the DON. She stated she would separate (the alleged perpetrator) from residents to make sure they were safe. She stated she would complete an investigation and report the allegation to the State Agency. The Administrator stated no one reported to her any concerns related to Staff A. She stated Resident #7 preferred to be out in the common area and agreed that if he gestured that he wanted out of his room, staff should honor his wishes. She stated she would suspend Staff A.On 2/25/26 at 2:28 p.m., the Administrator stated staff should treat residents with kindness and they should be free from abuse. The facility lacked documentation they reported the allegation of the abuse to the State Agency prior to 2/25/26.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure 2 of 2 residents reviewed for abuse were free from unreasonable confinement(Resident #7) and sexual exploitation(Resident #3). The facility reported a census of 62 residents.Findings: 1. The Minimum Data Set(MDS)assessment tool, dated 12/11/25, listed diagnoses for Resident #7 which included cerebral palsy(a disorder caused by brain abnormalities and characterized by symptoms including difficulty with movement, muscle tone, and balance), severe intellectual disabilities, and a history of healed traumatic fractures. The MDS stated the resident was dependent on staff for toileting and dressing, required partial to moderate assistance for transfers, and did not walk during the review period. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 1 out of 15, indicating severely impaired cognition. A 12/8/25 Care Plan entry stated Resident #7 liked to spend time in the common area watching tv, listening to music, and people watching. A 12/10/25 Care Plan entry stated Resident #7 had impaired cognitive function and was able to make basic needs known through body language and saying yeah or nah. The February 2026 Documentation Survey Report V2 documented on 2/21/26 during the day shift(6:00 a.m. to 2:00 p.m.), Staff A Certified Nursing Assistant(CNA) provided the resident with assistance including the following activities of daily living: chair to bed transfers, dressing, oral hygiene, personal hygiene, and toilet transfers.On 2/24/26 at 3:42 p.m., Staff E CNA stated that last Saturday(2/21/26) Resident #7 made vocalizations and Staff A CNA placed him in his room and closed the door so she wouldn't have to hear him. She stated she reported this to Staff F Registered Nurse(RN). Staff E stated the resident didn't like being in his room and he was in there 45 minutes to 1 hour. In a follow-up interview on 2/24/26 at 3:49 p.m., Staff E stated that the resident's roommate was also present in the room at the time this happened. On 2/25/26 at 8:14 a.m., Resident #8, resident #7's roommate, stated at times, Resident #7 wanted out of the room and staff shut the door. He stated resident #7 liked to be in the common area.The Quarterly MDS dated [DATE] Resident #8 had a BIMS score of 13 out of 15, which indicated intact cognitive skills.On 2/25/26 at 10:54 a.m., Staff F, Registered Nurse(RN) stated Resident #7 did not like to be in his room. He liked sitting by the nursing station people watching. She stated staff were aware of what he wanted because he would grunt and point. At first, Staff F stated she was not aware of any staff members who placed the resident in his room when he wanted out. Upon further questioning, Staff F stated Staff E(CNA) reported to her that Staff A(CNA) placed the resident in his room and closed the door. She stated Staff E told her that Resident #7's roommate alerted the call light. Staff E stated that Staff A entered the room and asked the resident what was wrong and he pointed at the door like he wanted to go out. Staff E stated Staff A told the resident that she would be back in a minute and closed the door. Staff F stated she was not sure what day Staff E reported this to her but it was in the last week. Staff F stated she did not feel that this incident occurred on the day Staff E reported it to her, but a couple weeks prior. She stated she reported this to the Director of Nursing(DON) in passing. She stated her expectation was for staff to bring the resident out of his room if this was his wish. On 2/25/26 at 11:32 a.m., Staff A(CNA) denied that she closed the door and would not allow the resident out of his room. She stated she was able to determine some of the resident's wishes per his gestures. For example, the resident made a driving motion when he wanted to go somewhere and also pointed and made noises. She stated this last weekend, she did not think she took care of him as she wasn't assigned to his hall. On 2/25/26 at 11:40 a.m., the DON stated she would want staff to report it if someone placed a resident in their room and closed the door against their wishes. She stated no one reported anything of this nature to her. She stated Resident #7 loved to be out in the common area. She stated if someone notified her of this, she would have suspended the staff member while the investigation was pending. On 2/25/26 at 11:50 a.m., the Administrator stated staff should report allegations of abuse to her or the DON. She stated she would separate (the alleged perpetrator) from residents to make sure they were safe. She stated she would complete an investigation and report the allegation to the State Agency. The Administrator stated no one reported to her any concerns related to Staff A. She stated Resident #7 preferred to be out in the common area and agreed that if he gestured that he wanted out of his room, staff should honor his wishes. She stated she would suspend Staff A. 2. The MDS assessment tool, dated 11/6/25, listed diagnoses for Resident #3 which included non-Alzheimer's dementia, anxiety disorder, and depression. The MDS listed the resident's BIMS score as 8 out of 15, indicating moderately impaired cognition. 1/30/25 Care Plan entries stated the resident had an alteration in neurological status related to altered mental status and directed staff to anticipate and meet his needs. An undated 5 Day Summary Staff to Resident form stated on 12/25/25, Staff B Registered Nurse(RN) witnessed Staff C, [NAME] kiss Resident #3 on his lips while holding his hand.The facility Abuse Policy, dated June 2023, stated residents had the right to be free from abuse and to be treated with respect and dignity. The policy defined abuse to include involuntary seclusion and exploitation. The facility would report abuse to the State Agency within 2 hours and complete a timely and thorough investigation. The policy did not specifically address how the facility would protect residents during the investigation. On 2/24/26 at 9:17 a.m. the DON stated that Staff C, [NAME] was friends with Resident #3 for a long time. She stated at times, Staff C would encourage the resident to change his clothes as he was reluctant to do so. At this time, she would tug on his shirt and encourage him to change it. The DON demonstrated that Staff C would gently tug on the resident's shirt while encouraging him to change it. She stated a staff member reported that she saw Staff C kiss the resident. The DON stated that this allegation was out of character for Staff C and it didn't make any sense. She stated that the resident asked about Staff C after the facility suspended her and that he called Staff C nicest when referring to her. She stated the resident denied that Staff C kissed him during the visit. On 2/24/26 at 10:21 a.m., via phone, Staff B, Registered stated she entered the resident's room to give him his medication and there was a female visitor in his room with a child around the age of 11. She stated the female visitor and the resident were standing in front of the resident's night stand and the female visitor kissed the resident twice on the mouth. She stated the visitor had both of her hands around the resident's waist at the time of the kiss and they separated when she walked in the room. She stated she heard the resident ask the visitor to leave. She stated later, she observed the resident and the visitor walk down the hall holding hands. Staff B stated she did not know that the visitor was a staff member(Staff C Cook) until she assisted her out the front door and the visitor mentioned she worked there. Staff B stated no one else was in the room at the time of the kiss except the resident, the female visitor, and the child who accompanied her. Staff B stated she could not tell from her vantage point whether it was a closed or open mouthed kiss. Later, she heard from an agency nurse that Staff B wanted to take another resident(Resident #10) out overnight but they did not permit this because they did not have permission from the resident's guardian. On 2/24/26 at 10:47 a.m., the Administrator stated Staff B reported to her the concern with Staff C. The Administrator stated Staff B reported that she observed Staff C kiss Resident #3 twice. When the Administrator spoke to the resident, he stated there was no inappropriate touching/kissing and it was no big deal. The resident did report that Staff C told him to take this off while he gestured to his shirt. At the time he said this, the Administrator stated she had no context to the statement. She determined later that Staff C knew the resident prior to his admission to the facility and at times encouraged him to change his shirt. The Administrator stated Staff D agency Licensed Practical Nurse(LPN) reported Staff C also wanted to check out another resident overnight. Staff C asked for the resident's medications so she could do so. Staff did not allow this as they could not get permission for the resident's guardian. The Administrator stated she thought this was inappropriate and there were boundary issues with Staff C and that she had poor judgement.On 2/24/26 at 11:25 a.m., Staff D, Licensed Practical Nurse(LPN) stated on Christmas Day there was a kitchen staff member(Staff C) who wanted to take a resident out of the facility overnight and requested his medications. Staff D stated she did not allow this as she did not have permission from the resident's guardian. She stated she did not observe Staff C kiss or touch any residents. On 2/25/26 at 2:28 p.m., the Administrator stated staff should treat residents with kindness and they should be free from abuse.

Based on electronic health record review (EHR) and staff interviews, the facility failed to maintain complete and readily accessible resident medical records for 7 of 7 residents reviewed. The EHR failed to provide Iowa Statutory Power of Attorney (POA) documentation for these residents that indicated having an appointed POA. The facility reported a census of 61 residents. Findings include: Review of Resident #1, #4, #5, #6, #7, #8, #9's EHR indicated each resident having designated POA. Review of these records failed to provide the Iowa Statutory POA documentation for review. During an interview on 11/24/25 at 1:50 PM, Staff A, Social Services, reviewed resident's records and acknowledged Resident #1, #4, #5, #6, #7, #8, and #9's EHR and facility paper chart, failed to provide the legal documentation identifying Resident's appointed POA. In an interview on 11/24/25 at 2:50 PM, Staff A, Social Services and Staff B, Director of Nursing (DON), acknowledged the failure to provide POA documentation in resident #1, #4, #5, #6, #7, #8, and #9's records. Staff B, DON stated the facility's plan of correction will include audits of all resident's records of POA documentation (for those residents who have designated POAs), a hard copy of this document would be placed in the resident's paper chart, a copy uploaded to resident's EHR and Staff A, Social Services would also have a binder in her office with copies of the documents.

Based on Resident's Electronic Record Review (EHR), staff interview, review of CMS-2567 reports (Federal Statement of Deficiencies), and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in a repeat deficiency identified on the facility's current complaint survey. The facility reported a census of 61 residents.Findings include: Review of Resident #1, #4, #5, #6, #7, #8, #9's EHR indicated each resident having designated POA. Review of these records failed to provide the Iowa Statutory POA documentation for review. During an interview on 11/24/25 at 1:50 PM, Staff A, Social Services, reviewed resident's records and acknowledged Resident #1, #4, #5, #6, #7, #8, and #9's EHR and facility paper chart, failed to provide the legal documentation identifying Resident's appointed POA.Review of facility's CMS-2567 Recertification report dated 8/14/25, revealed the facility had a deficiency due to the facility failing to maintain complete and readily accessible resident medical records for 2 of 3 residents reviewed during this survey. In an interview on 11/24/25 at 2:50 PM, Staff A, Social Services and Staff B, Director of Nursing (DON), both acknowledged the failure to provide complete and readily accessible medical records to include POA documentation in resident #1, #4, #5, #6, #7, #8, and #9's records. Staff B, DON stated the facility's plan of correction will include audits of all resident's records of POA documentation (for those residents who have indicated have a designated POA), a hard copy of this document would be placed in the resident's paper chart, a copy uploaded to resident's EHR, and Staff A, Social Services, would also have a binder in her office with copies of the documents.

Based on observations, electronic health record review (EHR), staff interview, and policy review, the facility failed to update resident Care Plans in a timely manner to reflect current conditions and interventions for 5 of 19 resident Care Plans reviewed (Residents #4, #6, #22, #26, and #46). The facility reported a census of 54 residents.Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment completed on [DATE] revealed Resident #4 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses on the MDS include diabetes and end stage renal disease (ESRD). The Care Plan for Resident #4, last revised on [DATE], listed an intervention for the use of Lido/Prilcn (a topical numbing cream under the Brand Name Emla) applied to the right fistula on Monday, Wednesday, and Friday. The Progress Note dated [DATE] documented the facility receiving a fax from the dialysis unit to discontinue EMLA due to patient complaints of itching. [DATE]’s Treatment Administration Record (TAR) showed the Lido/Prilo was discontinued on [DATE]. During an interview on [DATE] at 11:30 AM, the MDS Coordinator acknowledged the intervention for the use of Lido/Prilo. The MDS Coordinator explained there had been changes to the type of cream used and confirmed another class of medicated cream is currently in use. The Care Plan should reflect this change. While any staff member can update the Care Plan as needed, the MDS Coordinator is ultimately responsible for updates. 2. The Quarterly MDS completed on [DATE] revealed Resident #6 with a BIMS score of 15, indicating intact cognition. Diagnoses on the MDS include diabetes, heart failure, morbid obesity, peripheral vascular disease, and renal insufficiency. The MDS noted the presence of a colostomy, stage 3 pressure injuries, and urinary catheter. The weight on the MDS noted at 235#. The Care Plan for Resident #6, last revised on [DATE], listed an intervention for the use of negative pressure wound therapy (NPWT) to the resident’s abdominal surgical wound from an ostomy revision. This was added on [DATE]. The Care Plan listed a goal for Resident #6s’ weight to trend between 255-275# through the next review date. An Order Audit Report obtained on [DATE], indicated the NPWT was initiated on [DATE] and discontinued on [DATE]. Documented weights in the EHR showed Resident #6’s weight has been trending between 234-237# from [DATE] to present. During an interview on [DATE] at 4:00 PM, the Registered Dietitian explained they will typically review and update resident's Nutritional Plan of Care with each schedule MDS Assessment. The RD acknowledged the lack of nutrition Care Plan updates. During an interview on [DATE] at 11:30 AM, the MDS Coordinator acknowledged the intervention for the NPWT. The MDS Coordinator confirmed the NPWT had been discontinued. While any staff member can update the Care Plan as needed, the MDS Coordinator is ultimately responsible for updates. 3. The Quarterly MDS completed on [DATE] revealed Resident #22 with a BIMS score of 0, indicating a severe cognitive impairment. Diagnoses on the MDS include Alzheimer’s disease, cancer, coronary artery disease, diabetes, heart failure, and non-Alzheimer’s dementia. The weight on the MDS noted at 177#. The Care Plan for Resident #22, last revised on [DATE], listed a goal weight to trend between 160-170# through the next review date. Interventions included in this Focus area include weight loss to be unavoidable (initiated on [DATE] and revised on [DATE]) and resident has refused house supplement (initiated [DATE] and revised on [DATE]). Documented weights in the EHR showed Resident #22’s weight up and trending between 159-182# from February 2025 to present. Current Physician Orders listed the use of a protein supplement daily for wound healing, which was initiated on [DATE]. Neither the skin alteration nor the nutrition focus areas of the Care Plan include the supplement use a a current intervention. During an interview on [DATE] at 4:00 PM, the Registered Dietitian explained they will typically review and update resident's Nutritional Plan of Care with each schedule MDS Assessment. The RD acknowledged the lack of nutrition Care Plan updates. 4. The Significant Change in Status MDS for Resident #26 dated [DATE] section M-Skin Conditions documented pressure ulcer/injury Stage 3, 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. The MDS further documented Skin and Ulcer/Injury treatments: pressure reducing device for chair and bed. Prior MDS for Resident #26 dated [DATE] section M-Skin Conditions documented there was no risk for pressure ulcer/injury. The MDS further documented Skin and Ulcer/Injury treatments: pressure reducing device for chair and bed. The Care Plan document Resident #26 was at risk of skin breakdown related to history of skin breakdown on her bottom and low body fat level. Has actual skin impairment of stage 3 pressure to left buttocks, dated [DATE]. Interventions listed: “assess for and provide appropriate pressure-relieving devices as per PT/OT recommendations: chair cushion, mattress.” During a wound care treatment observation of Resident #26 on [DATE] at 10:30 am there was no cushion noted in the recliner where Resident #26 was seated. Staff A, LPN could not locate the chair cushion in the room. At that time the MDS coordinator stated the resident refused the cushion and was not using it consistently. The Care Plan for Resident #26 did not reflect alternative interventions or the history of refusal of the cushion. The MDS coordinator stated she will inquiry Physical Therapy/Occupational Therapy (PT/OT) for other alternatives. During an interview on [DATE] at 11:45 am with the DON confirmed Resident #26 did not like to use a cushion in her chair and that the Care Plan did not reflect her preferences. 5. An observation of Resident #46 on [DATE] at 11:55 am revealed staff used a mechanical lift to transfer her from her recliner to a wheelchair for lunch. A review of the Electronic Health Record (EHR) document titled “Care Plan” for Resident #46 documented advanced directive of Full Code, cardiopulmonary resuscitation (CPR) dated [DATE]. It also documented staff assistance of 2 with transfers using a front-wheel-walker and a gait belt, dated [DATE]. On [DATE], the Care Plan noted Resident #46 was on Hospice services and will have frequent 1-1 visits with her providers. During an interview on [DATE] at 2:11 pm, Staff A, Licensed Practical Nurse (LPN) stated in case of an emergency she looks in the EHR for the code status. Staff A stated they have physical charts/ paper charts located behind the main nurses station. After documents are uploaded into the EHR, then they can be filed in the paper charts. She stated some paperwork doesn't get filed immediately because they don't have a designated staff to do that task. She stated the PCC is the first and main place to look for any health-related information for the patient and paper-based charts are only for a back-up. The MDS for Resident #46 dated [DATE] documented Hospice services were added. It also documented functional abilities for mobility as “substantial/maximal” staff assistance required with transfers. During an interview on [DATE] at 10:25 am with the Director of Nursing (DON), she confirmed the Care Plans were not updated for Resident #26 and #46 to reflect changes in health status and current needs. She stated her expectations were that the Care Plans reflected current health status for each resident. The policy Care Plan: Comprehensive Person-Centered, revision date [DATE], revealed the following: a. The comprehensive, person-centered care plan is developed within seven days of the required MDS assessments (admission, annual or significant change) b. Care Plan interventions are derived from a thorough analysis of information gathered as part of the assessment c. The Care Plan describes services that are to be furnished to attain or maintain the resident’s highest practicable well-being d. Services provided for or arranged by the facility e. Assessments of residents are ongoing and Care Plans are revised as information about the residents and resident conditions changes f. The Interdisciplinary Team reviews and updated the Care Plan when there has been a significant change in the resident’s condition, when the desired outcome is not met, and at least quarterly, in conjunction with the required quarterly MDS assessment

Based on electronic health record (EHR) review, staff interview, and guidance form the 2024 Resident Assessment Instrument (RAI), the facility failed to submit accurate resident information on the Comprehensive Minimum Data Set (MDS) Assessments for 2 out of 19 residents reviewed for MDS assessments (Residents #6 for weight loss and #16 for mental illness diagnosis). The facility reported a census of 54. Findings include:1. 1. The Quarterly MDS assessment completed on 6/11/25 revealed Resident #6 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses on the MDS include diabetes, heart failure, morbid obesity, peripheral vascular disease, and renal insufficiency. The MDS further noted the presence of a colostomy, stage 3 pressure injuries, and urinary catheter. The recorded weight on the MDS Section K -Swallowing /Nutritional Status was entered at 235 pounds and noted as No or Unknown for weight loss of 5% or more in the last month or loss of 10% or more in the last six months.The documented weights in the EHR noted the following:a. 272.0# on 11/13/24b. 272.3# on 12/9/24c. 259.2# on 1/13/25d. 253.8# on 2/2/25e. 234.0# on 3/1/15f. 235# on 5/14/25Due to lack of a documented weight for April 2025, unable to determine if a 5% significant weight loss occurred in the past month. However, a significant weight loss of 10% or more did occur in the previous six months and was not noted on the MDS completed 6/11/25. 2. 2. The Annual MDS assessment completed on 5/28/25 revealed Resident #16 with a BIMS of 14, indicating intact cognition. Diagnoses on the MDS in Section I (Active Diagnoses) include bipolar disorder, depression, and Parkinson's disease.The diagnosis tab of the EHR noted a bipolar disorder on 10/21/19, which was identified from a previous short-term facility admission.The PASRR Notice of Nursing Facility Approval, dated 8/26/20, noted Resident #16 meets criteria for having a diagnosis of a mental illness as defined by PASRR. Bipolar disorder, Not otherwise specified was identified.Section A1500 Preadmission Screening and Resident Review (PASRR) of the MDS was checked No on the MDS completed 5/28/25. This question asked if the resident is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.During an interview on 8/14/25 at 11:30 AM, the MDS Coordinator acknowledged the weight loss section for Resident #6 was incorrectly answered on the MDS dated [DATE]. The MDS Coordinator explained the resident had a prolonged hospitalization and was on a weight loss medication, which was effective. Section K0300 should have been answered Yes, on a physician-prescribed weight loss regimen to a weight loss of 10% or more in the last six months.The MDS Coordinator acknowledged Resident 16's bipolar diagnosis and noted Question A1500 was incorrectly answered on the MDS dated [DATE]. Question A1500 should have been answered Yes which would direct staff to answer question A1510 Level II PASRR Conditions. The 2024 RAI stated the following for coding instructions:a. Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order.b. Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related conditions, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on observations, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards as staff did not wear gloves when administered an injection for 1of 1 resident (Resident #53) and failed to apply personal protective equipment (PPE) when provided hands on care for a resident on enhanced barrier precautions for 1 of 3 residents (Resident #16). The facility reported a census of 54 residents. Findings include: 1.Observation on 8/12/2025 at 11:26 AM, Staff A, Licensed Practical Nurse administered an insulin injection to Resident #53 with no gloves on. Interview at 8/12/25 at 11:45, Staff A stated she realized she did not wear gloves for the injection and that she should have. Interview on 8/13/2025 at 8::00 AM, the Director of Nursing (DON) stated her expectation for staff to always wear gloves when administering an insulin injection. Facility policy Personal Protective Equipment-Gloves revised July 2009, documented the use of disposable gloves is indicated during invasive procedures. 2. Observation on 8/12/2025 at 10:58 AM, Staff B, Certified Medication Aide applied gloves, no gown, and entered Resident # 16's room. Staff B placed her hands on Resident #16's shoulders and assisted resident to an upright position. After Staff B exited the resident's room, Staff B stated she should have had a gown on also to reposition resident as the resident was on enhanced barrier precautions and required a gown and gloves for hands on care. Interview on 8/12/25 at 11:15 AM, the DON acknowledged she observed Staff B staff did not have the proper PPE on to assist the resident and stated her expectation for staff to wear PPE of gown and gloves with resident contact for residents on EBP. Facility policy Enhanced Barrier Precautions revised December 2024, documented EBPs employ targeted gown and glove use during high contact resident care activities with examples of high-contact resident care activities requiring the use of gown and gloves for EBPS include: providing bed mobility.

Based on electronic health record review (EHR) and staff interviews, the facility failed to maintain complete and readily accessible resident medical records for 2 of 3 residents reviewed for nutrition (Residents #4 and #22). The EHR lacked Nutrition Progress Notes and Assessments for the past nine months. The facility reported a census of 54. Findings include: 1. The Quarterly Minimum Data Set (MDS) Assessment completed on 7/9/25 revealed Resident #4 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Diagnoses on the MDS include diabetes and end stage renal disease (ESRD). The Care Plan, last revised on 7/8/25, included a Focus Area related to the potential risk for altered nutritional status due to ESRD and diabetes. Interventions include the use of a protein supplements on non-dialysis days, monitor for signs and symptoms of malnutrition (cachexia, muscle wasting, significant weight loss), and the Registered Dietitian (RD) to consult quarterly and as indicated. Review of the EHR revealed the last identified nutrition documentation was a Dietary Assessment form completed on 4/18/24. 2. The Quarterly MDS Assessment completed on 7/2/25 revealed Resident #22 with a BIMS score of 0, indicating a severe cognitive impairment. Diagnoses on the MDS include Alzheimer's disease, cancer, diabetes, heart failure and non-Alzheimer's dementia. The MDS noted Resident #22 receives a mechanically altered diet. The Care Plan, last revised on 7/1/25, included a Focus Area related to the risk for impaired nutrition due Alzheimer's, dysphagia (swallowing difficulties), and a mechanically altered diet. Interventions include a puree diet order with nectar-thick liquids, history of weight loss, the use of adaptive equipment during meals, and past refusal of the house nutritional supplement. Review of the EHR revealed the last identified nutrition documentation was a Nutrition Risk Assessment form completed on 9/19/24. During an interview on 8/13/25 at 11:50 AM, the Director of Nursing (DON) attempted to located current RD documentation in the EHR but could not. The DON explained the RD is at the facility weekly but was unclear of the RD's charting process. During an interview on 8/13/25 at 3:20 PM, the DON explained RD Progress Notes for Resident #4 and Resident #22 have been scanned into the EHR. The scanned documents showed monthly RD Progress Notes for Resident #4 from January '25 to July '25 and for Resident #22 from March '25 to August '25. The DON explained they were not aware of the RD's current charting practices. The DON would expect RD Progress Notes/Assessments be entered into the EHR timely and to ensure staff have access. During an interview on 8/13/25 at 4:00 PM, the RD confirmed nutrition-related entries are documented on a jump drive that they maintain. The RD noted the facility does have access to the jump drive but it is unavailable today. Resident nutrition Progress Notes had been previously printed and sent to the facility. The RD explained this process has not been routinely completed for an unknown time frame.

Based on electronic health record review, resident and staff interview, and policy review, the facility failed to consistently complete pre and post dialysis assessments for 1 of 1 residents reviewed for dialysis (Resident #4). The facility reported a census of 54. Findings include: The Quarterly Minimum Data Set (MDS) Assessment, completed on 7/9/25, revealed Resident #4 with a Brief Interview for Mental Status score of 15, indicating intact cognition. Diagnoses on the MDS include diabetes and end stage renal disease. Current Physician Orders direct the completion of pre and post dialysis assessments on Monday, Wednesday, and Friday, which was initiated on 1/18/23. Review of monthly Treatment Administration Records revealed the following: No pre and post dialysis assessments identified for 4/14/25, 4/16/25, and 4/23/25No pre and post dialysis assessments identified for 5/2/25, 5/9/25, 5/12/25, 5/16/25, and 5/23/25No pre and post dialysis assessments identified for 7/7/25 and 7/11/25; No pre-dialysis assessment identified for 7/4/25No pre and post dialysis assessment identified for 8/11/25During an interview on 8/11/25 at 1:30 PM, Resident #4 unable to recall if staff obtains vitals (blood pressure, pulse) before going to dialysis. The resident believes staff obtain blood pressures upon their return from dialysis. During an interview on 8/14/25, the Administrator and Director of Nursing both acknowledged the lack of dialysis assessments on the identified dates.The facility unable to provide a policy which outlines a procedure for the completion of pre and post dialysis assessments.

Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change within federal guidelines for 2 of 2 residents (#37 & #60) reviewed for Hospice Admission. The facility reported a census of 54 residents. Findings include: 1. The Census Line portion of the Electronic Health Record (EHR) of Resident #37 documented the resident enrolled in hospice care on 1/27/25. The Significant Change MDS of Resident #37 documented an Assessment Reference Date (ARD) of 2/2/25. Page 58 of the MDS documented the MDS was signed as Assessment Completion on 2/15/25, 20 days following hospice admission. 2. The Census Line portion of the Electronic Health Record (EHR) of Resident #60 documented the resident enrolled in hospice care on 6/20/25. The MDS screen of Resident #60 failed to reveal any significant change MDS assessment was completed on Resident #60. On 8/14/25 at 11:20 am, the MDS Coordinator reviewed the MDS screen and verified no significant change MDS had been done for this hospice enrollment. According to the 2024 RAI, a Significant Change (comprehensive) assessment, the ARD must be no later than the 14th calendar day after determination that a significant change in the resident's status occurred. The RAI stated a Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program. The facility policy titled Change in a Resident’s Condition or Status, revision date February 2021, documented the following: Point 9: If a significant change in the resident’s physical or mental condition occurs, a comprehensive assessment of the resident’s condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide consistent bathing for the residents residing in the facility for four of twenty four days reviewed. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) of Resident #4, dated 1/23/25 identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognition intact. The MDS coded the resident required substantial/maximal assistance to shower/bathe self. The Care Plan of Resident #4, review date 2/13/25, documented the resident required two staff assistance for bathing. On 3/31/25 at 9:50 am, Resident #4 stated during her stay in the facility over the last two months she had missed showers multiple times. She stated this made her feel unclean. 2. The MDS of Resident #6, dated 1/28/25 identified a BIMS score of 12, which indicated moderate cognitive impairment. The Care Plan of Resident #6, review date 1/21/25, failed to document bathing status. On 3/31/25 at 2:12 pm, Resident #6 stated he primarily used a washcloth at the sink and gave himself sink baths and washed his own hair in the sink. He stated he didn't like the way staff gave showers and described it as just being wheeled in and stuck under the water. He stated when staff had provided a shower, they often did not wash his hair and didn't feel he got clean. 3. The MDS of Resident #9, dated 3/12/25, identified a BIMS score of 15, which indicated cognition intact. The MDS coded the resident required substantial/maximal assistance to shower/bathe self. The Care Plan of Resident #9, review date 1/21/25, documented the resident required two staff assistance for bathing. On 4/1/25 at 9:33 am, Resident #9 stated she had been bed bound for the last several weeks following a medical procedure in February. She stated she was only getting bed baths at this time and sometimes had not received them as scheduled. She stated she sometimes refused baths because some staff wanted to provide a bed bath with wet wipes instead of soap and water. She stated she preferred to wait for a bath by staff members who she knew would give her a bath how she wanted it done. She said some staff were in a rush and just wanted to wipe her down and not get her clean. On 4/1/25 at 10:38 am, the Assistant Director of Nursing (ADON) stated she maintains packets of the bathing schedules. She stated the staff member who provides a shower/bath is to document the shower in the resident's Electronic Health Record (EHR), fill out a bath sheet, and sign the packet. She said the packet included what type of bath (shower or bed bath), if the resident's bedding was changed, etc. She stated that she made an audit book to keep track of the residents' receiving showers. She said she then tracks the showers in the EHR, the bath sheets and the packets and places the information onto the audit forms. The ADON stated bed baths should never be given with wet wipes and she was not aware of the situation. She stated she was aware of one former employee who was doing bed baths using wet wipes and that employee was educated and corrected. She stated she will provide further education to staff regarding the proper procedures for bathing. Review of the bathing audit sheets for March of 2025, completed on 4/1/25, revealed the following: On Monday 3/3/25, twenty (20) facility residents were scheduled to receive a bath or shower. Of the 20 scheduled residents, 14 of them received no bath that day and no make up bath the following day. On Tuesday, 3/4/25, twenty (20) facility residents were scheduled to receive a bath or shower. Of the 20 scheduled residents, 18 of them received no bath that day and no make up bath the following day. On Wednesday, 3/5/25, twenty (20) facility residents were scheduled to receive a bath or shower. The audit sheet showed one staff member, Staff A, Certified Nurse Aide, was assigned to complete 11 of the 20 baths/showers. Staff A documented all 11 of the residents refused to shower that day. Of the remaining residents, other staff members completed five of the scheduled bathing and three other residents had no documentation of the bath or shower being completed. On Friday, 3/7/25, nineteen (19) facility residents were scheduled to receive a bath or shower. Only one resident was documented as having received a shower that day. On 4/1/25 at 1:40 pm, the ADON stated the audit sheets were correct and she had no record of the resident baths being completed on 3/3/25, 3/4/25 or 3/7/25. In regards to Staff A on 3/5/25, she stated the expected procedure if a resident refuses bathing, to approach the resident a total of three times and if the resident refuses all three times, the staff member is to report the refusal to the charge nurse and the charge nurse will speak to the resident. She said Staff A does not have a record of not completing scheduled bathing and this day was an isolated incident. She stated she spoke to him and he told her it was an especially busy evening shift and it was late in the shift when he attempted to start baths. She said many residents were already lying in bed and did not want to get back up and receive a bath at that time. On 4/2/25 at 8:15 am, the Administrator stated they try to have shower aides scheduled to give the majority of the baths. She stated if there is not a shower aide scheduled, then the scheduled baths are split up and the Certified Nurse Aides as well as the Certified Medication Aides. She said each staff member will typically have three to four baths to complete during an eight hour shift and it would not be a normal occurrence for a single staff member to have 11 baths in one shift. She said the resident baths are given six days a week and divided between the day shift and the evening shift. She stated they are currently looking at the bathing schedule and speaking to residents on their preferences to make sure the schedules can be completed. The facility policy Activities of Daily Living (ADLs), Supporting, revision date March 2018, documented the following: Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Point 2: Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems).

Based on resident and staff interviews, record review, and policy review the facility failed to respond to call lights in a timely manner and provide adequate weekend staffing to meet residents needs. The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #27, dated 9/12/24, included a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Interview on 9/24/24 at 11:27 AM, Resident #27 stated staffing on the weekends is really bad as have less staff and call lights are not usually answered timely on weekends. The MDS for Resident #52, dated 9/11/24, included a BIMS score of 14, indicating no cognitive impairment. Interview on 9/23/24 at 3:07 PM, Resident #52 stated less help on the weekend and takes longer than 15 minutes for their call light to be answered on the weekends. Interview on 9/24/24 at 10:22 AM, Staff F, Certified Nurse Aide (CNA) stated the facility has extra staff to assist during the week as management/office staff assist with answering call lights, pushing residents about facility, and also have a hospitality aide that assists with answering lights, filling water pitchers, and meals. Staff F stated on the weekend they work with at least 1 less CNA, not including if they have call-ins and if no replacement, and do not have the extra staff that assist during the week. Staff F stated she feels not able to meet the needs of the residents, not able to assist them timely, and residents are incontinent due to not assisting them quickly enough on the weekends due to the lower number of staff on the weekends. 48886 2. During an interview 9/24/24 at 11:17 AM, Resident #1 advised feeling the facility did not have enough staff to meet resident's needs. The resident stated about two days ago, on the weekend, resident waited an hour and 45 minutes after pulling call light. The resident pushed the call light as they wanted to get up in the morning, and waited that long for someone to come. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview 9/24/24 at 1:36 PM, Resident #26 stated the facility had been short staffed on the weekends. The resident stated staff would call in and not show up for work. The facility would try to find other people to fill in. There have been a few times the resident waited a half hour for a call light response. The resident stated she pushed her call light due to pain with arthritis. According to the MDS assessment dated [DATE] Resident #26 scored 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the facility grievance binder revealed a resident grievance form filed by Resident #26, reported she waited for call light for 30-45 minutes before wheeling up to the nurses station without oxygen at 3:00 AM. This was reported on 9/14/24, a Sunday. The investigation/outcome section of the grievance form documented follow up with nurse, aides were in rooms on rounds and nurse was with another resident. Will educate about staffing cares, call light audit. Call light audit shows audits completed 5 times, during day time hours and during the week, not on the weekend or in the middle of the night, completed 9/17/24 to 9/24/24. During an interview 10/01/24 at 2:26 PM, the Administrator was advised of the low weekend staffing trigger for the 3rd quarter in 2024, April 1st to June 30th. The Administrator stated their staffing numbers vary according to the census. The Administrator stated the administration team has come in often on the weekends and this would be on the schedule. The Administrator gave the necessary staffing numbers for the facility at full census, 70 residents, however did not give the necessary staffing numbers for the census being lower, stated they then use the 3.0 range to calculate staffing according to their census when they are not full. The Administrator stated they do not alter the number of staff working from the week to the weekend, the staffing stays the same. The Administrator stated they had a lot of call ins during the 3rd quarter and they were low in staffing due to weekend call ins and staff not showing up to work. They had attendance issues then. They have more staff hired now and rotate staff on weekends. The Administrator advised the facility has had some complaints from residents on call light response time, when they get complaints they do audits. During an interview 10/2/24 at 8:45 AM, the Administrator stated an expectation call lights be answered as quickly as possible and within 15 minutes. Review of facility policy Call Lights: Accessibility and Timely Response, implemented 12/1/23, documented the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure safe transport of residents in a wheelchair for 1 of 24 residents reviewed (Resident #1). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, dated 8/22/24, documented the resident had diagnoses to include other orthopedic conditions, unspecified lack of coordination, difficulty in walking, and other abnormalities of gait and mobility. The MDS further documented the resident used a walker and a wheelchair for mobility devices. The MDS revealed the resident was independent with the ability to wheel at least 50 feet and make two turns once seated in the wheelchair. The Care Plan for Resident #1, with a revision date of 9/20/24, documented the resident does propel herself to and from activities with no issue. The Care Plan instructed staff to ensure resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. During an observation 9/24/24, at 9:40 AM, Staff A, Certified Nursing Assistant (CNA), pushed Resident #1 while she was seated in her wheelchair, her feet were not on foot pedals, she had them lifted up off the ground, holding them off the ground while Staff A pushed her in the wheelchair. The resident did not have footwear on, she was barefoot and had a wrap around her calves that covered half of her foot, leaving her toes exposed. The resident was pushed from her room, down the 300 hallway and into the dining room without the use of foot pedals. During an interview 9/24/24 at 9:50 AM, Staff A advised normally will use foot pedals when pushing a resident in a wheelchair. Staff A stated he was told by management to not use foot pedals with Resident #1 a little while ago due to her having skin issues on her legs. Staff A felt he should still use foot pedals as it is a safety concern, however acknowledged he did not use foot pedals earlier with Resident #1. During an interview 9/25/24 at 11:15 AM, the Director the Nursing (DON) stated an expectation staff use foot pedals when pushing a resident in a wheelchair. The DON stated Resident #1 can propel herself in her wheelchair and does not typically require assistance in her wheelchair. The DON advised current management have not informed any staff not to use foot pedals with Resident #1. The DON stated a safety concern not using foot pedals when pushing a resident in a wheelchair. Review of the facility policy: Accidents and Supervision, with a copyright date of 2023, documented the resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.

Based on record review, resident interviews, staff interviews, and policy review, the facility failed to assure residents were treated with respect and dignity for 2 of 2 residents reviewed (Resident #13 and #40 ). The facility reported a census of 49 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #13 scored 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The resident required substantial/maximum assistance with toileting hygiene and toilet transfer. The resident's diagnoses included a stroke and Hemiplegia or Hemiparesis. The Care Plan for Resident #13, with a revision date of 9/27/24, included a focus area for Activities of Daily Living (ADL), documented the resident had a self-care deficit as evidenced by required assistance with ADLs, impaired balance during transitions, required assistance and walking, incontinence, and left sided neglect. The intervention area instructed staff to provide 1 person assist with toileting, resident was incontinent of bowel and bladder. Provide peri care with every incontinent episode and as necessary. During an interview 9/23/24 at 4:17 PM, Resident #13 stated about a month ago, he was constipated and a Certified Nursing Assistant (CNA) came in and gave him a bed pan. The CNA put the bed pan under him, he stated it was so far under him he could not move it himself. The resident stated the CNA left the room and left the bed pan under him for 3-4 hours. The resident stated it was so uncomfortable and hurt. The resident did not know the name of the CNA. The resident advised he talked to the Administrator about this and he was advised it would be taken care of. The resident stated it was incredibly uncomfortable to have the bed pan under him for 3-4 hours. The resident stated this incident took place in the night, not sure exactly what time, but knew he was left with the bed pan under him for hours. During an interview 9/30/24 at 2:30 PM, Staff C, Registered Nurse (RN), stated Resident #13 did talk to her about how he laid on a bed pan for a very long time, he said a CNA left a bed pan under him and did not return. Resident #13 told her about this the following morning, it happened in the night. Immediately after the resident telling her about this, Staff C called the Director of Nursing (DON) and the Administrator as it was on a weekend, she believed about a month ago. Staff C advised sitting with the resident that morning for awhile because he was upset. The resident also told her he did not like the way two CNA's talked in a foreign language while providing care to him as he did not know what they were saying. The resident reported to her feeling upset about the bed pan, and being left for a long time with the bed pan under him, and feeling upset about the two CNA's talking in a language he did not understand while in his room. During an interview 10/1/24 at 9:00 AM, the Administrator stated she recalled an incident reported to her on a Sunday morning about a month ago regarding Resident #13. Staff C called her and told her that the resident reported to her two CNA's were rough with him. The Administrator does not recall getting any other information from Staff C, she does not recall being told about the resident waiting for hours or a long time with a bed pan under him. The Administrator stated she talked to the resident on the phone that morning to get more information. He told her he felt two CNA's rushed his cares that night and were talking in their own language, he could not understand what they were saying and they were laughing. He did not say they were abusive to him, just that they rushed through cares and laughed, he thought they were laughing at him. The Administrator told the resident the CNA's would not provide care to him again, he was happy with this resolution. The Administrator said she educated the two CNA's about customer service and not talking in their own language around the residents who could not understand them. These two CNA's only work PRN (as needed ) hours. The Administrator stated she does not recall anything about the bed pan, but does remember the resident saying he had to wait a long time for a call light response. The Administrator completed an incident report. The Administrator stated an expectation residents are treated with dignity and respect. 40905 2. The MDS for Resident #40, dated 8/15/24, included diagnosis of Non-Alzheimer's Disease and required assistance of 1 staff for transfers and toileting. A BIMS score of 11, indicated moderate cognitive impairment for decision-making. Interview on 9/23/24 at 4:20 PM, Resident #40 stated the staff do not always answer the call light timely, then she pees in her pants, and it is embarrassing and makes her feel ashamed as she should not have to pee in her pants. The facility policy Quality of Life-Dignity revised August 2009 instructed that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Interview on 10/02/24 at 11:03 AM, the Director of Nursing stated an expectation to answer call lights timely to assist residents with toileting.

Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to follow professional standards of nursing care to ensure treatments and dressings were being completed and documented for 1 of 3 residents reviewed for wound care (Resident #1). The facility reported a census of 49 residents. Findings include: The Annual Minimum Data Set (MDS), dated [DATE], documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented diagnoses to include other orthopedic conditions and malnutrition. The MDS revealed Resident #1 was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. The resident had a stage 3 pressure ulcer: full thickness tissue loss. The MDS further documented the resident had moisture associated skin damage (MASD) to her feet. The Care Plan for Resident #1, with a revision date of 9/20/24, documented under the focus area the resident had the potential for and actual impairment to skin integrity with an unstageable wound to the left ischial tuberosity (sitting bones), unstageable to coccyx (small triangular bone at the base of the spinal column), vascular ulcer to right inner ankle, left front lower extremity, and to the left foot. The Care Plan instructed staff to follow treatment order scheduled/prescribed by the wound care ARNP (Advanced Registered Nurse Practitioner). During an interview 9/24/24 at 11:08 AM, Resident #1 stated she has wounds on both of her feet. She stated staff do not always do the same treatment, one day it is done one way and the other day it is done another way. The resident stated staff do not always put the white stuff on. Clinical record review of Resident #1's Treatment Administration Record between the months of June of 2024 through September of 2024 revealed treatments not recorded or documented as completed. For the month of June the following treatments/orders were not completed: CHLORHEXIDINE SOL 4%, Apply to entire body topically one time a day for cleansing for 30 Days, start date 5/11/2024 - not completed on June 6th, 2024. Order for left hip: cleanse with wound cleanser, apply skin prep to the peri wound and allow to dry completely, and cover with large [NAME] silicone super absorbent dressing; change daily and PRN (as needed) one time a day for wound care, with a start date 5/27/2024, and an end date 6/23/2024; this was not completed on June 6th, 2024. Order for MINERIN cream, apply to BLE (bilateral lower extremities) topically two times a day for dry skin, with a start date 5/16/2024; this was not completed on the night shift of June 1, 2024 and the day shift of June 6, 2024. For the month of July 2024, the following treatments/orders were not completed: DAKINS solution 0.125%, apply to left ischial tuberosity topically one time a day for wound care, clean with quarter strength DAKINS, apply collagen into wound bed, loosely pack with Iodoform, cover with Silicone dressings, start date of 6/14/2024; this was not completed July 6th, July 7th, or July 20th. Order for DAKINS solution 0.25%, apply to Left Ischial tuberosity topically one time a day for wound care, with a start date of 7/26/24; not completed on July 28th. Order for Left foot: start to clean with betadine, apply a nickel thick layer of Santyl into wound bed, cover with an ABD pad and secure with gauze roll. Change daily and PRN, with a start date 7/01/2024; not completed July 6th, July 20th, or July 28th. Order for Left lower leg: Clean with betadine, apply a nickel thick layer of Santyl into wound bed, cover with an ABD pad and secure with gauze roll. Change daily and PRN, one time a day for wound care, with a start date of 7/1/24; not completed July 6th, July 7th, July 20th, and July 28th. Order for constant compression to legs at all times, ace wraps. Check circulation every shift two times a day for leg integrity, with a start date of 7/18/2024; not completed July 19th and July 20th. Order for MINERIN cream, apply to BLE (bilateral lower extremities(legs))topically two times a day for dry skin, with a start date 5/16/2024; not completed July 6th, July 19th, July 20th, and July 23rd. Order for NYAMYC powder 100000, apply to right neck topically two times a day for MASD, with a start date of 6/7/24; not completed July 6th, July 19th, and July 20th. For the months of August 2024 and September 2024, the following treatments/orders were not completed: DAKINS solution 0.125%, apply to left ischial tuberosity topically one time a day for wound care, clean with quarter strength DAKINS, apply collagen into wound bed, loosely pack with Iodoform, cover with Silicone dressing and change daily, start date of 8/18/2024; this was not completed August 18th, August 20th, August 21st, September 3rd, September 26th, and September 28th. Order for left foot: start to clean with betadine, apply a nickel thick layer of Santyl into wound bed, cover with an ABD pad and secure with gauze roll. Change daily and PRN, start date of 7/01/2024; not completed August 20th, August 21st, and September 3rd. Order for left ischial tuberosity: continue treatment to cleanse with quarter strength Dakin's solution 0.25%, apply collagen powder into wound bed and loosely pack the tunneling with Iodoform gauze strip and cover with a silicone super absorbent dressing change daily and PRN one time a day for treatment, with a start date of 8/16/2024; not completed August 20th, August 21st, and September 3rd. Order for Left lower leg: Clean with betadine, apply a nickel thick layer of Santyl into wound bed, cover with an ABD pad and secure with gauze roll. Change daily and PRN one time a day for wound care with a start date of 7/01/2024; not completed August 20th and August 21st. Order for NYAMYC powder 100000, apply to right neck topically two times a day for MASD, with a start date of 6/7/24; not completed September 3rd, September 7th, September 14th, September 26th, and September 28th. Order for Skin prep to scab to right second toe BID (twice daily) until healed, with a start date of 8/22/2024; not completed September 3rd, September 7th, and September 28th. During an interview 9/30/24 at 1:00 PM, the Director of Nursing (DON) stated their electronic health care system was down on the 9th and 10th of September and they used paper charting for those days, and on occasion from the 11th to the 13th of September. The other dates of missing documentation in the TAR for Resident #1, the DON stated could have been her not documenting when she completed treatment as she does not take her cart or computer into the room and will forgot to do the documentation in the TAR. The DON will look into the dates and find hard copy or some notation the treatment was completed. During an interview 10/01/24 at 11:00 AM, the DON advised she reviewed the TAR for August and September for Resident #1 and inquired from nursing staff working on the days that were missing documentation of the treatment being completed if they recalled doing the treatment. Some of the nursing staff did recall doing the treatment, however acknowledged they did not document the treatment in the TAR. The DON stated on some of these dates, she did the treatment for Resident #1 and forgot to document in the TAR the treatment was completed. The DON stated there were some days in June, July, August, and September that there is no recall of completing the treatment and it is likely the treatment was not completed. The DON stated an expectation staff chart immediately after completing the treatment in the TAR and an expectation treatments and orders are followed as prescribed. During an interview 10/01/24 at 2:30 PM, the Administrator stated an expectation staff chart and document in the TAR immediately after treatment is completed. The Administrator stated an expectation treatment be completed as ordered. Review of the facility policy: Charting and Documentation, with a revision date of July 2017, documented all services provided to the resident shall be documented in the resident's medical record. Review of the facility policy Provision of Physician Ordered Services, undated, documented care and services are provided according to accepted standards of clinical practice to provide a reliable process for the proper and consistent provision of physician ordered services.

Based on observation, resident and staff interview, record review, and policy review the facility failed to assist residents with shaving for 2 of 10 residents reviewed (Resident #27 and #40). The facility reported a census of 49 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #27, dated 9/12/24, included diagnoses of Parkinson's (disease affecting the nervous system) and muscle weakness. A Brief Interview for Mental Status (BIMS) score of 15, indicated no cognitive impairment for decision-making. Observation and interview on 9/24/24 at 11:21 AM, Resident #27 with approximate 1/8-inch facial hair covering cheeks, upper lip, and chin. Resident #27 stated he needed to be shaved but only gets shaved on shower days, Tuesday and Friday. Resident stated he would like to be shaved more often, at least 3 times a week consistently. Resident stated the facility was frequently out of razors. Interview on 9/25/24 at 3:09 PM, Resident #27 stated he did not have shower yesterday as scheduled, have not been shaved, and staff do not offer to shave when assisting with morning cares. Resident #27's shower sheet dated 9/20/24 with documentation of don't have razors so I couldn't shave him. 2. The MDS for Resident #40, dated 8/15/24, included diagnosis of Non-Alzheimer's Disease. A BIMS score of 11, indicated moderate cognitive impairment for decision-making. Observation and interview on 9/23/24 at 4:13 PM, Resident #40 had approximate 1/8-inch gray/black/white facial hair on full chin. Resident #40 stated she does not like the facial hair, would like to be shaved more frequently as only shaved on shower days. Observations and interviews on 9/24/24 at 10:05 AM and 9/25/24 at 10:47 AM, Resident #40 remained with facial hair and resident stated she had not been shaved. Facility policy for shaving the resident revised February 2018 documented the purpose of the procedure is to promote cleanliness and to provide skin care. Interview on 9/26/24 at 9:13 AM, the Director of Nursing stated an expectation to shave residents on shower days and more frequently if the residents ask.

Based on clinical record review, resident interview, staff interviews, and policy review, the facility failed to accurately assess and provide intervention to 1 of 1 residents when a resident reported shoulder pain (Resident #13). The facility reported a census of 49 residents. Finding include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #13 scored 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. The resident required substantial/maximum assistance with toileting hygiene and toilet transfer. The resident's diagnoses included a stroke and Hemiplegia or Hemiparesis. The Care Plan for Resident #13, with a revision date of 9/27/24, included a focus area for Activities of Daily Living (ADL), documented the resident had a self-care deficit as evidenced by requiring assistance with ADLs, impaired balance during transitions requiring assistance and walking, incontinence, and left sided neglect. The intervention section instructed staff to provide 1 person assist with toileting, resident is incontinent of bowel and bladder. Provide peri care with every incontinent episode and as necessary. The Care Plan further included a focus area for pain, documented the resident was at risk for pain/discomfort and increased risk for injury from decreased function related to diagnosis of stroke with left sided weakness and hernias. During an interview 9/23/24 at 4:14 PM, Resident #13 stated about two to three weeks ago, a Certified Nursing Assistant (CNA), Staff D, was moving fast during cares while the resident was in bed. The resident stated Staff D slid him to the side to change him while he was in bed and his shoulder hit the wall. The resident stated his shoulder popped and it hurt. Staff D said oh and looked at the resident after this happened. Resident #13 stated he told a nursing staff, not sure of name, and she did not do anything, but did give him Tylenol. The resident stated his shoulder hurt like hell. The resident stated they never had him go to the doctor, and no one did an assessment on his shoulder. The resident stated his shoulder does not hurt anymore, but it hurt for awhile. The resident stated he had a stroke and was at this facility for skilled care, he had urine in his bed that night and he needed help with ADL's. The resident stated it was his left shoulder that hit the wall and popped that night, he was not sure of the time of day, he thought it was at night. During an interview 9/30/24 at 4:06 PM, Staff D stated Resident #13 told a staff member, Staff E, Certified Medical Assistant (CMA), that he slammed the resident into the wall. Staff D stated he did not do that. Staff E advised Staff D of the resident telling her this after she came out of the resident's room later that night. Staff D advised he works the 2-10 PM shift. Staff E told Staff D she did not believe he would do anything like this and said she did not think Staff D slammed the resident into the wall. Staff D thought the resident to be a two person assist, he is not sure. Staff D stated that night he went into the resident's room by himself to change the resident's brief. Staff D stated he did change his brief, during that process, he slid the resident toward him and grabbed his shoulder, his sore shoulder (the left one), and the resident told Staff D it hurt when he did that. The resident told Staff D he popped his shoulder out, but Staff D did not believe he did. The resident then told Staff E, the CMA working that night, that he slammed the resident's shoulder into the wall. Staff D stated he did not slam him into the wall. Staff E came out of the resident's room and told Staff D what the resident said, that he slammed him into the wall and popped his shoulder out. Staff E gave the resident Tylenol. Staff D stated the resident was lying, Staff D said he did not slam him into the wall. Staff D stated he did move the resident by his left shoulder and he knew the resident had pain in his left shoulder. Staff D stated he has not gone in to the resident's room alone again to provide care to the resident, by his own choice. Staff D stated he did not talk to management about this incident. Staff D stated he and Staff E did not talk to the charge nurse that night, or since then about this incident. Staff D believed the incident was a couple of weeks ago. During an interview 10/01/24 at 9:30 AM, the Administrator stated she was not aware of any reported incidents with Resident #13, other than what we talked about already with this resident. The Administrator stated the resident has pain and it does hurt him to move. During an interview 10/01/24 at 9:51 AM, Staff E stated she recalled Resident #13 telling her Staff D pushed his shoulder a little too hard, that he rolled him too hard. Staff E stated she did not recall Resident #13 saying Staff D popped his shoulder out. Staff E stated she came out of the resident's room and told Staff D they should tell the charge nurse what the resident said. Staff E did not remember when this was, she did not remember who the charge nurse was or what the charge nurse said, she thought she and Staff D talked to the charge nurse together. She thought it was a few weeks ago. Staff E stated Staff D told her he did not think he rolled the resident too hard. When asked if the resident said he was in pain, Staff E stated she did not remember. When asked if she gave the resident Tylenol for pain, Staff E stated she did not remember. When asked who are some of the charge nurses she works with, Staff E stated she did not know any of their names. Review of electronic health record did not reveal an assessment on Resident #13's shoulder, or follow up regarding the incident. During an interview 10/01/24 at 1:39 PM, the Administrator stated she had no knowledge of this incident, it was not reported to her or to the Director of Nursing (DON), this is the first she is hearing about this. The Administrator stated an expectation the CMA report this to the charge nurse and to the DON and/or Administrator and that an assessment and evaluation be completed on the resident's shoulder. If a resident reported being slammed into a wall and having pain in their shoulder and feeling their shoulder had popped out, an assessment and evaluation needed to completed to determine if the resident had an injury and if the resident required medical attention, and to adequately address and manage the pain. Review of the facility Pain Management and Assessment policy, with a revision date of March 2015, documented pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is a multidisciplinary care process that includes assessing the potential for pain.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to maintain infection control standards by not wearing personal protective equipment (PPE) of a gown and gloves while providing high contact care activity for a resident on enhanced barrier precautions (EBP) (an infection control intervention requiring staff to wear designated PPE to reduce transmission of organisms for designated residents) for 1 of 2 residents reviewed (Resident #50). The facility reported a census of 49 residents. Findings include: The Minimum Data Set (MDS) for Resident #50, dated 9/1/24, included a diagnosis of acquired absence of right leg above knee due to surgical amputation with a surgical wound and documented the resident had a Foley catheter. Observation on 9/24/24 at 3:17 PM, Resident #50 room door with a sign posted for EBP and PPE supplies outside door and resident sitting in a recliner with a Foley catheter (tube into penis to drain urine), wound vacuum (vac) (machine with tube attached to dressing on wound to pull drainage from wound) attached to right leg stump. Observation on 9/30/24 at 9:23 AM, Staff B, Registered Nurse (RN) was in Resident #50's room standing by the resident's bed without a gown or gloves on. Staff B proceeded to lift the resident's bed sheet with her right hand to look at the wound on the resident's leg, touched the wound vac tubing with her left hand, and without completing hand hygiene touched her own clothing by placing hands on her sides. Interview on 9/30/24 at 1:00 PM, Staff C, RN stated with any resident with EBP has sign on their door and EBP if has any type of tube, such as catheter, ostomy, or wounds. Staff C stated the protocol is to wear a gown, gloves, and mask anytime staff are going to provide direct care to the resident on EBP. Staff C stated she would wear PPE to look at a wound, when touching residents' bedding, or touching the wound vac and tubing. Facility policy for Enhanced Barrier Precautions revised 3/21/24 the facility should use EBP for residents that meet the following criteria, during high-contact resident care activities: EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices (including urinary catheter). Examples of high-contact resident care activities requiring gown and glove use include: changing linens and device care or use. Interview on 10/01/24 at 3:00 PM, the Director of Nursing (DON) stated staff are to wear required PPE in the resident's room when providing positioning, transfers, or any contact where staff or staff clothing come in contact with the resident. The DON further stated the expectation to wear PPE when touching the resident's sheets, looking at a wound, or touching a wound vac/tubing.

Based on record review, staff interview, and policy review the facility failed to have an Iowa Physician Orders for Scope of Treatment (IPOST) (medical order form with code status that records residents' treatment wishes in the event of a medical emergency) for 1 of 24 residents reviewed (Resident #49). The facility reported a census of 49 residents. Findings include: The Minimum Data Set for Resident #49, dated 9/12/24, included diagnoses of osteoporosis bone disease that causes bones to become brittle) and age-related physical disability and included a Brief Interview for Mental Status score of 11, indicating mild cognitive impairment for decision-making. Resident #49's Admission Narrative Bundle/Baseline Care Plan, dated and signed by the resident on 9/6/24, documented a Code Status of Do Not Resuscitate (DNR). Review of facility IPOST book and Resident #49's electronic record lacked an IPOST form for Resident #4 and lacked a physician's order for a code status. Interview on 9/25/24 at 10:55 AM, Staff G, Registered Nurse stated in the event of the need to check a resident's code status she would check the IPOST book first, and if not there, would check the physician's orders and if no order for code status she would treat the resident like a full code and perform cardiopulmonary resuscitation on the resident. Staff G confirmed Resident #49 did not have an IPOST form in the IPOST book and did not have a physician's order for code status. Facility policy of Advanced Directives, revised December 2016, instructed advance directives will be respected in accordance with state law and facility policy. Interview on 9/25/24 at 11:10 AM, the Director of Nursing stated an expectation to have an IPOST completed for all residents and in the IPOST book.

Based on observations, resident and staff interviews, record review, facility policy and procedure, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from deteriorating on residents with history of pressure ulcers for two of four residents reviewed (Resident #1 and #8). The facility reported a census of 54 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III 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 and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. 1. An Admission Minimum Data Set (MDS) completed for Resident #1 with an Assessment Reference Date (ARD) of 12/8/23, documented diagnosis for which included anemia, hypertension, hip fracture, malnutrition and unspecific mood disorder. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated moderately impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others and does not resist cares. The resident was dependent from staff for all activities of daily living, and dependent with transfers, and frequently incontinent of bladder and bowel. The MDS also documented a wheelchair/walker as prior mode of transportation. The MDS documented the resident with 1 stage 2 pressure ulcer and pressure reducing device for chair, bed and pressure ulcer/injury care and no turning or repositioning program. The Braden scale for predicting pressure sores, dated 12/15/23, documented a score of 13 for which indicated moderately risk for skin breakdown. The mobility portion of the Braden scale documented that the resident is very limited, makes occasional though slight changes in body or extremity position, and is chair fast. Friction and Shear, problem, requires moderate to maximum assistance in moving, requires frequent repositioning with maximum assistance. The Careplan with a focus area initiated 12/13/23, the resident had a pressure ulcer, Stage 2 on coccyx, present on admission. Interventions include: *(12/13/23) air mattress *(12/13/23) Bradens quarterly and as needed *(2/18/24) Encourage off loading by hanging positions as in turning side to side *(1/17/24) leave brief open while in bed as resident allows *12/13/23) report signs of cellulitis (localized pain, redness, swelling, tenderness, drainage, fever) *(12/13/23) treatment as ordered *(12/13/23) Weekly skin/treatment documentation in accordance to wound nurse assessment and plan of care recommended. *(12/13/23) Wound clinic as ordered *(1/9/24) Utilize pressure reduction equipment and procedures as indicated for preventative: turn and reposition, cushion to wheelchair/recliner, specialty mattress to bed, roho-cushion An Admission/Readmission Narrative bundle with no date or time, documented: *bilateral buttock, pressure 13 by 13. suspected deep tissue injury. The Progress Notes dated 12/4/23 at 3:57 p.m., documented, Admission assessment, bilateral buttock: - Pressure: Length = 13, Width = 13, - Stage Suspected Deep Tissue Injury The Progress Notes dated 12/5/23 at 03:19 a.m., There are no open areas/skin issues at this time on assessment. The Progress Notes dated 12/6/23 at 2:25 p.m., Nurses Note Text: new fax received with order to refer to dietitian due to low protein and albumin. The Progress Notes dated 12/7/23 at 4:33 p.m., Nurses Note Text: Faxed request to Doctor for a wound/skin care consult for her skin issues. Will await fax return. An Altered Skin Integrity Notification dated 12/8/23, documented Stage 1 pressure wound: bilateral buttocks, 13 by 13. The Progress Notes dated 12/8/23 at 11:45 p.m., documented Nurses Note Text: Provider, acknowledged altered skin integrity notification related to new stage 1 pressure wound to bilateral buttocks. New order provided to treat utilizing facility's protocol for specified wound. TAR updated. The Progress Notes dated 12/9/23 at 11:31 a,am., documented, Daily Skilled Charting pressure area to coccyx. The Progress Notes dated 12/10/23 at 12:58 p.m., documented Nurses Note Text: This nurse assessed resident's buttock and applied treatment as ordered. Entire buttock red and irritated. Left upper buttock appears to have worsened, appears to be a stage II pressure ulcer. This nurse sent a fax to Primary Care Provider to make aware of findings. Awaiting a fax back. This nurse and a CNA was able to get resident to sit in her recliner for a little while to try to relieve some pressure on her buttock. An Altered Skin Integrity Notification dated 12/10/23, documented Stage 2 pressure wound, *left buttock-9 centimeters (cm) by 4 cm by 1 cm *right buttock- 7 cm by 3 cm *current treatment: cleanse area, apply zinc based barrier, still needed for bottom of buttocks area, red and irritated. upper left and right buttocks, left buttocks worsening, now Stage 2, new treatment needed. Can we get an order for an air mattress? A Weekly Pressure Wound assessment dated [DATE], documented: *How many wounds are present=1 *Sacrum-pressure- Stage 2 The Progress Notes dated 12/12/23 at 9:21 a.m., documented, Nurses Note Text: Received order from provider for resident to receive an air mattress, also would like a wound consult due to stage 2 area located on patients left buttock The Progress Notes dated 12/13/23 at 11:45 a.m., documented, Nurses Note Text: This nurse called and spoke with Power Of Attorney (POA) regarding new treatment order Clotrimazole Cream 1% to affected area BID until healed then as needed. POA had no concerns. This nurse also spoke with him regarding wound consult, POA gave a verbal ok for resident to see the wound nurse. The Progress Notes dated 12/14/23 at 11:11 p.m., documented, Nurses Note Text: altered skin integrity notification sheet returned for stage 2 to left buttocks and right buttocks signed per Primary Care Provider The Progress Notes dated 12/18/23 at 10:00 a.m., documented, Nurses Note Text: Consent signed for Wound center with metro geriatrics by POA. faxed to Metro. The Progress Notes dated 12/18/23 at 3:16 p.m., documented Daily Skilled Charting: There are no open areas/skin issues at this time on assessment. The Progress Notes dated 12/19/23 at 00:38 a.m., documented, Daily Skilled Charting. There are no open areas/skin issues at this time on assessment. The Progress Notes dated 12/19/23 at 8:27 a.m., documented, Daily Skilled Charting Alterations in skin integrity are noted Right hip surgical incision, area to coccyx. Daily Skilled Charting A Metro-Geriatric Services, Wound Treatment Plan dated 12/22/23, documented: chief complaint= wound assessment-coccyx *Skin inspection= coccyx- etiology, moisture, secondary= pressure *Measurement= 3.5 cm by 5.1 cm by 0.2 cm, *Wound Status= 20% granulation, 50% pink/red epithelial, 30% biofilm *Exudates= moderate, thin, serous. *Pain=3/10 *Orders and Requisitions: Air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed The Progress Notes dated 12/24/23 at 00:43 a.m., documented, Daily Skilled Charting Alterations in skin integrity are noted, Has significant moisture associated skin damage to coccyx extends to bilateral buttocks. Area reddened with pain during peri cares and during treatment Resident irritable with nursing staff related to pain described as burning on coccyx. Writer unable to locate prescribed triad cream. House z-guard paste was applied. The Progress Notes dated 12/24/23 at 11:48 a.m., documented Daily Skilled Charting: There are no open areas/skin issues at this time on assessment. The Progress Notes dated 12/25/23 at 00:19 a.m., documented, Daily Skilled Charting Alterations in skin integrity are noted has moisture associated skin damage to coccyx with open area, utilizing prescribed treatments. reports pain to area while resting in bed on back. Continues to report pain to buttocks related to skin break down. Utilizing z-guard paste with cares and after incontinence episodes The Progress Notes dated 12/28/23 at 11:13 a.m., documented, Daily Skilled Charting: Alterations in skin integrity are noted has moisture associated skin damage to coccyx with open area treatment in place. A Metro-Geriatric Services, Wound Treatment Plan dated 12/29/23, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 2.0 cm by 3.1 cm by 0.2 cm *Wound Status= not healed, 20% granulation, 40% pink/red epithelia, 40% biofilm *Exudates= moderate, thin, serous *Pain=3/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2 hours The Progress Notes dated 12/30/23 at 5:30 p.m., documented Nurses Note Text: Wound nurse here on 12-29-23 area to coccyx, moisture secondary to pressure, 2.0 x 3.1 x 0.2 cm not healed tissue is 20% granulation 40% pink and red epithelial 40% biofilm, wound bed is granulation tissue, moderate, thin serous exudate no odor pain 3/10 periwound is clean red epithelial tissue. new orders received to d/c current treatment and do Triad cream do not scrub off and apply bid and as needed, gently wipe away soiled areas and reapply paste to open area. orders updated and all parties notified. The Progress Notes dated 12/30/23 at 10:41 p.m., documented, Daily Skilled Charting: Skin warm and dry and skin color is within normal limits. Skin turgor is normal. Mucous membranes are moist. There are no open areas/skin issues at this time on assessment. The Progress Notes dated 12/31/23 at 11:35 a.m., documented, Nurses Note Text: No complaints up to this time. Bottom not as sore as it was yesterday. Triad ointment applied as ordered. A Weekly Nursing Skin assessment dated [DATE] at 2:20 a.m., documented: *coccyx, treatment in place left side of coccyx *coccyx, treatment in place right side of coccyx A Metro-Geriatric Services, Wound Treatment Plan dated 1/5/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 1.2 cm by 1.3 cm by 0.2 cm *Wound Status= not healed, 30% granulation, 40% pink/red epithelia, 30% biofilm *Exudate= moderate, thin, serous *Pain=3/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2 hours A Metro-Geriatric Services, Wound Treatment Plan dated 1/19/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 1.0 cm by 0.6 cm by 0.2 cm *Wound Status= not healed, 10% granulation, 40% pink/red epithelia, 50% biofilm *Exudate= moderate, thin, serous *Pain=3/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2-3 hours A Metro-Geriatric Services, Wound Treatment Plan dated 1/26/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 0.6 cm by 0.4 cm by 0.2 cm *Wound Status= not healed, 10% granulation, 40% pink/red epithelia, 50% biofilm *Exudate= small, thin, serous *Pain=3/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2-3 hours A Weekly Nursing Skin assessment dated [DATE] at 4:57 a.m., documented: *coccyx= wound treatment in place A Metro-Geriatric Services, Wound Treatment Plan dated 2/2/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 0.6 cm by 0.4 cm by 0.2 cm *Wound Status= not healed, 30% granulation, 40% pink/red epithelia, 30% biofilm *Exudate= moderate, thin, serous *Pain=4/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2-3 hours A Weekly Nursing Skin assessment dated [DATE] at 1:52 a.m., documented: *coccyx= wound treatment in place A Metro-Geriatric Services, Wound Treatment Plan dated 2/9/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 0.8 cm by 0.4 cm by 0.2 cm *Wound Status= not healed, 20% granulation, 40% pink/red epithelia, 40% biofilm *Exudate= moderate, thin, serous *Pain=4/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Leave brief open when in bed Encourage off loading by changing positions every 2-3 hours Nurses Note dated 2/6/24 at 5:14 a.m. documented no reports of wanting to die this nights, Tramadol given as scheduled resident did complain of pain with dressing change. Nurses Note 2/7/24 at 4:27 a.m. documented right lower leg pain scheduled Tramadol effective no reportes of wanting to die with increase of Trazadone (used to treat anxiety or depression). A Weekly Nursing Skin assessment dated [DATE] at 00:32 a.m., documented: *coccyx= treatment in place A Metro-Geriatric Services, Wound Treatment Plan dated 2/16/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 0.8 cm by 0.3 cm by 0.2 cm *Wound Status= not healed, 30% granulation, 40% pink/red epithelia, 30% biofilm *Exudate= moderate, thin, serous *Pain=4/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Encourage off loading by changing positions every 2-3 hours A Weekly Nursing Skin assessment dated [DATE] at 00:33 a.m., documented: *coccyx= treatment in place A Metro-Geriatric Services, Wound Treatment Plan dated 2/23/24, documented=chief complaint=wound assessment=coccyx *Skin Inspection; Coccyx, etiology, moisture, secondary-pressure *Measurement= 0.6 cm by 0.3 cm by 0.2 cm *Wound Status= not healed, 20% granulation, 40% pink/red epithelia, 40% biofilm *Exudate= moderate, thin, serous *Pain=4/10 *Orders and Requisitions: Continue air mattress to bed, gel cushion to wheelchair/recliner Turn side to side when in bed Encourage off loading by changing positions every 2-3 hours Interview on 6/10/24 at 2:40 p.m., the facility Director of Nursing confirmed and verified that the clinical record lacked documentation of weekly skin measurements, and that it is the expectation of the nursing staff to follow the policy and procedures on wound documentation and assessments and that the clinical record lacked any documentation of the air mattress being applied to the bed upon admit. 2. A Re-entry MDS completed for Resident #8 documented return date of 2/17/24, from an acute care hospital. A Quarterly MDS completed for Resident #8 with an ARD of 3/28/24, documented diagnosis for which included anemia, diabetes mellitus, pressure ulcer of sacral and buttock regions and chronic pain. The MDS documented the resident had a BIMS score of 15 which indicated no impaired cognitive decisions and no difficulty for hearing and is able to be understood and understand others and does not resist cares. The resident required dependence with all activities of daily living. The MDS also documented a wheelchair as prior mode of transportation. The MDS documented the resident with 2 stage 3 pressure ulcer, pressure reducing device for chair, bed and pressure ulcer/injury care and no turning or repositioning program. The Braden scale for predicting pressure sores, dated 1/26/24, documented a score of 12, for which indicated high risk for pressure ulcers. The moisture portion of the Braden scale documented that the resident is very moist, skin is often but not always moist. Linen must be changed at least once a shift. The mobility portion of the Braden scale documented that the resident is very limited, makes occasional slight changes in body or extremity position but unable to make frequent or significant changes. Friction and Shear, problem, requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible The Plan of Care with an initiated dated 3/3/24, stated the resident has actual impairment to skin integrity related to Stage 3 right and left buttocks. Interventions include: *Complete Braden Scale every week x 4 following admission/readmission, then complete quarterly and as needed *Follow facility protocols for treatment of injury. *Keep skin clean and dry. Use lotion on dry skin. *Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. *Turn and reposition during rounds and as needed. *Utilizes a (pressure reducing/low air loss/etc) mattress *Wound nurse consult as needed. The Progress Notes dated 2/17/24 at 12:06 p.m., documented, Admission assessment: Abnormalities noted with skin assessment: sacral redness with tx in place. Skin is dry and flaky all over and tx with lotion in place. A Weekly Nursing Skin assessment dated [DATE] at 1:39 p.m., documented a sacrum wound, treatment in place, no size or description of the area. A Weekly Nursing Skin assessment dated [DATE] at 6:42 p.m., documented a sacrum wound, treatment in place, no size or description of the area. A Weekly Nursing Skin assessment dated [DATE] at 1:36 a.m., documented a sacrum wound, treatment in place, no size or description of the wound. The Progress Notes dated 3/9/24 at 3:47 a.m., documented, Nurses Note Text: Resident Peri wound warm dry and intact. A Weekly Nursing Skin assessment dated [DATE] at 4:10 a.m., documented a sacrum wound, treatment in place, no size or description of the wound. The Progress Notes dated 3/15/24 at 8:09 a.m., documented Nurses Note Text: During hour of sleep treatments, resident coccyx/sacrum starting to break down. Area is superficial. Area has some bleeding noted, with small amount of granulation tissue observed. Noted resident does have decrease in adipose tissue to area. Reported to this nurse,resident does not like to get up in wheel chair. When asked about getting up she stated it hurts too much A Weekly Nursing Skin assessment dated [DATE] at 1:35 p.m., documented an alteration in skin integrity with coccyx wound 3 cm by 1.5 cm, right buttock 3.5 cm by 1.7 cm and left buttock, 5 cm by 2.5 cm., these areas are new for this resident. An Skin/skin tear/abrasion/burn/bruise report dated 3/15/24 at 2:56 a.m., documented, during hour of sleep treatments, resident coccyx/sacrum starting to breakdown. Area is superficial. Area has some bleeding noted, with small amount of granulation tissue observed. Noted resident does have decrease in adipose tissue to area. Area cleansed and covered for protection. A Metro-Geriatric Services, Wound Treatment Plan dated 3/22/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 8.0 cm by 4.3 cm by 0.2 cm, very scattered *Wound Status= new tissue, 60% pink/red epithelia, 30% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=3.4 cm by 5.1 cm by 0.2 cm, scattered *Wound Status= new tissue, 70% pink/epithelia, 30% granulation *Orders and Requisitions: Continue air mattress Roho or equalgel cushion to wheelchair/and recliner Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 3/29/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 7.0 cm by 3.6 cm by 0.2 cm, very scattered *Wound Status= new tissue, not healed, 50% pink/red epithelia, 40% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=0.4 cm by 0.5 cm by 0.2 cm, scattered *Wound Status= new tissue, not healed, 30% pink/epithelia, 50% granulation, 20% biofilm *Pain=3/10 *Orders and Requisitions: Continue air mattress Roho or equalgel cushion to wheelchair/and recliner Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 4/5/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 6.0 cm by 4.5 cm by 0.2 cm, very scattered *Wound Status= not healed, 30% pink/red epithelia, 60% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=2.2 cm by 0.9 cm by 0.2 cm, scattered *Wound Status= new tissue, not healed, 30% pink/epithelia, 60% granulation, 10% biofilm *Pain=3/10 *Orders and Requisitions: Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 4/19/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 6.3 cm by 3.2 cm by 0.2 cm, very scattered *Wound Status= not healed, 30% pink/red epithelia, 40% granulation, 30% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=0.9 cm by 0.6 cm by 0.2 cm, scattered *Wound Status= new tissue, not healed, 30% pink/epithelia, 50% granulation, 20% biofilm *Pain=3/10 *Orders and Requisitions: Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 4/26/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 10.3 cm by 3.1 cm by 0.2 cm, very scattered *Wound Status= not healed, 50% pink/red epithelia, 30% granulation, 20% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=0.6 cm by 0.3 cm by 0.2 cm, scattered *Wound Status= new tissue, not healed, 30% pink/epithelia, 50% granulation, 20% biofilm *Pain=3/10 *Orders and Requisitions: Strict turning schedule when in bed A Weekly Nursing Skin assessment dated [DATE] at 4:28 a.m., documented, right and left buttock, stage 3 pressure ulcers, no size or description of ulcers. A Metro-Geriatric Services, Wound Treatment Plan dated 5/3/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 9.8 cm by 2.9 cm by 0.2 cm, very scattered *Wound Status= not healed, 50% pink/red epithelia, 40% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=0.7 cm by 0.3 cm by 0.2 cm, scattered *Wound Status= new tissue, not healed, 30% pink/epithelia, 70% granulation, *Pain=3/10 *Orders and Requisitions: Strict turning schedule when in bed A Weekly Pressure Wound assessment dated [DATE] at 1:32 p.m., documented, right buttock pressure area, 0.7 cm by 0.3 cm by 0.2 cm Stage 3. left buttock pressure area, 9.8 cm by 2.9 cm by 0.2 cm Stage 3. A Metro-Geriatric Services, Wound Treatment Plan dated 5/10/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 9.2 cm by 2.5 cm by 0.2 cm, very scattered *Wound Status= not healed, 50% pink/red epithelia, 40% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Pain=4/10 *Skin Inspection: right buttocks, pressure Stage 3 *Measurement=0.0 cm by 0.0 cm by 0.0 cm, scattered *Wound Status= resurfaced, 100% pink/epithelial *Pain=0/10 *Orders and Requisitions: Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 5/10/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 0.2 cm by 0.2 cm by 0.2 cm, very scattered *Wound Status= not healed, 30% pink/red epithelial, 60% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Orders and Requisitions: Strict turning schedule when in bed The Progress Notes dated 5/17/24 at 9:02 a.m., documented, resident seen by wound nurse today, area to upper left buttock near coccyx is 0.2 cm by 0.2 cm by 0.1 cm, all other areas to buttock healed and will continue to look at next week on wound rounds to ensure areas remain closed. A Metro-Geriatric Services, Wound Treatment Plan dated 5/24/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 0.4 cm by 0.7 cm by 0.2 cm, very scattered *Wound Status= not healed, 30% pink/red epithelial, 60% granulation, 10% biofilm *Exudate= moderate, thin, sanguineous *Skin Inspection; coccyx, pressure Stage 3, *Measurement= 4.1 cm by 2.4 cm by 0.2 cm *Orders and Requisitions: Strict turning schedule when in bed A Metro-Geriatric Services, Wound Treatment Plan dated 6/7/24, documented=chief complaint=wound assessment=buttocks/sacrum *Skin Inspection; left buttocks, pressure, Stage 3, *Measurement= 0.4 cm by 0.5 cm by 0.2 cm, very scattered *Wound Status= not healed, 40% pink/red epithelial, 20% granulation, 10% biofilm, 30% partial thickness *Exudate= moderate, thin, sanguineous *Skin Inspection; coccyx, pressure Stage 3, *Measurement= 0 cm by 0 cm by 0 cm *Orders and Requisitions: Strict turning schedule when in bed Observation on 6/5/24 at 4:20 p.m., resident was lying in bed on an air mattress on her back, no wheelchair or recliner in the room. Observation on 6/6/24 at 10:00 a.m. resident lying in bed on an air mattress with blue bolsters on right side of her shoulders, resident stated that staff don't reposition her as often as she would like, sometimes it will be an extended long period of time, at least over 2 hours before they come in to reposition her. Interview on 6/11/24 at 10:00 a.m., the facility DON and ADON, both confirmed and verified that the clinical record lacked any documentation of a strict turning schedule, and that the expectation of a strict turning schedule would be at least every 1 hour. The Policy/Procedure for Documentation of Wound Treatments with a implemented date 12/1/23, stated that the policy of the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, an d changes in treatment. 1. Wound assessments are documented upon admission, weekly and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound, and anatomical location b. Stage of the wound, if pressure injury (stage 1,2,3,4, deep tissue pressure injury, unstageable pressure injury) or the degree of skin loss if non-pressure. c. Measurements: height, width, depth, undermining, tunneling d. Description of the wound characteristics: *color of the wound bed *type of tissue in the wound bed *condition of the peri wound skin *Presence, amount and characteristics of wound drainage/exudate *Presence of absence of odor or pain A General Chart Documentation Guidelines with no dated, instructed staff to: *Wound documentation-weekly wound notes with measurements/wound characteristics, changes in wound status, unavoidable wounds, treatments used or changed, practitioner/family notification/updates

Based on clinical record and policy review and medical provider, pharmacy, and staff interviews, the facility failed to prevent 1 of 5 residents reviewed from experiencing withdrawal signs and symptoms which resulted in an emergency room transfer for evaluation, and treatment due to a significant medication error for 1 of 5 residents reviewed (Resident #25). The facility reported a census of 65 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #25 identified she scored 11 of 15 possible points on the Brief Interview for Mental Status (BIMS) est, which meant she demonstrated moderately impaired cognitive abilities. The MDS revealed she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's Care Plan dated 11/18/21 included a focus area for potential for episodes of alteration in mood related to history of anxiety, depression and [CONDITION(S)]. The Care Plan directed staff to Administer medications as ordered, monitor for side effects and to monitor, document and report mood to determine if issues seen to be related to external causes (medication, treatments and concern over diagnosis). Resident #25's hospital discharge instructions listed home medications and to continue these medications and listed [MEDICATION(S)] (antipsychotic medication) 200 mg by mouth at bedtime every day. Resident #25's Order Summary Report signed by provider 11/8/21 included [MEDICATION(S)] 200 mg by mouth at bedtime with a start day of 10/28/21. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Nursing 2020 Drug Handbook included the following on pages 377 - 381: [MEDICATION(S)] indications for [CONDITION(S)] in severely ill patients unresponsive to other therapies. If a drug is to be discontinued and patient doesn't have moderate to severe [CONDITION(S)], reduce dose gradually over 1 to 2 weeks. To discontinue the drug abruptly for a reason unrelated to [CONDITION(S)], continue to monitor. When discontinuing drug, monitor for recurrence of psychotic symptoms and symptoms related to cholinergic rebound (perfuse sweating, headache, nausea, vomiting, and diarrhea). Caution patient not to restart the drug and to notify provider if more than 2 days of treatment have been missed. The document titled Adverse Consequences and Medication errors revised 4/2014 included the following: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions and side effects. Adverse consequences shell be reported to the Attending Physician and Pharmacist and to the federal agencies as appropriate. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Examples of medication errors include: Omission a drug is ordered but not administered. In the event of a significant mediation related error or adverse consequences, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant is defined as: Requiring mediation discontinuation or dose modification (a current list of medication that should not be abruptly discontinues should be consulted before discontinuing a medication. Requiring hospitalization , or extending a hospitalization Resulting in cognitive deterioration or impairment. The Attending physician is notified promptly of any significant error or adverse consequences. The facility's Administering Medications policy revised on 12/2012 included the following: - Residents not in their rooms or otherwise unavailable to receive medication during med pass may cause the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Report (MAR) space provided for that drug and dose. - The person administering the medication must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - Each nurse's station will have a current Physician's Desk Reference (PDR) and /or other medication reference. Resident #25's Progress Notes dated 11/14/21 at 9:36 AM included a fax sent to Resident # 25's provider due to complaints of nausea and vomiting. Resident #25's Progress Notes dated 11/14/21 at 9:22 PM included the following while assisting the resident at 8:30 PM from her recliner to bed she took a few steps and her legs gave out. Staff eased her to the floor. She appeared weak and less alert than normal. When asked, it took a while for her to state she was nauseous. She had an unsteady gait, and tremors in her arms and legs. Staff E, ADON agreed to send the resident to ER since was not at her baseline condition. While in the ambulance at the facility, she vomited. A Physician Telephone/ verbal order dated 11/14/21 documented: Received permission to send to emergency room (ER). During an interview on 6/20/22 at 9:19 AM with Staff M, Pharmacy Licensed Practical Nurse (LPN) explained the resident had a new order sent on 10/28/21, which the pharmacist approved. Staff M said the resident needed lab tests and then to be put on the Resident, Evaluation and Mitigation System (REMS) program before taking the medication. The Pharmacist approved the medication for 11 days instead of 5 days. During an interview on 6/20/22 at 11:48 AM, Staff C RN explained the process for medications when a new resident is admitted . If the facility's pharmacy did not have the medications, they would have local pharmacy deliver them. We always had them within a couple of days. We would then put a hold on the medication and notify the physician. Staff C reported the resident gets her medications through a different program, but the process it the same. During an interview on 6/20/22 at 12:31 PM with Staff E Assistant Director of Nursing (ADON) explained the process for ordering refills if someone is almost out of medicine. Staff can pull a sticker from the container to reorder the mediation, place it on the fax sheet, and fax it to the pharmacy. They can also reorder through the computerized system. If a dose is missed, staff notify the provider. She commented, if I recall correctly, Resident #25's had to be on the REMS program to get the medication. I think it's a new process. During an interview on 6/20/22 at 3:33 PM, Staff O, Pharmacist from facility's pharmacy, verified the facility requested a refill on 11/6/21 and again on 11/11/21. Staff O said [MEDICATION(S)] therapy required a Complete Blood Count (CBC) with differential prior to starting the medication. Staff O reported the pharmacy created spread sheet for everyone on [MEDICATION(S)] because new regulations went into effect on 11/15/21. He stated the 11-day supply is different: usually, it is a 1 week or 2 week supply. Staff O explained withdrawal from [MEDICATION(S)] caused general weakness, a light headed feeling, and vomiting after stopping the medication abruptly. He verified one would definitely show withdrawal signs and symptoms after 3 to 5 days. He verified that a 200 mg dose was on the upper end of what he had seen prescribed. During an interview on 6/21/22 at 3:23 PM, the resident's medical provider explained how she was unhappy with the care Resident # 25 is receiving at the facility. She reported she was not notified when the need to go to the emergency room and added the facility is very bad about following through with orders. She added that she writes orders and it takes forever for them to do anything about them. And said she had to leave a note to remind herself to make sure they are getting done. She said the most egregious thing was when Resident #25 missed her [MEDICATION(S)]. The provider did not feel the staff understood the importance of her taking her antipsychotic medication and the withdrawal symptoms and nobody notified her when the facility did not have the medications. She said they could have provided samples of the medication until they were able to get it straightened out with the pharmacy. During an interview on 6/22/22 at 11:36 AM, the Regional Clinical Nurse stated she believed the facility reached out to the provider and family about the medication error. She said she thought Staff E, ADON noticed the resident might be having signs and symptoms of withdrawal and has staff send the resident to theER on [DATE]. She added that the resident came right back from the ER. During an interview on 6/22/22 at 11:55 AM Staff E, ADON said facility staff called her on 11/14/22 because the resident had weakness and tremors and had to be lowered to the floor while staff helped her to the bathroom. She said she had been in contact with the resident's provider and also told the about the medication [MEDICATION(S)] and the need for the resident to be on the REMS program before she received the medication. On 11/14/22 Staff E had staff end Resident #25 to ER since she was not at her normal baseline. At the ER, they did provide her with [MEDICATION(S)] and when she was she still not back to baseline in a couple of days the facility reached out to her provider. During an interview on 6/21/22 at 2:48 PM Staff O Pharmacist called back and explained he had talked to IT and was unable to retrieve the spread sheet for following up on the [MEDICATION(S)]. He said he was sure what happened but it looked as if Resident #25 fell through the cracks. He reported he reached out to the pharmacist on duty when the medication was filled for the 11 day supply, but he was to recall because of the length of time that had passed.

Based on observation, record review, and interviews, the facility failed to provide services in accordance with professional standards of practice to prevent the formation of a pressure sore, and also failed to provide preventative nursing interventions to aid in continued healing for 1 of 3 residents reviewed (Resident #33). The facility reported a census of 65 residents. Findings included: According to the Minimum Data Set (MDS) dated [DATE], Resident #33 demonstrated severely impaired cognitive abilities and required extensive assist of 2 staff for bed mobility, transfers, and personal hygiene. The MDS identified the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #33 had an infection in her foot and also had one Stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) The Care Plan dated 4/28/22 documented Resident #33 had a potential for alteration in skin integrity and directed staff to encourage good nutrition and hydration in order to promote healthier skin, reposition the resident with assist of 2 staff, and ensure the resident wears Prevalon boots (to relieve pressure on the heels) at all times. An Altered Skin Integrity Notification form dated 12/22/21 documented Resident #33 had a Stage 1 pressure wound on her left heel that measured 1.8 cm x 1 cm and directed apply skin prep twice a day until heeled. A Physician Notification form dated 1/7/22 documented the pressure area on Resident #33's heel had opened. The form contained a new order that directed staff to discontinue skin prep. Cleanse area with wound cleaner, apply [MEDICATION(S)]-soaked gauze, and wrap with Kerlix every day and as needed. Weekly Wound Assessment Form dated 1/7/22 documented Resident #33's left heel pressure ulcer measured 5 cm x 5.8 cm x 0 cm (no depth) and contained serous drainage. Weekly Wound Assessment Form dated 1/14/22 documented Resident #33's left heel pressure ulcer measured 4.5 cm x 4 cm x 0 cm and contained serous drainage. A Physician Notification form dated 1/19/22 documented Resident #33 currently had skin breakdown. The form contained a new order to give a stress tablet with zinc every day. Weekly Wound Assessment Form dated 1/28/22 documented Resident #33's left heel pressure ulcer measured 3.1 cm x 5 cm x 0 with no drainage. A Physician Notification form dated 2/3/22 documented Resident #33's left heel pressure ulcer is closed. The form contained a new order to discontinue [MEDICATION(S)] and start skin prep to the area twice a day. Weekly Wound Assessment Form dated 2/4/22 documented Resident #33's left heel pressure ulcer measured 3 cm x 3.5 cm x 0 cm with no drainage. Weekly Wound Assessment Form dated 2/11/22 documented Resident #33's left heel pressure ulcer measured 3 cm x 3.5 cm x 0 cm with no drainage. Weekly Wound Assessment Form dated 2/18/22 documented Resident #33's left heel pressure ulcer measured 3 cm x 3.5 cm with no drainage. Weekly Wound Assessment Form dated 2/25/22 documented Resident #33's left heel pressure ulcer measured 2.7 cm x 1.3 cm with no drainage. Weekly Wound Assessment Form dated 3/4/22 documented Resident #33's left heel pressure ulcer measured 2 cm x 1 cm with no drainage . Weekly Wound Assessment Form dated 3/11/22 documented Resident #33's left heel pressure ulcer measured 2 cm x 1 cm with serous drainage. An Altered Skin Integrity Notification dated 3/11/22 documented Resident #33's pressure area on her left heel had decreased in size, but then reopened. New order obtained to discontinue skin prep and start [MEDICATION(S)]-soaked gauze and wrap with Kerlix. Change every day. Weekly Wound Assessment Form dated 3/18/22 documented Resident #33's pressure area measured 3 cm x 2.5 cm x 0.1 cm with yellow green drainage. Weekly Wound Assessment Form dated 3/25/22 documented Resident #33's pressure area measured 1.5 cm x 1.5 cm with no drainage. The Wound Treatment Plan dated 3/25/22 included the following information: - Location: left heel; Unstageable; Measurement: 1.5 cm x 0.1 cm; Tissue: 100% slough; unable to assess wound bed; Exudate: thin yellow to green; Odor: none. - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Weekly Wound Assessment Form dated 4/1/22 documented Resident #33's pressure area measured 0.5 cm x 1.2 cm x 0.1 with yellow green drainage. The Wound Treatment Plan dated 4/1/22 included the following information: - Location: left heel; Unstageable; Measurement: 0.5 cm x 1.2 cm x 0.1 cm; Tissue: 100% slough; unable to assess wound bed; Exudate: thin yellow to green; Odor: none. - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue with Prevalon boots to both feet at all times: do not stand or walk while wearing them. Weekly Wound Assessment Form dated 4/8/22 documented Resident #33's pressure area measured 0.9 cm x 1.1 cm x 0.1 cm with yellow green drainage. The Wound Treatment Plan dated 4/8/22 included the following information: - Location: left heel; Unstageable; Measurement: 0.9 cm x 1.1 cm x 0.1 cm; Tissue: 100% slough; unable to assess wound bed; Exudate: thin yellow to green; Odor: none. - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Orders and Requisitions: Prevalon boots at all times please. [MEDICATION(S)] one tablet by mouth twice daily x 7 days. Weekly Wound Assessment Form dated 4/15/22 documented Resident #33's pressure area measured 1.5 cm x 2 cm x 0.1 cm with no drainage. Weekly Wound Assessment Form dated 4/22/22 documented Resident #33's pressure area measured 0.5 cm x 0.8 cm x 0.1 cm with yellow green drainage. Weekly Wound Assessment Form dated 4/29/22 documented Resident #33's pressure area measured 0.5 cm x 0.5 cm x 0.1 cm A Physician Notification dated 4/29/22 directed discontinue current treatment to Resident #33's heel and start skin prep to left heel every day. A Wound Treatment Plan dated 5/6/22 included the following information: - Location: left heel; Unstageable; Measurement: 0.5 cm x 1.0 cm x 0.1 cm; Tissue: 100% eschar; Unable to assess wound bed; Exudate: none; Odor: none. - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) Weekly Wound Assessment Form dated 6/6/22 documented Resident #33's pressure area measured 0.5 cm x 1 cm x 0.1 cm with no drainage. A Wound Treatment Plan dated 5/13/22 included the following information: - Location: left heel; Unstageable; Measurement: 0.5 cm x 0.1 cm x 0.1 cm; Tissue: 100% eschar; Unable to assess wound bed; Exudate: none; Odor: none - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . -Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) A Weekly Wound Assessment Form dated 5/16/22 documented Resident #33's pressure area measured 0.5 cm x 0.9 cm x 0.1 cm with no drainage. A Wound Treatment Plan dated 5/20/22 included the following: - Location: left heel; Unstageable; Measurement: 0.7 cm x 0.5 cm x 0.1 cm; Tissue:100% red; Wound bed: granulation; Exudate: thin serous; Odor: none -treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . -Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) A Weekly Wound Assessment Form dated 5/23/22 documented Resident #33's pressure area measured 0.7 cm x 0.5 cm x 0.1 cm with serous drainage. Document titled Wound Treatment Plan dated 5/27/22 included the following: - Location: left heel; Unstageable; Measurement: 0.5 cm x 1.1 cm x 0.1 cm; Tissue: 100% red; Wound bed: granulation; Exudate: thin serous; Odor: none - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) Weekly Wound Assessment Form dated 5/31/22 documented Resident #33's pressure area measured 0.5 cm x 1.1 cm x 0.1 cm with serous drainage. The Wound Treatment Plan dated 6/3/22 included the following: - Location: left heel; Unstageable; Measurement: 0.5 cm x 1.3 cm x 0.1 cm; Tissue:100% eschar; Wound bed: granulation; Exudate: none; Odor: none -treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) A Weekly Wound Assessment Form dated 6/6/22 documented Resident #33's pressure area measured 0.5 cm x 1.1 cm x 0.1 cm with no drainage. Document titled Wound Treatment Plan dated 6/10/22 included the following: - Location: left heel; Unstageable; Measurement: 0.6 cm x 1.1 cm x 0.1 cm; Tissue:100% eschar; Wound bed: granulation; Exudate: thin serous; Odor: none - treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . - Orders and Requisitions: PREVALON BOOTS ON AT ALL TIMES, PLEASE (sic) Weekly Wound Assessment Form dated 6/13/22 documented Resident #33's pressure area measured 0.6 cm x 1.1 cm x 0.1 cm with no drainage. An observation on 6/15/22 at 11:03 AM, revealed Staff C, RN with observer Staff D, Assistant Director of Nursing (ADON) placed a barrier on a tray. Staff C placed the following items on the barrier: wound cleanser, gauze, gloves, and skin prep. Staff C had removed the Prevalon boot from Resident #33's left foot, washed her hands, donned gloves, and sprayed wound cleanser on some gauze, cleansed the pressure sore on Resident # 33's heel, removed her gloves, and used hand sanitizer to cleanse her hands. She than dried the area, applied skin prep (which caused the resident to visibly react), allowed the area to dry, and put the Prevalon boot on Resident #33's left foot. She removed her gloves, used hand sanitizer to clean her hands, and picked up the wound treatment items. Observation revealed an area of eschar tissue on Resident #33's left heel approximately the size of a quarter. Observation on 6/16/22 revealed the following: a. 8:05 AM: Resident # 33 sat in her recliner with her feet up wearing white socks, and no Prevalon boots in view. b. 9:51 AM: Resident # 33 sat in her recliner with her feet down and no Prevalon boots in view. c. 2:07 PM: Resident # 33 sat in her recliner, feet down and resting on the overbed table with her heels positioned on the brace that holds the wheels. No Prevalon boots in sight. Observation on 6/20/22 revealed the following: a. 8:16 AM: Resident # 33 sat in her recliner with her feet up and no Prevalon Boots seen. b. 11:39 AM: Resident # 33 sat in her recliner, feet up, heels touching the footrest, with no Prevalon boots in view. Observation on 6/21/22 revealed the following: a. 9:06 AM: Resident # 33 sat in her recliner with her heels resting on the footrest and no Prevalon boots in view. b. Observation on 6/21/22 at 11:22 AM revealed Resident # 33 sat in her recliner, feet up, and heels resting on the footrest. No Prevalon were visible in the room. During an interview on 6/22/22 at 11:31 AM with Staff D, ADON reported she would expect staff to apply Resident # 33's Prevalon boots to both feet at all times. Staff D also reported sometimes the resident kicks her feet and the boots turn.

Based on review of the facility's medication reference handbook, clinical record review, and staff and provider interviews, the facility failed to ensure staff provided proper assessment and timely interventions for 1 of 18 residents reviewed (Resident # 25). This failure caused Resident #25 to suffer [MEDICATION(S)] withdrawal symptoms which required a transfer to the emergency room for evaluation and treatment. The facility reported a census of 65 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #25 documented the resident scored 11 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant she demonstrated moderately impaired cognitive abilities. The MDS also documented she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's Care Plan dated 11/18/21 identified a potential for episodes of alteration in mood related to history of anxiety, depression, and [CONDITION(S)]. The Care Plan directed staff to administer medications as ordered, monitor for side effects, and to monitor, document, and report mood to determine if any issues seen could be related to external causes (medication, treatments, and concern over diagnosis). Resident #25's hospital discharge instructions listed home medications and directed facility staff to continue these medications. The form contained orders for [MEDICATION(S)] (antipsychotic medication) 200 mg by mouth at bedtime every day, continue [MEDICATION(S)] ( an antibiotic) 750 mg by mouth daily for 4 days, and obtain urinalysis via straight catheterization after completion of antibiotic. The discharge summary also directed the facility to have the resident see the medical provider for follow-up on 11/3/21. Resident #25's Order Summary Report signed by the provider on 11/8/21 included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #25's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Adverse Consequences and Medication Errors policy revised on 4/2014 included the following: - Medication error: the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - Examples of medication errors include: omission - a drug that is ordered but not administered. - In the event of a significant mediation related error or adverse consequences, immediate action is taken, as necessary, to protect the resident's safety and welfare. - Significant is defined as: * Requiring mediation discontinuation or dose modification (the policy directed staff to consult a current list of medications that should not be abruptly discontinued before discontinuing a medication). * Requiring hospitalization , or extending a hospitalization * Resulting in cognitive deterioration or impairment. - The policy also directed staff to report any adverse reactions, adverse consequences, and medication related problems to the attending physician and pharmacist and to the federal agencies as appropriate, and also to notify the attending physician promptly of any significant error or adverse consequences. Review of Resident #25's Medical Record revealed a lack of documentation that showed the facility followed the order to obtain a urinalysis after the resident completed the antibiotic. The record did include the urinalysis obtained when the facility transferred the resident to the emergency room (ER) on 11/14/21 (14 days after she finished the antibiotic). The clinical record also lacked documentation to show staff conducted any assessments or provided interventions after the facility failed to administer Resident #25's [MEDICATION(S)] and did not obtain the urinalysis as ordered. On 6/20/22 at 10:08 AM, Staff D, Assistant Director of Nursing (ADON) reported she called the laboratory and requested all of the November 2021 laboratory (lab) results for Resident # 25. She verified the lab did not locate a urinalysis obtained just after the resident finished their antibiotic therapy as ordered. During an interview on 6/22/22 at 11:35 AM, Staff D, ADON reported the facility did not keep the books on a year-to-year basis, so they do not have a record of labs ordered. Staff D added if staff make a medication error, they are to report it to the provider right away, obtain any potential new orders, and then notify family. In a subsequent interview on 6/21/22 at 12:33 PM, Staff D, ADON reported she put a call out to the other ADON (Staff E) to inquire about the location of the lab book and appointment calendar. She reported she had torn her office apart to find it, but could not. On 6/20/22 at 12:31 PM, Staff E, ADON explained that staff order medication refills when a resident is almost out of meds by removing a sticker from the medication and adhering it to the fax sheet that goes to the pharmacy. They can also enter it in the computer for reorder. The ADON reported if a resident misses a dose, staff are to notify the provider. The ADON continued, that if she recalled correctly, Resident #25's medication had to do with the REMS program that she had to be on the program to get the medication. She added that she thought it was a new process. During an interview on 6/20/22 at 1:33 PM, Staff N, RN reported staff are to document a new lab order on the calendar and fax a new medication order to the pharmacy at that time. Staff are also to document a new order in the computer, add it to the 24 hour report for a 2nd shift nurse to note, and place a copy in the ADON's box for a third check. She added that staff are also supposed to document the resident's response to a new medication in the resident's record for a period of time. On 6/20/22 at 3:33 PM, Staff O, Pharmacist reported the facility requested a [MEDICATION(S)] refill on 11/06/21 and again on 11/11/21. If the physician prescribes [MEDICATION(S)], the resident would need a Complete Blood Count (CBC) with differential drawn. Staff O said the pharmacy created a spread sheet to track every resident on [MEDICATION(S)] because new regulations took effect on 11/15/21. Staff O stated the 11-day supply is usually either a 1 week or 2 week supply. Staff O reported [MEDICATION(S)] withdrawal signs and symptoms included general weakness, feeling light-headed, and vomiting after abruptly stopping the medication. Staff O continued that within 3 to 5 days, one would definitely show signs and symptoms of withdrawal and added that 200 mg is on the upper end of the dosage what he had seen prescribed. During an interview on 6/21/22 at 3:23 PM, Resident #26's medical provider reported she was unhappy with the care the facility provided for Resident # 25. She stated Resident # 25 was scheduled for follow-up appointments after their hospital discharge on 11/1, 11/3, and 11/9/21 and they were all canceled. She also stated the facility did not notify her when the resident went to emergency room and are very bad about following through with orders: it takes them forever. The provider added that she leaves herself a note to remind her to follow-up with the facility to ensure they were implementing the orders she gave them. She also said the facility was very bad at obtaining labs when ordered and she or her nurse had to call the facility and then wait days for them to get done. The provider reported the most egregious thing that occurred was when Resident #25 missed her [MEDICATION(S)]. She said she did not feel the staff understood the importance of ensuring that she took her antipsychotic medication and the withdrawal symptoms that followed if she did not take the pill. The provider verified the facility failed to notify her that they could not get the medication. She explained she could have obtained samples of the medication and could have gotten it for them until they were able to get it straightened out with the pharmacy. She reported that follow through at the facility was not good, so now the family call her office directly instead of going through the facility when they have concerns. On 6/22/22 at 11:36 AM, the Regional Clinical Nurse stated she believed the facility notified the resident's medical provider and family about the medication error. She reported that Staff E, ADON thought Resident #25 displayed signs and symptoms of withdrawal at that time, so they sent her to theER on [DATE] and then she came right back to the facility. During an interview on 6/22/22 at 11:55 AM, Staff E, ADON reported facility staff called her on 11/14/22 at 8 PM because Resident #25 was not at her baseline condition. When they assisted her to the bathroom, she had exhibited weakness and tremors and staff had to lower her to the floor. Staff E said she was aware of the REMS program and had contacted the pharmacy about it before Resident #25 received the medication. Staff E explained she then had staff send Resident #25 to ER since she was not acting like her normal self and there they provided her with [MEDICATION(S)]. The ADON added when Resident #25 was still not back to baseline functioning after a couple of days, they notified her medical provider. During an interview on 6/21/22 at 2:48 PM, Staff O Pharmacist called back and explained he could not retrieve the [MEDICATION(S)] spread sheet even when he tried working with IT. He reported he was not sure what happened, but it looked as if Resident #25 fell through the cracks. Staff O reported he did reach out to the pharmacist on duty when the medication was filed for the 11 day supply, but that pharmacist could not recall anything else due to the length of time that had passed. The facility's Nursing 2020 Drug Handbook included the following information on pages 377 - 381: [MEDICATION(S)] is used for [CONDITION(S)] in severely ill patients that are unresponsive to other therapies. If the drug is to be discontinued and the patient doesn't have moderate to severe [CONDITION(S)], reduce the dose gradually over 1 to 2 weeks. If the drug is discontinued abruptly due to another reason unrelated to [CONDITION(S)], continue to monitor. When discontinuing the drug, monitor for recurrence of psychotic symptoms and symptoms related to cholinergic rebound (profuse sweating, headache, nausea, vomiting, and diarrhea). Caution the patient not to restart the drug, and tell them to notify their medical provider if more than 2 days of treatment have been missed. The facility's Accepting Delivery of Medications policy revised on 4/2007, directed all staff shall follow a consistent procedure when accepting medication. Staff shall also bring any errors noted in receiving medications to the attention of the Pharmacist and Director of Nursing Services. The facility's Administering Medications policy revised on 12/2012 included the following: - Residents not in their rooms or otherwise unavailable to receive medication during med pass may cause the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Report (MAR) space provided for that drug and dose. - The person administering the medication must initial the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - Each nurse's station will have a current Physician's Desk Reference (PDR) and /or other medication reference.

Based on observation, record review and staff interviews, the facility failed to implement and monitor a complete and consistent screening process for staff and visitors to prevent a COVID 19 outbreak for 52 of 56 residents. The facility reported census was 54. Findings include: According to the facilities COVID 19 Pandemic Guidelines: *All employees, contractors, consultants and all other type of person entering the building will be subject to the screening process. Each employee will be screened prior to starting their shift each day they work. *The screening process will be in accordance with CDC guidelines with the following questions: 1. Do you currently have any respiratory symptoms such as fever, cough, sore throat, shortness of breath, or any other type of upper respiratory symptoms? 2. Have you traveled outside the country in the last 14 days to restricted areas? 3. Have you been in contact with any person or entity who has been exposed, being investigated, or diagnosed with [REDACTED]. *Any person answering YES to above questions will be restricted from entering. *The facility will also screen related to temperature readings. Those individuals with a temperature reading above 99.1 orally will be restricted from entry. *For employees, contractors, and consultants who have no negative responses to the screening process, they will be required to wash their hands and proceed to their designated work area. According to the Employee/Contractor Screening form used by the facility, staff are to print their name and title and answer; 1. Do you have any respiratory symptoms such as fever, chills, cough, sore throat, congestion, runny nose, shortness of breath or any other type of respiratory symptoms or any nausea, vomiting, diarrhea, headache, fatigue, muscle body aches, loss of taste or smell? 2. Have you had any contact with any person or entity who is being investigated (test pending), or diagnosed with [REDACTED].? 3. Have you traveled internationally in the past 14 days to restricted international countries? 4. Have a nurse check their temperature and route and record it. (must be less than 99.1 orally) 5. Hands and shoes sanitized and mask and face protection provided. 6. Employee signature. 7. Screener signature. In an interview on 7/28/20 at 8:09 p.m. the Director of Nursing (DON 1) stated she first developed symptoms of a runny nose and cough on or around 7/1/20 which she thought was just allergies. The DON 1 stated she was afebrile. The DON 1 remained at work and worked the next day (7/2/20) before taking off for the Fourth of July holiday. On Friday, 7/3/20 a family member developed a temperature and diarrhea and by Monday, 7/6/20, they were both tested for COVID 19. The DON 1 was confirmed positive with COVID 19 on 7/11/20. The DON 1 stated her symptoms worsened with a cough and shortness of breath and she went to the hospital emergency roiagnom on [DATE] or 7/12/20. The DON 1 stated she returned to work on 7/19/20. The DON 1 stated the screening process requires staff to answer questions and check their temperature. A nurse is supposed to verify the answers and temperature, then sign the screening tool. Staff are to be sent home if they have any symptoms noted on the screening tool. Review of the facilities Employee/Contractor Screening tool from 7/1/20 through 7/7/20 noted 243 entries in which 164 entries or 67.5% did not have a nurse signature verifying the answers and temperatures of the employees entering the building. According to the Employee/Contractor Screening tool, Staff A, Registered Nurse (RN), failed to fill out the screening form on 7/1/20 and on 7/2/20, 7/4/20, 7/5/20, 7/8/20, indicated affirmative for having symptoms related to COVID 19. In an interview on 7/23/20 at 5:15 p.m., Staff A, RN, stated sometime in mid-June her friend became positive for COVID 19 and at that time, she was quarantined and did not work for a couple weeks. On 6/24/20, the facility tested all of their staff and she was negative, but noted at around that time she had lost her sense of taste. Once she returned to work her loss of taste persisted and when she told her supervisors, they stated it was probably just her allergies and allowed her to continue to work. In early July her symptoms included headache and nausea. Staff A stated she continued to work despite indicating her symptoms on the screening tool. On 7/16/20, after an outbreak of COVID 19 in the facility, the facility tested all of their staff again and this time she was positive for COVID 19. According to the Employee/Contractor Screening tool on 7/3/20 and 7/4/20, Staff B, Certified Medication Aide (CMA) indicated affirmative for having symptoms related to COVID 19. In an interview on 7/23/20 at 2:05 p.m., Staff B, CMA, stated on 7/3/20 she arrived to work with a headache, low-grade temperature and sore throat. Staff B stated she indicated this on the screening form and informed the Assistant Director of Nursing (ADON) she was not feeling well. The ADON asked Staff B if she felt ok to stay and work and she responded I guess so and remained at work. On Saturday, 7/4/20, Staff B returned to work, still not feeling well and stayed until about noon before leaving. Staff B stated her symptoms had gotten worse and on 7/6/20, the ADON stated she needed to get tested . Staff B stated she got tested that day and on 7/10/20, got results indicating she was positive for COVID 19. Staff B stated she remained off work until returning on 7/20/20. In an interview on 7/30/20 at 1:30 p.m., the Assistant Director of Nursing (ADON) stated on 7/3/20, Staff B had reported not feeling well, but had no cough or temperature and was allowed to work. The ADON stated she had later heard Staff A, RN, sent Staff B home early on 7/4/20. According to the Employee/Contractor Screening tool, Staff C, Certified Nurse Aide (CNA) on 7/5/20 and 7/6/20 indicated affirmative for having symptoms related to COVID 19. In an interview on 7/23/20 at 2:30 p.m. Staff C, CNA, stated on 7/4/20 and 7/5/20 she was having migraine headaches and a stomach ache, but continued to work her shifts. The next day on Monday, 7/6/20, she was achy and had a bad cough. She was telling everyone at work she was not feeling well, including Staff D, MDS Coordinator, Staff E and the ADON. Staff C stated she was asked if she wanted, tested and if so she would have to be sent home. Staff C stated she insisted on being tested and the ADON gave her the test. Staff C stated she was sent home and for the next five days had a very elevated temperature. Staff C stated that on 7/11/20 she got results indicating she was positive for COVID 19. Staff C stated she was not scheduled to return to work until 7/27/20. According to the Employee/Contractor Screening tool, Staff G, Licensed practical Nurse (LPN) on 7/4/20, 7/5/20, 7/6/20 and 7/9/20 indicated affirmative for having symptoms related to COVID 19. In an interview on 7/30/20 at 11:24 a.m., Staff G, LPN, stated on 7/4/20, 7/5/20, 7/6/20 and 7/9/20 she had been responding yes on the facilities screening tool related to nausea, vomiting and diarrhea. Staff G stated she thought the symptoms were related to her medication. Staff G stated the Director of Nursing allowed her to continue to work. Staff G stated she has been tested for COVID 19 three times (6/24, 7/16, 7/30) by the facility and once at her doctors and all were negative. Staff G questioned about an entry on the screening tool on 7/15/20 in which she answered affirmative to exposure to someone with COVID 19 and recorded a temperature of 99.3. Staff G stated the Administrator was notified and she was sent home. Staff G stated the next day she was scheduled on the COVID 19 positive halls and has been assigned there since. In an interview on 7/30/20 at 2:25 p.m., the Director of Nursing (DON 1) stated she does not recall having any conversations with Staff G about her symptoms and working status in early July. In an interview on 7/23/20 at 1:05 p.m., Staff D, MDS Coordinator, stated on 7/1/20 she had an increase in allergy symptoms, runny nose, nasal stuffiness, but no cough, shortness of breath, headache or temperature. Staff D stated she worked 7/1/20, 7/2/20 and until noon on Monday, 7/6/20. Her stuffiness continued and she was swabbed for COVID 19 and sent home. On 7/7/20 Staff D stated she visited her physician who thought it was sinusitis. Staff D stated that on 7/10/20 she received her results, which were positive for COVID 19. During an observation on 7/22/20 at 2:48 p.m. Staff F, CNA, observed entering the room of Resident #5, who was on isolation precautions related to developing symptoms of COVID 19, but remained on the non-COVID hall. Staff F removed his gown, mask, exchanged them for a disposable gown, mask, and then donned gloves prior to entering the resident's room. Staff F did not sanitize his hands prior to donning gloves. When finished attending to Resident #5's needs which included some physical contact, Staff F doffed his gown, gloves and mask and disposed them in a box without a hazard bag lining it. Staff F then re-donned his original gown and N95 mask and again failed to complete hand hygiene. At 3:05 p.m. Staff F returned to Resident #5's room, again removing his cloth gown and N95 mask, then donning a disposable gown, disposable mask and gloves all without completing hand hygiene. Staff F physically assisted Resident #5, then doffed his gown, gloves and mask, exited the room and re-donned his cloth gown and N95 mask again without washing or sanitizing his hands. Observations found no sanitizer available within the proximity of the room. On 7/23/20, Resident #5 tested for COVID 19 and discovered positive just days later. On 7/30/20 at 3:10 p.m., the facility was informed of an Immediate Jeopardy situation related to their screening process. The plan of correction included assigning a trained screener at the employee entrances to screen and monitor sanitation practices. A screening assignment sheet was used to identify who would be responsible for screening employees at designated times. The designated times were 5:00 a.m. to 6:00 a.m., 6:00 a.m. to 10:00 a.m., 1:30 p.m. to 2:30 p.m. and 5:30 p.m. to 6:30 p.m. During an observation on 8/3/20 at 2:00 p.m. Staff F, CNA entered through the employee entrance for the negative COVID halls. There was no screener present and Staff F filled out the screening questions and took his own temperature. Staff F then proceeded to the Nurse's Station, where he was then escorted back into the entry hallway by the assigned screener, DON 2. Staff F then re-entered the negative COVID halls and began working while the assigned screener, DON 2, remained at the screening table. According to the Screening Assignment sheet for 8/3/20, the Director of Nursing (DON 2) was assigned from 1:30 p.m. to 2:30 p.m. In an interview on 8/3/20 at 2:05 p.m., the interim Director of Nursing (DON 2) stated she was the scheduled screener from 1:30 p.m. to 2:30 p.m. The DON 2 stated she was on a phone call and did not get to the screening table until 1:45 p.m. Observations noted DON 2 escorting Staff F from the nurse's station, back into the entry hallway at around 2:02 p.m. In an interview on 8/3/20 at 2:08 p.m., Staff F, CNA, stated he entered the facility and answered the screening questions, took his temperature, sanitized his hands and disinfected his feet without a witness. Staff F stated he is the only one who comes in at 2:00 p.m. for the negative COVID side and checked in at the Nurse's Station before proceeding to work. Staff F stated he was requested by the DON 2 to return to the entry hallway. Staff F stated he was not informed by anyone of the new screening process. In an interview on 8/3/20 at 3:06 p.m. Staff H, Maintenance Staff, stated he arrived at work around 9:30 a.m. that morning and filled out the screening questions, sanitized his hands, disinfected his feet and proceeded to the Nurse's Station to have the ADON check his temperature. Staff H stated there was no one sitting at the screening table when he arrived. According to the Screening Assignment sheet for 8/3/20, Staff I, CNA was assigned from 5:00 a.m. to 10:00 a.m. that morning. In an interview on 8/4/20 at 9:40 a.m. Staff J, CNA, assigned as the screener from 6:00 a.m. to 10:00 a.m. stated when they first started screening employees back in March, they had a designated screener at the entrance, but at some point they just stopped doing it. The Facility abated the Immediate Jeopardy situation by educating all staff by 8/4/20 regarding the screening process and not allowing a staff person to work if showing signs and symptoms of COVID. The screening process education included: -Staff instructed to enter by the front door. -The front doors will remain locked and anyone who enters must ring the doorbell to enter the facility. -The Screener will be positioned at the locked front door during specified hours. -If staff arrive outside the specified hours and the screener is not present, the employee will have to ring the doorbell for entrance, and whoever answers the doorbell will get the assigned screener. During observations on 8/4/20 from 5:57 a.m. to 7:10 a.m., the facility had a screener positioned at the front entry as staff arrived. The assigned screener appropriately screened employees as they entered the facility and checked temperatures as staff left. There were no concerns with the facilities current screening process. Based on the results of the corrective measures taken by the facility lowered the scope and severity of the deficiency from a L level to a F level.

Based on observation, record review and staff interviews, the facility failed to prevent the development of avoidable pressure ulcers and implement interventions to promote healing of pressure ulcers. The sample consisted of 2 of 13 residents reviewed. The facility identified a census of 60 residents. Findings include: The stages of Pressure ulcers (sores) are reflected as the following: Stage I intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also be an open or intact blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling. 1. Resident #2 ' s 8/20/16 Admission Assessment document the resident had a 3 cm (centimeter) red pressure area on the mid spine; a 5 cm bright red raw area on the right buttock and an unmeasured pink raw area on the left buttock. The assessment documented the resident had a pressure reducing mattress to the bed and a pressure reducing cushion to the chair. Resident#2 ' s 11/23/16 Minimum Data Set (MDS) documented the resident required extensive assistance of 2 staff for bed mobility and transfers. The resident did not ambulate. The MDS documented the resident had [DIAGNOSES REDACTED]. The resident had limitation in functional range of motion in one arm and one leg. The resident's 11/23/16 Pressure Ulcer Risk Assessment documented the resident at moderate risk for development of pressure ulcers. During an interview on 12/7/16 at 2:06 p.m. Staff F, Registered Nurse stated no Pressure Sore Risk Assessment had been done prior to 11/23/16. She stated they usually did the assessments on admission and quarterly. During interview on 12/6/16 at 12:31 p.m. the Director of Nursing confirmed the resident's bed had previously had a standard mattress in place. At 12:37 p.m. Staff F brought a receipt which showed the pressure relieving Roho seat cushion had been ordered on [DATE]. She stated the resident had no pressure relieving cushion in the chair prior to the Roho. She confirmed the chair had no pressure relieving device present for the resident's spine and stated the resident often slept in the recliner. During observation on 12/5/16 at 1:22 p.m. the resident slept in the recliner with the backrest reclined and the footrest elevated. During observation on 12/6/16 at 9:04 a.m. the resident slept in the recliner with the backrest reclined and the footrest elevated. During observation on 12/7/16 at 10:17 a.m. the resident's bed had no pressure relieving device present. At 12:21 p.m. the resident sat in the recliner eating lunch with a Roho (pressure relieving) cushion in the seat of the chair. The resident had no pressure relieving device to the back of the chair. At 12:21 p.m. an alternating pressure mattress had been applied. During observation on 12/6/16 at 1:19 p.m. Staff C and Staff G, CNA's assisted the resident with toileting and incontinence care. When that had been completed they stood the resident so Staff F, Registered Nurse could change the protective dressing on the resident's spine. When she removed the dressing the resident had an open area 1.5 by 1.2 cm. by .1 cm. deep. Staff F stated the area had not been open before, only red. The resident's Pressure Ulcer Wound Sheet documented on 8/20/16, the resident's admitted , staff measured a Stage II (open) pressure ulcer on the right buttock which measured 5 cm. by 2.5 cm. and had no depth. The wound sheet documented date of onset as 6/10/16. During an interview on 12/7/16 at 1:22 p.m. the Director of Nursing stated staff had documented the onset dated because the resident's spouse reported the ulcer had first been found on that date. On 8/20/16 staff documented on the Pressure Ulcer Wound sheet of the left buttock with a Stage I (reddened, but not opened) pressure ulcer which measured 4 cm. by 1.5 cm. with no depth. Staff documented the date of onset for the left buttock ulcer 8/3/16. On 8/23/16 staff documented the left buttock now open (Stage II) and measured 5 cm. by 2.5 cm. by 0.1 cm. deep. On Unit Weekly Skin Logs staff documented the pressure ulcers measured as follows: On 9/6/16 staff measured the right buttock ulcer 2.1 by 1.0 cm. The left buttock ulcer measured 2.1 by 1.3 cm. On 9/13/16 staff measured both ulcers larger. The right buttock ulcer measured 3.0 by 1.5 cm. and the left buttock ulcer measured 2.8 by 1.7 cm. On 9/20/16 staff measured the right buttock ulcer 2.5 by 1.3 cm. and the left buttock ulcer 2.5 by 1.7 cm. On 9/27/16 staff measured the right buttock ulcer 2.1 by 1.0 cm. and the left buttock ulcer 2.1 by 1.3 cm. On 10/4/16 staff documented both ulcers unmeasured. On 10/18/16 staff documented measurements of both ulcers significantly larger the previous week. They documented the right buttock ulcer now measured 5 by 2.2 cm. and 0.1 cm. deep. Staff documented the left buttock ulcer measured 6 cm by 4.2 cm. by 0.2 cm. The documentation lacked any measurements for the current week. On 10/25/16 staff measured the right buttock ulcer 4.8 by 2.2 cm with 0.1 cm. depth. They measured the left buttock ulcer 6 by 4 cm. and 0.2 cm. depth. On 11/1/16 staff measured the right buttock ulcer 4.5 by 2.2 cm with 0.1 cm. depth and the left buttock ulcer 5.4 by 3.9 cm with 0.2 cm. depth. On 11/8/16 staff documented the right buttock ulcer measured 4.1 by 2.0 cm. with 0.1 cm. depth. The left buttock ulcer measured 5.0 by 3.6 cm. with 0.1 cm. depth. On 11/15/16 staff measured the right buttock ulcer 3.0 by 1.5 cm. and the left buttock ulcer 3.5 by 2.4 cm. On 11/22/16 staff measured the right buttock ulcer 2.2 by 1.5 cm. and the left buttock ulcer 3.2 by 1.9 cm. On 11/29/16 staff measured the right buttock ulcer 1.6 by 1.3 cm. and the left buttock ulcer 2.4 by 1.4 cm. The resident's Care Plan revised on 11/28/16 stated the resident had pressure reduction devices on the bed and the chair for prevention of skin breakdown, but lacked any problem of related to risk for pressure ulcers. The Care Plan lacked any mention of actual pressure ulcers or directions to staff in regard to them. 2. Resident #4 had a MDS (Minimum Data Set) assessment with a reference date of 9/15/16. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 8. A score of 8 identified the resident with moderately impaired cognition. The MDS indicated the resident required extensive assistance from 1 staff member for bed mobility. The resident required extensive assistance from 2 staff members for transfers, ambulation, and toilet use. The MDS indicated the resident required staff assistance to balance during transitions and walking, the resident without any upper and lower extremity range of motion impairment, and used a wheel chair and walker for locomotion. The MDS identified Resident #4 had frequent bladder incontinence, without bowel incontinence, and not at risk for pressure ulcer development. The MDS indicated the resident used a pressure reducing device on the bed and chair but did not identify a turning and repositioning program. The MDS revealed the resident's [DIAGNOSES REDACTED]. An Admission Pressure Ulcer Risk (Braden) assessment completed 8/3/16 and another Braden completed 8/15/16 revealed the resident scored 14. A score of 14 indicated the resident had a moderate risk for pressure sore development. The resident's care plan with a start date of 8/26/16, revision date of 9/6/16, and goal date of 3/14/17, revealed the resident had an ADL (Activities of Daily Living) self-care deficit related to confusion, behaviors, a history of a TIA, and decreased ability to provide own self care. The interventions included a pressure reduction mattress on the bed pressure reduction cushion in the wheel chair. The care plan directed staff the resident had leg weakness and needed 2 staff to help with toileting, transfers, and walking. The resident's care plan lacked documentation the resident had a moderate risk for pressure sore development and lacked interventions related to positioning changes to reduce pressure. The care plan lacked documentation the resident had urine incontinence and direction to provide any type of preventative skin care. A hospital laboratory report dated 8/10/16 documented the resident had a blood Total Protein level of 7.6 (normal range 6.4 to 8.2) and an [MEDICATION NAME] blood level of 3.0 (normal range 3.4 to 5.0). A Dietary Full Review Assessment, dated electronically on 8/17/16 by the Consultant Dietitian, revealed the resident received a regular diet, the resident confused, without vitamin and mineral supplements, had an [MEDICATION NAME] level of 3.0, free of open areas, intakes at 50%, had a risk for weight loss due to dementia, and had no referral needs. A Dietary Quarterly Review, dated electronically on 9/9/16 by the Consultant Dietitian, revealed the resident's oral food intake 76 to 100% of estimated needs, fluids oral intake 1,500 to 2,000 cc (cubic centimeters) daily, the resident fed self, dined in the HUB (area by nurse's station) at times due to yelling and agitation, intakes 50%, had a significant weight gain of 13# in the previous month, had swelling due to [MEDICAL CONDITION], staff planned to notify the physician, without pressure sores, and no dietary changes documented. An Altered Skin Integrity Notification to the physician, dated 10/26/16, and signed by the physician 10/27/16, revealed the resident had a Stage II pressure wound on the coccyx and directed staff to apply a Matrix wound dressing to the coccyx area every 3 days and when needed until resolved and cover the Matrix with a transparent dressing. The Pressure Ulcer Wound Sheets, completed by the facility skin nurse identified the following: On 10/27/16, the Stage II mid gluteal cleft pressure ulcer was acquired in the facility. The open area measured 1.5 cm by 0.7 cm by 0.3 cm, had no undermining or drainage, 80% slouch, the surrounding skin appeared normal, and the resident had pain. The treatment included cleaning the areas with normal saline, pat dry, apply Matrix dressing, and cover with a transparent dressing every 3 days and when needed. The treatment included a cushion (pressure relief) in the wheel chair. On 11/1/16, the pressure ulcer remained the same, had no slough, and the treatment unchanged. On 11/8/16, the ulcer measured 1.4 cm by 0.7 cm by 0.3 cm, had a scant amount of serous drainage, 20 % granulation present, the surrounding skin normal, the resident had pain, and the treatment remained the same, except documented the Matrix moistened. On 11/15/16, the ulcer measured 1.5 cm by 0.7 cm by 1.0 cm, without undermining, no drainage, 10% granulation, 20% slough, 20% necrotic, surrounding skin normal, pain present, the treatment remained unchanged from 11/8/16 and the resident used a pressure relieving mattress and wheel chair cushion. On 11/22/16, the ulcer measured 2.0 cm by 1.0 cm by 1.2 cm, without drainage, 60% slough, surrounding skin normal, and pain present. A treatment note revealed staff planned to notify the physician and change the transparent dressing to cover the Matrix to a Duoderm Thin cover. The note documented staff encouraged the resident to go to bed to sleep, but the resident refuses and becomes agitated at times. The resident used a wheel chair and recliner cushion (pressure relief). A Physician Notification sheet dated 11/23/16 and signed by the physician 11/29/16 directed staff to packed the wound with moistened [MEDICATION NAME], apply skin prep to the surrounding area, and apply Duoderm Thin every 3 days and when needed. On 11/29/16, the ulcer measured 2.3 cm by 1.0 cm by 1.2 cm without drainage, 25% slough, surrounding skin normal, pain present, and Duoderm Thin used to cover the Matrix. The resident continued to use a cushion in the wheel chair and recliner. On 12/6/16, the ulcer measured 1.4 cm by 1.1 cm by 1.2 cm, without drainage, 30% granulation, surrounding skin normal, pain present, and continued to use the cushion in the wheel chair and recliner. The skin nurse documented the area slightly smaller and stated the resident needed to use the bathroom. Observation on 12/6/16 at 10:25 a.m., revealed Staff B, CNA (Certified Nurse's Aide) assisted the resident to pivot/transfer to the toilet. The resident sat on the toilet until 10:45 a.m. Staff B assisted with personal care and had the resident pivot/transfer back to the wheel chair. The wheel chair seat had a pressure relief cushion. Observation on 12/6/16 at 1:05 p.m. revealed the resident in bed positioned on the left side with a wedge cushion behind the back. During an observation on 12/6/16 at 1:10 p.m., Staff F, facility Skin Nurse, changed the resident's dressing with Staff D, RN (Registered Nurse), and the Assistant Director of Nursing (ADON) assisting. The resident remained in bed on the left side and cooperated well with the dressing change. Observation revealed the pressure ulcer was located approximately 1 to 1 1/4 inches above the rectal opening in the gluteal fold. Staff F stated the wound measured 1.4 cm by 1.1 cm by 1.2 cm. The wound base appeared pink red color and clean. Staff F cleaned the wound with normal saline, inserted [MEDICATION NAME], and applied Duoderm Thin. Staff K stated Matrix was a generic name for [MEDICATION NAME]/collagen products. The resident remained in bed on the left side following the treatment. Staff K stated the resident cooperated with the treatment better than usual. During an observation 12/6/16 at 3:30 p.m., the resident sat in a wheel chair in the hub area near the nurse's station. During an observation 12/7/16 at 6:40 a.m., the resident lay in bed on his/her back. A wedge cushion was located on the right side of the bed. During an observation 12/7/16 at 7:15 a.m., the resident sat in a wheel chair and staff pushed the resident to the dining room. During an interview 12/6/16 at 4:00 p.m., the DON verified she noticed that morning that the resident's care plan had not been updated until that morning to reflect the resident had a Stage II pressure ulcer as of 10/27/16. The ADON stated the Consultant Dietitian aware the resident had a pressure ulcer. The MDS nurse stated no additional interventions added to the care plan after the pressure ulcer developed on 10/27/16 because the resident already had a pressure reduction mattress on the bed and pressure reduction cushion in the wheel chair. The MDS nurse stated the lipped mattress added to the resident's bed after the resident had a fall on 9/2/16. The DON stated the lipped mattress also a pressure reduction mattress. During the same interview on 12/6/26 at 4:00 p.m., the ADON stated the CNA's used a care sheet posted in the resident's room for a care plan. The undated sheet obtained from the resident's room documented the resident repositioned self in bed, the resident had assistance with positioning self in bed, and the resident had a standard pressure relief mattress in bed. The sheet had no directions to staff for position changes and box checked no for an air mattress on the bed. The care plan with a revision date of 12/6/16, revealed the resident had a Stage II pressure sore on the mid coccyx area related to spending extended periods of time in a wheel chair, incontinence, and needed assistance with mobility. The care plan interventions included to treat the wound, assess the wound at least weekly and report findings to the physician, if the resident refused treatment discuss methods to improve compliance, monitor nutritional status, laboratory work as needed, and treat pain when needed. A Consultant Dietitian Progress Notes, dated 12/6/16 at 11:12 a.m., documented the resident had a weight loss of 1# the previous month and a gain of 8# during the previous 3 months. The note documented the resident had a Stage 2 coccyx treatment, the resident ate 50 to 75% of food, drank 1650 cc of fluids, and the resident's intakes borderline to meet estimated needs. The dietitian recommended the facility contact the physician to begin a Stress Vitamin with Zinc and protein supplements that included Marginalia daily and 60 cc of House Supplement twice daily. During an interview 12/7/16 at 7:45 a.m., the DON stated she had been at the facility a little over 2 weeks. She hoped to obtain a contract with a wound nurse to see residents at the facility. The DON planned to begin weekly meetings for skin issues and involve the Consultant Dietitian. During an interview 12/7/16 at 8:45 a.m., the facility Certified Occupational Therapy Assistant (COTA) stated the resident had 2 Roho pressure relief cushions obtained at the time the pressure sore developed, one for the wheel chair and one for the recliner the resident sat in by the nurse's station. The COTA lifted an incontinence pad located on top of the Roho cushion in the recliner and directed the Director of Nursing (DON) to keep the incontinence pad off the Roho cushion for improved pressure relief. During an observation 12/7/16 at 9:45 a.m., the resident sat in the wheel chair in room. During an observation at 10:15 a.m., the resident sat in the wheel chair in the hub area by the nurse's station. During an observation at 12:20 p.m., Staff C pushed the resident to the dining room for lunch after the resident toileted. During an interview 12/7/16 at 12:47 p.m., the DON stated the resident had not been to bed that morning for pressure relief. At 1:00 p.m., the DON stated the resident had not gone to bed during the morning today. During an interview on 12/7/16 at 1:50 p.m., Staff F stated the resident's wound covering had been changed to a transparent dressing to Duoderm Thin because the transparent dressing had not always stayed in place and had been missing at times. Staff F stated the resident had refused to lay down for the treatment at times, but she had always been able to complete the treatment when due. Staff F stated staff had encouraged the resident to go to bed during the day for pressure relief, but the resident had refuses at times. Staff F believed the resident had gone to bed for a while that morning. At 2:10 p.m., Staff F verified the resident had not gone to bed that morning. During an interview 12/8/16 at 9:30 a.m., the MDS nurse stated she was unaware of when the Consultant Dietitian became aware of the resident's pressure Ulcer and verified the dietitian had not addressed the pressure sore until 12/6/16. 2. 2. Resident #2's 8/20/16 Admission Assessment documented the resident had a 3 centimeter (cm.) red pressure area on the mid spine; a 5 cm. bright red raw area on the right buttock and an unmeasured pink raw area on the left buttock. The assessment documented the resident had a pressure reducing mattress to the bed and a pressure reducing cushion to the chair. Resident #2's 11/23/16 Minimum Data Set (MDS) documented the resident required extensive assistance of 2 staff for bed mobility and transfers. The resident did not ambulate. The MDS documented the resident had [DIAGNOSES REDACTED]. The resident had limitations in functional range of motion in one arm and one leg. The resident's 11/23/16 Pressure Ulcer Risk Assessment documented the resident at moderate risk for development of pressure ulcers. During interview on 12/6/16 at 2:06 p.m. Staff F, Registered Nurse stated no Pressure Sore Risk Assessment had been done prior to 11/23/16. She stated they usually did the assessments on admission and quarterly. During observation on 12/6/16 at 10:17 a.m. the resident's bed had no pressure relieving device present. At 12:21 p.m. the resident sat in the recliner eating lunch with a Roho (pressure relieving) cushion in the seat of the chair. The resident had no pressure relieving device to the back of the chair. At 12:21 p.m. an alternating pressure mattress had been applied. During interview on 12/6/16 at 12:31 p.m. the Director of Nursing confirmed the resident's bed had previously had a standard mattress in place. At 12:37 p.m. Staff F brought a receipt which showed the pressure relieving Roho seat cushion had been ordered on [DATE]. She stated the resident had no pressure relieving cushion in the chair prior to the Roho. She confirmed the chair had no pressure relieving device present for the resident's spine and stated the resident often slept in the recliner. During observation on 12/5/16 at 1:22 p.m. the resident slept in the recliner with the backrest reclined and the footrest elevated. During observation on 12/6/16 at 9:04 a.m. the resident slept in the recliner with the backrest reclined and the footrest elevated. During observation on 12/7/16 at 10:17 a.m. the resident slept in the recliner with the backrest reclined and the footrest elevated. During observation on 12/6/16 at 1:19 p.m. Staff C and Staff G, CNA's assisted the resident with toileting and incontinence care. When that had been completed they stood the resident so Staff F, Registered Nurse could change the protective dressing on the resident's spine. When she removed the dressing the resident had an open area 1.5 by 1.2 cm. buy .1 cm. deep. Staff F stated the area had not been open before, only red. The resident's Pressure Ulcer Wound Sheet documented on 8/20/16, the resident's admitted , staff measured a Stage II (open) pressure ulcer on the right buttock which measured 5 cm. by 2.5 cm. and had no depth. The wound sheet documented date of onset as 6/10/16. During interview on 12/7/16 at 1:22 p.m. the Director of Nursing stated staff had documented that onset dated because the resident's spouse reported the ulcer had first been found on that date. On 8/20/16 staff documented the left buttock had a Stage 1 (reddened, but not opened) pressure ulcer which measured 4 cm. by 1.5 cm. with no depth. Staff documented the date of onset for the left buttock ulcer 8/3/16. On 8/23/16 staff documented the left buttock now open (Stage II) and measured 5 cm. by 2.5 cm. by 0.1 cm. deep. On Unit Weekly Skin Logs staff documented the pressure ulcers measured as follows: On 9/6/16 staff measured the right buttock ulcer 2.1 by 1.0 cm. The left buttock ulcer measured 2.1 by 1.3 cm. On 9/13/16 staff measured both ulcers larger. The right buttock ulcer measured 3.0 by 1.5 cm. and the left buttock ulcer measured 2.8 by 1.7 cm. On 9/20/16 staff measured the right buttock ulcer 2.5 by 1.3 cm. and the left buttock ulcer 2.5 by 1.7 cm. On 9/27/16 staff measured the right buttock ulcer 2.1 by 1.0 cm. and the left buttock ulcer 2.1 by 1.3 cm. On 10/4/16 staff documented both ulcers unmeasured. On 10/18/16 staff documented measurements of both ulcers significantly larger the previous week. They documented the right buttock ulcer now measured 5 by 2.2 cm. and 0.1 cm. deep. Staff documented the left buttock ulcer measured 6 cm by 4.2 cm. by 0.2 cm. The documentation lacked any measurements for the current week. On 10/25/16 staff measured the right buttock ulcer 4.8 by 2.2 cm with 0.1 cm. depth. They measured the left buttock ulcer 6 by 4 cm. and 0.2 cm. depth. On 11/1/16 staff measured the right buttock ulcer 4.5 by 2.2 cm with 0.1 cm. depth and the left buttock ulcer 5.4 by 3.9 cm with 0.2 cm. depth. On 11/8/16 staff documented the right buttock ulcer measured 4.5 by 2.2 cm. with 0.1 cm. depth. The left buttock ulcer measured 5.4 by 3.9 cm. with 0.2 cm. depth. On 11/15/16 staff measured the right buttock ulcer 3.0 by 1.5 cm. and the left buttock ulcer 3.5 by 2.4 cm. On 11/22/16 staff measured the right buttock ulcer 2.2 by 1.5 cm. and the left buttock ulcer 3.2 by 1.9 cm. On 11/29/16 staff measured the right buttock ulcer 1/6 by 1/3 cm. and the left buttock ulcer 2.4 by 1.4 cm. The resident's Care Plan revised on 11/23/16 stated the resident had pressure reduction devices on the bed and the chair for prevention of skin breakdown, but lacked any problem of related to risk for pressure ulcers. The Care Plan lacked any mention of actual pressure ulcers or directions to staff in regard to them.

Based on clinical record review, staff interviews and residents interviews, the facility staff failed to interact with residents in a manner that maintained the resident's dignity and respect for two (Resident #3 and Resident #5) of five residents reviewed in the standard sample. The facility reported a census of 45 residents. Findings included: 1. A quarterly MDS ( Minimum Data Set Assessment Tool ) dated 12/16/14 identified Resident # 3 with a BIMS (brief interview of decision making) score of 14 indicating intact cognitive function related to daily decision making skills. The MDS indicated the resident required extensive staff assistance for bed mobility, transfers, toileting, personal hygiene and bathing. The MD'S coded the resident used a wheelchair propelled by self and/or staff for mobility while up. The February 2015 physician order [REDACTED]. The resident's care plan with a goal date of 03/31/15 instructed staff that the resident at risk for self-care deficits related to weakness, pain and hand deformities. The care plan instructed staff that at times the resident would request to eat in his/her room when the arthritis in hands bothered him/her so would not be embarrassed by dropping food/silverware in the dining room. The care plan indicated the resident required the assistance of two staff, gaitbelt and pivot disc to ensure safe transfers. The care plan noted the resident had difficulty coping due to a history of depression due to the belief of not getting proper care or sufficient response from others for medical concerns, and perceived loss of control of events. The staff were instructed to provide medications as directed, assist the resident and family to identify strengths and positive coping skills, provide the resident time to talk, encourage to express feelings and to process concerns through social services. The care plan noted the resident to be at risk for increased pain related to physical disability, chronic pain and arthritis. The staff were instructed to administer medication as physician ordered, monitor and record medication effectiveness, report pain to the nurse as needed. On 02/02/15 a concern had been received by the Department of Inspections and Appeals that a facility staff nurse had been notified by Resident #3 that another staff nurse (Staff A, RN) had grabbed the resident out of bed and forced him/her into a wheelchair and into the dining room for a meal after the resident had asked to stay in bed related to having increased arthritic pain. The incident had occurred on 12/18/14. On 02/16/15 at 12:55 p.m. Resident #3 stated he/she had been having increased pain in his/her hands and fingers due to the cold weather. The resident stated that in December before Christmas he/she had asked Staff C, certified nursing assistant if he/she could stay in bed and have the meal in the bedroom. The resident stated Staff C said she would have to check with the charge nurse. The resident stated that Staff C returned to the room with Staff A, RN. Staff A informed the resident they had to get up and go to the dining room. The resident stated he/she told Staff A that he/she did not feel well, had increased pain, but Staff A would not listen to what he/she had been telling her. The resident stated she "grabbed my legs and pulled them to the side of the bed, then grabbed my arm and pulled me up, then Staff C came over and helped her stand me up". The resident stated she made me sit in the wheelchair and told Staff C to take me to the dining room. The resident stated "I told Staff A no, but she wouldn't listen", " I told her I was going to tell the director of nursing", she stated go ahead and just left the room. When asked if she and Staff A had any problems before, the resident stated "yes, she is always mean to me, she mocks me and says mean things". The resident stated Staff A is the only nurse that makes the resident go to the dining room when he/she doesn't feel well and has told him/her that they don't have the choice. The resident stated Staff A will take him/her to the dining room to await meals when there is no one else in the dining room. The resident noted that Staff A would not give him/her their medication at the correct time. The resident stated he/she is supposed to get his/her stomach medicine one hour prior to a meal but Staff A waits until right before the food is served. The resident stated that "no one else had treated me this bad, it makes me cry". Resident #3 stated that no other staff are disrespectful to him/her. On 02/16/15 at 4:45 p.m. Resident #3 stopped the surveyor in the dining room and thanked the surveyor for listening to his/her concerns. The resident stated that he/she feels the facility staff does not take the concerns about Staff A seriously. On 02/17/15 at 2:55 p.m. Staff G, LPN stated that there had been a conflict between Staff A, RN and Resident #3 for several months. Staff G stated that at first she believed Staff A when she had been telling new staff that Resident #3 made up stuff about staff trying to get them in trouble, especially Staff A. Staff G stated that she began to pay more attention to interactions between the two and noticed that Staff A would make comments to Resident #3 that appeared to agitate the resident. When asked if she had witnessed any physical altercations between the two, Staff G stated that right before Christmas, Resident #3 had been sitting in the dining room before lunch working on a crossword puzzle. The resident began to propel self out of the dining room when Staff A asked him/her where they were going. Resident #3 replied their back hurt and was going back his/her bedroom. Staff G stated that Staff A grabbed the wheelchair, turned it back to the dining room telling the resident that he/she needed to stay in the dining room for the meal. Staff G stated the resident holding onto the wheelchair wheels, kept saying " no, no, I want to go back to my room, my back hurts" but Staff A would not listen to the resident. Staff G stated she finally said, why don't you just let him/her go back to the bedroom, he/she can eat in the room, then Staff A finally let the resident go. Staff G stated that on another occasion during the medication pass Staff A told Resident #3 to "shut-up" because he/she felt his/her medication had not been given at the correct time. Staff G stated that there had been several incidents like this. When asked if she had spoken to anyone in administration about these incidents, she stated she had told the director of nursing. Staff G stated that the nursing assignment were changed around for awhile. Staff G stated she the whole conflict needed to be resolved and it is up to the nurse to let it go, not the resident because the residents live here. On 02/18/15 at 2:05 p.m. Staff C, CNA stated on the day of the incident, Resident #3 had told her that he/she had been having a lot of pain because of the weather and wanted to stay in bed. Staff C stated the resident had been up earlier in the day but had laid down after breakfast. Staff C stated she told the resident she would go talk to the charge nurse. Staff C stated when she told Staff A about the resident wanting to stay in bed, she replied "No, he/she needs to get up. " Staff C stated Staff A went to the resident's room and told the resident he/she needed to get up. Staff C stated the resident said he/she was in pain and wanted to stay in bed. Staff C stated Staff A reached down and pulled the resident's legs off the side of the bed and let them drop to the side of the bed, then reached down grabbed the resident's arm below the shoulder and started to pull him/her up. Staff C stated the resident started to cry and told Staff A he/she was going to tell the DON and she was so mean. Staff C stated she went to grab her gaitbelt to put around the resident's waist but Staff A told her just grab the other arm and help me get him/her up. (The resident had been care planned for a two person transfer utilizing a gait belt and pivot disc for safety). Staff C stated she hooked her hand under the resident's left arm and helped him/her up on the pivot disc and into the wheelchair. Staff C stated that Staff A told her to get the resident dressed and take the resident to the dining room. Staff C stated the resident had been pretty upset about the incident. When asked how often Resident #3 wanted to stay in his/her room, Staff C stated not very often, that is had been pretty cold out that day and the resident seemed to have increased pain. Staff C stated she had not seen that kind of interaction between Staff A and Resident #3 before, and Resident #3 had not complained to her about Staff A but she did think that Staff A had been too rough and had not been speaking very nicely to the resident. Staff C stated she did not think the incident had been abusive but felt the nurse acted against the resident's wishes. Staff C stated she apologized to the resident about the incident and the resident told her it was not her fault. On 02/23/15 at 2:10 p.m. Staff K, LPN stated she had worked with Staff A, RN quite a bit. When asked if she had witnessed any nurses not giving pain medications when requested, stated not pain medication but had witnessed Staff A not giving Resident #3 a medication when he/she was supposed to have it. Staff K stated Resident #3 had been scheduled [MEDICATION NAME] to be given one hour prior to meals. Staff K stated this happened many times, especially if Resident #3 asked for it. She felt that Staff A withheld the medication on purpose to upset Resident #3. Staff K stated she felt Staff A just did not like Resident #3, stating she felt Resident #3 irritated Staff A, so she would blow the resident off. Staff K stated she had witnessed Staff A be verbally abuse to the resident, told the resident to shut up occasionally, and on one occasion when Resident #3 was talking at the nurses desk, Staff A looked at her and said "yap, yap. yap" to her, interrupting the resident. Staff K stated the resident finally left and went to his/her room. When asked if she had reported Staff A's behaviors, Staff K stated that every one knew that Staff A was in charge and none of the other staff would cross her because she would have made all their lives difficult. 2. A quarterly MDS ( Minimum Data Set Assessment Tool ) dated 02/11/15 identified Resident # 5 with a BIMS (brief interview of decision making) score of 15 indicating intact cognitive function related to daily decision making skills. The MDS indicated the resident to be independent for bed mobility, transfers, toileting, personal hygiene and bathing. The MDS indicated the resident's [DIAGNOSES REDACTED]. The resident's care plan with a goal date of 05/06/15 instructed staff that the resident independent in environment but may need reminders if forget walker, but may use quad cane in his/her room instead of the walker. The care plan indicated the resident to be a risk for pain related to a [DIAGNOSES REDACTED]. The February 2015 physician order [REDACTED]. On 02/13/15 a physician notification indicated the resident had increased back pain and requested an order to increase the [MEDICATION NAME] to two times a day and every four hours as needed, physician agreed to request. On 02/13/15 the staff notified the physician the resident complained of back pain increasing and trauma not controlling the discomfort with a level of 8 on a 1/10 scale. The physician ordered [MEDICATION NAME] 25 microgram and to replace every 72 hours. On 02/19/15 the facility administrator documented: at approximately 3:30 p.m. Resident #5 approached a staff member and made an allegation of abuse against Staff A, RN. The resident informed the administrator and social worker that he/ she didn't want to say anything, not wanting to shake the tree, stating that Staff A was about one thing, power and control. The administrator documented when asking for an example the resident stated when he/she asked for pain medication, and how often, was told every four hours. When he/she asked Staff A for the as needed medication after 4 hours she would tell him/her it was four to six hours. The resident stated he/she would ask Staff A for the medication she would tell him/her it would be in a little bit it would be two hours later before she brought the medication to the resident's room. When the social worker asked the resident if he/she remembered the last time this occurred, he stated it had been awhile because Staff A hadn't been there much, probably a few weeks, but then stated it happened about a week ago. The administrator asked the resident if he/she felt he had ever been physically, verbally or mentally abused by Staff A, the resident replied, "yeah, mentally because she keeps messing with my medication, she keeps medication out of my hands and fights about it. The resident stated he did not have problems with the other nurses, they've always been good about it. On 02/23/15 at 1:10 p.m. Staff H, Activity Director stated that Resident #5 had grabbed her arm and asked if Staff A, RN was working today (02/19/15), then asked if she would be there the following day, again she stated no. Staff H stated that Resident #5 asked if she could come to his room. When they got to the resident's room, he/she stated that he had been lying to a lot of people including the social worker. Staff H stated that the resident told her that the social worker had asked his/her if questions that he had not answered truthfully. Staff H stated the resident told her that he did not think that Staff A, RN was not a good person and should not be working with residents, and should be terminated. Staff H stated the resident became tearful and told her that Staff A had been messing with his pain medication and a lot of stuff. Staff H stated she did not ask for specifics and stated she would get the administrator and social worker to talk with him/her. Staff H stated the resident had been agreeable it that, she stated she went to another staff nurse and asked her to talk with the resident about his medication. On 02/23/15 at 1:40 p.m. Resident #5 stated that he/she had been at the facility for 7 months. The residents that he/she had chronic back pain for many years and had taken [MEDICATION NAME] to control the pain. The resident stated when he first came to the facility he received the [MEDICATION NAME] twice a day and as needed but then "they" started to mess around with his medications and he/she did not feel like the pain was under control. The resident stated that when he/she asked Staff A for his pain medication, she would tell him/her that they could only get them every 4-6 hours. The resident stated that the other nurses told him/her every 4 hours. The resident stated that on several occasions he had asked Staff A for a as needed pain pill and she would tell the resident to go to his/her room and would bring it to the room, but then would make the resident wait 1-2 hours. The resident stated that he felt Staff A was just about power and control and did not want anyone else to be in charge, it was always her way, and she thought she was always right. The resident stated he/she was getting ready to find another facility and move because didn't want to have to go through a struggle everytime he/she needed pain medication. The resident stated he/she had recently been given a new pain medication, a patch that is helping to keep the pain under control but still requires an as needed pain pill occasionally. On 02/23/15 at 2:10 p.m. Staff K, LPN stated she had not witnessed Staff A refuse pain medication for Resident #5, but stated the resident told me that she had not given the resident pain medication when he/she had asked for it. Staff K stated she had processed the order received for the [MEDICATION NAME] 50 mg BID (two time a day) and every 4 hours as needed. Staff K stated she did not understand why Staff A placed the medication times mid-day and evening. Staff K stated the normal BID times are 8 a.m. and 8 p.m. Staff K stated when she came back to work after her weekend, she did change the times to the normal BID schedule. On 02/13/15 at 12:00 noon the facility social worker stated on 02/19/15 at around 3:30 p.m. the activity director came to he and told her Resident #5 had come to her with a concern regarding Staff A, RN. The activity director stated the resident felt that Staff A had been rude, controlling and on a power struggle. The social worker stated before she and the administrator went to talk with the resident regarding the concerns she looked at the medications the resident had been on. The social worker stated the resident had been receiving [MEDICATION NAME] 50 mg BID and then every four hours PRN (as needed). The resident had also recently been started on a [MEDICATION NAME]. When they went in to talk with the resident he/she repeated to them that felt Staff A was all about power and control, but didn't want to get anyone in trouble, making mountains out of molehills. The resident stated he had not been truthful with us regarding Staff A because he didn't want to get the facility in trouble. The social worker stated the resident had a tearful affect, seemed tense and it was clearly difficult for the resident to talk about the concerns. The social worker stated the resident voiced a concern that Staff A had been messing around with his/her pain medications and she would not talk to him/her about the changes. Resident #5 stated that he/she know that should have been able to get the pain meds every 4 hours and not the 4-6 that Staff A told him/her. The resident stated that Staff A would make him/her wait for the pain meds sometimes up to 2 hours after they were asked for. On 02/23/15 at 2:55 p.m. Staff G, LPN stated that when on duty a couple of weeks ago Resident #5 complained of increased back pain despite having [MEDICATION NAME] on a regular basis. Staff G stated the resident told her he/she did not think he/she was getting the [MEDICATION NAME] as needed to keep the pain under control. Staff G stated that Staff K had started the paperwork to get the resident a different medication and requested a [MEDICATION NAME] (a narcotic pain medication) for the resident to use with the [MEDICATION NAME] scheduled and as needed doses. Staff G stated she had been at the nurse ' s desk on 02/13/15 about 9:45 a.m. when Resident #5 came up the hallway moaning. She stated the resident stopped at the desk and asked Staff A for a pain pill. Staff G stated Staff A told the resident he/she would be getting the medication at 12:00 noon. She stated the resident then asked, you mean I can't get the one on demand anymore, and Staff A told the resident if he/she got the pill at that time, could not have the noon one. Staff G stated she told Staff A to check the as needed order. Staff A then told the resident that she would bring the medication to him. Staff G stated she looked at the Medication Administration Record [REDACTED].

Based on clinical record review, observations and staff and family interviews the facility failed to plan for and implement services to ensure residents received adequate supervision from hazards for three (3) of twelve (12) residents reviewed (Resident #1, #4 and # 11). The facility failed to ensure interventions determined to keep resident's safe were implemented. The facility reported a census of 56 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no cognitive impairments and had [DIAGNOSES REDACTED]. The assessment identified Resident #1 required extensive assistance from one staff to provide weight-bearing support during transfers, when dressing or toileting the resident. The MDS revealed Resident #1 required extensive assistance from staff when he/she ambulated in his/her room or when walking in the corridor. The resident used a walker and wheelchair for locomotion, and the assessment documented the resident had no history of falls. The resident ' s balance during transition and walking identified he/she as not steady, only able to stabilize with human assistance when moving from seated to standing position, when walking, when turning around, when moving on and off toiled and during surface to surface transfers. The MDS revealed the resident on a scheduled pain medication regimen, however he/she did not receive as needed (PRN) pain medication. The Care Plan dated 3/27/12 identified the resident had potential for falls related to diminished independent mobility and directed staff to encourage resident to ask for assistance, assist with ambulating, transferring, toileting and have call light within reach. The physician's orders [REDACTED]. A Fall Risk assessment dated [DATE] revealed Resident #1 scored 12 (scores of 10 or above represented a high risk for falls). The assessment indicated Resident #1 had balance problems when standing, walking, and had decreased muscular coordination. The Nurse's Notes dated 06/14/2012 documented at 5:55 p.m., the nurse observed Resident #1 on the floor complaining of severe low back pain and a left elbow skin abrasion with swelling present. The resident transferred to the emergency room and admitted to the hospital. The resident fell backwards from a standing position two steps outside bathroom door. The Fall Report dated 06/14/2012 at 5:55 p.m. indicated a CNA (Certified Nurse's Aide) toileted a resident with a gait belt on. The resident got off the toilet with a walker, the CNA got the wheel chair and the resident lost balance, falling backwards landing on head and back two steps outside of the bathroom door. The resident complained of severe mid and lower back pain. With movement of left leg the resident's pain worsened. Interventions put in place: Staff talked to, never let go of gait belt, get more help if needed. The Skin Report documented the resident sustained [REDACTED]. Radiological exams dated 06/14/2012 included Resident #1 had mild compression deformities at T (Thoracic) 3, 5, 6, 7, 8, and 9, and extensive soft tissue swelling of the left elbow, an underlying fracture of the olecranon process cannot be entirely excluded. The History and Physical dated 6/14/12 identified Resident #1 had been admitted to the hospital due to his/her significant pain and inability to move after falling backwards landing on his/her back and hitting his/her head. The report indicated the Thoracic spine showed compression deformity of T3, T5 T6, T7 T8 and T9; however the hospital was unable to determine whether these were all old or new injuries. The resident required pain medication (Fentanyl) to treat his/her pain needs. The resident ADL (Activities of Daily Living) sheet revealed Resident #1 transferred with the assistance of one staff, and staff should stay behind resident during transfers. During an interview on 06/27/2012 at 1:35 p.m., Staff J reported on 06/14/2012, he/she assisted Resident #4 to the bathroom. Staff J indicated the wheel chair sat outside the bathroom door. Staff J assisted the resident from the toilet to the wheelchair with a gait belt and walker. Staff J reported he/she let go of the gait belt for 2-3 seconds to grab the wheelchair so the resident could sit. The resident fell backwards when Staff J let go of the gait belt. Staff J revealed the facility covered gait belt use in orientation and monthly staff in-services and he/she knew to hold onto it. The set sheet or ADL directs staff how to transfer residents and all staff carry it with them at all times. Resident #1 required the assistance of one staff and a gait belt to transfer and ambulate. During an interview on 07/02/2012 at 10:20 p.m. Resident #1's family member reported the resident remained in the hospital recovering from compression vertebrae fracture injuries sustained in the fall. The resident indicated staff did not have a hold of the gait belt and he/she fell backwards into the bathroom. 2. According to the MDS dated [DATE], Resident #4 had no cognitive impairment, transferred and ambulated with limited assistance of one staff, no falls, and had [DIAGNOSES REDACTED]. The Care Plan identified Resident #4 had a risk for falls related to reconditioning, vision problems and a history of falls, initiated 04/12/2012. The Care Plan directed staff to anticipate and meet the resident's needs, ensure the resident wore appropriate footwear, remind to ask for assistance and place pad alarms in the bed and chair, check placement every shift and replace batteries monthly. The TAR (Treatment Administration Record) revealed staff signed every shift, daily during the month of June, 2012 that they checked the pressure alarm bed and chair, and replaced batteries on June 22. The Nurse's Notes dated 05/02/2012 at 12:50 a.m., documented staff walked into the resident's room during rounds and found the resident sitting on the floor beside the bed stating he/she needed to go to the bathroom. Pressure alarm on bed connected, but not hooked up, and not on safety checks log; added at this time. The Fall Investigation/Follow Up dated 05/02/2012 included new interventions/safety measures that were put into place: remind resident to ask for assistance, educate nurse/staff on alarms and update sheets to reflect these. Pressure alarms put on. The Injury/Incident Report dated 05/02/2012 included the resident got up unassisted, the pressure alarm not activated (plugged in) or on safety device check sheets (TARS). Observation on 06/26/2012 at 3:45 p.m. revealed Resident #4 seated in his/her recliner with call light and front wheeled walker nearby, and a pressure pad alarm in the chair but not connected to the alarm box placed on the tray table. The DON (Director of Nursing) connected the pad alarm to the box. At 4:00 p.m. the DON reported changing the box to a self activating box, therefore sounding if someone removed the cord. Observation on 07/02/2012 at 2:15 p.m. revealed Resident #4 seated in a chair near the nurse's station with a front wheeled walker nearby. The resident had no pressure pad alarm present. The DON indicated staff failed to place the pressure pad alarm on the resident's chair. 3. The MDS dated [DATE] revealed Resident #11 had no cognitive impairment, required total dependence on two staff to transfer between surfaces, and had [DIAGNOSES REDACTED]. The Care Plan documented Resident #11 had an ADL self care deficit and directed staff to transfer the resident with total assistance using a Hoyer lift. Observation on 06/27/2012 at 11:45 a.m. revealed Staff A, CNA and Staff L, CNA transfer Resident #11 from the bed to wheel chair with the use of a mechanical lift and a blue with green trim sling that appeared too small for the resident. Staff weighed the resident during the transfer at 337 pounds. During an interview at 12:00 p.m. the DON reported staff used the wrong sling during the transfer. The blue with green trim sling required the resident's weight be 175 - 285 pounds. Staff should have used the blue with royal blue trim for residents weighing between 265 - 500 pounds. The DON reported he/she placed a sign on every mechanical lift that identified the appropriate sling for each weight. Observation on 07/02/2012 at 2:00 p.m. revealed two staff transfer Resident #11 with the appropriate blue with royal blue trim. During an interview on 07/02/2012 at 1:47 p.m., Staff A reported using the incorrect sling to transfer Resident #11 on 06/27/2012. Staff A took the blue and green sling from the resident's recliner, where it lay on top of two other slings. Staff A said he/she just grabbed it, and knew better. During an interview on 06/27/2012 at 4:00 p.m., the DON reported staff knew how to transfer each resident as instructed on the "set sheet", or the ADL sheet. Staff signs off on it at the end of every shift. Physical therapy determines how each resident transfers. The new staff are given a gait belt policy and the facility recently added direction to "hold onto it" at all times. The QA began doing audits in June, and will be doing transfer audits weekly. In March, 2012, during a staff in-service, physical therapy demonstrated resident transfers. The DON reported discussing safe transfers during each staff in-service, and planned to do a skills lab this year. During an interview on 07/02/2012 at 10:35 a.m., the Administrator reported the facility had no orientation checklist for new hires to complete. The new staff worked with other staff for 3-5 shifts. The facility began doing performance evaluations the past couple of months, prior to that, they were not completed.