Every finding on record at Via Christi Village Hays KS LLC

Based on record review, observation, and interview, the facility failed to provide urinary catheter care based on current standards of practice for Resident (R) 1 when the facility failed to unclamp the resident's catheter for approximately 8 hours, which caused the resident pain and discomfort. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), overactive bladder, Stage 4 chronic kidney disease (a disease causing severe kidney damage and waste builds up in the blood), and obstructive and reflux uropathy (a blockage that stops urine flowing normally through the urinary tract causing the backflow of urine from the bladder into the kidneys). R1's Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented he had impairment on both sides of his lower extremities and required a manual wheelchair. The MDS documented R1 required substantial staff assistance to total dependence on staff for his activities of daily living (ADLs), except for eating and oral care. The MDS documented R1 had an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and was frequently incontinent of bowel. The MDS documented R1 had a urinary tract infection (UTI-an infection in any part of the urinary system) within the last 30 days. The Functional Abilities Care Area Assessment (CAA), dated 07/02/2026, documented R1 required assistance for ADLs due to a decreased ability to care for himself. The Urinary Incontinence/Indwelling Catheter CAA, dated 07/02/2026, documented R1 had an indwelling urinary catheter due to neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and obstructive uropathy, and R1 was at risk for UTIs. The Pain CAA, dated 07/02/2026, documented R1 had chronic pain and was at risk for ineffective pain relief. R1's Care Plan, initiated 07/21/2026, documented R1 had an indwelling urinary catheter. The care plan documented R1 would be free from catheter-related trauma through the review date. The care plan directed staff to anchor the catheter tubing to prevent injury, provide catheter care every shift and as needed, keep the catheter bag positioned below R1's bladder, check the catheter tubing for kinks each shift, and monitor R1 for pain related to the catheter. R1's August 2026 Treatment Administration Record (TAR) documented an order with a start date of 05/22/2026 for gentamicin sulfate (antibiotic) solution. The order directed staff to insert 60 milliliters (ml) via catheter tubing into the urethra (small tubular structure that drains urine from the bladder) every day shift on Tuesdays and Fridays for UTI. The medication would be administered while R1 was in bed, prior to getting up in the morning. Staff were to clamp catheter tubing for 15 minutes, then unclamp. The Nurse's Note, dated 08/05/2026, documented R1's wife voiced concerns at 08:15 AM about R1 not having his call light or water, and having pain in his groin. R1's wife reported when R1 was transferred back to his bed his catheter tubing was found to be clamped, and once unclamped a large amount of urine drained into the catheter bag. Administrative Nurse E was notified of the complaint. The Family Grievance Form, dated 08/05/2026, documented R1's wife stated when she arrived in R1's room at 06:00 PM on 08/04/2026, R1's call light was clipped to the wall, and his table with his water was out of reach. R1's wife stated when R1 was laid down in bed, his catheter tubing was clipped, and he was feeling a lot of pain in his abdomen. R1's wife stated when she unclipped the catheter tubing, R1 had 1000 ml of urine output. The investigation revealed R1's catheter was clamped following a catheter flush for approximately six hours. R1 reported lower abdominal pressure. Upon assessment, the clamp was immediately removed, resulting in the drainage of 1000 ml of urine. R1 reported relief after the clamp was removed. On 08/17/2026 at 10:30 AM, observation revealed R1 sat in a wheelchair in his room. R1's catheter bag was hooked to the wheelchair with a privacy bag over it. R1 watched television. R1's call light was on the bed next to him. On 08/17/2026 at 10:30 AM, R1 stated he was in a lot of pain the day the nurse left his catheter tubing clamped. R1 stated he told staff he was in a lot of pain and no one did anything about it until his wife came in. On 08/17/2026 at 11:00 AM, Administrative Nurse D stated the nurse who forgot to remove the binder clip used to clamp off the catheter tubing did not accept that she had forgotten it, though the nurse was presented with the evidence. Administrative Nurse D stated it was simply human error that caused the incident to happen, but the catheter clamp should have been removed within 15 minutes per the physician's order. Administrative Nurse D said clamping the catheter tube was added to the TAR to help the nurses remember to remove the catheter clamp after the flush. The facility's Indwelling Catheter Use Policy, dated 11/26/2025, documented the facility will provide appropriate care for catheters in accordance with current professional standards of practice and resident care policies and procedures. The facility completed corrective actions, which included one-on-one education with the nurse who forgot and facility-wide urinary catheter care education and management, including verifying catheter tubing is free of kinks, clamps, and other obstructions during catheter assessment and at least every four hours with all nurses. The facility put in the TAR for nurses to take off the urinary clamp after irrigation twice a day. Urinary catheter audits were completed and are still ongoing to ensure catheter care and monitoring procedures are being followed. Corrective actions included and were completed by 08/05/26: Care plan updated to reflect catheter monitoring interventions. Treatment Administration Record (TAR) updated with a specific intervention reminding staff to remove the catheter clamp immediately following each catheter flush. One-on-one education completed with the involved nurse regarding proper catheter flushing procedures and the importance of immediately removing the clamp following irrigation. Facility-wide education provided to all licensed nursing staff regarding catheter management, including verifying that catheter tubing is free from kinks, clamps, and other obstructions during routine catheter assessments at least every four hours. Catheter audits completed three times per week for four weeks to verify catheter tubing remains patent, free from kinks or clamps, and that catheter care and monitoring procedures are being consistently followed. Audit results will be reviewed for compliance, with additional education provided as indicated. All corrective actions were completed prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance and remained at the scope and severity of a G (actual harm, isolated).

Based on record review, observation, and interview, the facility failed to provide restorative therapy services to ensure Resident (R) 3, R4, R5, R6, and R7 maintained or improved mobility with the maximum practicable capability. Findings included:1. R3's Electronic Medical Record (EMR) documented R3 had diagnoses of muscle weakness, difficulty walking, unsteadiness on feet, and abnormalities of gait and mobility.The Quarterly Minimum Data Set (MDS), dated 04/28/2026, documented R3 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated R3 had moderate cognitive impairment. The MDS documented R3 required staff supervision for most of his activities of daily living (ADLs). The MDS documented R3 had three days of restorative therapy in the seven-day look-back period.The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/11/2025, documented R3 had a diagnosis of dementia.The Functional Abilities CAA, dated 07/11/2025, was triggered in the MDS but did not have any information.R3's Care Plan dated 10/28/2025 documented R3 received restorative care to achieve the highest level of optimal functioning and directed staff to perform active range of motion to all R3's extremities using orange bands for 15-20 reps 4-6 times weekly and the NuStep (a recumbent cross-trainer designed for inclusive, low-impact, total body workout) 10-15 minutes a day 4-6 times a week.R3's EMR documented R3 had received two days of restorative therapy in the last 30 days.No opportunities for observations of restorative therapy existed over two consecutive days. 2.R4's EMR documented R4 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the right, dominant side, and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).The Quarterly MDS, dated 06/17/2026, documented R4 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS documented R4 had moderate to substantial assistance with some of her ADLs and was dependent on staff for other ADLs. The MDS documented R4 had three days of restorative therapy in the seven-day look-back period.The Cognitive Loss/Dementia CAA, dated 09/01/2025, documented R4 had orientation, memory, and recall deficits and was at risk for self-care deficits, falls, injury, and pain.The Functional Abilities CAA, dated 09/01/2025, documented R4 required assistance with her ADLs due to a cerebrovascular accident (CVA - a type of medical stroke), which resulted in weakness and decreased safety awareness.R4's Care Plan, dated 10/28/2025, documented R4 received restorative care to achieve her highest level of optimal functioning. The care plan directed staff to assist R4 with active range of motion to all extremities using the orange bands, 10-15 reps, 4-6 times weekly. F4's EMR documented R4 received 8 days of restorative therapy out of 30 days.No opportunities for observations of restorative therapy existed over two consecutive days. 3. R5's EMR documented R5 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).The Quarterly MDS, dated 07/07/2026, documented R5 had a BIMS of six, which indicated severely impaired cognition. The MDS documented R5 was independent with his ADLs. The MDS documented R5 received one day of restorative therapy in the seven-day look-back period.The Cognitive Loss/Dementia CAA, dated 03/30/2026, documented R5 had a BIMS score of less than 13 and had orientation, memory, and recall deficits. The CAA documented R5 was at risk for self-care deficits, falls, injuries, and weight loss.The Functional Abilities CAA, dated 03/30/2026, documented R5 required assistance with ADLs and had chronic conditions which resulted in a decreased ability to care for himself.The Care Plan, revised 10/28/2025, documented R5 received restorative care to achieve his highest level of optimal functioning. The care plan directed staff to assist R5 with range of motion to his bilateral upper extremities and bilateral lower extremities with 10-15 reps with the green band 4-6 times weekly, and the NuStep for 10-15 minutes 4-6 times weekly.R5's EMR documented R5 had received restorative therapy four times in the last thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. 4. R6's EMR documented diagnoses of dementia, psychotic disturbance, mood disturbance, and anxiety.The Quarterly MDS, dated 04/13/2026, documented R6 had a BIMS score of seven, which indicated severely impaired cognition. The MDS documented R6 required moderate to substantial staff assistance for all her ADLs. The MDS documented zero days of restorative therapy during the seven-day look-back period.The Cognitive Loss/Dementia CAA, dated 12/31/2025, documented R6 had a BIMS score of less than 13 and had orientation, memory, and recall deficits. The CAA documented R5 was at risk for self-care deficits, falls, injuries, and weight loss.The Functional Abilities CAA, dated 12/31/2025, documented R6 required assistance with ADLs and had a recent injury which affected her ability to take care of herself.The Care Plan dated 07/03/2025 lacked any intervention related to restorative therapy.R6's EMR documented R6 was to have restorative therapy 4-6 times weekly.The EMR documented R6 had participated in restorative therapy nine times in thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. 5. R7's EMR documented diagnoses of Parkinson's disease, anxiety, and hypertension.The Quarterly MDS, dated 05/28/2026, documented R7 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS documented R7 required substantial staff assistance with most ADLs. The MDS documented R7 had two days of restorative therapy out of the seven-day look-back period.The Functional Abilities CAA, dated 11/18/2025, documented R7 had a chronic condition which resulted in a decreased ability to care for herself and was at risk for further decline in ADLs, falls, and pain.R7's Care Plan dated 10/28/2025 documented R7 was to receive restorative therapy 4-6 times daily.The EMR documented R7 had received five days of restorative therapy out of thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. On 07/07/2026 at 09:15 AM, Administrative Nurse D stated the Certified Nursing Assistants (CNA) on each floor of the facility were responsible for completing restorative therapy with residents who were on restorative therapy, and if the day shift did not get to it then the evening shift would complete the tasks. On 07/08/2026 at 09:45 AM, CNA P stated there was not enough staff and not enough time in an eight-hour shift for the CNAs to complete restorative therapy with the residents. CNA P stated there used to be restorative aides, and that was helpful to get the restorative done with residents. On 07/08/2026 at 09:50 AM, CNA Q stated they did not have enough staff to get restorative therapies done during the day, especially on the heavier care halls. On 07/08/2026 at 12:00 PM, Licensed Nurse (LN) G stated there were not enough staff to get restorative done. On 07/08/2026 at 12:45 PM, LN H stated there was no way she could ensure CNAs were completing their tasks all the time, especially given how the facility was set up. As for evening shift staff completing restorative tasks that did not get done during the day shift, no way was that going to happen. The facility's undated Restorative Nursing Program Policy documented it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained in basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. The training may include but is not limited to: Maintaining proper body positioning, encouraging and assisting residents in turning and repositioning, encouraging residents to remain active and assist with any exercises according to the plan of care, promoting independence in ADLs (performing tasks for residents only as needed to ensure the completion of the tasks), assisting resident in adjustment to their disabilities and use of any assistive device, assisting residents with range of motion exercises, and promoting continence with various bladder and bowel training activities. All residents will receive maintenance services as described above, as needed, by certified nursing assistants.

Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing to ensure Resident (R) 3, R4, R5, R6, and R7 were provided with the restorative services designed to improve their abilities to the highest practicable level. (Refer to F688) Findings included:1. R3's Electronic Medical Record (EMR) R3 received restorative care to achieve the highest level of optimal functioning and directed staff to perform active range of motion to all R3's extremities using orange bands for 15-20 reps 4-6 times weekly and the NuStep (a recumbent cross-trainer designed for inclusive, low-impact, total body workout) 10-15 minutes a day 4-6 times a week.R3's EMR documented R3 had received two days of restorative therapy in the last 30 days.No opportunities for observations of restorative therapy existed over two consecutive days. 2.R4's EMR documented R4 received restorative care to achieve her highest level of optimal functioning. The care plan directed staff to assist R4 with active range of motion to all extremities using the orange bands, 10-15 reps, 4-6 times weekly.R4's EMR documented R4 received 8 days of restorative therapy out of 30 days.No opportunities for observations of restorative therapy existed over two consecutive days. 3. R5's EMR documented R5 received restorative care to achieve his highest level of optimal functioning. The care plan directed staff to assist R5 with range of motion to his bilateral upper extremities and bilateral lower extremities with 10-15 reps with the green band 4-6 times weekly, and the NuStep for 10-15 minutes 4-6 times weekly.R5's EMR documented R5 had received restorative therapy four times in the last thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. 4. R6's EMR documented R6 was to have restorative therapy 4-6 times weekly.The EMR documented R6 had participated in restorative therapy nine times in thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. 5. R7's EMR documented R7 was to receive restorative therapy 4-6 times daily.The EMR documented R7 had received five days of restorative therapy out of thirty days.No opportunities for observations of restorative therapy existed over two consecutive days. On 07/07/2026 at 09:15 AM, Administrative Nurse D stated the Certified Nursing Assistants (CNA) on each floor of the facility were responsible for completing restorative therapy with residents who were on restorative therapy, and if the day shift did not get to it then the evening shift would complete the tasks. On 07/08/2026 at 09:45 AM, CNA P stated there was not enough staff and not enough time in an eight-hour shift for the CNAs to complete restorative therapy with the residents. CNA P stated the CNAs did their best but could not always get it done. CNA P stated there used to be restorative aides, and that was helpful to get the restorative done with residents. On 07/08/2026 at 09:50 AM, CNA Q stated they did not have enough staff to get restorative therapies done during the day, especially on the heavier care halls. CNA Q stated the staff was lucky to get everything they did get done. CNA Q stated staff did the best they could for all the residents. On 07/08/2026 at 12:00 PM, Licensed Nurse (LN) G stated there were not enough staff to get restorative done. LN G stated activities expected nursing staff to get any activity done later in the afternoon with the residents, and that did not happen either. LN G stated there was no way she could ensure the CNAs were completing all their tasks with residents when she had two floors to care for. LN G stated there was no accountability for CNAs when the nurse was off the floor. On 07/08/2026 at 12:45 PM, LN H stated on her shifts, she always had at least two floors to take care of and sometimes had to take care of three floors, which could be up to 44 residents. LN H stated there was no way she could ensure CNAs were completing their tasks all the time, especially given how the facility was set up. As for evening shift staff completing restorative tasks that did not get done during the day shift, no way was that going to happen. LN G stated there were no activities on the evening shift unless a resident was independent and could do it on their own. The facility's undated Restorative Nursing Program Policy documented it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained in basic or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. The training may include but is not limited to: Maintaining proper body positioning, encouraging and assisting residents in turning and repositioning, encouraging residents to remain active and assist with any exercises according to the plan of care, promoting independence in ADLs (performing tasks for residents only as needed to ensure the completion of the tasks), assisting resident in adjustment to their disabilities and use of any assistive device, assisting residents with range of motion exercises, and promoting continence with various bladder and bowel training activities. All residents will receive maintenance services as described above, as needed, by certified nursing assistants.

Based on interviews and record review, the facility failed to implement the policy to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Findings included:- Review of Dietary Staff BB's personnel file recorded a hire date of 02/24/26. The file lacked evidence that an accurate background check was performed before Dietary Staff BB's employment began. The file indicated the facility became aware of a concern regarding Dietary Staff BB and performed another background check using the right name on 06/29/2026. The background check revealed Dietary Staff BB had been convicted of crimes against a person. Dietary Staff BB was terminated from employment. On 07/07/2026 at 10:00 AM, Administrative Staff A stated the human resources employee at the time of Dietary Staff BB's employment in February 2026 had spelled Dietary Staff BB's name wrong on the background check, and the background check came back clear. Administrative Staff A stated a new process had been implemented to complete the pre-employment background check process. Administrative Nurse D would complete all the background checks, and then Administrative Staff A would double-check the background checks. The facility's undated Employee Background Check Policy documented the facility is committed to maintaining high-quality care and service while protecting its residents from abuse, neglect, and exploitation. Conducting a thorough pre-hire background check of relevant individuals: individuals have not been found guilty of abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law; do not have a finding in the state nurse aide registry concerning abuse, neglect, exploitation, or mistreatment or misappropriation of property; and do not have a disciplinary action in effect taken against their professional license. Developing and implementing policies and procedures related to conducting the above pre-hire background checks.

Based on record review, observation, and interview, the facility failed to ensure Certified Nurse Aides (CNAs) had sufficient training to ensure Residents (R) 1 and R2 received quality care in accordance with standards of practice. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of muscular dystrophy (MD-group of inherited disorders that involve muscle weakness and loss of muscle tissue, and worsen over time), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with residual deficits, dizziness, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R1's Quarterly Minimum Data Set (MDS), dated 05/28/2026, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R1 had physical limitations of her bilateral upper and lower extremities that interfered with her activities of daily living (ADLs). The MDS documented R1 was dependent on staff for most of her ADLs. The Functional Abilities Care Area Assessment (CAA), dated 07/28/2025, documented R1 had a decreased ability to care for herself and was at risk for further ADL decline, falls, skin breakdown, and pain. R1's Care Plan, revised 07/23/2025, documented R1 was dependent on staff for most of her ADLs. The care plan documented R1 was dependent on staff to meet her emotional, physical, and social needs. On 07/07/2026 at 10:30 AM, observation revealed R1 sat on a red electric scooter with a handlebar sitting in the middle of the hallway. R1's arms and hands were contracted. R1 could barely reach the handlebars of the electric scooter to locomote. On 07/07/2026 at 10:30 AM, R1 stated on 07/03/2026 at approximately 06:00 PM after supper, she was ready to get ready for bed and CNA M brought the full lift into her room and placed the full lift sling behind her. CNA M lifted the electric chair handlebars away from R1. R1 stated R1 left the room to find another staff member to help her get R1 in bed and on the bedpan. R1 stated CNA M did not ensure her call light was within reach and left her in the room with no way to move in her electric chair to either get her call light or get to the door. R1 stated she started to get too hot in her room and got dizzy. R1 stated she was without any way to request help besides yelling for thirty minutes as she looked at the clock on her wall. R1 stated CNA M's actions were unacceptable and felt like she was abused. On 07/08/2026 at 10:15 AM, CNA M stated she had taken R1 into her room to get her ready for bed and put her on the bedpan. CNA M stated she had taken R1's shirt off and washed R1 up per her preference. CNA M stated she had put the handlebars of R1's scooter up so she could better wash R1. CNA M stated she had put the lift sling behind R1 and the full lift was in the room in front of the door. CNA M stated she was too young to run the lift and had to leave the room to get the other CNA on duty. CNA M stated the resident next to R1 had thrown a glass or something on the floor, and it had broken. Dietary staff were cleaning up the glass. CNA M stated that the resident was throwing a fit, so she decided to go and get him ready for bed first because he would not take too long. CNA M stated after she got the other resident in bed, she went out and found the other CNA to help her with R1. CNA M stated R1's call light was on the bed and she had not made sure R1 had her call light. CNA M stated she forgot she had a walkie-talkie to call for help and should have used it instead of leaving R1 by herself. CNA M stated she was probably out of R1's room for about fifteen minutes. On 07/08/2026 at 11:00 AM, Administrative Nurse E stated camera footage had been reviewed regarding the incident with R1. Administrative Nurse E stated CNA M had only left R1's room for approximately fifteen minutes. Administrative Nurse E stated she was sure R1 had felt like it had been longer. Administrative Nurse E stated CNA M should not have left R1 and should have used her walkie-talkie to call for assistance to transfer R1 to bed. Administrative Nurse D stated CNA M should have ensured R1 had her call light before leaving the room if she had to leave. 2.R2's EMR documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R2's Significant Change MDS, dated 06/17/2026, documented R2 could not complete the BIMS evaluation, had short-term and long-term memory problems, and was moderately cognitively impaired. The Cognitive Loss CAA, dated 06/04/2026, documented R2 had a BIMS of less than 13, R2 had orientation, memory, and recall deficits, and was at risk for falls, injuries, wandering, decreased socialization, and weight loss. The Functional Abilities CAA, dated 06/04/2026, documented R2 required assistance with ADLs and had a decreased ability to care for herself. R2's Care Plan, revised 05/2820/26, documented R2 required partial to moderate assistance with most of her ADLs. The care plan documented R2 had an indwelling urinary catheter and directed staff to anchor the tubing to prevent injury, perform catheter care every shift and as needed, check for tubing kinks when providing care, and monitor and document intake and output. On 07/08/2026 at 11:30 AM, observation revealed R2 sat in her wheelchair at the dining room table. R2's urinary catheter bag was attached to the bottom of the wheelchair. The urinary catheter bag did not have a privacy cover to prevent the urine in the bag from being seen by others. When CNA N and CNA O were made aware of the lack of a privacy cover on R2's urinary catheter bag, they did nothing about the lack of dignity R2 was provided and walked away to perform other duties. On 07/08/2026 at 11:30 AM, CNA N and CNA O stated they were not aware of anything wrong with R2's catheter showing her urine. Upon more questioning. CNA N and CNA O stated R2's catheter did not have the privacy leaf over the urine. CNA N stated R2's catheter should be covered so it would not gross people out. CNA O stated R2's catheter should be covered to maintain her dignity. On 07/08/2026 at 12:00 PM, Administrative Nurse E stated she could not provide CNA M's and four other randomly selected CNAs' nurse competencies as there had been a filing error and no one knew where the competencies were. On 07/08/2026 at 01:30 PM, Administrative Nurse D stated R2's catheter should have been covered with a privacy leaf, and it was the staff's job to ensure the resident's dignity was maintained. Administrative Nurse D stated CNA N and CNA O should have taken R2 back to her room and let the nurse know about the lack of a privacy leaf. The facility's undated Nursing Services and Sufficient Staff Policy documented it was the facility's policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care.

The facility identified a census of 84 residents, with 10 residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to follow R49's care plan and failed to transfer R49 with a full lift, which placed R49 at risk for injury. On 06/04/25, two unidentified Certified Nurse's Aides (CNAs) transferred R49 by lifting her under her arms and pivot transferred R49 from her wheelchair to the shower chair. R49's left foot, which had a non-skid slipper on it, caught on the floor and her left knee twisted during the transfer. R49 sustained a left nondisplaced medial tibial plateau fracture (a break in the shinbone at the knee joint). On 06/11/25 two unidentified CNAs transferred R49 again by lifting her up under her arms and pivot transferred R49 from her wheelchair to the shower chair. R49's left leg twisted again during the transfer, and R49 had pain. A follow-up x-ray on 06/20/25 showed R49's previously non-displaced medial tibial plateau fracture was now displaced. This deficient practice caused R49 to sustain a tibial fracture and pain. Findings included:- R49's Electronic Medical Record (EMR) documented diagnoses of anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle weakness, and foot drop (difficulty in lifting the front part of the foot).The Quarterly Minimum Data Set (MDS), dated 05/06/25, documented R49 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R49 was completely dependent on staff for assistance with toileting, bathing, lower body dressing, donning footwear, sit-to-lying, and transfers. The MDS documented R49 had impaired functional range of motion on one side of her upper extremity and to both sides of her lower extremities. The MDS documented R49 had zero falls during the lookback period.The Care Area Assessments (CAAs), dated 03/01/25, lacked any documentation or development.R49's Care Plan documented R49 required total assistance of two staff with a total lift device for transfers, total assistance of one staff for mobility in a wheelchair, extensive assistance of one staff for bathing, extensive assistance of one to two staff for bed mobility, total assistance of one to two staff for toileting, and total assistance of one to two staff for dressing (04/15/25). The care plan documented R49 would demonstrate adequate pain control by verbalizing satisfaction and ability to participate in activities of daily living (ADL) to the best of her ability (04/15/25). The care plan documented R49 would not develop complications from blood-thinning medications and directed staff to monitor for petechiae (tiny round brown-purple spots due to bleeding under the skin, may be in a small area due to minor trauma) and bruises (04/15/25).The EMR lacked any documentation in the skin evaluations of any bruising, purpura (a rash of purple dots due to small blood vessels leaking blood into the skin), or petechiae.The EMR documented R49 had a shower on 06/04/25 and 06/11/25 on the 2 PM to 10 PM shift.The Nurses Note, dated 06/06/25, documented the facility received orders from R49's orthopedic (bone specialist) doctor, which stated Weight bearing as tolerated, physical therapy for gait training, mobility, and strength exercises. Follow-up in four months. The Orthopedic Office Note, dated 06/06/25, documented R49 presented for follow-up after a left thigh ‘I and D' (incision and drainage). The note documented R49 told the doctor she was having pain in her left knee from when the staff picked her up to transfer her from her chair to the shower chair. R49 mainly had pain in the medial (middle) aspect of her left knee, and R49 had no pain at the surgical site on her left thigh. X-rays of the left knee were obtained and showed a possible nondisplaced medial tibial plateau fracture. The orthopedic doctor ordered R49 to use ice and rest to help with pain, and noted she was non-weight bearing on her left lower extremity. The office directed staff to follow up in two weeks for repeat X-rays.The Nurses Note, dated 06/16/25, documented R49 had a half-dollar-sized irregular-shaped area of reddish purpura to her left inner bicep. R49 did not show any signs of pain when staff touched the area. R49's family was concerned it was a bruise and the nurse explained purpura could happen for many reasons, like taking blood-thinning medication, which R49 took daily. The plan was to monitor and notify the doctor if new areas or other symptoms occurred.The Orthopedic Office Note, dated 06/20/25, documented R49 presented and still noted pain to the medial aspect of her left knee. R49 had a non-weight-bearing status on her left lower extremity and required the use of a full mechanical lift. It was approximately two weeks out from the left medial tibial plateau fracture, and now the fracture was slightly displaced. The note documented they would continue with conservative treatment of the fracture. R49 was placed in a knee immobilizer and was advised to wear it at all times, except when sleeping. R49 would also need to remain non-weight-bearing on her left lower extremity. R49 had a follow-up appointment in two weeks for repeat X-rays and left knee evaluation.The Nurse's Note, dated 06/20/25, documented R49 had an appointment with an orthopedic physician this morning. The staff called and requested the results be faxed to the facility. R49 was to be non-weight-bearing with an immobilizer in place. The order documented R49 could take the immobilizer off at night, but R49 requested to leave it on even when in bed.The Facility Incident Report, dated 06/24/25, documented on 06/16/25, R49's responsible party reported to the Administrative Nurse, at the time, improper transfers and injury. R49's responsible party stated R49 recalled being manually transferred by two staff members without the use of a mechanical lift on or around 06/06/25 and on or around 06/14/25, during which time R49's left leg/knee twisted, and a bruise appeared on her left inner arm. Upon assessment, the Administrative Nurse identified an irregularly shaped purpura, rather than a bruise, which typically occurred with trauma. The Administrative Nurse at the time explained purpura could occur spontaneously, particularly in elderly individuals on blood thinners. By 06/18/25, no discoloration was visible, and the assigned CNAs reported proper mechanical lift use. R49's responsible party later took R49 to an orthopedic appointment on 06/20/25 and reported in writing on 06/23/25 that R49's knee was broken. The facility lacked evidence or documentation supporting that a manual transfer occurred. Only one CNA, CNA OO, was unresponsive to the inquiry, creating a partial information gap.On 07/22/25 at 10:30 AM, observation revealed R49 sat in her wheelchair reading a book in her nightshirt. R49's left leg was in an immobilizer and elevated. On 07/22/25 at 10:30 AM, R49 stated that about a month ago, two CNAs did not transfer her with the full mechanical. She reported they picked her up underneath her arms to transfer her from the wheelchair to the bathchair. The staff members did not lift her all the way up; her left leg caught on the floor, and her left knee twisted. R49 stated that a week later, two CNAs came in and transferred her from her wheelchair to the shower chair. She told them they had to use the full mechanical lift, and they said no, it was easier to just do it their way. The staff members lifted her without the use of the mechanical lift again and twisted her left knee. R49 stated she could not walk for three plus years, and her feet did not move at all. R49 stated her knee hurt, she needed pain medication to take care of her pain, and the pain made it hard for her to sleep at night.On 07/22/25 at 01:30 PM, CNA M stated she knew two CNAs who transferred R49 without using the mechanical lift. CNA M stated that CNA MM and CNA OO both transferred R49 manually.On 07/22/25 at 01:35 PM, CNA N stated CNA MM and CNA OO both transferred R49 by lifting her rather than using the full lift.On 07/22/25 at 01:45 PM, Licensed Nurse (LN) H stated R49 had more pain since she sustained the left knee fracture. LN H stated staffing on the living units was poor, and it would not surprise her if the CNAs did not take the time to go and get the mechanical lift to transfer R49.On 07/23/25 at 09:36 AM, CNA MM, who still worked at the facility, stated she always used a full mechanical lift when transferring R49. CNA MM denied ever transferring R49 manually.On 07/23/25 at 12:36 PM, CNA OO, who quit the facility shortly after the incident, stated there were times when CNAs manually transferred R49 with the use of a pivot transfer. CNA OO stated a mechanical lift was to be used on R49 for all transfers.On 07/23/25 at 01:00 PM, Administrative Nurse D stated she expected all staff to follow the care plans for all the residents. Administrative Nurse D stated R49 was care planned to be transferred by a full mechanical lift to avoid any kind of injuries. Administrative Nurse D stated she felt like the previous Administrative Nurse did not investigate the incident fully.The facility's Safe Lifting and Moving of Patients Policy, dated January 2024, documented in order to protect the safety and well-being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, interview, and record review, the facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 84 residents of the facility at risk for inadequate nutrition or foodborne illness.Findings included: - On 07/21/25 at 08:30 AM, Dietary Staff (DS) BB was managing the kitchen and overseeing production of meals for the residents of the facility. On 07/21/25 at 08:30 AM, DS BB stated he was not certified as a dietary manager but was currently taking the course. He stated the Registered Dietitian (RD) had been communicating with him weekly, reviewing resident charts remotely, and visiting the facility weekly.On 07/23/25 at 11:36 AM, Administrative Staff A verified that the facility's Dietary Manager was not certified but was taking the certification course. The facility's Roles of Key Staff policy, dated 2020, stated the Dining Services Manager provided direction to the employees of the dining services department in all activities of food service to provide safe food and a positive dining experience for residents while meeting their nutritional needs.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.Findings included: - On 07/22/25 at 11:55 AM, three drawers in the facility's main kitchen had food crumbs and dried liquid spills among the scoops and ladles.On 07/22/25 at 11:55 AM, Dietary Staff BB verified the drawers had dried food spills and needed to be cleaned.The facility's Sanitation of Dining and Food Service Area policy, dated 2020, stated that a cleaning schedule would be posted for all cleaning tasks, and staff would initial the tasks as they are completed. Staff would be held responsible for all cleaning tasks.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 84 residents who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues.Findings included:- The facility failed to provide R70 dignified dining when she was not served her noon meal at the same time as her tablemates, and she had to wait to be assisted. Refer to F550.The facility failed to obtain a gradual dose reduction for R28, who was on a psychotropic medication. Refer to F605The facility failed to provide the bed hold policy and notify the ombudsman for two residents, R12 and R20. Refer to F628.The facility failed to revise care plans for two residents, R12, who was on supplemental oxygen, and R49, who had an immobilizer (a medical device designed to keep the knee in a fixed, straightened position) brace and skin breakdown. Refer to F657.The facility failed to prevent skin breakdown from an immobilizer brace for R49. Refer to F686.The facility failed to provide foot care for R49, who had long toenails. Refer to F687.The facility failed to follow R49's care plan for a transfer, and R49 sustained a knee fracture. Refer to F689.The facility failed to implement nutritional interventions for R20, who had a 9.6% weight loss in three months. Refer to F692.The facility failed to provide instructions to the oncoming staff regarding R49's wounds from her immobilizer. Refer to F686.The facility failed to provide two Certified Nurse Aides with their yearly 12-hour in-services and failed to have a system in place to track in-services. Refer to F730.The facility failed to follow up on R37's request for new dentures. Refer to F745.The facility's Consultant Pharmacist did not recommend a Gradual Dose Reduction for R28, who received a psychotropic medication. Refer to F756.The facility failed to hold R49's hypertension (high blood pressure) medication when her blood pressure was out of the physician-ordered parameters. Refer to F757.The facility failed to label insulin pens when opened and failed to discard an expired over-the-counter medication. Refer to F761.The facility failed to provide dental services for R37. Refer to F791.The facility failed to provide a Certified Dietary Manager. Refer to F801.The facility failed to provide a sanitary kitchen and failed to discard expired nutritional drinks. Refer to F812.The facility failed to ensure staff wore PPE (personal protective equipment) during care for R49, R35, and failed to wear PPE when handling soiled linens. Refer to F880.On [DATE] at 03:00 PM, Administrative Nurse F stated, the committee met monthly to go over various items of concern and was excited to have the new company take over. Administrative Nurse F further stated they were excited for the future and the improvements they would make, and the improvements they had already seen. The facility's Quality Assurance and Performance Improvement Plan, dated 11/24, documented that the scope of the quality program encompasses each type and segment of care and services that impact clinical care, quality of life, resident choice, and care transitions. The team would identify dashboards that are used to monitor and report overall performance. They would report activity results to the team quarterly,

The facility had a census of 84 residents. The sample included 27 residents. Based on record review and interview, the facility failed to ensure the nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired care.Findings included: - The facility's employment records documented two nurse aides who were employed at the facility for the last year had not completed the required 12 hours of in-service training in the past year.On 07/23/25 at 08:00 AM, Administrative Nurse D stated Certified Nurse Aide (CNA) PP had completed 6.5 of the 12 hours in-service hours, and CNA QQ had completed 7.5 hours of the required 12 in-service hours, and the aides lacked the required number of in-service hours. On 07/23/25 at 10:00 AM, Administrative Nurse D stated the facility became aware of the lack of aides completing the required in-service hours. Administrative Nurse D stated the facility had recently been bought, and they presently have a new owner. Administrative Nurse D stated the past owner had human resources out of the building, including all the information and record tracking for the in-service hours, and they had to rely on the past company to gather the information, and that was what they were provided.The Facility Training and Education policy dated 10/2020, documented the purpose of the policy is to provide specific guidelines with respect to required training and education courses. The facility provides associate training and education to meet job, state, and federal requirements as well as to support career development opportunities. Staff are expected to complete mandatory training courses within the assigned timeline. Staff are expected to complete educational courses within the established timeframe. Full-time, part-time, and PRN staff were expected to comply with the expectations. The manager was responsible for communicating all training and educational requirements to associates. Online course completion or in-person course would be tracked, and the manager was responsible for addressing non-compliance issues in a timely manner in accordance with Associate coaching, counseling, and corrective action policy.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, interview, and record review, the facility failed to use appropriate barriers while sorting soiled resident laundry and to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) for Residents (R) 35 and R49's wound care. The deficient practice placed the residents who reside in the facility at risk of infectious disease processes.Findings included:- On 07/23/25 at 08:10 AM, Laundry Staff U observed removing soiled resident clothing and placing the items into a washing machine. Laundry Staff U wore gloves only and failed to use a gown or apron as a barrier to her clothing. Laundry Staff U stated the use of gowns or aprons was only for heavily soiled laundry. The facility's Handling Soiled Linen policy, dated 11/01/19, documented all linens should be handled using standard precautions and treated as potentially contaminated. Linens should not be allowed to touch the uniform or floor and should be handled as little as possible. - R35’s “Electronic Medical Record” documented diagnoses of iron deficiency anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), and dementia (progressive mental disorder characterized by failing memory, confusion). R35’s “Quarterly Minimum Data Set” (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R35 required maximum staff assistance with toileting, bathing, dressing, and mobility. R35 had one venous ulcer and skin lesions requiring dressings and received antibiotics. R35’s ”Care Plan,” dated 07/03/25, directed staff to assess and report signs of impaired skin or breakdown. R35’s care plan documented she had impaired skin integrity related to vascular ulcers to both feet and directed staff to provide treatments ordered, provide pain management with wound dressing changes, and provide supplements as ordered. The care plan directed staff to follow infection prevention protocol, including Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact cares), post-EBP signage, and supplies at the entrance to R35’s room. Staff were to wear gowns and gloves for high-contact resident care. R35’s medical record documented the vascular wounds had been ongoing since July 2024. The “Physician Order,” dated 07/01/25, directed staff to perform EBP for wound care, don a gown and gloves with personal care every shift. On 07/21/25 at 12:50 PM, Certified Nurse Aide (CNA) O and Licensed Nurse (LN) J assisted R35 to the toilet with a maximum of two staff assistance and a gait belt. The CNA O and the LN J did not wear EBP gowns during the close contact cares. On 07/22/25 at 09:04 AM, CNA P and CNA O used two staff maximum assistance to transfer R35 from her wheelchair to her recliner. No EBP gowns were worn. On 07/22/25 at 09:38 AM, LN K entered R35’s room, did not don an EBP gown, and performed wound care to R35’s feet. LN K cleansed between R35’s toes, applied calcium alginate maxsorb between the toes for both feet. When LN K was asked what the EBP signage on the doorway was for, LN K stated she thought it might be for the former roommate. On 07/22/25 at 01:20 PM, Administrative Nurse D verified that staff were to wear EBP gown and gloves for high contact care, including dressing changes to R35’s wounds. The facility's Enhanced Barrier Precautions (EBP) policy, dated 04/01/24, stated it was the policy of the facility to implement enhanced barrier precautions for the prevention of multidrug-resistant organisms (MDRO). The policy stated all staff receive training on high-risk activities and common organisms that require EBP. An order for EBP would be obtained for residents with chronic wounds, indwelling devices, even if the resident was not known to have an infection. Gowns and gloves were to be available near or outside of the resident's room. High contact care activities included dressing, bathing, transfers, providing hygiene, toileting assistance, and any skin opening wound care. EBP should be used for the duration of the resident's stay or until resolution of the wound. - The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure). The Quarterly/Five Day Medicare Minimum Data Set (MDS) dated [DATE] documented R49 had intact cognition. R49 was dependent upon staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, was at risk for skin breakdown, and had a surgical wound. R49's Care Plan, dated 04/15/25, documented she was at risk for pressure ulcers and other skin-related injuries. R49's plan of care directed staff to observe for redness and breakdown during routine care, follow community skin care protocols, and treat as indicated. The plan of care directed staff to assist her with splinting/bracing and the use of assistive devices. The care plan lacked direction to staff on when to remove her immobilizer and if she had any skin breakdown. The Braden Scale (formal assessment for predicting pressure ulcer risk) dated 05/07/25, documented R49 was a mild risk for pressure ulcers. The Physician's Order dated 06/20/25, directed staff to leave immobilizer in place unless sleeping, and nwb (non-weight bearing) to LLE (left lower leg). The Nurse's Notes, dated 07/18/25 at 05:38 PM, documented R49 had two small open sores on her left leg from where her knee brace had been rubbing against her skin. The sore on the outside of her thigh (the part of the human leg between the hip and the knee) measured 0.4 centimeters (cm) x 0.5 cm. The sore on her calf (the back portion of the lower leg) measured 0.5 cm x 0.5 cm. The wounds were cleaned with wound cleanser and covered with a Mepilex (absorbent, bordered foam dressing). The physician and the durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) were notified of the skin break. The EMR lacked a skin assessment, directions to staff for monitoring R49's skin daily, or any daily standing orders for dressing changes until further direction from the physician from 07/18/25 to 07/22/25 (five days). The Nurse's Notes, dated 07/22/25 at 03:45 PM, documented that the physician received the documentation from the facility regarding the sores and had no further orders. On 07/22/25 at 09:37 AM, Licensed Nurse (LN) H stated she did not normally work in that household and was unsure if R49 had a skin breakdown, but would go with this surveyor and assess her skin. Observation revealed R49 had a leg immobilizer on her left leg from mid-thigh to her ankle. R49 stated the immobilizer needed to be repositioned and tightened because it was too loose on her leg and was slipping. Observation revealed nothing between her skin and the immobilizer to protect it from breakdown. R49 had a foam dressing on her left calf but no dressing on the sore on her left thigh. LN H washed her hands and donned clean gloves. She asked R49 if staff were changing the dressing daily, and she replied No but did not know when they had changed the dressing last. LN H removed the dressing from the calf, and there was brown in color drainage. LN H did not clean the area but washed her hands and donned clean gloves to put a new foam dressing on her calf. The area on her calf was pink but not open. Further observation revealed the sore on her left thigh was approximately the size of a pencil eraser and was starting to scab. LN H did not put a dressing on the sore. On 07/23/25 at 08:48 AM, Certified Nurse Aide (CNA)N stated, nurse aides were responsible for putting the immobilizer on R49 every morning, but sometimes the night shift forgot to take it off, and she had it on all night. CNA N stated she was unaware of any skin breakdown under the immobilizer. On 07/23/25 at 10:00 AM, LN G stated she had not worked in the household for at least two weeks and did not know that R49 had any skin breakdown. LN G washed her hands, donned clean gloves, and opened the immobilizer from R49's left leg, and there was nothing between her skin and the immobilizer. Observation revealed a dried substance inside the immobilizer, from where it had lain against the sore on her thigh. The sore was scabbed and not actively draining. LN G removed the dressing from her calf, and the skin was slightly pink. LN G washed her hands, donned clean gloves, and placed a clean foam dressing on the calf wound, but did not put one on the sore on her thigh. This surveyor observed a yellow PPE (personal protective equipment) hanging on the back of R49's door and when LN G was asked what it was for, she stated, Oh, she is on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), because of wounds, I forgot.” LN G further stated that there should be a sign on her door stating that, but there was not. On 07/23/25 at 10:30 AM, Administrative Nurse F stated, she had been made aware of R49's sores on 07/21/25, but had not looked at them yet. Administrative Nurse F stated that today (07/23/35) was the day she would do her weekly skin assessment. Administrative Nurse F further stated that because the sores were not chronic, they did not require staff to wear PPE during care. At 02:30 PM, Administrative Nurse F stated she had looked at R49's wounds and did not feel that the immobilizer had caused the sore on her thigh because R49 had told her she thought she had scratched it, and that was why she got the sore. Administrative Nurse F stated she did not think the immobilizer had dried drainage because the sore was scabbed, but thought it was dried food. Administrative Nurse F stated, R49 told her that she would wear thin pajama pants so her leg would be protected when the immobilizer was on and would contact the physician for guidance. On 07/23/25 at 01:49 PM, Administrative Nurse D stated she would contact the physician to see about the EBP precautions and would get everything taken care of for R49. The facility's Enhanced Barrier Precautions (EBP) policy dated 04/01/24 stated it was the policy of the facility to implement enhanced barrier precautions for the prevention of multidrug-resistant organisms (MDRO). The policy stated that all staff receive training on high-risk activities and common organisms that require EBP. An order for EBP would be obtained for residents with chronic wounds, indwelling devices, even if the resident was not known to have an infection. Gowns and gloves were to be available near or outside of the resident's room. High contact care activities included dressing, bathing, transfers, providing hygiene, toileting assistance, and any skin opening wound care. EBP should be used for the duration of the resident's stay or until resolution of the wound.

The facility had a census of 84 residents. The sample included 27 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility staff failed to treat Resident (R) 70 (who required assistance with eating) with dignity when staff served R52 and R53, who sat at the same dining room table, their meals without serving R70. This placed the resident at risk for an undignified experience.Findings included:- On 07/22/25 at 07:30 AM, R70 sat in a Geri-chair (a recliner on wheels that can be pushed) around like a wheelchair, usually with a removable tray. at the dining room table with R52 (on her right side) and R53 (across the table). Dietary Staff (DS) CC served R52 and R53 their breakfast, with R70 able to observe them eating. At 08:15 AM, R53 finished her meal and left the dining room, and R52 finished her meal and stayed at the table. At 08:30 AM, staff retrieved R70's meal tray, sat beside her, and assisted her in eating her breakfast.On 07/22/25 at 12:00 PM, R70 sat in a Geri chair at the dining room table with R52 and R53. At 12:01 PM, staff served R52 and R53 their noon meal, with R70 able to observe them eat. At 12:28 PM, R52 and 53 finished their noon meal, and R70 had not been served. At 12:30 PM, staff retrieved a meal tray, sat by R70, and assisted her in eating her meal.On 07/23/25 at 09:46 AM, Licensed Nurse (LN) L stated staff would assist R70 with her meals as soon as they could, but if they have other residents who need to use the bathroom or have their call light on, staff would take care of them first. LN L stated that dietary staff monitor which residents come to the dining room, but waited until the aides can provide staff assistance with R70's meal.On 07/23/25 at 12:45 PM, Administrative Nurse D stated that if staff served R52 and R53 meals at the same table with R70, who required staff assistance, she would expect staff to serve R70 a plate of food and assist R70 with eating at the same time as the other two residents.The facility's Promoting/Maintaining Resident Dignity Policy, revised 01/01/20, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

The facility identified a census of 84 residents. The sample included 27 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 28 was free from psychotropic (a class of medications that alters mood or thought) medication without a gradual dose reduction (GDR - tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The facility failed to ensure the physician provided the risk versus benefit for the continued use of buspirone (anti-anxiety) medication. This deficient practice placed R28 at risk of unnecessary medication administration and related complications.Findings included:- R28's Electronic Medical Record documented diagnoses of anxiety disorder (mental or emotional disorder characterized by apprehension, uncertainty and irrational fear), hypertension (elevated blood pressure), auditory and visual hallucinations (sensing things while awake that appear to be real, but the mind created), dementia (progressive mental disorder characterized by failing memory, confusion), chronic pain, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R28's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired decision making. The MDS documented R28 had no mood or psychosis but did have verbal behaviors. R28 received antidepressant and antianxiety medications with no GDR.R28's Care Plan, dated 07/03/25, included interventions for behaviors and side effects for R28's medications. Administer psychotropic medications as ordered by the physician. The plan of care directed staff to consult with the pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly. The plan of care directed staff to discuss with the physician and family the ongoing need for use of the medication. The plan of care directed staff to review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. The plan of care directed staff to provide R28 with necessary cues, to stop and ensure her safety, and return if she becomes agitated. R28's plan of care directed staff to monitor R28 for and address episodes of anxiety, fear, or distress.R28's Physician Order, dated 12/23/24, directed staff to administer Buspirone (antianxiety drug), five milligrams (mg), three times daily (TID) for anxiety and depression.R28's Physician Order, dated 04/04/25, directed staff to administer Bupropion (antidepressant), 300 mg daily for anxiety and depression.R28's Consultant Pharmacist Medication Reviews from 01/01/25 to 07/22/25 documented no irregularities had been found in her medication regimen.On 07/22/25 at 07:45 AM, Licensed Nurse (LN) J administered medications to R28, including bupropion and buspirone. R28 took the pills whole in applesauce without problems.On 07/22/25 at 12:04 PM, R28 sat calmly in her wheelchair throughout the meal, without yelling or other behaviors observed. She did offer the staff a bite of her lunch but accepted their refusal calmly. She was confused but still able to answer most questions appropriately.On 07/23/25 at 11:45 AM, Consultant GG stated the resident had visual and auditory hallucinations. She verified the pharmacist had not recommended a GDR for R28's buspirone. The physician had not written a rationale for continuing the medication.The facility's Psychotropic Medication policy, dated 6/2025, stated the residents would only receive psychotropic medications when medically necessary to treat specific conditions for which they are indicated and effective. Residents who use psychotropic medication would receive GDR and behavioral interventions, unless clinically contraindicated in an effort to use the lowest effective dosage and potentially discontinue. GDR would be attempted within the first year in which a resident was prescribed a psychotropic drug. GDR would be attempted in at least two separate quarters unless clinically contraindicated.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Residents (R) 12 and R20, and the State Ombudsman Agency notifications of R12. This placed the residents at risk of being uninformed.Findings included: - R20's Electronic Health Record (EHR) revealed diagnoses of extended spectrum beta lactamase (ESLB, an infection cause by a bacteria that produces extended-spectrum beta- lactamases enzymes that make certain antibiotics effective such as e coli and klebsiella, making the infection harder to treat and can occur in urinary tract infections or bloodstream infections), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic kidney disease Stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), and major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness). R20's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded that she was independent with transfers and activities of daily living (ADL). R20's Care Plan, dated 07/18/25, recorded that R20 was independent with eating, oral hygiene, toilet hygiene, personal hygiene, and walking. The care plan documented that the resident was at risk for CHF, MDD, chronic kidney disease, malnutrition, and was underweight for age. The care plan documented that the resident had a risk for shortness of breath and respiratory complications related to the recent diagnosis of Influenza and acute respiratory failure, and staff would monitor oxygen saturation and administer oxygen per physician order and monitor for shortness of breath or difficulty breathing. The” Nurse’s Note” dated 01/31/25 at 08:33 PM documented that the resident complained of urinary tract symptoms and requested the physician to order a urinalysis test and an antibiotic. The nurse’s notes documented that the physician assistant was contacted and ordered a urinalysis and would await results before ordering an antibiotic. On 01/31/25 at 03:22 PM, the Nurses Notes documented that the facility was awaiting the urinalysis, and R20 was noted to have a cough. The on-call physician ordered Augmentin (antibiotic) 500 milligrams (mg) for seven days to cover the urinary tract infection and respiratory issues. On 02/01/25 at 11:10 AM, the Nurse's Notes documented R20 continued with a cough and had received two doses of the antibiotic. The nurse’s notes documented that the urinalysis results had not come back to the facility at this time. R20’s family was at the facility and requested/urged that R20 be evaluated at the hospital with the following vital signs: blood pressure 144/70 (normal 120/80), pulse 79 (normal 60-100), temperature 98.4 degrees (normal 96.4 degrees to 98.5 degree), and oxygen saturation 86% (normal between 95% and 100%) on room air. R20's respirations were even and not labored. The facility called for ambulance transport to the hospital. On 02/01/15 at the resident was admitted to the hospital with a diagnosis of Influenza A (a viral infection of the respiratory tract caused by the influenza A virus, which is highly contagious and can cause a range of symptoms from mild to severe. Potentially leading to serious complications. Influenza primarily affects the respiratory system, including the nose, throat, and lungs.) On 02/05/25 at 04:06 PM, the Nurse's Notes documented R20 returned to the facility per facility staff. R13 entered the facility in a wheelchair with staff assistance. R20 requested oxygen, and it was applied. R20 lungs were clear to auscultation, and no swelling was noted. R20's EHR lacked a bed-hold notification. On 07/21/25 at 12:00 PM, observation revealed that staff delivered R20 her dinner plate to the table that contained chicken, noodles, carrots, and Jello. Continued observation revealed she ate approximately 50 % of the meal. On 07/21/25 at 11:10 AM, Administrative Nurse D verified the facility lacked evidence of a signed bed hold policy notice that had been verbally acknowledged, provided, or signed by the resident's representative when R20 was transferred and admitted to the hospital on [DATE]. The facility’s Bed Holds and Returns policy, dated 01/2024, documented that, at the time of transfers for hospitalization or therapeutic leave, the nursing facility must provide to the resident or the resident's representative written notice that specifies the duration of the bed-hold. The current bed-hold return policy established by the state will apply to residents in the community e resident exceed the bed-hold period, he or she will be permitted to return to the community, t his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room provided that the resident: requires the services of the community and is eligible for Medicare or Medicaid skilled nursing services. - R12’s Electronic Medical Record (EMR) included the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pain, acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and age-related physical debility. R12’s “Comprehensive Minimum Data Set” (MDS), dated [DATE], documented that R12 had intact cognition. R12's MDS documented R12 required functional range of motion of one side of the upper and lower body extremities, required substantial/maximal assistance with upper and lower body dressing, personal hygiene, bed rolling, and transfers. The MDS further recorded that R12 had occasional pain, which affected sleep and day-to-day activities, shortness of breath or trouble breathing with exertion. R12 received oxygen therapy and had a non-invasive mechanical ventilator. R12’s MDSs recorded: On 02/03/25, a Discharge Return Anticipated. On 02/06/25, an Entry. On 03/25/25, a Discharge Return Anticipated. On 03/27/25, an Entry. On 06/26/25, a Discharge Return Anticipated. On 06/27/25, an Entry. The “Progress Note” dated 02/03/25 at 04:22 PM, documented that R12’s Durable Power of Attorney (DPOA) was wanting to hold the bed. The facility failed to provide a written Bed Hold signature from the DPOA. Upon request, the facility failed to provide an Ombudsman notification policy for discharge and transfers. On 07/22/25 at 01:15 PM, Social Service Staff X reported she had not sent a bed hold to the DPOA or had the resident sign one with discharges to the hospital, and lacked notification to the ombudsman for discharges on 03/25/25 and 06/26/25. The facility's Bed-Holds and Return policy, dated 01/2024, documented that at the time of transfer for hospitalization or therapeutic leaves, the nursing facility must provide to the residents or resident representative written notice that specifies the duration of the bed-hold.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to revise the care plan to include Resident (R) 12's use of oxygen and R49's leg immobilizer. This placed the residents at risk for unmet care needs.Findings included:- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure). The Quarterly/Five Day Medicare Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition. R49 required staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, was at risk for skin breakdown, and had a surgical wound. R49's Care Plan, dated 04/15/25, documented she was at risk for pressure ulcers and other skin-related injuries. Staff were directed to observe for redness and breakdown during routine care, follow community skin care protocols, and treat as indicated. They were also to assist her with splinting/bracing and the use of assistive devices. The care plan lacked direction to staff on when to remove her immobilizer and if she had any skin breakdown. The Braden Scale (formal assessment for predicting pressure ulcer risk) dated 05/07/25, documented R49 was a mild risk for pressure ulcers. The Physician's Order dated 06/20/25, directed staff to leave immobilizer in place unless sleeping, and nwb (non-weight bearing) to LLE (left lower leg). The Nurse's Notes, dated 07/18/25 at 05:38 PM, documented R49 had two small open sores on her left leg from where her knee brace had been rubbing against her skin. The sore on the outside of her thigh (the part of the human leg between the hip and the knee) measured 0.4 centimeters (cm) x 0.5 cm. The sore on her calf (the back portion of the lower leg) measured 0.5 cm x 0.5 cm. The wounds were cleaned with wound cleanser and covered with a Mepilex (absorbent, bordered foam dressing). The physician and the durable power of attorney (DPOA-a legal document that names a person to make healthcare decisions when the resident is no longer able to) were notified of the skin break. The EMR lacked a skin assessment, directions to staff for monitoring R49's skin daily, or any daily standing orders for dressing changes until further direction from the physician from 07/18/25 to 07/22/25 (five days). The Nurse's Notes, dated 07/22/25 at 03:45 PM, documented that the physician received the documentation from the facility regarding the sores and had no further orders. On 07/22/25 at 09:37 AM, Licensed Nurse (LN) H stated she did not normally work in that household and was unsure if R49 had a skin breakdown, but would go with this surveyor and assess her skin. Observation revealed R49 had a leg immobilizer on her left leg from mid-thigh to her ankle. R49 stated the immobilizer needed to be repositioned and tightened because it was too loose on her leg and was slipping. Observation revealed nothing between her skin and the immobilizer to protect it from breakdown. R49 had a foam dressing on her left calf but no dressing on the sore on her left thigh. LN H washed her hands and donned clean gloves. She asked R49 if staff were changing the dressing daily, and she replied No but did not know when they had changed the dressing last. LN H removed the dressing from the calf, and there was brown in color drainage. LN H did not clean the area but washed her hands and donned clean gloves to put a new foam dressing on her calf. The area on her calf was pink but not open. Further observation revealed the sore on her left thigh was approximately the size of a pencil eraser and was starting to scab. LN H did not put a dressing on the sore. On 07/23/25 at 08:48 AM, Certified Nurse Aide (CNA) N stated, nurse aides were responsible for putting the immobilizer on R49 every morning, but sometimes the night shift forgot to take it off, and she had it on all night. CNA N stated she was unaware of any skin breakdown under the immobilizer. On 07/23/25 at 10:00 AM, LN G stated she had not worked in the household for at least two weeks and did not know that R49 had any skin breakdown. LN G washed her hands, donned clean gloves, and opened the immobilizer from R49's left leg, and there was nothing between her skin and the immobilizer. Observation revealed a dried substance inside the immobilizer, from where it had lain against the sore on her thigh. The sore was scabbed and not actively draining. LN G removed the dressing from her calf, and the skin was slightly pink. LN G washed her hands, donned clean gloves, and placed a clean foam dressing on the calf wound, but did not put one on the sore on her thigh. This surveyor observed a yellow PPE (personal protective equipment) hanging on the back of R49's door and when LN G was asked what it was for, she stated, Oh, she is on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), because of wounds, I forgot.” LN G further stated there should be a sign on her door that stated that, but there was not. On 07/23/25 at 10:30 AM, Administrative Nurse F stated that she had been made aware of R49's sores on 07/21/25, but had not looked at them yet. Administrative Nurse F stated that today (07/23/25) was the day she would do her weekly skin assessment. Administrative Nurse F further stated that because the sores were not chronic, they did not require staff to wear PPE during care. At 02:30 PM, Administrative Nurse F stated she had looked at R49's wounds and did not feel that the immobilizer had caused the sore on her thigh because R49 had told her she thought she had scratched it, and that was why she got the sore. Administrative Nurse F stated she did not think the immobilizer had dried drainage because the sore was scabbed, but thought it was dried food. Administrative Nurse F stated that R49 told her that R49 would wear thin pajama pants so her leg would be protected when the immobilizer was on and would contact the physician for guidance. On 07/23/25 at 01:49 PM, Administrative Nurse D stated, staff should update the care plan to reflect the resident’s condition and problems. The facility's Comprehensive Person-Centered policy, dated 09/2023, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, which were identified through evaluation and assessment, and was developed and implemented for each resident. Assessments and ongoing care plans are revised as information about the residents and their conditions changes. - R12’s Electronic Medical Record (EMR) included the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pain, acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and age-related physical debility. R12’s “Comprehensive Minimum Data Set” (MDS), dated [DATE], documented that R12 had intact cognition, functional range of motion of one side of upper and lower body extremities, required substantial/maximal assistance with upper and lower body dressing, personal hygiene, bed rolling, and transfers. The MDS further recorded that R12 had occasional pain, which affected sleep and day-to-day activities, shortness of breath, or trouble breathing with exertion. R12 received oxygen therapy and had a non-invasive mechanical ventilator. R12’s “Functional Abilities Care Area Assessment” (CAA), dated 04/09/25, documented R12 had chronic respiratory failure with hypoxia and hypercapnia (a condition in which high levels of carbon dioxide build up in the bloodstream), reduced mobility, and hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side. R12’s “Care Plan” dated 06/27/25, documented R12 had potential for shortness of breath and/or respiratory complications related to sleep apnea, wore a continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) at bedtime. The Care Plan directed staff to monitor for complications such as dyspnea (difficulty breathing), shortness of breath, cyanosis (a bluish discoloration of the skin), or tachypnea (rapid breathing). The Care Plan further directed staff to provide pulmonary treatments per the physician's orders and monitor responses. The Care Plan lacked the use of oxygen. The “Physician Order” dated 06/20/25, instructed staff to assess lung sounds, pulse, respirations, and oxygen saturation before and after nebulizer treatments (a device that changes liquid medication into a mist easily inhaled into the lungs) and CPAP every day for respiratory failure. The “Physician Order” dated 07/01/25, directed staff to provide oxygen at three liters via nasal canula to keep oxygen saturations above 90 percent (%). The “Progress Note” dated 07/04/25 at 04:02 PM, documented R12 wore oxygen tubing per nasal canula, was alert and oriented, reported shortness of breath with exertion and when sitting at rest, and was unable to lie flat. R12 had portable oxygen and an oxygen concentrator in her room. The Progress Note further documented that R12 had a nebulizer and CPAP machine in her room. On 07/21/25 at 04:16 PM, R12 was sitting in her recliner, wearing an oxygen canula. R12 had a portable oxygen tank on her wheelchair with the unwrapped tubing and canula wrapped around the top of the canister. R12’s bedside tables had a nebulizer treatment and CPAP equipment not in use, and not wrapped or bagged. On 07/23/25 at 08:30 AM, R12 reported she was doing well, but stated her room was cluttered. On 07/23/25 at 10:13 AM, Licensed Nurse (LN) GG reported that the oxygen tubing and nebulizer, and CPAP equipment should be cleaned and stored in bags when not in use. On 07/23/25 at 01:45 PM, Administrative Nurse D verified oxygen should be included on R12’s “Care Plan.” The facility's Comprehensive Person-Centered policy, dated 09/2023, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, which were identified through evaluation and assessment, and then developed and implemented for each resident.

The facility has a census of 84 residents. The sample included 27 residents, with five reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent skin breakdown for one resident, Resident (R) 49, who developed two open areas from a leg immobilizer (a brace or support device designed to restrict knee movement and keep the leg straight. This placed the resident at risk for further breakdown.- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure).The Quarterly/Five Day Medicare Minimum Data Set (MDS). dated 04/21/25, documented R49 had intact cognition. R49 was dependent upon staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, was at risk for skin breakdown, and had a surgical wound.R49's Care Plan, dated 04/15/25, documented she was at risk for pressure ulcers and other skin-related injuries. Staff were directed to observe for redness and breakdown during routine care, follow community skin care protocols, and treat as indicated. They were also to assist her with splinting/bracing and the use of assistive devices. The care plan lacked direction to staff on when to remove her immobilizer and if she had any skin breakdown.The Braden Scale (formal assessment for predicting pressure ulcer risk) dated 05/07/25, documented R49 was a mild risk for pressure ulcers.The Physician's Order dated 06/20/25, directed staff to leave immobilizer in place unless sleeping, and nwb (non-weight bearing) to LLE (left lower leg).The Nurse's Notes, dated 07/18/25 at 05:38 PM, documented R49 had two small open sores on her left leg from where her knee brace had been rubbing against her skin. The sore on the outside of her thigh (the part of the human leg between the hip and the knee) measured 0.4 centimeters (cm) x 0.5 cm. The sore on her calf (the back portion of the lower leg) measured 0.5 cm x 0.5 cm. The wounds were cleaned with wound cleanser and covered with a Mepilex (absorbent, bordered foam dressing). The physician and the durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) were notified of the skin break.The EMR lacked a skin assessment, directions to staff for monitoring R49's skin daily, or any daily standing orders for dressing changes until further direction from the physician from 07/18/25 to 07/22/25 (five days).The Nurse's Notes, dated 07/22/25 at 03:45 PM documented that the physician received the documentation from the facility regarding the sores and had no further orders.On 07/22/25 at 09:37 AM, Licensed Nurse (LN) H stated she did not normally work in that household and was unsure if R49 had a skin breakdown but would go with this surveyor and assess her skin. Observation revealed R49 had a leg immobilizer on her left leg from mid-thigh to her ankle. R49 stated the immobilizer needed to be repositioned and tightened because it was too loose on her leg and was slipping. Observation revealed nothing between her skin and the immobilizer to protect it from breakdown. R49 had a foam dressing on her left calf but no dressing on the sore on her left thigh. LN H washed her hands and donned clean gloves. She asked R49 if staff were changing the dressing daily, and she replied No but did not know when they had changed the dressing last. LN H removed the dressing from the calf, and there was brown in color drainage. LN H did not clean the area but washed her hands and donned clean gloves to put a new foam dressing on her calf. The area on her calf was pink but not open. Further observation revealed the sore on her left thigh was approximately the size of a pencil eraser and was starting to scab. LN H did not put a dressing on the sore. On 07/23/25 at 08:48 AM, Certified Nurse Aide (CNA) N stated, nurse aides were responsible for putting the immobilizer on R49 every morning, but sometimes the night shift forgot to take it off, and she has it on all night. CNA N stated she was unaware of any skin breakdown under the immobilizer.On 07/23/25 at 10:00 AM, LN G stated she had not worked in the household for at least two weeks and did not know that R49 had any skin breakdown. LN G washed her hands, donned clean gloves, and opened the immobilizer from R49's left leg, and there was nothing between her skin and the immobilizer. Observation revealed a dried substance inside the immobilizer, from where it had lain against the sore on her thigh. The sore was scabbed and not actively draining. LN G removed the dressing from her calf, and the skin was slightly pink. LN G washed her hands, donned clean gloves, and placed a clean foam dressing on the calf wound, but did not put one on the sore on her thigh. This surveyor observed a yellow PPE (personal protective equipment) hanging on the back of R49's door and when LN G was asked what it was for, she stated, Oh, she is on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), because of wounds, I forgot. LN G further stated, there should be a sign on her door stating that, but there was not. On 07/23/25 at 10:30 AM, Administrative Nurse F stated she had been made aware of R49's sores on 07/21/25, but had not looked at them yet but today was the day she would do her weekly skin assessment. Administrative Nurse F further stated that because the sores were not chronic, they did not require staff to wear PPE during care. At 02:30 PM, Administrative Nurse F stated she had looked at R49's wounds and did not feel that the immobilizer had caused the sore on her thigh because R49 had told her she thought she had scratched it, and that was why she got the sore. Administrative Nurse F stated she did not think the immobilizer had dried drainage because the sore was scabbed, but thought it was dried food. Administrative Nurse F stated, R49 told her that she would wear thin pajama pants so her leg would be protected when the immobilizer was on and would contact the physician for guidance.On 07/23/25 at 12:45 PM, Consultant GG stated, normally there would be standing orders for treatments of skin breakdown while staff waited for doctor orders, but since they were a new company for the facility, all standing orders were sent to the physicians to sign and had not been returned yet. Consultant GG further stated she would have expected staff to protect R49's skin from breakdown when the immobilizer was originally placed on her. Consultant GG further stated that there should be communication to staff related to the breakdown and assessment of the skin daily.On 07/23/25 at 01:49 PM, Administrative Nurse D stated that staff should have protected her skin when she had the immobilizer on and felt that there should have been better communication related to the wounds to the nursing staff.The facility's Prevention of Pressure Injuries Protocol, dated 01/2024, documented pressure can come from splints, casts, bandages, and wrinkles in the bed linen. If a pressure injury was not treated when discovered, it quickly gets larger, becomes very painful for the resident, and often becomes infected. Staff should routinely assess and document the condition of the resident's skin per the community wound and skin care program. Staff should assess for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor.

The facility had a census of 84 residents. The sample included 27 residents, with one reviewed for foot care. Based on observation, record review, and interview, the facility failed to provide foot care to one resident, Resident (R) 49, whose toenails were long and over the top of her toes. This placed the resident at risk for complications, poor hygiene, discomfort, and injuries.Findings included:- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure).The Quarterly/Five Day Medicare Minimum Data Set (MDS). dated 04/21/25, documented R49 had intact cognition. R49 required staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, and required assistance with footwear.R49's Care Plan, dated 04/15/25, documented R49 required assistance from staff for bathing, dressing, putting on and taking off footwear, and personal hygiene. The care plan directed staff to monitor for edema and brittle nails.The Nurse's Note dated 07/22/25 at 11:14 AM documented nail care provided and noted curling on the middle toenails.On 07/22/25 at 09:37 AM, Licensed Nurse (LN) H removed R49's socks, and her toenails were long; some of the middle toenails curled over the top of the toes on each foot. LN H asked R49 when the last time she had any foot care. R49 stated she did not know. LN H stated she would come back in and cut her toenails for her because it looked like she had not had them cut for a long time.On 07/22/25 at 12:46 PM, Certified Nurse Aide (CNA) M stated she thought the nurse provided all of R49's nail care.On 07/23/25 at 08:48 AM, CNA N stated R49 had an afternoon shower, and the CNAs were responsible for her nail care.On 07/23/25 at 01:49 PM, Administrative Nurse D stated that staff should make sure her toenails are cut during her shower.The facility's Nail Care policy, dated 12/03/24, directed staff to provide routine nail care, to include trimming and filing on a regular schedule and as needed.

The facility had a census of 84 residents. The sample included 27 residents, with nine reviewed for nutrition and weight loss. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 20. This deficient practice resulted in significant weight loss and placed the resident at risk for further weight loss or health issues.Findings included: - R20's Electronic Health Record (EHR) revealed diagnoses of Extended spectrum beta lactamase (ESLB, an infection cause by a bacteria that produces extended-spectrum beta- lactamases enzymes that make certain antibiotics effective such as e coli and klebsiella, making the infection harder to treat and can occur in urinary tract infections or bloodstream infections,) congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic kidney disease Stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood), and major depressive disorder (MDD- major mood disorder that causes persistent feelings of sadness).R20's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded she was independent with eating and activities of daily living (ADL). The MDS documented R20's weight at 117.0 lbs.R20's Care Plan, dated 07/18/25, recorded R20 was independent with eating, oral hygiene, toilet hygiene, personal hygiene, and walking. The care plan documented the resident was at risk for CHF, MDD, chronic kidney disease, malnutrition, and was underweight for age. The care plan directed staff to administer medications as ordered and documented for side effects and effectiveness. The care plan documented the resident had a risk for shortness of breath and respiratory complications related to a recent diagnosis of Influenza and acute respiratory failure, and staff would monitor oxygen saturation and administer oxygen per physician order and monitor for shortness of breath or difficulty breathing. The Physician Order, dated 02/05/25, 06/11/25, and 07/02/25, directed staff to provide R20 a regular diet, regular texture, and regular consistency.The Mini Nutritional Assessment dated 02/05/25, documented R20 weighed 113.9 lbs. and she was at risk for malnutrition.The Nutritional Risk Assessment dated 02/11/25 documented R20 weight was 113.0 lbs. and she required 1285-1540 calories, 51-61 grams of proteins, and 1285 to 1540 milliliters (ml) of fluids. The assessment documented the resident had a recent hospitalization with a 5.60% significant weight loss in one month. And she was at risk for unintendedly weight loss. The Dietician Assessment, dated 07/23/25, documented R20 weighed 108.4 lbs. and her intakes were all adequate, mostly 51-100%. The Registered Dietician (RD) recommended to add meal fortification to R20's diet order and snacks at bedtime with Ensure Enlive (provides advanced nutrition with 20 grams of high-quality protein) supplement daily. R20's EMR documented R20's weights as follows:04/14/25 120.4 lbs.04/18/25 117.8 lbs.04/28/25 117.2 lbs.05/02/25 117.0 lbs.05/06/25 117.4 1lbs. 05/16/25 115.6 lbs. = 3.99% weight loss in 30 days.05/23/25 112.4 lbs.05/27/25 113.2 lbs.05/30/25 112.6 lbs. 06/03/25 112.2 lbs.06/06/25 111.2 lbs.06/14/25 111.2 lbs.06/20/25 112.0 lbs.= 6.40% weight loss in 60 days 06/27/25 109.0 lbs.07/04/25 110.0 lbs.07/11/25 109.8 lbs.07/17/25 110.8 lbs.07/18/25 108.4 lbs.07/23/25 107.0 lbs. = 11.13% weight loss in 90 days. On 07/21/25 at 12:00 PM, observation of R20 revealed that staff delivered her dinner plate to the table that contained chicken, noodles, carrots, and Jello. Continued observation revealed she ate approximately 50 % of the meal. On 07/21/25 at 09:00 AM, Administrative Nurse D stated staff notified the RD of R20's weight loss that week and the weight loss over the last few months, and the RD completed a nutritional assessment with suggestions. On 07/21/25 at 10:00 AM, Administrative Nurse D verified staff had obtained R20's weights weekly or more often and said staff should have notified the physician and the RD earlier of the resident's significant weight loss to obtain orders for recommendations to prevent the continued weight loss. The facility's Weight Monitoring policy, dated January 2023, signed 07/2025, documented that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% s in 30 days, 7.5% in 90 days, or 10% in 180 days daily for the first 3 days of admission, weekly for the first four weeks, and monthly thereafter. Residents with a weight change of 5 pounds or greater should be reweighed to determine an accurate weight. The accurate weight should be entered in the resident's medical record. A report should be generated from the electronic medical record (EMR) system identifying all residents with a significant weight loss in 30 days, 90 days, and /or 180 days. At the weekly Resident at Risk Preview huddle, the IDT team should discuss residents who triggered a significant weight loss and who loss more than five lbs. since the last weight. The RD should make recommendations or nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. RD's recommendations should be reviewed and initiated by nursing associates. A nursing or nutritional associate should notify the health care provider of any significant weight change that is unexplained or in which the RD has requested a nutritional intervention.

The facility had a census of 84 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store oxygen cannula, nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs), and a continuous positive airway pressure (CPAP- a ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) equipment in sanitary conditions for Resident (R) 12, which placed the resident at risk of respiratory infections.Findings included:- R12's Electronic Medical Record (EMR) included the diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), pain, acute and chronic respiratory failure with hypoxia (inadequate supply of oxygen), and age-related physical debility.R12's Comprehensive Minimum Data Set (MDS), dated [DATE], documented that R12 had intact cognition, functional range of motion of one side of upper and lower body extremities, required substantial/maximal assistance with upper and lower body dressing, personal hygiene, bed rolling, and transfers. The MDS further recorded that R12 had occasional pain, which affected sleep and day-to-day activities, shortness of breath or trouble breathing with exertion. R12 received oxygen therapy and had a non-invasive mechanical ventilator.R12's Functional Abilities Care Area Assessment (CAA), dated 04/09/25, documented R12 had chronic respiratory failure with hypoxia and hypercapnia (a condition in which high levels of carbon dioxide build up in the bloodstream), reduced mobility, and hemiplegia and hemiparesis following a cerebrovascular disease affecting the left non-dominant side.R12's Care Plan dated 06/27/25, documented R12 had potential for shortness of breath and/or respiratory complications related to sleep apnea, wore a CPAP- at bedtime. The Care Plan directed staff to monitor for complications such as dyspnea (difficulty breathing), shortness of air, cyanosis (a bluish discoloration of the skin), or tachypnea (rapid breathing). The Care Plan further directed staff to provide pulmonary treatments per the physician's orders and monitor responses. The Care Plan lacked the use of oxygen.The Physician Order dated 06/20/25, instructed staff to assess lung sounds, pulse, respirations, and oxygen saturation before and after nebulizer treatments and CPAP every day for respiratory failure.The Physician Order dated 07/01/25, directed staff to provide oxygen at three liters via nasal canula to keep oxygen saturations above 90 percent (%).The Progress Note dated 07/04/25 at 04:02 PM, documented R12 wore oxygen tubing per nasal canula, was alert and oriented, reported shortness of breath with exertion and when sitting at rest, and was unable to lie flat. R12 had portable oxygen and an oxygen concentrator in her room. The Progress Note further documented that R12 had a nebulizer and CPAP machine in her room.On 07/21/25 at 04:16 PM, R12 was sitting in her recliner, wearing an oxygen canula. R12 had a portable oxygen tank on her wheelchair with the unwrapped tubing and nasal canula wrapped around the top of the canister. R12's bedside tables had nebulizer treatment and CPAP equipment not in current use, also not wrapped or bagged.On 07/23/25 at 08:30 AM, R12 reported she was doing well, but stated her room was cluttered.On 07/23/25 at 10:13 AM, Licensed Nurse (LN) GG reported that the oxygen tubing and nebulizer, and CPAP equipment should be cleaned and stored in bags when not in use.On 07/23/25 at 01:45 PM, Administrative Nurse D verified that oxygen, nebulizer, and CPAP equipment should be stored in bags when not in use.The facility's Oxygen Administration policy, dated 04/09/25, documented that oxygen was administered to residents who needed it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. Staff shall keep delivery devices covered in a plastic bag when not in use. The facility's undated CPAP/BiPAP Cleaning policy documented common equipment including the machine, tubing, mask, headgear/straps, disposable filters, and humidifier chamber, clean the mask frame daily after use with a CPAP cleaning wipe or soap and water. Dry well. Cover with a plastic bag or completely enclose in machine storage when not in use. The facility's Nebulizer Therapy policy, dated 04/09/25, documented it was the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Store the nebulizer and mouthpiece in a zip-lock bag.

The facility had a census of 84 residents. The sample included 27 residents, with one reviewed for competent staffing. Based on observation, record review, and interview, the facility failed to ensure staff possessed the appropriate skills and knowledge to monitor and communicate nursing orders, while waiting for direction from the physician, for one resident, Resident (R) 49, who sustained two open areas from an immobilizer. This placed the resident at risk for further breakdown.- The Electronic Medical Record (EMR) for R49, documented diagnoses of hypertension (high blood pressure), muscle weakness, atrial fibrillation (rapid heart rate), and disorders of bone density and structure (a condition where bones become weakened and more prone to fractures due to reduced bone mass and/or changes in bone structure).The Quarterly/Five Day Medicare Minimum Data Set (MDS), dated [DATE], documented R49 had intact cognition. R49 was dependent upon staff assistance for lower body dressing, bathing, transfers, mobility, and toileting hygiene. The MDS documented R49 had upper functional impairment on one side, lower functional impairment on both sides, was at risk for skin breakdown, and had a surgical wound.R49's Care Plan, dated 04/15/25, documented she was at risk for pressure ulcers and other skin-related injuries. Staff were directed to observe for redness and breakdown during routine care, follow community skin care protocols, and treat as indicated. They were also to assist her with splinting/bracing and the use of assistive devices. The care plan lacked direction to staff on when to remove her immobilizer and if she had any skin breakdown.The Braden Scale (formal assessment for predicting pressure ulcer risk) dated 05/07/25, documented R49 was a mild risk for pressure ulcers.The Physician's Order dated 06/20/25, directed staff to leave immobilizer in place unless sleeping, and nwb (non-weight bearing) to LLE (left lower leg).The Nurse's Notes, dated 07/18/25 at 05:38 PM, documented R49 had two small open sores on her left leg from where her knee brace had been rubbing against her skin. The sore on the outside of her thigh (the part of the human leg between the hip and the knee) measured 0.4 centimeters (cm) x 0.5 cm. The sore on her calf (the back portion of the lower leg) measured 0.5 cm x 0.5 cm. The wounds were cleaned with wound cleanser and covered with a Mepilex (absorbent, bordered foam dressing). The physician and the durable power of attorney (DPOA-a legal document that names a person to make healthcare decisions when the resident is no longer able to) were notified of the skin breakdown.The EMR lacked a skin assessment, directions to staff for monitoring R49's skin daily, or any daily standing orders for dressing changes until further direction from the physician from 07/18/25 to 07/22/25 (five days).The Nurse's Notes, dated 07/22/25 at 03:45 PM, documented that the physician received the documentation from the facility regarding the sores and had no further orders.On 07/22/25 at 09:37 AM, Licensed Nurse (LN) H stated she did not normally work in that household and was unsure if R49 had a skin breakdown but would go with this surveyor and assess her skin. Observation revealed R49 had a leg immobilizer on her left leg from mid-thigh to her ankle. R49 stated the immobilizer needed to be repositioned and tightened because it was too loose on her leg and was slipping. Observation revealed nothing between her skin and the immobilizer to protect it from breakdown. R49 had a foam dressing on her left calf but no dressing on the sore on her left thigh. LN H washed her hands and donned clean gloves. She asked R49 if staff were changing the dressing daily, and she replied No but did not know when they had changed the dressing last. LN H removed the dressing from the calf, and there was brown in color drainage. LN H did not clean the area but washed her hands and donned clean gloves to put a new foam dressing on her calf. The area on her calf was pink but not open. Further observation revealed the sore on her left thigh was approximately the size of a pencil eraser and was starting to scab. LN H did not put a dressing on the sore. On 07/23/25 at 08:48 AM, Certified Nurse Aide (CNA) N stated, nurse aides were responsible for putting the immobilizer on R49 every morning but sometimes the night shift forget to take it off, and she has it on all night. CNA N stated she was unaware of any skin breakdown under the immobilizer.On 07/23/25 at 10:00 AM, LN G stated she had not worked in the household for at least two weeks and did not know that R49 had any skin breakdown. LN G washed her hands, donned clean gloves, and opened the immobilizer from R49's left leg, and there was nothing between her skin and the immobilizer. Observation revealed a dried substance inside the immobilizer, from where it had lain against the sore on her thigh. The sore was scabbed and not actively draining. LN G removed the dressing from her calf, and the skin was slightly pink. LN G washed her hands, donned clean gloves, and placed a clean foam dressing on the calf wound, but did not put one on the sore on her thigh. This surveyor observed a yellow PPE (personal protective equipment) hanging on the back of R49's door and when LN G was asked what it was for, she stated, Oh, she is on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care), because of wounds, I forgot. LN G further stated, there should be a sign on her door stating that, but there was not. On 07/23/25 at 10:30 AM, Administrative Nurse F stated, she had been made aware of R49's sores on 07/21/25 but had not looked at them yet but today was the day she would do her weekly skin assessment. Administrative Nurse F further stated that because the sores were not chronic, they did not require staff to wear PPE during care. At 02:30 PM, Administrative Nurse F stated she had looked at R49's wounds and did not feel that the immobilizer had caused the sore on her thigh because R49 had told Administrative Nurse F that she thought she had scratched it, and that was why she got the sore. Administrative Nurse F stated she did not think the immobilizer had dried drainage because the sore was scabbed, but thought it was dried food. Administrative Nurse F stated, R49 told her that she would wear thin pajama pants so her leg would be protected when the immobilizer was on and would contact the physician for guidance.On 07/23/25 at 12:45 PM, Consultant GG stated that normally there would be standing orders for treatments of skin breakdown while staff waited for doctor orders, but since they were a new company for the facility, all standing orders were sent to the physicians to sign and had not been returned yet. Consultant GG further stated she would have expected staff to protect R49's skin from breakdown when the immobilizer was originally placed on her. Consultant GG further stated that there should be communication to staff related to the breakdown and assessment of the skin daily.On 07/23/25 at 01:49 PM, Administrative Nurse D stated that staff should have protected her skin when she had the immobilizer on and felt that there should have been better communication related to the wounds to the nursing staff.The facility's Nursing Services and Sufficient Staff policy, undated, documented that the facility provided sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility would ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs as identified through resident assessment and described in the plan of care.

The facility identified a census of 80 residents with three reviewed for code status. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures indicated by his full code status (code status determination for residents who wish to receive CPR). At 09:00 AM on [DATE] Certified Nurse Aide (CNA) M answered R1's call light and found R1 on the floor. CNA M informed Licensed Nurse (LN) G, who responded to R1's room, and noted R1 was unresponsive. LN G assessed R1's carotid artery (major blood vessel which supplies blood to the brain) and could not feel a pulse, so LN G obtained a stethoscope and assessed for lung sounds which were absent. Staff then notified 911 and verified R1 was a full code, but still did not initiate CPR. Eleven minutes later, at 09:11 AM, Emergency Medical Services (EMS) arrived onsite, and EMS initiated CPR shortly thereafter. The delay in resuscitative measures placed R1 and the fifteen other residents with full code status in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and gout (inflammation of the joints). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of fourteen, which indicated intact cognition. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living (ADL) except eating. The Advance Directives Care Plan, dated [DATE], documented R1 was a full code and R1's preferences regarding full code status would be honored. The Facility Intake Assessment, dated [DATE], documented R1 was a full code. The Nurse's Note, dated [DATE], documented at 09:00 AM CNA M informed LN G that R1 was on the floor. R1 was unresponsive when LN G entered the room. R1 laid face down on the floor with his walker underneath his legs, his arm was crossed underneath of him, and red drainage coming from R1's head. R1's call light was attached to his recliner and turned on when staff found R1. CNA M and LN G removed the walker from underneath R1's legs, in order for staff to assess R1. LN G could not access R1's carotid artery or lung sounds in the position R1 was found in due to the walker underneath R1's legs and his dresser on his right side. LN G palpated (felt) R1's carotid artery and determined there was no pulse. LN G obtained a stethoscope, assessed and noted R1's lungs sounds were absent, and called 911 immediately. The facility receptionist notified staff EMS was on the way. R1's code status was verified. EMS arrived at 09:11 AM and began CPR. Staff notified R1's primary care physician via phone call regarding R1's transfer to the hospital emergency room at 09:30 AM. The Facility Incident Report, dated [DATE], documented CNA M notified LN G at 09:09 AM that CNA M went to answer R1's call light and found R1 lying prone (facing downward) in his room. LN G assessed R1's carotid artery and could not palpate a pulse. LN G assessed R1 for lung sounds which were absent. R1's code status was verified. 911 was called. EMS arrived at 09:15 AM and began CPR. The staff notified R1's representative, the on-call nurse, and R1 primary care physician. R1 transferred to the local hospital emergency room at 09:35 AM. The emergency department notified the facility of R1's death. CNA M's Witness Statement, dated [DATE], documented CNA M found R1 around 09:00 AM. CNA M stated she was answering R1's call light and found R1 face down on the floor, laying on his walker. CNA M stated she approached R1, called R1's name, R1 did not respond, and was not breathing. CNA M stated she immediately alerted LN G and continued to try and arouse R1. LN G's Witness Statement, dated [DATE], documented LN G saw R1 at 07:10 AM in the dining room. LN G sat down beside R1 to check R1's blood pressure and obtain a finger stick blood sugar. LN G stated this was the last time she saw R1 prior to his fall. The statement directed to see nurses notes for fall documentation. On [DATE] at 10:00 AM, CNA M stated she found R1 unresponsive on the floor in his room. CNA M stated R1 was not breathing. CNA M stated she immediately notified LN G. LN G came into R1's room and they removed R1's walker from under him. LN G assessed R1 for pulse and breath sounds and there were none. CNA M stated she had not started CPR on R1 because she did not know his code status because the residents were all elderly and most were Do Not Resuscitate (DNR-advance directive for no CPR). CNA M stated she and LN G did not roll R1 over; EMS rolled R1 over and started CPR when they got to his room. CNA M stated she had been educated about code status and CPR since the incident. On [DATE] at 10:55 AM, LN G stated she assessed R1 for carotid pulse and lungs sounds and they were absent. LN G stated she did not initiate CPR because she could not move R1 into a good position to give CPR. LN G stated she called 911 and the front desk to initiate code blue response, but no one came. EMS arrived and started CPR and transported R1 to the hospital. On [DATE] at 11:30 AM, Administrative Nurse D stated LN G and CNA N had never had anything like that happen before and they did not think about starting CPR; they were just in shock and did not think they could move R1 off of his stomach to start CPR. Administrative Nurse D stated LN G and CNA M were able to get R1's walker out from underneath him and when EMS got to the facility, EMS moved furniture to get R1 moved. Administrative Nurse D stated LN G did not think to call staff from other areas of the building to assist. Administrative Nurse D stated a plan of correction was started regarding code blues (cardiac or respiratory arrest situation) and code Blue mock drills were performed three times a week on every shift and were now done weekly. Administrative Nurse D stated all staff were in-serviced on CPR and the steps to follow when a code blue occurred. On [DATE] at 11:45 AM, Administrative Staff A verified there were three Automated External Defibrillators (AED-used to deliver electrical shock in sudden cardiac arrest situation) in the building to be used for code blues. The facility's Cardiopulmonary Resuscitation and Code Blue Policy, revised [DATE], documented licensed staff are required to complete training on the cardiopulmonary resuscitation (CPR) and basic life support, including defibrillation for victims of sudden cardiac arrest. Training in BLS includes recognizing presentations of sudden cardiac arrest (SCA). The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. Early delivery shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase changes of survival. If an individual is found unresponsive and not breathing, staff member who is certified in CPR/BLS shall initiated CPR unless it is known that a DNR order that prohibits CPR and external defibrillation exists or there are obvious signs of irreversible death. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. If an individual is found unresponsive, for no more than 10 seconds, assess for abnormal or absence of breathing. If sudden cardiac arrest is likely begin CPR. Instruct a staff member to activate the emergency response team (code) and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status. Initiate basic life support BLS sequence of events (CAB) chest compressions, airway, breathing. The facility failed to ensure staff immediately initiated CPR on R1, who was a full code. The delay in initiating resuscitative measures placed R1 and the fifteen other residents with full code status in immediate jeopardy. On [DATE] the facility completed all corrective measures which included: Community-wide staff educations on Code Blue Policy and procedure. Mock code drills were performed over three days on all shifts. With education provided during the drills to staff. Medical Director was notified. All staff were e re-educated on delivery of CPR specific to placement of resident and delivery of chest compressions. Competency testing was completed by clinical staff. All corrective measures were completed prior to the onsite survey, therefore the citation was deemed past noncompliance and the scope and severity existed at a K.

The facility identified a census of 73 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate assistance using safe practices when repositioning Resident (R)1 in her electric wheelchair. This deficient practice resulted in R1 sustaining a left non-displaced humerus (a long bone that runs from the shoulder to the elbow) fracture. Findings included: - R1's Electronic Medical Record documented the following diagnoses: multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), muscular dystrophy (group of inherited disorders that involve muscle weakness and loss of muscle tissue, and worsen over time), and major depressive disorder (major mood disorder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of fifteen, which indicated intact cognition. The MDS further documented R1 required extensive assistance of one to two staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. The Fall Care Area Assessment (CAA), dated 06/20/22, documented R1 required a full body lift for transfers, was not steady, and needed staff assistance for moving on and off the toilet and surface to surface transfers. The Activities of Daily Living (ADL) Care Plan, dated 07/6/20, documented R1 was unable to move her legs and had limited mobility to her bilateral arms. R1 used a motorized scooter for locomotion and required a total assistance from two staff using a full body lift for transfers. The Facility Incident Report, documented on 11/09/22 at approximately 12:00 PM, R1 was transferred with a total lift from R1's bed to her power wheelchair. Certified Nurse Aide (CNA) M and CNA N noticed after the transfer that R1's buttocks were not fully on her power wheelchair seat, and used a two-person manual maneuver to reposition R1 further back onto the chair. When they did so, CNA M and CNA N heard a pop and R1's left arm flopped forward and hit her arm on the arm of the power chair. R1's Durable Power of Attorney (DPOA) and primary care physician were notified and R1 was advised that her primary care physician thought she should be seen to check for any injury. R1's primary care physician asked for an in-person visit and x-ray and R1 refused to leave the facility in the cold. R1's primary care physician was informed of R1's decision and ordered staff to monitor R1. On the morning of 11/16/22, R1 requested to speak to Administrative Nurse D and R1 requested to see her primary care physician as her arm was very sore. Administrative Nurse D was able to get R1 an appointment the same day. R1 had x-rays obtained on 11/16/22, which showed a non-displaced distal humerus fracture to R1's left arm. The Nurse's Note, dated 11/11/22 documented the facility received a returned fax from R1's primary care physician advising the facility there was not a clear indication for an x-ray at that time. The Nurse's Note, dated 11/12/22, documented R1 sat in her scooter and related her left arm felt better and was just a little sore. R1 was able to move her left arm a little. R1's left arm had reddish/purple bruising from her upper arm/elbow and upper forearm measuring 18 centimeters (cm) by 12 cm. The Skin Evaluation Report, dated 11/14/22, documented R1 had a reddish/purple bruise to her left arm measuring 16 cm by 11cm. The Nurse's Note, dated 11/16/22 documented R1 stated her left arm was very sore and when R1 rolled over in bed she had a very painful sensation in her left arm. An appointment was set up with R1's primary care physician at 10:00 AM the same day. The Nurse's Note, dated 11/16/22, documented the facility received a fax from R1's primary care physician regarding R1's painful left arm. X-rays were obtained and the facility would be faxed the results and recommendations. The Nurse's Note, dated 11/17/22, documented the facility received the results of R1's x-rays and noted R1 sustained a non-displaced humerus fracture. R1's primary care physician would be referring R1 for an orthopedic (bone specialist) appointment. The facility could schedule R1 Tylenol (pain medication) 1000 milligrams (mg) three times a day for pain and apply a cool pack as needed. The Nurse's Note, dated 11/21/22 revealed the facility received and noted the physician visit form from R1's orthopedic appointment. X-rays were repeated this day and continued to show non-displaced humerus fracture. A left splint and sling were applied to R1's left arm and R1 was to return in three weeks. The Skin Evaluation Report, dated 11/21/22, documented R1 had reddish/purple bruising to her left arm measuring 16 cm by 11 cm. Fracture of the distal left humerus with sling in place. On 12/07/22 at 11:30 AM, observation revealed R1 sat in her electronic scooter watching television. R1 had a splint to her left arm and her left arm was in a sling. On 12/07/22 at 11:30 AM, R1 stated on the day she sustained her left humerus fracture CNA M and CNA N were running the full body lift and they did not pull her back her back far enough in her chair before they sat her down and she was on the edge of her seat. R1 stated CNA M and CNA N removed the lift sling from underneath of her and then got on her left side and right side and grabbed her underneath her arms and legs and lifted her back into the seat, and she heard a large pop and her left arm flopped forward and hit the arm of the chair. R1 stated that her arm hurt terribly bad at the time. R1 stated she did not want to go out to her primary care physician due to the cold weather but wanted a portable x-ray. R1 stated she thought maybe her elbow had been popped out of place and it would just pop back into place on its own. R1 stated when she continued to have pain, she knew something was wrong with her left arm and so agreed to go out of the facility for an appointment. R1 stated, now that she had the splint to her arm, she was having little to no pain. On 12/07/22 at 12:00 PM, CNA M stated on 11/09/22 she and CNA N used the full body lift to transfer R1 from her bed back to her electric scooter. CNA M stated she and CNA N had not fully placed R1 back far enough onto the seat of her scooter, so after taking the sling out from underneath R1, she and CNA N placed their hands underneath R1's arms and legs to lift R1 back farther into her seat and then heard a pop. CNA M stated she did not know where the pop came from but reported the incident to the charge nurse immediately. CNA M stated she and CNA N should have left the lift sling underneath R1 and lifted her back up and repositioned R1 back farther onto the seat of her chair. On 12/07/22 at 12:15 PM, CNA N stated on 11/09/22, she and CNA M transferred R1 with the full body lift from her bed to her electric scooter. R1 slid down the seat of the electric scooter and she and CNA M arm and legged R1 back into her seat and heard a loud pop. CNA N stated she was on R1's left side and did not feel anything happen when she lifted R1. On 12/07/22 at 01:00 PM, Administrative Nurse D stated she expected all of the staff at the facility to safely lift and move residents to prevent injuries to the residents and to staff. The facility's Safe Lifting and Moving of Patients Policy, dated December 2019, documented in order to protect the safety and well-being of associates and residents and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. The facility failed to follow safe lifting practices when positioning R1 in her electric scooter resulting in a R1 sustaining a non-displaced left humerus fracture which caused pain and impaired mobility.

The facility identified a census of 75 residents. The sample included three residents reviewed for neglect. Based on observation, record review, and interview, the facility failed to follow the care plan and provide the necessary goods and services for Resident (R) 1, which resulted in a second degree burn with fluid filled blisters to R1's upper right thigh. Subsequently, R1 required specialty wound clinic care and suffered from pain that could have been avoided. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission Minimum Data Set (MDS), dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated R1 was cognitively intact. The MDS further documented R1 required limited to extensive assistance of one to two staff for bed mobility, transfer, ambulation, locomotion, dressing, toilet use, and personal hygiene. The MDS documented R1 required oversight, encouragement, or cueing of one staff for eating. The Activities of Daily Living Care Area Assessment (CAA), dated 06/28/22, documented R1 had poor vision, used a platform walker, and required limited to extensive assistance with all activities of daily living. The Vision CAA, dated 06/28/22, documented R1 had poor vision. The Nutrition CAA, dated 06/28/22, documented R1 had poor vision and staff would need to explain to R1 where and what foods were on her plate. The Hot Liquid Assessment, dated 06/23/22, documented R1 was safe to have hot liquids and documented an intervention for R1 to have a lid with all hot liquids. The Cognitive Loss Care Plan, dated 06/25/22, directed staff to provide cues to R1 to promote independence and ensure R1's safety. The Activity of Daily Living Care Plan, dated 06/21/22, directed staff R1 required bilateral hearing aids and was legally blind. R1's Care Plan lacked instruction R1 was to have lids on all hot liquids until 08/18/22, after the incident. The Progress Note, dated 08/18/22 at 09:53 AM, documented R1 sustained a 15 centimeter (cm) by 5 cm burn to her right inner thigh after she spilled hot tea water in her lap while eating breakfast. The burned area to R1's right inner thigh contained two blisters that were 1cm wide by 3 and 4 cm's long, respectively. Staff reported the incident to R1's primary care physician and the facility awaited orders for treatment after faxing and calling the primary care physician. The Communication with Physician Note, dated 08/18/22 at 10:27 AM, documented R1's primary care physician wanted R1 to be seen in the clinic before treating the burn. R1 was unwilling to go to the clinic as her primary care physician was scheduled to be at the facility the next day for nursing home rounds. Staff administered a needed acetaminophen (pain medication) to R1 as the only available intervention for the pain. The Progress Note, dated 08/18/22 at 10:54 AM, documented at the time of the incident staff removed R1's clothing and treated R1 right away. Staff notified R1's primary care physician by phone. A Hot Liquids Evaluation was completed for a second time and a new intervention was put in place for R1 to have hot liquids in a cup with a lid for safety. The Skin Evaluation Record, dated 08/18/22 documented R1 had a partial thickness wound. The wound to the right upper thigh had a reddened area measuring 15 cm by 5 cm and two blisters within the reddened area which measured 1 cm by 4 cm and 1 cm by 4 cm. The Electronic Medical Administration Record (MAR), dated 08/18/22 documented R1 rated her pain an 8 on a scale of 0-10 on a numeric pain scale rating with zero being no pain and 10 being the worst pain. Staff administered R1 Tylenol (pain medication) 650 milligrams (mg) at 10:25 AM. The Physician Communication Note, dated 08/19/22 at 12:09 PM, documented R1's primary care physician was at the facility to see R1 on rounds and ordered [MEDICATION(S)] 4% cream (pain cream) three times a day as needed for pain to the right thigh burn and instructed staff to keep blisters to right thigh intact if possible; inform R1's primary care physician if the blisters opened. The primary care physician further instructed staff to monitor the burn wound daily until healed or blisters were gone. The Treatment Administration Record (TAR), dated 08/19/22, directed staff to monitor R1's blisters twice a day until healed and let R1's primary care physician know if the blisters opened. This order was discontinued on 08/24/22. The MAR, dated 08/19/22 documented R1 rated her pain a 4 on a scale of 0-10. The Skin Evaluation Record, dated 08/20/22, documented R1 had a partial thickness wound to her upper right thigh with a reddened area which measured 15 cm by 5 cm with two blisters inside the reddened area that measured 1cm by 4 cm and 1 cm by 3 cm. The facility was directed to keep the blisters intact and let the primary care physician know if the blisters opened. The MAR, dated 08/20/22, documented R1 rated her pain a 3 on a scale of 0-10. The MAR, dated 08/21/22 documented R1 rated her pain a 2 on a scale of 0-10. The Physician Communication Note, dated 08/22/22, documented R1's primary care physician was notified of one of R1's blisters to her right upper thigh broke open and were scabbed over. The Skin Evaluation Record, dated 08/22/22, documented R1 had a partial thickness wound to her upper right thigh and recorded two blisters both measuring 5.2 cm by 2.0 cm and the facility was to monitor the fluid filled blisters. The MAR, dated 08/22/22 documented R1 rated her pain a 2 on a scale of 0-10. The Physician Communication Note, dated 08/24/22, documented the facility contacted R1's primary care physician regarding changing R1's dressing every three days and R1's primary care physician ordered for R1's dressing to be changed every three days. The TAR, dated 08/27/22, directed staff to cleanse the popped blisters with wound cleanser, apply [MEDICATION(S)] ointment (an antibiotic cream), and to cover with a foam dressing. The order was discontinued on 09/12/22. The Skin Evaluation Record, dated 08/28/22, documented R1 had a partial thickness wound to her upper right thigh with two blisters that had drained and scabbed over measuring 2.0 cm by 1.0 cm. The Skin Evaluation Record, dated 08/28/22, documented R1 had popped blisters to her upper right thigh which measured 6.0 cm by 2.0 cm. The record lacked any description of the wound. The Skin Evaluation Record, dated 08/28/22, documented R1 had popped blisters to her upper right thigh which measured 5.5 cm by 2.0 cm. The record lacked any description of the wound. The Skin Evaluation Record, dated 08/29/22, documented a popped blister to R1's upper right thigh which measured 5.5 cm by 2.0 cm. The record lacked any description of the wound. The Physician Communication Note, dated 08/29/22, documented staff contacted R1's primary care physician and asked to change R1's treatment order to the three [CONDITION(S)] on her upper right thigh from [MEDICATION(S)] ointment to [MEDICATION(S)] cream (a medication used to treat [CONDITION(S)]). The Physician Communication Note, dated 08/30/22, documented the facility received a signed fax communication for R1's primary care physician directing the facility to have another nurse look at R1's wounds since he could not visualize the wounds and could not advise whether wound care referral was appropriate and suggested an appointment could be scheduled if needed. The Progress Note, dated 09/06/22, documented the facility faxed R1's primary care physician asking for new orders for R1's burn wounds. R1's primary care physician responded that he had asked for another nurse to look at the wound, since he could not assess the wound, and decide if wound referral was needed. The Physician Communication Note, dated 09/08/22, documented the facility received a fax from R1's primary care physician ordering a referral to the wound care clinic. The Skin Evaluation Record, dated 09/10/22, documented a wound to R1's right upper thigh which measured 6.0 cm by 1.0 cm with treatment to cleanse with wound cleanser and gauze and apply Allevyn (a bordered dressing). The Skin Evaluation Record, dated 09/10/22, documented a wound to R1's right upper thigh which measured 5.0 cm by 0.5 cm with treatment to cleans with wound cleanser and gauze and apply Allevyn. The Medication Treatment Note, dated 09/12/22, documented new wound care orders received from R1's appointment at the wound care clinic to apply [MEDICATION(S)] Advantage (an antimicrobial dressing for use in acute or hard-to-heal wounds that are infected or are at risk for infection) to the three [CONDITION(S)] to R1's right upper thigh, cover with [MEDICATION(S)] (a bordered dressing), and change on Wednesdays, Fridays, and as needed. R1 should return to the wound care clinic in one week and all other previous wound care orders were to be discontinued. On 09/13/22 at 12:15 PM, observation revealed R1 slept in her recliner with her legs elevated. R1's lunch tray was on a tray table in front of her, was not set up for her to eat as evidenced by her utensils were still rolled up in a napkin at the tip of the tray, and the tray had no liquids for R1 to drink. R1 woke up upon hearing the knock on the door. On 09/13/22 at 12:17 PM, R1 stated she had [CONDITION(S)] on her leg from several weeks ago. R1 stated she did not have the hot tea water in her hand when it spilled. R1 stated she did not have a bed side table and used her walker that had a tray on it for meals. R1 stated that whoever put the tray on her walker tray did not make sure the walker tray was all the way attached and the tray with the hot tea spilled in her lap. R1 stated the burned area to her upper right thigh hurt very bad at first and then it just kind of went numb. R1 stated she went to the wound care clinic the previous day and was there for three hours while they took all of the dead skin out of the burn wounds and that was very painful. R1 pulled up her shorts and showed the dressing on her upper right thigh. R1 further stated, I am legally blind. I didn't know it [her lunch tray] was there. Can you tell me what I am eating? R1 stated her family took her walker home. On 09/13/22 at 12:30 PM, Dietary Staff (DS) BB stated she worked in the kitchen area the day that R1 was burned with the hot tea water. DS BB stated the whole tray had ended up in R1's lap and all of her fluids on the tray had spilled. DS BB stated when she took the tray into R1, she noticed that the right side of R1's walker with the tray was notall of the way down but she did not think anything about it. DS BB stated she did not set up R1's breakfast tray that morning when she placed the tray in front of R1. DS BB stated she set up R1's tray sometimes when she brought the tray to R1, but it depended on how busy she was. DS BB stated she put R1's hot tea water in the microwave and when she took it out it was about 160 degrees Fahrenheit (F) but she would let it sit for a bit and let it cool down to around 130 degrees F. On 09/13/22 at 12:45 PM, Certified Nurses Aide (CNA) M stated R1 ate her meals off her walker with a tray since her admission. CNA M stated that the walker with the tray was not stable and CNA R reported to the charge nurses that it was not safe. On 09/13/22 at 01:00 PM, Licensed Nurse (LN) G stated R1 had been eating her meals off her walker with a tray since her admission. LN G stated that the walker with the tray was not stable enough to eat off and she had reported to administrative staff that it was not safe. LN G stated R1 had a tray table in her room now. On 09/13/22 at 03:00 PM, Administrative Staff A stated she did not know R1 did not have a tray table in her room and no one had informed her the walker with the tray on it was not safe, as she would have ensured a tray table was placed in R1's room. Administrative Staff A stated R1 was legally blind and could have easily knocked the food tray off her walker tray by accident and received the burn. The facility's Safety of Hot Liquids policy, revised December 2017, documented residents will be evaluated for safety concerns and potential for injury from hot liquids on admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverage while minimizing the potential for injury. The potential for [CONDITION(S)] from hot liquids is considered an on-going concern among residents with weakened motor skills, balance issues, and nerve or musculoskeletal conditions. Resident with these or other conditions may suffer from accidental [CONDITION(S)] and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. Residents who prefer hot beverages with meals will not be restricted from these options. Associates should complete a Hot Liquid Safety Evaluation as indicated and document the risk factors in the care plan. Once risk factors for injury are identified, appropriate interventions will be implemented to minimize the risk from [CONDITION(S)]. Such intervention may include: serving hot beverages with a lid, encouraging residents to sit at a table while drinking or eating hot beverages, protective lap covering or clothing to protect skin from accidental spills, and associate supervision or assistance with hot beverages. Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding and maintain a palatable temperature. Person Centered Care Plan will be updated for those at risk with appropriate interventions. The facility failed to follow the care plan and provide appropriate care and services for R1, which resulted in R1 obtaining a burn causing fluid filled blisters (second degree [CONDITION(S)]) to her upper right thigh which required specialty wound clinic care and caused avoidable pain.

The facility identified a census of 76 residents with three residents reviewed for neglect. Based on observation, record review, and interview, the facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in a resident's condition. On 07/06/22 at 03:36 PM Resident (R)1 had an oxygen saturation below normal parameters at 90 percent (%), which was down from the normal reading (96%) the previous day. Staff did not respond to or assess this change. On 07/07/22 03:18 PM, R1's oxygen saturation was decreased from the previous day, at 88%. R1's pulse was 102 (normal adult range 60-100), which was flagged as abnormal and increased from 62 the previous day. Staff did not respond to these changes and/or abnormal findings. On 07/07/22 at 07:33 PM Certified Medication Aide (CMA) M recorded R1's medications were not given at that time due to R1 had labored breathing and was unresponsive to CMA M's attempts to wake the resident. A note documented at 07:33 PM CMA M reported this to Licensed Nurse (LN) G. On 07/07/22 at 09:20 PM, almost two hours after identification of R1's decreased level of consciousness and labored breathing, the facility initiated emergency services. At that time R1 had an oxygen saturation of 64-71% on 5 liters (l) of oxygen. R1 was cyanotic (bluish colored skin as a result of oxygen deprivation). R1 was transferred via ambulance to an acute center where he was intubated (placement of a tube in a person's airway to maintain patency) and admitted to critical care with [CONDITION(S)], pneumonia (lung inflammation caused by bacterial or [CONDITION(S)] infection) and septic shock (a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention). Staff failed to detect, thoroughly assess, and respond to changes in the resident's condition which placed R1 in Immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Quarterly Minimum Data Set (MDS), dated [DATE] documented R1 was rarely understood, had short term memory problems, had long term memory problems, and had severely impaired cognition. The MDS further documented R1 was totally dependent on two staff for transfers and bathing, required extensive assistance of two staff for bed mobility, dressing, and toilet use, and required extensive assistance of one staff for locomotion on the unit, eating, and personal hygiene. The MDS recorded R1 did not have any shortness of breath and required no respiratory treatments during the look back period. R1's Cognitive Loss Care Area Assessment, dated 12/16/21, documented R1 had short- and long-term memory problems and was rarely/never understood. R1's Cognitive Loss/Dementia Care Plan, dated 09/09/17, documented R1 had memory problems, impaired decision-making skills and impaired ability to comprehend and documented R1 would have his needs met daily and directed staff to anticipate his needs and monitor for non-verbal cues. R1's Infection/IV's Care Plan, dated 04/08/20, directed staff to monitor for signs and symptoms of infection, document signs and symptoms of infection, and promptly report signs and symptoms of infection. The care plan directed staff to monitor for fever, coughing, sneezing, sore throat, and respiratory issues; respiratory assessment per facility protocol. The care plan directed staff to report change of condition to R1's primary care physician and resident representative. R1's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/06/22 at 03:36 PM, R1's EMR under the Vital Stats tab documented R1 had an oxygen saturation below normal parameters at 90%, which was down from the normal reading (96%) the previous day. Review of the resident's clinical record revealed the record lacked evidence staff assessed R1 in regard to the above change and/or notified the physician of the finding. On 07/07/22 03:18 PM, the Vital Stats tab recorded R1's oxygen saturation was decreased from the previous day, at 88%. R1's pulse was 102, which was flagged blue as abnormal and increased from 62 the previous day. Review of the resident's clinical record revealed LN I signed off on the respiratory observation, which lacked information whether R1 had a cough or respiratory distress. The record lacked evidence staff responded to changes and/or abnormal findings. On 07/07/22 at 07:33 PM Certified Medication Aid (CMA) R recorded on the EMAR R1's medications were not given at that time due to R1 had labored breathing and was unresponsive to CMA M's attempts to wake the resident. The note documented at 07:33 PM CMA M reported this to Licensed Nurse (LN) G. On 07/08/22 at 01:19 AM, the Progress Note documented CMA R notified LN G R1's respirations were labored and congested. LN G went and assessed the resident and advised CMA R to get a set of vital signs while LN G started checking R1's chart. When LN G got back to R1's room, he checked on R1's vital signs and called for LN H to come and assist him. LN H noted R1's oxygens saturation to be 64% and told CMA R to get oxygen. CMA R returned to R1's room with an oxygen concentrator and 5 Liters (L) of oxygen was administered to R1. R1's oxygen saturation rose to 71% on 5 L of oxygen via nasal cannula. LN G noted rhonchi (continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation) to the right upper lobe of the lung. R1 was cyanotic. 911 was called and LN H sent CMA R to meet Emergency Medical Staff (EMS) at the front door. LN G stayed with R1 until EMS arrived. After EMS arrived, R1's oxygen saturation was still at 71%. R1 was admitted to acute care facility at 11:39 PM with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/12/22 at 01:30 PM Resident D stated that R1 hollered out, screamed all day long, and told the aides and the nurse that something was wrong with R1 because he couldn't speak, but he never screamed out like that. Resident D stated the nurse told her R1was fine and she should not worry about him. On 07/12/22 at 08:55 PM LN H stated he was unaware of any changes to the resident's condition until LN G came to get him to assist in R1's care. When he got to the room R1 was struggling to breathe, EMS was called, and the crash cart was obtained. LN H stated that if a resident's pulse of 102 and an oxygen saturation of 88% were reported to him he would immediately call the doctor and report the findings because those are signs of [CONDITION(S)]. LN H stated respiratory assessments and vital signs were performed at 04:00PM every day in the facility. On 07/13/22 at 05:30 AM LN G stated that he had not assessed R1 prior to the change in condition but he had seen R1 out at the dinner table and R1 appeared to be fine. LN G said that he did not get any information in the change of shift report that would make him suspect any change in R1's condition until the CMA R came to get him. LN G stated when he got to the room R1 was struggling to breath and was lethargic. LN G stated if a pulse of 102 and an oxygen saturation of 88% had been reported to him, he would have immediately went to assess R1 and called to doctor to report the findings. On 07/13/22 at 09:30 AM CNA M stated that the day before R1 was sent to the hospital, CNA M had noticed a change in R1 as he wasn't moving around in bed like he normally did, had liquid diarrhea, and when she checked R1's blood pressure she could not obtain a reading in either leg. The legs had to be used because R1 was so contracted in his arms. CNA M reported her finding to the nurse and she did not observe the nurse perform an assessment on R1. On 07/13/22 at 09:30 am CNA N stated she had noticed a change in R1 prior to him being sent out to the hospital. R1 was much more lethargic than normal and was not eating like he normally would when she assisted him. R1's head was rolling back like he didn't have any strength. CNA N stated she reported her findings to the nurse and never observed the nurse assess R1. On 07/13/22 at 12:20 PM, Consultant GG stated she had nothing to say about R1's situation or lack of notification by the facility of R1's change in condition. On 07/13/22 at 02:00 PM Administrative Nurse D stated the respiratory assessments and vitals signs were assigned daily on the 2-10 shift and they are scheduled for 04:00 PM. The nurses were supposed to assess the respiratory status of all of the residents to ensure they were not having respiratory distress. Administrative Nurse D verified the abnormal vital signs should have been reported to R1's primary care physician and the respiratory assessment should have been performed on R1. On 07/13/22 Consultant Emergency Services HH stated in a telephone interview the emergency call was placed to 911 at 09:20 PM on 07/07/22. The facilities Change in a Resident's Condition or Status Policy, reviewed March 2022, documented the facility shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's health care provider or physician on call when there has been a(an): accident or incident involving the resident, discover of injuries of unknown source, adverse reaction to medication, significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, need to transfer the resident to a hospital/treatment center, discharge without proper medial authority, and/or specific instruction to notify the health care provider of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by associate or implementing standard disease-related clinical intervention. The facility failed to ensure licensed nursing staff possessed the skills, and knowledge necessary to detect and respond to changes in R1's condition. Staff failed to detect, thoroughly assess, and respond to changes in the resident's condition which placed R1 in Immediate Jeopardy. On 07/13/22 the facility completed the following actions to remove the immediacy: Current licensed nurses will be re-educated by the DON or designee on 07/13/2022 on the community's policy regarding identification and notification of a resident's change in status. Licensed nurses will not be allowed to take an assignment until the education is completed. Interdisciplinary team has reviewed the re-education regarding identification and notification of a resident's change in status and it is in compliance with the CMS regulation F726. The scope and severity remained at a G.

The facility had a census of 66 residents. The sample included three residents with one reviewed for accident hazards. Based on observation, record review, and interview the facility failed to provide adequate supervision and implement interventions to prevent a hot coffee spill for Resident (R) 1. This deficient practice resulted in [CONDITION(S)] with blistering on R1's inner thighs. Findings included: - The Physician Order Sheet, dated 10/03/21, recorded diagnoses of muscle weakness, [CONDITION(S)] (disease that alters normal function of the brain), dementia (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by agitation and irrational fear), and [CONDITION(S)] with behaviors (major mental disorder characterized by gross impairment in reality thinking). The Significant Change Minimum Data Set (MDS), dated [DATE], recorded R1 had memory problems, and severe cognitive impairment with hallucinations (perception that imagined thoughts appear to be real), delusions (persistent belief or perception held by a person although evidence shows it untrue), physical and verbal behaviors, and rejection of cares. The MDS recorded R1 required extensive staff assistance with most activities of daily living (ADLs), and supervision with eating. The ADL Function Care Plan, dated 10/05/21, recorded R1 had severe cognitive impairment, conversed with nonsensical (having no meaning) speech, and was not able to make decisions about her cares. The care plan directed staff to provide extensive assistance with transfers, dressing, toileting, personal hygiene, and supervision with eating. The Hot Liquid Safety Evaluation, dated 08/05/21, recorded R1 was a safety risk due to poor decision making, frequent impulsive acts, and quick mood swings with agitation and behaviors. The Hot Liquid Safety Evaluation lacked documentation staff implemented interventions to protect R1 from hot liquid spills. The Psychological Consultation, dated 09/17/21, recorded staff reported that R1 had increased behaviors of anger, yelling, and throwing dishes. The Psychological Consultation recorded R1 had worsening [CONDITION(S)] and directed staff to administer [MEDICATION(S)] (antianxiety medication used to calm and relax people with excessive tension and agitation) 0.5 milligrams (mg) to R1 two times a day for anxiety. The Social Service Designee (SSD) Progress Note, dated 10/04/21, recorded staff completed a Significant Change MDS due to R1's severely impaired cognition, speech rarely/never understood, and staff reports of frequent temper outbursts with physical and verbal behaviors. The Nursing Progress Note, dated 10/06/21 at 04:33 AM, recorded R1 had more difficulty feeding herself due to not being able to stay on task during the meal. The Nursing Progress Note, dated 10/14/21 at 07:31 PM, recorded dietary staff served a meal tray with hot coffee to R1 in her room, and the resident spilled the coffee on her lap causing reddened skin. The 'Nursing Progress Note recorded R1 had a 20 centimeter (cm) by 15 cm reddened area on the right frontal thigh, 2.8 cm reddened area on the left frontal thigh, 5 cm by 5 cm reddened area on the left inner thigh, and staff notified the physician. The Nursing Progress Note, dated 10/18/21 at 01:48 PM, recorded R1 had a 4.5 cm by 2.5 cm fluid filled blister surrounded by dark maroon skin on left upper thigh, a 9 cm by 6 cm raised reddened area on left inner thigh, and 22 cm by 10 cm raised reddened area on the right thigh. On 11/02/21 at 08:33 AM, observation revealed R1 sat in her wheelchair at the dining table, and staff, seated next to R1, provided extensive assistance with the resident's food and drinks. On 11/02/21 at 09:23 AM, observation revealed R1 sat in her wheelchair at the dining table with an unlidded glass of cranberry juice within reach on the table and staff seated at the table across from the resident. Continued observation revealed R1 dropped the glass of cranberry juice, spilled the contents, and the glass broke on the floor. On 11/02/21 at 10:27 AM, Licensed Nurse (LN) G stated R1 required extensive staff assistance with food and drink, and usually ate in the dining room due to her assistance and safety needs. LN G stated dietary staff served R1's meal in her room, the hot coffee did not have a lid, and the resident was not supervised. LN G stated staff should have implemented safety interventions, when staff assessed R1 at risk with hot liquids. On 11/02/21 at 10:29 AM, Certified Nurse Aide (CNA) M stated R1 usually ate in the dining room, and the resident required extensive staff assistance at meals due to not being able to use utensils to feed herself. CNA M stated dietary staff served R1's meal in her room, without supervision, and R1 spilled the unlidded hot coffee on her lap. On 11/02/21 at 03:45 PM, Administrative Nurse D stated R1 had severe cognitive impairment with behaviors, and staff should ensure the resident ate her meals in the dining room with staff supervision and assistance. Administrative Nurse D stated staff assessed R1 at risk with hot fluids, and safety interventions should have been implemented. Upon request the facility was not able to provide a hot liquid policy. The facility failed to provide adequate assessment and supervision to prevent a hot coffee spill that caused burned areas with blisters on the bilateral thighs of R1. Prior to 10/21/21 the facility implemented the following corrective measures: All residents who scored at risk on the Hot Liquid Assessment were care planned with appropriate interventions. All nursing and dietary staff were educated on the interventions. All diet cards were updated to reflect residents at risk and interventions. The deficient practice was cited as past noncompliance.

The facility had a census of 69 residents. The sample included 18 residents with four reviewed for pressure ulcers (PU- localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to provide timely assessment and interventions to prevent the development of one unstageable (full thickness skin or tissue loss with unknown depth) PU and one Stage 2 (partial-thickness skin loss into but no deeper than the dermis, outer layer of skin) pressure ulcer for one of four sampled residents, Resident (R) 59. Findings included: - R59's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of four. The resident required extensive assistance from one to two staff for all activities of daily living (ADLs), including extensive assistance of two staff for bed mobility, always incontinent of urine, and recent hip surgery. The MDS documented the resident was at risk for PU and had no unhealed PU. The MDS documented the resident used a pressure reducing cushion in her chair and bed, nutrition interventions, and received surgical wound care. The Significant Change MDS, dated [DATE], documented the same as the 09/23/20 MDS except the resident had a BIMS score of 99, short and long term memory problems, and severely impaired decision making skills. The MDS documented the resident was frequently incontinent of urine and received scheduled pain medication for almost constant severe pain. The MDS documented the resident had one Stage 1 PU (superficial reddening of the skin) not present upon admission and received PU care. The Pressure Ulcer Care Area Assessment (CAA), dated 10/19/20, documented the resident required assistance of two staff with ADLs and had frequent bladder incontinence. The Skin/PU Care Plan, dated 09/16/20, directed staff to assist or remind the resident to elevate her legs while sitting. The 09/30/20 update documented a PU to the resident's right outer heel and directed staff to provide treatment per physician orders. The 10/14/20 update documented a PU to the resident's right buttock and directed staff to monitor the wound for infection, provide treatment per physician orders, and assist the resident to reposition every hour to promote healing of buttock wound. The Skin Assessment, dated 09/16/20, documented blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation) redness on midline buttock. The Braden Scale Assessment, (scale to determine pressure ulcer risk) dated 09/17/20, recorded a score of 15 (12 or less indicated high risk), indicating the resident not at mild risk for developing a PU. The Physician Order, dated 09/24/20, directed staff to administer Ensure (dietary supplement) twice daily (BID) for weight loss. The Skin Assessment, dated 09/26/20, (10 days later) documented blanchable redness to midline buttock, cause other, and staff applied barrier cream. The Skin Assessment, dated 09/30/20, (14 days after admission to the facility) documented an unstageable (full thickness skin or tissue loss with unknown depth) PU to outer right heel that measured 2.0 centimeter (cm) x 1.0 cm x unable to determine depth (UTD). The PU had eschar (dead skin) and intact skin with a dark purple center. The Physician Order, dated 10/01/20, directed staff to provide Juven (wound healing supplement) packet BID, Vitamin C (essential nutrient involved in the repair of tissue) 500 milligrams (mg) BID, and Zinc (nutrient important for wound healing) 50 mg daily. Apply Alevyn (brand name wound dressing for wounds with drainage) dressing to outer right heel, change every five days and as needed (PRN). The Nutrition Note, dated 10/06/20, documented the registered dietician (RD) recommended liberating the resident's diet due to poor appetite. The Skin Assessment, dated 10/03/20, documented the outer right heel wound measured 2.0 cm x 1.0 cm x UTD. The assessment lacked a description of the wound characteristics. The Progress Note, dated 10/10/20 at 10:55 AM, recorded the nurse reported wound concerns to the charge nurse who faxed the physician requesting orders for wound care evaluation and treatment. The Skin Assessment, dated 10/11/20, documented the resident had a new heart shaped Stage 2 facility acquired PU on her right buttock that measured 2.0 cm x 2.0 cm, with granulation (new tissue formed during wound healing) tissue, and light brown drainage. The assessment documented the physician notified by staff. The Skin Assessment, dated 10/14/20, documented the right buttock PU measured 2.5 cm x 1.0 cm, appeared superficial, with minimal brown drainage. The Skin Assessment, dated 10/14/20, documented the outer right heel wound measured 2.0 cm x 2.3 cm x UTD and appeared as a closed large soft yellowish colored blister. The Skin Assessment, dated 10/17/20, documented the right buttock wound measured 2.5 cm x 1.0 cm, superficial, and healing. The Skin Assessment, dated 10/17/20, documented the outer right heel wound measured 2.0 cm x 2.3 cm x UTD. The assessment lacked a description of the wound characteristics. The Braden Scale Assessment, dated 10/20/20, recorded a score of 12 (high risk). The Progress Note, dated 10/24/20, documented the resident refused a skin assessment. The Skin Assessment, dated 10/31/20, (14 days later) documented the outer right heel wound measured 2.0 cm x 2.3 cm intact, movable. The assessment lacked a description of the wound characteristics. The Skin Assessment, dated 10/31/20, (14 days later) documented the healing right buttock wound open to air, area red, and blanchable. The Progress Note, dated 11/05/20 at 09:59 AM, recorded nursing sent a fax to the physician with an update on the PU to outer right heel which measured 2.0 x 2.3 x UTD with intact yellow raised skin, wound edges blanchable, painful to touch, and no drainage. The right buttock wound measured 2.5 x 1.0 cm healing, blanchable and peeling, and open to air. The Skin Assessment, dated 11/07/20, documented the healed right buttock wound with peeling skin, and open to air. The Skin Assessment, dated 11/07/20, documented the outer right heel wound measured 2.0 cm x 2.3 cm, intact, and movable. The assessment lacked a description of the wound characteristics. On 11/05/20 at 11:36 AM, observation revealed R59 in a wheelchair in her room with an air cushion in the wheelchair, air mattress on bed, and other cushions in recliner and chair. R59 wore open back house slippers and rested her feet on the wheelchair footrests. On 11/10/20 at 07:50 AM, observation revealed R59 in bed on her back, arm over her eyes, and large black pressure offloading booties in a chair. On 11/10/20 at 09:40 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N provided morning cares. Licensed Nurse (LN) I performed wound care with appropriate infection control. LN I used wound cleanser and gauze to clean the right outer heel wound which measured approximately 2.0 cm x 1.5 cm. The open wound appeared dry with 50% slough (dead tissue, usually cream or yellow in color) and a small 0.5 cm round dry area on the upper back of heel. LN I applied Alevyn foam to cover both areas and instructed the aides to ensure R59's heels were floated. On 11/10/20 at 10:00 AM, CNA M stated staff should have ensured the pillow was under R59's legs to float her heels. CNA M stated the resident used to wear the black booties, but the Velcro scratched her legs. On 11/10/20 at 09:50 AM, Administrative Nurse E stated nurses were to perform weekly skin assessments and verified weekly skin assessments for the facility acquired PU on the resident's outer right heel and right buttock were not completed. Administrative Nurse E stated she expected nurses to ask the resident at least daily until the resident agreed to allow them to perform the skin assessment and expected staff to float the resident's heels if not using the foot protectors. R59's physician was unavailable for interview. The facility's Prevention of Pressure Injuries Protocol policy, dated December 2019, documented the facility should have a system to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported, and addressed. Skin would be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated. The facility's Pressure Injury Assessment and Treatment policy, dated December 2019, documented staff were to complete skin risk and general skin assessment upon admission and then weekly. If the resident refused the treatment, notify the supervisor, document family and physician notification of refusal, explain the risks of refusing the treatment. The facility failed to ensure R59's heels were offloaded of pressure when in bed and perform timely skin assessments for R59, at risk for PU, and developed a facility acquired unstageable PU to her outer right heel and a Stage 2 PU to her buttocks, placing the resident at risk for infection.

The facility had a census of 93 residents. The sample included 20 residents, of which 4 residents were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) . Based on observation, record review and interview the facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers from developing for 4 of 4 sampled residents. (#27, #18, #30, #71) Resident #27 developed two avoidable facility acquired stage 2 pressure ulcers (open, shallow wound with a red or pink wound bed) and two avoidable facility acquired stage 3 pressure ulcers ((full thickness tissue loss with possible slough (dead tissue)) on his/her bilateral feet and developed 2 new open areas on the top of his/her right foot. Resident #71 redeveloped 2 facility acquired pressure ulcers on his/her buttocks. Resident #18 developed a stage 3 pressure ulcer on his/her right shoulder. The facility failed to provide individualized care plan interventions to prevent pressure ulcers for Resident #30, who had a history of [REDACTED]. Findings included: - Review of Resident #27's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 09/06/17, recorded the resident required extensive staff assistance with bed mobility and transfers, was at risk for the developing pressure ulcers, and had one stage 2 pressure ulcer. The MDS recorded the resident had pressure reducing devices on his/her bed and chair, was on a repositioning program, and received ulcer care. The quarterly MDS assessment, dated 12/05/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 15 (cognitively intact). The MDS also recorded the resident required extensive 1 staff assistance with bed mobility, transfers and walking, and used a wheelchair for mobility. The MDS further recorded the resident had 1 unstageable pressure ulcer ((not stageable due to wound bed covered with slough or eschar (dead tissue covers the wound)), that was not present on the 09/06/17 MDS assessment. The 03/08/17 admission (CAA) Care Area Assessment for pressure ulcers recorded the resident was at risk for the development of pressure ulcers due to immobility and a history of pressure ulcers on his/her feet. The 06/05/17 Braden Scale assessment (determines the risk to develop pressure ulcers) recorded the resident's score was 18 (at risk). The 07/18/17 care plan recorded the resident had a history of [REDACTED]. The care plan directed staff to provide extensive staff assistance with bed mobility and transfers, and place pressure reducing devices on the resident's bed and chair. The 11/10/17 weekly skin assessment recorded the resident had no skin issues on his/her feet. The 11/17/17 weekly skin assessment recorded the resident had skin trauma (bruising) on his/her right lateral heel and a callus (thickening and enlargement of hardened layers of skin) on left medial side bunion (abnormal enlargement at the base of the big toe). The assessment directed staff to apply skin prep (solution that forms a protective waterproof barrier) to the resident's skin issues until healed. The 12/01/17 at 2:21 PM, nurse's note recorded the resident had skin issues on both feet and the resident stated he/she rubbed his/her feet on the mattress at night. The nurse's note recorded staff placed Prevalon boots (padded, pressure reducing boots) on both of the resident's feet at night. The 12/01/17 care plan update directed the staff to place Prevalon boots on the resident's feet, while the resident was in bed. The 01/01/18 weekly skin assessment recorded the resident had skin trauma to the right lateral (pertaining to the side, away from the middle) heel and a reddened right bunion below the great toe. The assessment directed staff to apply skin prep to the resident's skin issues until healed. The 01/18/18 care plan update recorded the resident had stage 2 and stage 3 pressure ulcers on his/her bilateral feet and directed staff to report worsening changes or new pressure ulcers to the wound nurse. The care plan directed staff to provide the resident's pressure ulcer treatments as ordered by the physician and notify the physician, if the pressure ulcers worsen. The care plan recorded the resident refused all supplements, despite risk education from staff. The 01/22/18 weekly skin assessment recorded the following skin assessments: 1) Skin trauma to the right lateral heel had dry eschar (dry, dead tissue) in the middle and a small amount yellow drainage. The wound measured 1.2 (cm) centimeter by 1.4 cm. 2) Reddened bunion at the base of the right great toe measured 1.6 cm by 1.6 cm. 3) Wound on the inner right great toe had slough and measured 1.0 cm by 0.8 cm. The 01/22/18 physician's orders [REDACTED]. The 01/25/18 wound clinic progress note recorded the following skin assessments: 1) Right metatarsal head (instep and bunion area) had a stage 2 pressure ulcer that measured 0.7 cm by 1.0 cm by 0.1 cm deep. Post debridement (medical removal of dead, damaged or infected tissue to improve the healing potential for remaining healthy tissue) the wound was a stage 3 pressure ulcer. 2) Right lateral great toe had a stage 3 pressure ulcer that measured 0.8 cm by 0.5 cm by 0.1 cm deep. 3) Left heel had a stage 2 pressure ulcer that measured 0.7 cm by 0.7 cm by 0.1 cm deep. 4) Left metatarsal head (instep and bunion area) had a stage 2 pressure ulcer that measured 0.5 cm by 0.5 cm by 0.1 cm deep. The progress note recorded the wound clinic obtained a tissue culture (laboratory test to detect infection) from the resident's right metatarsal wound, and ordered [MEDICATION NAME] (antibiotic medication), 100 (mg) milligrams, twice a day for 7 days, for the resident's wound infection. The progress note directed staff to cleanse the resident's wound with wound cleanser daily, apply [MEDICATION NAME] (soft, sterile, non-woven pad or ribbon dressing use to absorb wound drainage), foam, gauze, and secure with tape. The progress note further directed staff to apply Prevalon boots to the resident's bilateral feet (ordered clarified on 02/27/18). The 01/25/18 (CBC) Complete Blood Count (laboratory blood test) recorded an elevated white blood cell count (indicates increased production to fight infection). The 02/12/18 physician's progress note recorded the resident's stage 3 pressure ulcers continued to have drainage and the physician ordered [MEDICATION NAME], 100 mg, twice a day for 7 days. The 02/13/18 laboratory test recorded a low [MEDICATION NAME] level (blood test used to measure the amount of protein in the blood to determine a person's nutritional level) of 2.6 (normal range 3.4 - 5.0). The 02/13/18 physician's orders [REDACTED]. Review of the resident's medical record lacked documentation the facility had a system to monitor the resident's supplement intake. The staff recorded administration of the resident's supplement on the (MAR) Medication Administration Record, [REDACTED]. The 02/19/18 weekly skin assessment recorded the following: 1) Left bunion pressure ulcer had a small amount of serosanguineous drainage (semi-thick reddish drainage) and measured 0.6 cm by 0.7 cm x 0.2 cm deep. 2) Right inner great toe pressure ulcer had a moderate amount of serosanguineous drainage and measured 1.4 cm by 0.7 cm by 0.2 cm deep. 3) Right bunion pressure ulcer had a moderate amount of serosanguineous drainage and measured 3.5 cm by 1.8 cm by 0.1 cm deep. 4) Right heel pressure ulcer had a small amount of serosanguineous drainage and measured 0.5 cm by 0.5 cm by 0.2 cm deep. The 02/27/18 at 6:37 PM, nurse's note recorded the resident had a new area on the top of his/her right foot, which measured 1.4 cm by 1.6 cm, and contained two areas of eschar. The nurse's note included documentation of a physician's orders [REDACTED]. The 02/27/18 weekly skin assessment recorded the following: 1) Left bunion pressure ulcer had a small amount of serosanguineous drainage and measured 0.8 cm by 0.8 cm x 0.2 cm deep. 2) Right inner great toe pressure ulcer had a moderate amount of serosanguineous drainage and measured 1.0 cm by 0.5 cm by 0.1 cm deep. 3) Right bunion pressure ulcer had a moderate amount of serosanguineous drainage and measured 2.8 cm by 1.8 cm by 0.1 cm deep. 4) Right heel pressure ulcer had a small amount of serosanguineous drainage and measured 0.3 cm by 0.4 cm by 0.2 cm deep. 5) Right foot medial (middle) top has 2 areas of eschar in an area that measures 1.4 cm by 1.6 cm. Review of the resident's medical record lacked documentation staff initiated interventions to protect the resident's foot wounds during the day, other than socks when the resident was in his/her wheelchair. On 02/20/18 at 4:32 PM, observation revealed the resident sat in a wheelchair, with socks on both feet, and his/her feet on the floor. Continued observation revealed the resident used his/her feet to propel the wheelchair in his/her room. On 02/21/18 at 9:46 AM, observation revealed the resident sat in a wheelchair, with socks on both feet. The resident's left foot rested on the horizontal metal support of an over bed table and the right foot was on the floor. On 02/26/18 at 7:57 AM, observation revealed the resident sat in a wheelchair at the dining room table, with socks on both feet. The resident's feet rested on the horizontal metal table leg. On 02/26/17 at 8:45 AM, observation revealed the resident sat in a wheelchair, in his/her room and Nurse K changed the resident's pressure ulcer dressings. The inner right great toe dressing had a small amount of serosanguineous drainage, the right heel dressing had a small amount of serosanguineous drainage, the right bunion dressing had a moderate amount of serosanguineous drainage and the left bunion dressing had a small amount of serosanguineous drainage. The pressure ulcers had no odor or signs of infection. Continued observation revealed 2 open areas, with surrounding reddened skin, on the top of the resident's right foot. The lower open area measured approximately 0.5 cm and the upper open area measured approximately 1.0 cm. Nurse K verified the wounds were present (developed in the facility) for several days and were treated with skin prep. On 02/26/18 at 11:54 AM, observation revealed the resident sat in a wheelchair at the dining room table, with socks on both feet, and the resident's feet rested on the horizontal, metal table leg. On 02/26/18 at 2:30 PM, observation revealed the resident, sat in a wheelchair, in his/her room reading a book. Continued observation revealed the resident had socks on both feet, and the resident's feet rested on the horizontal, metal support of an over bed table. On 02/28/18 at 7:33 AM, observation revealed the resident sat in a wheelchair in his/her room, and Administrative Nurse G assessed the resident's top right foot wound area. Continued observation revealed an approximately 0.5 cm eschar covered wound, an approximately 1.0 cm eschar covered wound, and the surrounding area with reddened skin. Administrative Nurse G verified the wounds were new since his/her last skin assessment several days ago. On 02/26/18 at 9:01 AM, Nurse K stated the resident had multiple pressure ulcers on his/her feet and staff provided treatments as ordered by the physician and wound clinic. Nurse K stated the resident wore socks on his/her feet during the day and usually spent most of the day in his/her wheelchair. Nurse K further stated the wounds on the top of the resident's right foot developed several days ago, staff treated the wounds with skin prep, and he/she thought staff notified the wound nurse. On 02/26/18 at 2:27 PM, Nurse Aide R stated the resident had multiple pressure ulcers on his/her feet, wore socks during the day, and spent all day in his/her wheelchair. On 02/27/17 at 7:44 AM, Nurse L stated the resident had multiple pressure ulcers on his/her feet, wore socks during the day, and spent most of the day in his/her wheelchair. He/she stated the resident's heels were floated when the resident rested them on the metal table leg. On 02/27/18 at 9:11 AM, Administrative Nurse G stated the resident had multiple pressure ulcers on his/her feet, the resident's wounds were evaluated and treated at the wound clinic, and staff provided treatments as ordered by the wound clinic. Administrative Nurse G stated the resident wore Prevalon boots at night due to rubbing his/her feet on the bed, which probably contributed to the development of the resident's pressure ulcers. Administrative Nurse G stated the resident wore socks on his/her feet during the day, spent most of the day in his/her wheelchair, and staff had not implemented pressure relieving footwear for the resident during the day. Administrative Nurse G stated staff did not inform him/her of new wounds on the top of the resident's right foot. On 02/27/18 at 10:11 AM, Nurse Aide S stated the resident had pressure ulcers on his/her feet, wore socks on his/her feet during the day, and spent most of the day in his/her wheelchair. Nurse Aide S stated he/she observed the resident with his/her feet on the dining room table and over bed table legs many times. On 02/27/18 at 1:45 PM, Administrative Nurse C stated the resident had pressure ulcers on both feet, received evaluation and treatment at the wound clinic, and staff provided the resident's wound treatment as directed by the wound clinic. Administrative Nurse C stated the resident wore socks during the day and staff did not implement pressure relieving footwear to protect the resident's pressure ulcers or prevent the development of new pressure ulcers. On 02/28/18 at 7:37 AM, Administrative Nurse G stated the wounds on the top of the resident's right foot were new since the resident's last skin assessment several days ago and staff should have reported the resident's new wounds immediately. Administrative Nurse G stated the resident had an appointment at the wound clinic the next day and the wound clinic would determine the origin or type of wound. Administrative Nurse G stated the wounds were probably pressure ulcers and assessed as unstageable due to the eschar on top of the wound. The facility's 01/2018 Pressure Ulcer Prevention Policy directed staff to identify risk for pressure ulcer development and implement specific interventions to address those risks. The facility's 01/2018 Pressure Ulcer Treatment Policy recorded pressure ulcer treatment requires a comprehensive approach and directed staff to implement interventions to protect residents' pressure ulcers. The facility failed to provide necessary treatment and services to promote healing or prevent new pressure ulcers from developing for Resident #27, who had two avoidable facility acquired stage 2 pressure ulcers, two avoidable facility acquired stage 3 pressure ulcers, and developed 2 new avoidable open areas on the top of his/her right foot. The staff had not implemented interventions to protect the resident's foot wounds during the day, other than socks when the resident was in his/her wheelchair. - Resident #71's physician's orders [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 10/18/2017, documented the resident had a (BIMS) Brief Interview for Mental Status score of 12, indicating intact cognition. The MDS documented the resident required extensive assistance of 2 staff with (ADLs) Activities of Daily Living, including bed mobility, transfers, locomotion on and off the unit, and personal hygiene. The MDS documented the resident was at risk for pressure ulcers, had a pressure reducing device to his/her chair, but not on the bed, and had no pressure ulcers. The quarterly MDS, dated [DATE], recorded the resident had a (BIMS) Brief Interview for Mental Status of 5, indicating severely impaired cognition. The MDS documented the resident required extensive assistance of 2 staff with ADLs, including transfers, toilet use, locomotion on and off the unit, and required extensive assistance of 1 staff for bed mobility and personal hygiene. The MDS recorded the resident had a pressure reducing device for his/her chair, but not the bed, nutrition or hydration interventions, applications of ointment other than to feet, and had two - Stage 2 pressure ulcers. The 5/13/2017 (CAA) Care Area Assessment summary for skin indicated the resident was at risk for skin breakdown and pressure ulcers due to his/her incontinence, history of pressure ulcers, decreased mobility, and required extensive staff assistance with most ADLs. The 1/16/2018 care plan instructed the staff to inspect the resident's skin for signs of breakdown and notify the physician of any new skin issues. The care plan instructed the staff to place a gel cushion in his/her wheelchair and recliner, and assist the resident to reposition every two hours. The 10/13/2017 Braden scale (predicting pressure ulcer risk), documented a score of 19. (19-23 represents no risk) The 1/04/2018 quarterly dietary assessment nutritional services note documented the resident's height was 69, weighed 229#, meal intake of 50-100%, received no supplements, and was independent with eating his/her meals. The notes documented will not refer to the registered dietician for evaluation. The medical record lacked documentation the registered dietician made any recommendations after the resident developed the two Stage II pressure ulcer on 1/22/2018. The 1/22/2018 skin/wound assessments documented the resident had a reoccurring area to his/her right and left buttocks below the coccyx (small triangular bone at the base of the spine). The assessment documented ridges of old scarring to the area, on the right measured 2.0 (cm) centimeters by 1.8 cm, and the left measured 2.5 cm by 1.8 cm, the notes documented the area had red shearing (forces moving in opposite directions are applied to tissue in the body) underneath with a small amount of bleeding. The note's documented staff covered the wound with a dry dressing, secured with tape, and were to change twice a day until healed. The medical records documented the staff requested an order for [REDACTED]. The 1/28/2018 wound note documented the nurse observed the area to the bilateral sides of the resident's coccyx. The area continued open with a moderate amount of serosanguanous (wound discharge that contains both blood and thin watery liquid) drainage. The note documented the upper right side measured 1.0 cm by 6.0 cm by 1.0 cm depth, the lower right side measured 1.0 by 6.0 by 1.0 cm, and the left side measured 3.0 cm by 5.0 cm by 1.0 cm. The note documented staff cleansed the wound and applied collagen (the main protein found in skin and other connective tissue), border dressings, and changed daily, but the area continued to have serosanguanous drainage, and had not improved as quick as anticipated. The 1/28/2018 facility fax documented the staff requested an order to change the treatment to [MEDICATION NAME] (a freeze dried collagen dressing, that is soft, [MEDICATION NAME], biodegradable/disintegration gel dressing that allows contact with all areas of the wound and maintains a moist environment at the wound surface). The physician approved the request and stated to add Zinc 50 (mg) milligrams, by mouth daily for 30 days. The 1/29/2018 facility fax to the physician requested to start [MEDICATION NAME] (a supplemental powdered drink designed to help with wound healing) three times a day, to help with wound healing. The physician stated to continue with wound cleansing, apply collagen with silver, add border dressings daily, change out the wheelchair and recliner cushion to a gel cushion to aid with pressure reduction. The 2/05/2018 wound note documented the nurse observed the reopened area to the right and left side of the coccyx. The note described the skin as macerated (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) with a heavy amount of sanguineous drainage and granulation (tissue formed during wound healing) present stage 2 pressure injury. The left side measured 4.5 cm by 1.5 cm by 0.2 cm and the right side measured 5.0 cm by 2.0 cm by 0.3 cm. The wound educator was present for the assessment and suggested to cleanse, apply collagen powder and silver calcium alginate (absorbent dressing derived from seaweed that provides a moist environment healing and the formation of tissue), cover with absorbent dry dressing and change daily until healed. The note documented the nurse faxed there physician with the request. The family was present during the assessment and would continue to encourage the resident to lay down and change positions, along with staff encouragement, since the resident preferred to be in the recliner. The note documented staff placed cushions in the recliner and wheelchair and initiated [MEDICATION NAME] for additional wound healing support as interventions. The resident denied pain unless staff touched or cleansed the area with toileting. The note documented staff would continue to monitor per facility policy, and update as needed. The 2/13/2018 wound note documented the nurse observed multiple areas to the right and left side of the coccyx so measurements enlarged to include surrounding peri wound area, the depth was decreased on the open area to less than 0.1 cm and documented to continue current treatment. The 2/21/2018 wound note documented the nurse requested a dressing change and the resident stated he/she did not feel well and did not want to get out of his/her recliner. The nurse reproached the resident after lunch and he/she again refused. On 2/27/2018 at 2:00 PM, observation revealed staff transferred the resident from his/her recliner, to the bed with use of a total body lift. Continued observation revealed Nurse G removed the resident's brief and cleansed his/her buttock wounds, the left buttock wound measured 3.8 cm by 3.6 cm by 0.2 cm, red wound bed, pink/purple colored and blanched (the skin turns white with pressure then as the blood flow returns to natural color). The right buttock wound measured 8.0 cm by 6.0 cm by <0.1, peri wound purple colored and blanched. Nurse G verified the resident had an order to cleanse the wound with soap and water and apply barrier cream. On 2/26/2017 at 11:00 AM, Nurse I verified the resident required a total body lift for transfers, and preferred to sit in his/her recliner and not the bed. Nurse I verified staff encouraged the resident to get out of the recliner and lay in bed to take pressure off his/her buttocks, however the resident would tell the staff no and refused to transfer to bed. On 2/27/2018 at 1:45 PM, Nurse G verified the resident redeveloped two facility acquired Stage II pressure ulcers on his/her buttocks on 1/22/2018. Nurse G verified the facility discussed the residents who had skin issues at each weekly stand up meeting, the nurse and the certified dietary manager discussed treatment, and implement new interventions, and the recommendation for this resident was to start [MEDICATION NAME]. Nurse G verified the Registered Dietician had not made any recommendations since the resident redeveloped the pressure areas. On 2/ 8 at 2:40 PM, Dietary Consultant GG verified he/she had not had any documented dietary interventions regarding the resident developing the new pressure areas after 1/22/2018. Dietary Consultant GG verified he/she had information the resident developed the pressure ulcer but lacked interventions. The facility's 1/2018 Pressure Ulcer prevention policy directed the staff to identify the residents at risk factors and interventions for specific risk factors. The policy documented pressure injury are often made worse by continual pressure, heat, moisture, irritating substance on the resident's skin, decline in nutrition and hydration status, acute illness and/or decline in the resident's physical or mental condition. The pressure injury are usually formed when a resident remained in the same position for an extended period of time causing increased pressure or a decreased or a decreased in circulation (blood flow) to that area and subsequent destruction of tissue. The facility failed to develop and implement timely and effective interventions, weekly wound assessments, registered dietician's interventions, to prevent the redevelopment of 2 facility acquired pressure ulcers on Resident #71's buttocks, placing the resident at risk for skin breakdown and infection. - Resident #18's (POS) physician's orders [REDACTED]. The annual (MDS) Minimum Data Set assessment, dated 2/24/17, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. The assessment revealed the resident needed limited assistance of 1 staff for bed mobility, transfers, toilet use, personal hygiene, and had impairment of functional range of motion of upper and lower extremities on one side. The MDS recorded the resident was not at risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The 3/2/17 (CAA) Care Area Assessment for pressure ulcers, recorded the resident was not at risk for pressure ulcers as evidenced by a Braden scale (a standardized test to assess a patient's risk for developing a pressure ulcer), adequate nutritional intake, was able to reposition him/herself, and a nurse completed a skin assessment weekly, and reported findings to the physician. The quarterly MDS, dated [DATE], recorded the resident had a BIMS of 4, indicating severe cognitive impairment. The assessment recorded the resident needed extensive assistance of 1 staff for bed mobility, dressing, toilet use, personal hygiene, had impairment of functional range of motion of upper and lower extremity on one side, and was at risk for pressure ulcers. The MDS did not record the presence of a pressure ulcer. The 12/13/17 care plan recorded the resident had an air mattress, and directed staff to inspect the resident's skin for signs and symptoms of breakdown. He/she was at risk for skin issues due to diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The care plan recorded the resident liked to lay on his/her right side, and instructed staff to monitor for bruising because the resident received aspirin. The care plan update on 2/5/18, recorded the resident laid on his/her right side and had an area of pressure to his/her posterior (back) right shoulder. The update instructed staff to provide assistance to the resident to change positions frequently, and apply treatment as physician ordered. The 1/10/18 skin evaluation documented the resident's right shoulder had a red circle area with a second circle inside, pink colored, and included 2 white spots, which measured 2.2 (cm) centimeters in length x 2.5 cm in width. The 1/10/18 interdisciplinary note documented the resident had a new issue identified during the skin check. The in-house wound consultant and medical director observed the resident's right shoulder area, documented cause was unknown, not pressure related, and ordered [MEDICATION NAME] (an antibacterial used to treat skin infections) apply daily, until healed. The 1/15/18 interdisciplinary note recorded, a new order to discontinue the [MEDICATION NAME] and to start [MEDICATION NAME] (used to treat fungal skin infections) topical cream, 2 times a day for 14 days, and to call if no improvement in 7 days. The note recorded staff notified the resident's representative. The 1/17/18 skin evaluation documented a red area to the resident's right shoulder. Inside of the red area was a circle of slightly different colored (pink) skin with white spots on it. The 1/21/18 Braden Scale score was 13, criteria of a score of 12 or less considered the resident was at risk for pressure ulcer development. The 1/24/18 skin evaluation documented a red area to the right shoulder. Inside the red area was a circle of a slightly different color (pink) and the white spots were gone. The 1/31/18 skin evaluation documented the red area to the right shoulder remained red, inside the red area was a circle of slightly different color (pink), and a 0.3 cm x 0.3 cm area that had a tint of green to it. The red area measured 2.2 cm x 2.5 cm. The 2/2/18 response from the physician questioned if the resident had a fever, what was the status of the surrounding redness, if the wound was open, and if there was drainage from the wound. The physician ordered staff to resume the [MEDICATION NAME] cream for 14 days, but to advise further in regards to the questions and the resident may need an appointment with the physician. The 2/5/18 skin evaluation documented a full thickness wound, pressure ulcer, with reddened open area to the posterior right shoulder, white slough (dead tissue, usually cream or yellow in color) center which measured 1.2 cm x 0.8 cm x <0.1 cm depth. It was purple/blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation), the periwound (skin surrounding an injury), measured 1.2 cm x 0.8 cm with slough and, light clear drainage, and was a stage 3 (bed sore pressure sore or decubitus ulcer extends into the underlying subcutaneous tissue layer, but not all the way to the bone) pressure ulcer. The 2/5/18 wound care evaluation recorded the posterior right shoulder wound, onset date of 1/5/18, was a facility acquired full thickness pressure ulcer, stage 3, that measured, 1.2 cm x 0.8 cm x <2 cm with serous (clear) drainage. The evaluation documented the wound bed was 30% red, healthy granulation (new connective tissue and microscopic blood vessels that form on the surface of a wound during the healing process), 70% yellow proteinceous (adjective form of protein) tissue, and the periwound was firm and had well defined edges. The wound evaluation recorded daily dressing changes in order to monitor the fragile periwound and to ensure no further breakdown occurred. An absorbent dressing was indicated to provide a semi occlusive covering, to facilitate autolytic (the destruction of a cell through the action of its own enzymes) debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining he (TRUNCATED)

The facility had a census of 94 residents. The sample included 22 residents of which 5 were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to administer medication as ordered by the physician to prevent a significant medication error for 1 of 5 (#28) sampled residents. Resident #28 received double the dose ordered of an antibiotic, which resulted in critical high lab values and hospitalization for treatment. Findings included: - Resident #28's [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/19/16, indicated the resident had intact cognition and required limited assist of 2 staff for walking, toileting, bathing and limited assist of 1 staff for bed mobility and transfers. The MDS did not indicate the resident received any antibiotics during the look back period. The 2/12/16 care plan did not address the resident's infection, antibiotic use, or renal function. The 1/20/16 physician's orders [REDACTED]. The physician's orders [REDACTED]. The 1/20/16 physician's progress note indicated physician had seen the resident in the facility on 1/20/16, continued current medications and ordered Bactrim single strength, twice a day for 1 month. On 1/22/16, the pharmacy delivered Bactrim DS (double strength) and staff administered the first dose to the resident at 9:00 PM. The resident received Bactrim DS (double the ordered dose) twice daily on 1/23/16 through 2/8/16 (17 consecutive days). The 1/25/16 at 12:51 PM, nurse's notes indicated the physician ordered a (BMP) Basic Metabolic Panel (blood test that measures the body's kidney function) in two weeks. On 1/26/16 at 1:30 PM, the nurse's notes indicated the resident had complaints of not feeling well, had diarrhea (loose, watery stools), had complaints of feeling tired and his/her neck hurting. On 1/27/16 at 2:02 AM, the nurse's notes indicated the resident had complaints of an upset stomach. On 2/8/16, routine lab orders for a BMP were drawn. The lab results indicated the resident had a critical high level of Creatinine at 4.6 (mg) milligram per (dL) deciliter, with normal test result parameters 0.5-1.0 mg/dL. Creatinine levels measure kidney function, abnormally high levels can indicate kidney failure. The BMP further indicated the resident's potassium level was elevated at 5.4 (mmol) millimole per (L) liter, with normal test result parameters of 3.8-5.2 mmol/L. Potassium levels in the blood is critical to the function of nerve and muscle cells, including heart muscles. On 2/8/16 the physician directed staff to send the resident to the emergency room due to critical high Creatinine levels. Symptoms of high creatinine levels may include feeling dehydrated, fatigue, swelling, shortness of breath, confusion or other non-specific symptoms such as nausea, vomiting, and dry skin. The 2/8/16 hospital (H&P) History and Physical indicated the resident came into the emergency department after outpatient labs showed acute [MEDICAL CONDITION] (an abrupt decline in kidney function) and [MEDICAL CONDITION] (high potassium). Further blood tests were taken in the emergency department that reflected the resident's Creatinine level was further increased at 4.98 mg/dL and potassium further elevated at 6.4 mmol/L. The H&P further indicated the resident reported some complaints of generalized weakness, had a history of [REDACTED]. The H&P further indicated the acute [MEDICAL CONDITION] and [MEDICAL CONDITION] may be in part secondary to the resident's Bactrim with [MEDICAL CONDITION], and may be partially due to some hypovalemia (decreased volume of circulating blood in the body). The resident admitted to the hospital and the physician discontinued his/her Bactrim. The resident remained hospitalized from [DATE] through 2/12/16 and returned to the facility on [DATE] with his/her Creatinine levels back to his/her baseline. The 2/17/16 physician's progress note indicated the resident recently admitted to the hospital for acute [MEDICAL CONDITION] due to accidentally receiving Bactrim double strength instead of the Bactrim single strength the physician ordered. The progress note further indicated the facility verified the order was written correctly and sent to the pharmacy correctly, however the pharmacy sent the wrong dosage and the medication technician giving the medications did not know that there was a difference to look for between the Bactrim and the Bactrim DS. On 7/5/16 at 11:13 AM, Administrative Staff L verified the resident received the wrong dosage of Bactrim, and admitted to the hospital. He/she further stated once the facility was made aware of the medication error, the facility had investigated the cause of the error, self-reported the error to the state agency, provided education and training to all licensed nursing and Certified Medication Aide staff, including checking medications coming in from the pharmacy and correct medication administration, and conducted audits to prevent further medication errors. On 7/6/16 at 3:50 PM, Physician O verified the medication error of the resident receiving Bactrim DS, instead of single strength Bactrim, did contribute to his/her existing [MEDICAL CONDITION] by worsening it to acute [MEDICAL CONDITION], resulting in critical high creatinine levels and hospitalization . The facility's Administration of Medications policy, revised 10/30/2012, stated medications must be administered in accordance with the written orders of the ordering physician and prior to administering the resident's medication the nurse should compare the drug and dosage schedule on the resident's Medication Administration Record [REDACTED]. The facility failed to prevent a significant medication error when staff failed to administer Resident #28's antibiotic as physician prescribed (administered double the ordered dose), which resulted in the resident having critical lab values and admission to the hospital for [MEDICAL CONDITION].

The facility had a census of 90 residents. The sample included 22 residents. Based on observation, record review and interview the facility failed to implement effective interventions to prevent the development of pressure ulcers for 4 of 4 residents of which 2 developed osteo[DIAGNOSES REDACTED] (infection in the bone), Resident #4 and Resident #74, which put them in immediate jeopardy. (#4, #74, #116, #121) Findings included: - Resident #4's (POS) Physician order [REDACTED]. blood as well as it should). The admission (MDS) Minimum Data Set assessment, dated 2/17/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 8 which indicated moderately impaired cognition. The assessment revealed the resident was dependent upon 2 staff assistance for bed mobility, transfers, dressing, and extensive assistance of 2 staff for toileting. The assessment further revealed the resident was at risk for pressure ulcers and had 2 stage 2 pressure ulcers (a loss of partial thickness of the outer layer of skin and may present as an intact fluid filled blister). The assessment revealed the resident had pressure relieving devices for the bed and chair, was on a turning and repositioning program, and received pressure ulcer care. The 14 day Medicare MDS, dated [DATE], indicated the resident had a (BIMS) Brief Interview for mental Status score of 9 which indicated moderately impaired cognition. The assessment revealed the resident was dependent on 2 staff assistance for bed mobility, toileting, transfers and extensive assistance of 1 staff for dressing and personal hygiene. The assessment further revealed the resident was at risk for pressure ulcers and had one stage 1 (skin appears reddened and does not blanch) pressure ulcer and 1 unstageable (the base of the sore is covered by a thick layer of other tissue that cannot be staged). The unstageable pressure ulcer measured 4.8 (cm) centimeter x 5.5 cm x 0.1 cm with eschar (dead tissue). The assessment revealed the resident had pressure relieving devices for the bed and chair, was on a turning and repositioning program, and received pressure ulcer care. The 2/23/15 (CAA) Care Area Assessment for pressure ulcers stated the resident admitted on [DATE] with a stage 1 pressure ulcer to his/her coccyx and had acquired a pressure ulcer to the left heel and right lateral malleolus (ankle bone) on 2/16/15. The assessment stated the resident was dependent upon staff for position changes. The 2/10/15 at 6:50 PM, admission nursing note indicated the resident came to skilled nursing after hospitalization . The 2/10/15 skin assessment indicated the resident was a moderate risk for skin breakdown. Review of the medical record revealed the facility failed to implement an admission care plan including interventions to prevent skin breakdown. The 2/17/15 care plan stated the resident's skin integrity would improve through next review but lacked or implemented skin interventions on admission for staff regarding the development of his/her skin breakdown on 2/16/15. The 3/1/15 care plan update (12 days later) directed the staff to use an air mattress to help prevent breakdown, to assist the resident to change positions frequently, every 1 to 2 hours to prevent pressure on bony areas, to monitor the existing pressure areas on his/her coccyx (lower extremity of the spinal column), left heel and right malleolus. The care plan directed staff to follow current physician orders [REDACTED]. The 2/16/15 weekly skin assessment revealed the resident had a 7 (cm) centimeter x 6 cm left heel blister and a reddened coccyx. (first documentation of skin breakdown on left heel) The 2/16/15 physician's orders [REDACTED]. The 2/17/15 at 4:17 PM, nurse's note stated the resident had a wound on his/her right malleolus (ankle bone) which measured 1 cm x 0.5 cm, and [MEDICATION NAME] (an absorbent foam dressing) applied. The 2/18/15 Nutrition Assessment, indicated the resident's meal intakes were 75-100%, and received a multivitamin and vitamin C which was adequate to help in wound healing. The 3/15/15 fax to the physician stated the facility requested an order for [REDACTED]. The 3/16/15 weekly skin assessment revealed the following measurements: -Left heel- 9 cm x 9 cm x 4 cm with a 5 cm x 4 cm dark area at the bottom of the heel and a 6 cm x 4 cm red area to the left side. -Right malleollus- 0.25 cm x 0.25 cm reddened. The note further indicated staff applied skin prep to the right malleollus. The 3/27/15 physician's orders [REDACTED]. The 3/30/15 physician's orders [REDACTED]. The 3/31/15 blood laboratory report revealed a total protein level of 5.1 low (6.4-8.2 normal) and an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) level of 2.1 low (3.4-5 normal). The 4/6/15 physician's orders [REDACTED]. The 4/20/15 weekly skin assessment revealed the left heel had a white wound bed with a dark brown area in the center, and no measurements provided. The 4/29/15 physician's progress note stated the resident's bone scan showed osteomylitis (an inflammation of the bone and bone marrow, usually caused by bacterial infection) and was to have I & D (incision and drainage) to his/her left heel with a possible partial ostectomy (surgical removal of a bone). The 5/5/15 at 10:47 PM, nurse's note indicated the resident returned from surgery with an intact dressing to his/her left heel and physician orders [REDACTED]. The 5/5/15 physician's orders [REDACTED]. On 5/6/15 at 10:51 AM, observation revealed the resident sat at the dining room table with his/her left foot bandaged with an ace wrap, and a sock on it. Further observation revealed the resident did not have any pressure relieving devices on either foot. Continued observation revealed the resident had ate all of his/her hot cereal, scrambled eggs and toast. On 5/7/15 at 2:30 PM, observation revealed the resident lying flat in bed with bilateral pressure relieving boots on, laying directly on the mattress. Continuous observation at 2:45 PM, 3:00 PM, 3:15 PM, 3:30 PM, 4:00 PM, 4:15 PM, 4:30 PM, revealed the resident continued lying flat on the bed with the bilateral pressure relieving boots flat on the mattress. The resident's heels were not offloaded per physician's orders [REDACTED]. On 5/7/15 at 3:20 PM, Licensed Nurse H stated the resident [MEDICAL CONDITION] (a Staph infection) in the heel wound and would not be able to look at his/her heel until his/her follow up appointment on 5/14/15. Licensed Nurse H verified there were no nursing interventions in place to prevent the breakdown in his/her heel. On 5/7/15 at 4:40 PM, Nurse Aide FF stated staff assisted the resident to bed after lunch, around 1:00 PM, and would not be getting his/her up for supper until around 5:00 PM. Nurse Aide FF verified the resident had not been repositioned since he/she had been laid down.(4 hours) On 5/12/15 at 2:45 PM, Administrative Nurse A stated the resident should be repositioned every 2 hours and no interventions were put in place prior to his/her skin breakdown. On 5/12/15 at 10:30 AM, Physician HH stated staff should have implemented interventions prior to the resident's skin breakdown, due to the resident at risk. Physician HH further stated the resident should be repositioned at least every 2 hours and the skin breakdown was avoidable. Physician HH stated the resident was sent to the wound clinic for treatment. On 5/14/15 at 9:00 AM, Physician Assistant II verified the osteomylitus was caused by the pressure ulcer on the resident's left heel and stated the skin breakdown was avoidable. The 4/28/2010 facility Prevention Protocol directed the staff to reposition the resident every 2 hours while in bed if he/she is a moderate to high risk for breakdown and a licensed nurse will complete a full body skin assessment within the first 24 hours of admission. The protocol further directed staff to initiate preventative measures even if no wound exists. The facility failed to implement effective interventions for Resident #4 who developed a facility acquired pressure ulcer on his/her heel, resulting in infection in the bone which required surgical intervention.This failure placed this resident in immediate jeopardy. The immediate jeopardy was abated on 5/15/15 at 10:57 AM, when the facility completed in- servicing on all nursing staff regarding wound and skin policies on prevention and treatment processes of skin and wound issues. Two nursing associates are inactive at this time and will received education prior to returning to active employment status. Documents used while providing the education were policies for Positioning in Bed, Prevention Protocol, Risk Assessment Screening, Skin Care Protocol, and form Skin Integrity Review. Education was provided by the Director of Nursing. The deficient practice remains at a scope and severity of a G - Resident #74's medical record revealed the facility readmitted the resident to skilled nursing on 2/6/15, from the hospital, due to pneumonia (infection of the lung). The (POS) physician order [REDACTED]. pressure ulcer (right heel pressure ulcer). The quarterly (MDS) Minimum Data Set assessment, dated 1/19/15, indicated the resident had a BIMS of 15 which indicated the resident had intact cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, eating and limited assistance of 2 staff for toileting and personal hygiene. The assessment further revealed the resident at risk, had a pressure reducing device for his/her chair, and a nutrition and hydration interventions but did not have any skin breakdown. The significant change MDS, dated [DATE], indicated the resident had a (BIMS) Brief Interview for Mental Status score of 15 which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff for toileting, transfers, and dependent on 2 staff for dressing and bed mobility. The assessment further revealed the resident had 1 unstageable pressure ulcer (full thickness skin or tissue loss, depth is unknown), a pressure reducing device for his/her chair, and nutrition and hydration interventions. The 4/17/15 (CAA) Care Area Assessment for pressure ulcer stated the resident had a recent decline in (ADL's) Activities of Daily Living, and was at risk for impaired skin integrity. The 2/8/15 care plan directed staff to float the resident's heels when in bed, wear gripper socks and no shoes but lacked direction to staff for repositioning of the resident. The 3/6/15 care plan update directed staff to keep the resident's legs elevated and to wear a provalon (pressure reducing) boot on the right foot at all times. (indicated for use by the wound clinic progress notes on 2/16/15). The updated 4/6/15 and 4/7/15 care plan directed staff to obtain an air mattress, provide wound care to the resident's heels daily, and change the resident's position from side to side only. The 2/6/15 skin assessment indicated the resident was at risk for pressure ulcers and directed staff to initiate appropriate interventions. The 2/6/15 readmission skin assessment indicated the resident had a 4.5 (cm) centimeter x 5 cm black area to his/her right heel. (No mention of this in the nurse's note on 2/6/15) The 2/8/15 at 3:49 AM, nurse's note stated the resident had a 4 cm x 5 cm eschar (a piece of dead tissue that is cast off the surface of the skin) area to the right heel. The note further stated staff implemented the facility protocol of skin prep application (liquid film-forming dressing), float the resident's heels, use gripper socks without shoes, and inform staff and physician. The 2/11/15 weekly skin assessment indicated the resident had a 4.5 cm x 4 cm black area to his/her right heel and a newly developed 0.5 cm x 0.5 cm darkened area to his/her left heel. The 2/11/15 physician's orders [REDACTED]. The 2/16/15 wound clinic progress note revealed the resident had bilateral heel ulcers for 2 to 3 weeks and stated the ulcers were from pressure. The note further stated wound clinic staff performed debridement (the process of removing nonliving tissue from pressure ulcers) of the right heel, applied a foam dressing, and ordered prevelon boots. (Which were not added to the care plan until 3/6/15) The 2/23/15 wound clinic progress note revealed the resident's right heel measured 4.2 cm x 3.2 cm x 0.1 cm and the left pressure ulcer with necrotic (dead) tissue, and slough (a mass of dead tissue). The note directed staff to place santyl (a sterile enzymatic [MEDICATION NAME] ointment) to the right heel, a foam dressing to the left heel, and stressed wearing the prevalon boots at all times.(still not added to the care plan) The 3/2/15 wound clinic progress note indicated the resident did not know if he/she had been wearing the prevalon boots at all times. The note further indicated the right heel measured 4.3 cm x 1.0 cm x 0.5 cm. (No mention of the left pressure ulcer) The 3/2/15 physician's orders [REDACTED]. The 3/9/15 wound clinic progress note indicated the right heel measured 3.1 cm x 2.5 cm x 0.3 cm and the left heel measured 0.5 cm x 0.5 cm x 0.1 cm. The note stated wound clinic staff debrided both of the ulcers and placed hydro fiber (highly absorbent) dressings on the resident's heels. The 3/14/15 physician's orders [REDACTED]. The 3/16/15 wound clinic progress note stated the resident did not seem to be wearing his/her prevolan boots as the tissue on the right heel was necrotic again. The note stated the resident must offload his/her heels and wear the prevolan boots. The 3/23/15 orthopedic clinic progress note indicated the resident had a large pressure ulcer over the right calcaneus and the resident was to wear the prevalon boots but family stated the resident often did not have on the boots when they visit. The note further stated the resident's right heel measured 3.5 cm x 2.4 cm x 0.2 cm. The 3/30/15 at 4:45 PM, nurse's note stated the resident admitted to a local hospital for acute [MEDICAL CONDITION] and elevated creatinine (a test of renal function). The 4/6/15 physician's readmission order directed staff to administer Cefepine, 500 mg, intravenously (administered into a vein), every 24 hours, [MEDICATION NAME], 350mg, intravenously, every 48 hours, both to end on 5/1/15. The order further directed staff to change the resident's position from side to side only, use [MEDICATION NAME] (a highly absorbent wound dressing), [MEDICATION NAME] (a foam wound dressing) to the right heel, and [MEDICATION NAME] (a topical antinfective) to the left heel, use prevalon boots, and obtain a specialty mattress. The 4/20/15 orthopedic clinic progress note indicated the resident had bilateral heel pressure ulcers. The 4/27/15 orthopedic clinic progress note indicated the resident's right heel measured 3.5 cm x 3.7 cm x 0.2 cm. The 4/28/15 new physician's orders [REDACTED]. The 4/29/15 orthopedic clinic progress note indicated the resident did not want surgery for [REDACTED]. The 5/4/15 skin assessment indicated the resident was at low risk for skin breakdown. The 5/11/15 orthopedic clinic progress note indicated the right heel measured 3.0 cm x 2.5 cm x 0.3 cm and directed the staff to continue to offload the resident's heels. Review of the medical record revealed the resident was compliant with cares. On 5/6/15 at 4:29 PM, observation revealed Licensed Nurse SS removed the old dressing on the resident's right heel and measured the wound at 3 cm x 2 cm. Licensed Nurse SS used Cara Klenz (wound cleanser), applied Santyl and wrapped the foot with gauze. Licensed Nurse SS stated staff change the dressing daily and administer intravenous medication for healing. On 5/7/15 at :30 PM, observation revealed the resident lying flat on his/her back with bilateral prevalon boots on his/her feet. (Not on his/her side as ordered) On 5/6/15 at 9:05 AM, Nurse Aide Z stated staff reposition the resident every 2 hours due to a pressure ulcer on his/her heel but did not realize the resident should be placed side to side only. On 5/11/15 at 10:30 AM, Physician HH stated staff should have had interventions in place to prevent the resident's skin breakdown as he/she was at risk. On 5/12/15b at 2:45 PM, Administrative Nurse A verified the resident acquired a pressure ulcer on his/her left heel at the facility and stated interventions should have been put into place due to the resident was at risk. On 5/14/15 at 9:00 AM, Physician UU stated the pressure ulcer was avoidable and the osteo[DIAGNOSES REDACTED] in the resident's right heel was caused by the pressure ulcer. Physician UU stated the facility should have had interventions in place. On 5/14/15 at 5:15 PM, Administrative Staff SS stated that although the resident did not acquire one of the pressure ulcers at the facility, the outcome of the resident's pressure ulcer was unacceptable. The 4/28/10 facility's Prevention Protocol for Skin and Wound Care directed staff to strive to prevent any skin breakdown through appropriate assessment and early intervention and to document in nurse's notes a summary of interventions and compliance of improvement or decline. The protocol further directed staff to educate the resident regarding pressure ulcers and relieve pressure on the resident's heels by using positioning devices to keep the resident's heels elevated off the bed. The facility failed to implement effective interventions for Resident #74 who developed a facility acquired pressure ulcer on the left heel and a bone infection in the right heel. This failure placed this resident in immediate jeopardy. The immediate jeopardy was abated on 5/15/15, when the facility completed in servicing on all nursing staff regarding wound and skin policies on prevention and treatment processes of skin and wound issues. Two nursing associates are inactive at this time and will received education prior to returning to active employment status. Documents used while providing the education were policies for Positioning in Bed, Prevention Protocol, Risk Assessment Screening, Skin Care Protocol, and form Skin Integrity Review. Education was provided by the Director of Nursing. The deficient practice remains at a scope and severity of a G - Resident #121's (POS) Physician order [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 3/6/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 13 which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff for bed mobility, transfers, and required extensive assistance of 1 staff for personal hygiene. The assessment further revealed the resident was at risk for developing pressure ulcers. The assessment revealed the resident had pressure relieving devices for his/her bed and chair, turning and repositioning, and pressure ulcer care. The 14 day Medicare (MDS) Minimum Data Set assessment, dated 3/13/15, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 14 which indicated intact cognition. The assessment revealed the resident required extensive assistance of 2 staff members for bed mobility, transfers, toileting, and extensive assistance of 1 staff member for personal hygiene. The assessment further revealed the resident had a stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure relieving devices for his/her bed and chair, turning and repositioning, and pressure ulcer care. The 3/11/15 (CAA) Care Area Assessment for pressure ulcer stated the resident required extensive assistance with 2 staff for bed mobility and transfers. The CAA further stated the resident had periods of confusion, needed a turning schedule, and weekly skin assessments. The 2/27/15 skin assessment indicated the resident was at low risk for breakdown. The 2/27/15 initial care plan indicated the resident did not have any skin breakdown and directed staff to encourage and assist with repositioning, and to place a cushion in the resident's wheelchair. The 3/17/15 care plan indicated the resident was on skin precautions due to a high risk for breakdown, reposition on frequent intervals, wear prevalon (pressure relieving) boots, keep the resident's heels offloaded, and to monitor the blister for changes. The 3/12/15 at 9:12 AM, nurse's note stated the resident had a 2.5 (cm) centimeter x 2.7 cm intact blister on the left heel. The note further stated staff advised the resident to float his/her heels while in bed and the resident was in bed most of the day due to increased fatigue. The 3/12/15 at 1:02 PM, physician's orders [REDACTED]. at all times, leave off the resident's shoes, and to ensure the resident wore prevalon boots. The 3/19/15 at 12:20 PM, nurse's note indicated the resident had a 1.3 cm x 1.0 cm x 0.1 cm deep open area to his/her right lower gluteal (buttocks), with some granulation tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound) but mostly slough (a mass of dead tissue separating from an ulcer). The note further stated staff cleansed the area with wound cleanser, and applied [MEDICATION NAME] (an absorbent dressing) to the wound bed, covered with an optiform (a non adhesive dressing). The 3/20/15 weekly skin assessment revealed the left heel blister was still intact and the resident had an open area to his/her buttocks. The 3/21/15 at 12:59 PM, physician's orders [REDACTED]. On 5/7/15 at 3:29 PM, Nurse Aide QQ stated the resident required total care staff and he/she did not remember if the resident had any skin breakdown. On 5/12/15 at 2:45 PM, Administrative Nurse A stated due to the resident's fragile state, staff should have implemented interventions for the resident's heels prior to the skin breakdown, and should have floated the resident's heels upon admission. The 4/28/2010 facility Prevention Protocol directed the staff to reposition the resident every 2 hours while in bed, and an individualized turning schedule may need to be developed and implemented, based on the resident's needs. The facility failed to implement effective interventions for Resident #121 who developed a facility acquired pressure ulcer on his/her heel and buttocks. - Resident #116's readmission (MDS) Minimum Data Set assessment, dated 3/20/15, indicated the resident had intact cognition, with a (BIMS) Brief Interview for Mental Status score of 13. The resident required extensive assistance of 1 staff with bed mobility, transfer, and toilet use. The MDS indicated the resident was at risk for pressure ulcers, no current pressure ulcers, on a turning/repositioning program, and received a diuretic (excess fluid medication). The 3/20/15 pressure ulcer (CAA) Care Area Assessment indicated the resident had episodes of confusion, a history of [MEDICAL CONDITIONS] (a condition with low heart output and the body becomes congested with fluid), and incontinent of urine and bowel at times. The 3/16/15 care plan directed staff to assess the resident's pain each shift, complete a weekly skin assessment, and monitor for increased [MEDICAL CONDITION] (accumulation of fluid in the tissues). The care plan had no interventions regarding pressure ulcer prevention. The 3/24/15 initial care plan update directed staff to reposition the resident on frequent intervals to avoid pressure areas. The 4/14/15 care plan update (5 days after staff identified a pressure ulcer on the resident's bottom) directed staff to place an air mattress on the bed, a cushion to the wheelchair, reposition the resident every 2 hours and dressing changes per protocol. The 4/17/15 care plan update directed staff to change the resident's position from side to side, due to the status of his/her pressure wound. Review of the medical record revealed the resident had a significant weight loss while hospitalized which indicated the resident was at severe risk for poor nutrition. On 2/22/15 the resident weighed 164 pounds and upon reentry to the facility on [DATE], the resident weighed 134 pounds (30 pound weight difference). The 3/13/15 Braden Skin Assessment (an assessment used to evaluate a resident's pressure ulcer risk) indicated the resident was at moderate risk for development of a pressure ulcer. The 3/24/15 Nutrition Assessment, indicated the resident had a weight loss since previous admission. The meal intakes varied between 25-100%, and the resident received Ensure Plus (a nutritional supplement), 1 can, three times a day for added calorie/protein. The medical record revealed no documentation the facility monitored the percent of Ensure Plus the resident consumed. The 4/2/15 blood laboratory report revealed a total protein level of 6.8 (6-8.3 normal) and an [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person's nutritional status) level of 2.3 low (3.4-5 normal). The 4/4/15 weekly skin assessment sheet, indicated the resident had no open areas. The 4/6/15 weekly skin assessment sheet indicated the resident had a blister on his/her left gluteal cleft (the groove between the buttocks). The 4/9/15 dietician progress note, stated the resident was to receive [MEDICATION NAME] (nutritional supplement) added to his/her food, at each meal, due to his/her varied oral intake and weight loss. Review of the meal intake for April and May revealed the resident consumed 0 - 100% of his/her meals. The progress note had no mention of the resident's pressure ulcer. The weekly skin assessment records revealed the pressure ulcer on the resident's left gluteal cleft with the following measurements: 4/9/15 at 9:34 AM 4 (cm) centimeter x 5.3 cm hardened raised area, with no opening. 4/9/15 at 4:58 PM 3 cm x 2 cm x 0.2 cm, open area with a reddened, hard 10 cm x 8 cm area around the pressure ulcer. 4/14/15 1 cm x 0.5 cm black area with a 2 cm x 2.5 cm red area around the pressure ulcer. 4/18/15 a silver dollar sized open blister. 4/25/15 no open area noted. 4/28/15 1.5 cm x 3 cm open area with a 5 cm x 5 cm red area around the pressure ulcer. 5/2/15 1.5 cm x 0.75 cm, x 0.2 cm open area. (The above assessments revealed no pressure ulcer stage identified) 5/8/15 2 cm x 1.5 cm x 2.5 cm open area beginning to tunnel, Stage 3 pressure ulcer, with foul smelling drainage. 5/10/15 2.2 cm x 2.1 cm x 2.2 cm open area with tunneling to wound bed sides with a dark red area around the pressure ulcer. (no pressure ulcer stage identified) The 5/8/15 at 9:24 AM nurses notes, stated change of position precautions were increased for the resident, to be in bed more, with weight bearing side to side, as shearing in the resident's chair was the cause of the pressure ulcer. On 5/7/15 at 2:49 PM, observation revealed the resident seated in his/her wheelchair in his/her room. Nurse B entered the resident's room with dressing change supplies. Nurse Aide C placed a gait belt on the resident and provided support as the resident stood up to the walker. Nurse B pulled down the resident's attend and revealed a dressing to the resident's left gluteal cleft. The attend had brownish spots on the area where the dressing was. Nurse B removed the dressing which had a small amount of light brown drainage, from the pressure ulcer. The pressure ulcer wound bed had yellowish mucous on the edges and the wound measured 2 cm x 1 cm. The nurse did not measure the depth of the wound. The skin around the wound was approximately 3 cm on each side and purple in color. On 5/11/15 at 11:32 AM, observation revealed Nurse D in the resident's room with dressing supplies to replace the resident's pressure ulcer dressing which had fallen off. The resident was lying on his/her bed on the right side. Nurse D pulled down the resident's attend and obtained a culture of the wound bed. Nurse D measured the wound at 2 2. cm x 1.7 cm x 1.4 cm depth and the wound bed with blood noted. The area around the pressure ulcer measured 4 cm x 4 cm and was a purplish red color. On 5/6/15 at 9:39 AM, Nurse B stated staff are to move the resident from side to side. Nurse B stated the resident does not eat very well. On 5/11/15 at 11:33 AM, Dietary Consultant Staff I stated he/she was not aware the resident had a pressure ulcer. On 5/11/15 at 4:35 PM, Nurse D stated the resident does not like to reposition and he/she does have pain when staff transfer and move the resident. Nurse D stated the resident's pressure ulcer had a foul odor yesterday and the wound was now tunneling. On 5/12/15 at 10:31 AM, Administrative Nurse A verified staff should have provided pressure ulcer prevention interventions when the resident readmitted from the hospital on [DATE]. On 5/12/15 at 11:43 AM, Nurse N stated he/she readmitted the resident to the facility on [DATE] and verified he/she did not update the resident's care plan. On 5/12/15 at 12:11 PM, Nurse Aide E stated he/she was unable to look in the computerized care plans to know how to provide care for the residents. Nurse Aide E stated he/she received report from the other aides when he/she comes on shift. On 5/12/15 at 4:42 PM, Dietary Staff M stated the (DON) Director of Nursing or (ADON) Assistant Director of Nursing gave him/her a wound report weekly and the resident was not on the report fo

The facility had a census of 90 residents. The sample included 22 residents. Based on observation, record review, and interview the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 5 of 6 residents sampled for accidents of which 3 received injuries. Resident #133 received a wrist fracture, #103 received a hematoma (localized swelling that is filled with blood) to the right side of his/her head, #76 received a hematoma to the back of his/her head. (#133, #103, #54, #76, #34) Findings included: - Resident #133's admission (MDS) Minimum Data Set assessment, dated 4/27/15, indicated the resident had short term memory problems with moderately impaired decision making skills. The assessment revealed the resident required supervision for walking in his/her room. The assessment revealed the resident had no upper or lower extremity impairment, and had no falls since admission. The 4/14/15 care plan indicated the resident would remain free of falls. There were no interventions or directions to staff to prevent falls. The updated 4/21/15 care plan indicated the resident received a wrist fracture from crawling out of the end of his/her bed, which was brought from home, and the bed could not be lowered to the floor for the resident's safety. The care plan update indicated staff needed to completed an evaluation of the resident's safety regarding the resident's personal bed. The 4/14/15 fall assessment indicated the resident was not at risk for falls. The 4/19/15 at 9:53 AM, nurse's note stated the resident had been up all night, but was in a private room. The note stated the resident was roaming throughout the neighborhood as if he/she had been looking for something. The 4/20/15 at 7:51 AM, nurse's note stated the resident had been awake all night, and scratched a staff member who had redirected him/her after going into another resident's room. The 4/20/15 at 10:19 PM, nurse's note stated the resident went behind another resident and slapped the resident on the back. The note further stated the resident had been going in and out of other resident rooms, staff had not been able to redirect him/her, and he/she had become verbally and physically aggressive. The note stated the resident had also punched a staff member in the face. The 4/20/15 at 10:35 PM, physician's orders [REDACTED]. The 4/21/15 at 4:45 AM, nurse's note stated the resident had been on 15 minute visual checks due to receiving Valium for behaviors. The note stated, at 4:10 AM, the resident fell out of the end of his/her bed. The note further stated the resident complained of severe pain and could not move his/her left arm. The note stated the resident was incontinent of urine, the nurse received a physician's orders [REDACTED]. The 4/21/15 at 11:17 AM, nurse's note stated the resident had a wrist fracture and would have surgery that day. The 4/21/15 X-ray report stated the resident had a left wrist fracture. The 4/22/15 hospital transfer sheet stated the resident had a distal radius percutanous left wrist fracture and directed the staff to keep the splint clean, dry and in place, use an ice pack as needed, and elevate the resident's arm. The 4/24/15 at 8:41 PM, nurse's note stated the resident was sent to a behavioral unit. On 5/6/15 at 1:20 PM, Nurse Aide DD stated he/she had been doing 15 minute visual checks on the resident, and had assisted another resident when he/she heard a noise. Nurse Aide DD stated the resident was laying on the floor, and had fallen off of the bed, which was really high off the floor. Nurse Aide DD further stated he/she assisted the nurse with the resident, and the resident was taken to the hospital. On 5/8/15 at 2:40 PM, Licensed Nurse EE stated the resident had received Valium earlier in the evening for behaviors, and had not slept for 3 days prior to his/her fall. Licensed Nurse EE stated the resident had tried to climb out of the end of his/her bed, which was approximately 3 feet off the floor, had complained of wrist and leg pain, and was taken to the hospital by EMS. On 5/12/15 at 2:45 PM, Administrative Nurse A stated the resident's bed that was brought from home should have been evaluated for safety by the facility. The 4/28/2010 facility Fall investigation and Management Policy stated the staff will investigate each fall that occurs to ensure that risk from falls is decreased for the individual resident. The facility failed to ensure the resident's environment remained free of accident hazards for Resident #133, who received a wrist fracture from a fall out of bed. - Resident #76's annual (MDS) Minimum Data Set assessment, dated 10/7/14, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 3, had severely impaired vision, and required extensive assistance from 2 staff for bed mobility, transfers, toilet use, and bathing. The MDS further indicated the resident's balance was unsteady, only able to stabilize with staff assistance, had a range of motion impairment on 1 side, used a walker, wheelchair, a splint, and had no falls. The 1/27/15 fall (CAA) Care Area Assessment informed staff the resident was at risk for falls and required staff assistance with transfers and ambulation. The CAA further indicated the resident had poor decision making skills, unable to see, and unaware of his/her environment or surroundings. The 10/17/14 care plan instructed staff to ask the resident, when assisted with ambulation, if he/she needed to take a rest. The 10/31/14 care plan instructed staff to ask the resident if he/she was ready to transfer, make sure his/her catheter tubing was free from pulling or tugging, and to give directions he/she was able to follow. The care plan informed staff the resident could not see and to use directions such as right, left, forward, and backwards when transferring the resident. The care plan further instructed staff to make sure the bed was in the lowest position, against the wall, to provide a fall mat, and the resident used a body pillow to help define the edge of the bed. The care plan informed staff the resident was at risk for falling and instructed staff not to leave the resident unattended when in the bathroom. The care plan further instructed staff to always ambulate with 2 staff, and to remind the resident he/she can stop for a rest while ambulating. The 12/18/14 care plan update instructed staff to provide the resident cues not to get up, until staff is ready to assist with transfers. The 1/18/15 care plan update instructed staff to check on the resident hourly. The 1/21/15 care plan update instructed staff to use a mattress on the floor beside his/her bed. The 3/31/15 care plan update instructed staff to keep the remote to the residents recliner, out of reach of the resident, by draping it over the arm of the recliner. The 4/8/15 care plan instructed staff to place a chair alarm in the recliner or chair. The 4/15/15 care plan update instructed staff to Velcro the chair remote to the side table at all times. The 12/17/14 at 9:53 PM, nurse's note indicated at 8:45 PM staff assisted the resident with a bath, and staff stopped to put clothes into the hamper. The note indicated the resident had stood from his/her wheelchair, and fell on his/her left side. The note further indicated the resident sustained [REDACTED]. The 12/21/14 at 5:21 PM, nurse's note indicated staff observed a 2 cm by 2 cm hematoma to the back of the resident's head, which was raised and purple. The note further indicated the resident had a fall on 12/17/14, and staff would continue to monitor. The 12/22/14 at 12:23 PM, nurse's note indicated the physician's office had called regarding the resident's fall and the hematoma on his/her head. The note indicated staff reassured the office staff neurological checks were performed at the time of the fall. The 1/18/15 at 3:22 AM, nurse's note indicated the resident had rolled out of his/her bed, on his/her left side, and sustained no injuries. The 3/31/15 at 2:20 AM, nurse's note indicated on 3/30/15 at 7:19 PM, staff found the resident on the floor, beside his/her recliner, with the electric recliner in the up position, and the remote lying on the inside of the right arm of the recliner. The note indicated the resident's head was pointed toward the window and the wall, lying sideways, with his/her feet pointed towards the TV, and part of his/her head underneath the left side of the recliner. The note indicated the resident had no injuries, and staff placed the remote out of the residents reach. The 4/7/15 at 7:00 PM, nurse's note indicated at 3:30 PM, staff found the resident on the floor beside the recliner, with the electric recliner in the up position, and the remote lying on the inside of the right arm of the recliner. The note further indicated no injuries were noted, and staff implemented a chair alarm. Review of the facility's fall investigations indicated no root cause analysis identified for the resident's falls. The medical record revealed no fall risk assessments completed by staff. On 5/8/15 at 8:45 AM, observation revealed the resident seated in his/her wheelchair, with his/her legs extended and straight, and not on the foot pedals. Continued observation revealed staff repositioned the resident in his/her wheelchair and he/she slid back to the same position. Further observation revealed the resident had contractures of his/her bilateral hands, and after toileting the resident staff assisted the resident to stand, and instructed his/her to hold onto the walker. Continued observation revealed the resident was unable to grab onto the walker, and used his/her thumb and index finger to hold the walker. On 5/11/15 at 1:44 PM, observation revealed the resident seated on the toilet, with staff assisting the resident to stand, and ambulate to his/her bed. Continued observation revealed the resident's bed in the lowest position, almost to the floor, and staff assisted him/her to sit on the bed from a standing position. Further observation revealed the resident sat on the bed, appeared confused, and had a difficult time sitting down, with the bed being so low. Continued observation revealed staff assisted the resident to stand and ambulated him/her to the recliner, as the resident ambulated with the assistance of staff, his/her feet twisted, causing him/her to trip. Further observation revealed staff assisted the resident to sit in the recliner. On 5/7/15 at 8:45 AM, Nurse Aide F verified the resident did not fit in his/her wheelchair correctly, and he/she would slide down, but had not slid out of it. Nurse Aide F further stated staff kept an eye on the resident when he/she was in the wheelchair, and he/she had never fallen out of the recliner. On 5/8/15 at 9:02 AM, Nurse G verified the resident's major fall issue would be when he/she would fall out of his/her recliner, and would sit down on the remote and hit the button after shifting position. On 5/11/14 at 4:05 PM, Nurse H stated he/she did not know when the resident's body became stiff and rigid, but he/she used to sit up correctly in the wheelchair. Nurse H further verified staff are to offer the resident rest periods during ambulation, and staff should watch the resident while seated in his/her wheelchair. On 5/12/15 at 3:30 PM, Administrative Nurse A verified the resident's hematoma could have been a result of his/her fall on 12/17/14, and to keep the resident's remote to his/her recliner was an inappropriate and ineffective intervention. Administrative Nurse A further verified staff should have raised the resident's bed before sitting him/her on the side of the bed. Administrative Nurse A further verified the resident's falls were not thoroughly investigated by the facility in order to prevent further falls. The facility failed to provide Resident #76 with a safe environment and effectively prevent falls, and effectively identify root cause. - Resident #34's (POS) physician's orders [REDACTED]. made or the body cannot respond to the insulin), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. The annual (MDS) Minimum Data Set assessment, dated 1/16/15, indicated the resident had highly impaired vision, severely impaired cognition and decision making skills, with delusional behaviors noted. The MDS further indicated the resident was continent of bladder and bowel, total dependence on staff for transfers and personal hygiene, required extensive 2 staff assistance for bed mobility, toilet use, and bathing. The MDS further indicated the resident used a wheelchair, had 2 or more falls since admission (no injury noted), and received antianxiety, antidepressant, hypnotic, and anticoagulant medications. The 1/16/15 fall risk (CAA) Care Area Assessment indicated the resident was at high risk for falls (score of 33), and had one fall in the last quarter. The CAA further indicated the resident could no longer ambulate, and required a sit to stand lift for transfers. The CAA further indicated the resident had a visual impairment, required staff assistance to urinate frequently, due to BPH, and was unable to use a call light. The 1/21/15 care plan directed staff to provide assistance to the resident with (ADL's) Activities of Daily Living, and to refer to physical or occupational therapy for a decline in ADL's. The care plan revealed a restorative program was recommended. The care plan further informed staff to use a full lift for transfers for the resident, versus a sit to stand, as the resident was not always able to stand, and the resident had a sling for the mechanical lift in his/her room. On 5/11/15 at 12:24 PM, observation revealed the resident seated in his/her wheelchair, and a sit to stand lift was in the resident's room. On 5/12/15 at 3:45 PM, observation revealed staff were unable to locate the resident's sling for the mechanical lift, in the resident's room. On 5/6/15 at 4:00 PM, Nurse Aide VV verified the sit to stand lift was used to transfer the resident, and the resident was totally dependent on the staff for cares. On 5/7/15 at 10:02 AM, Nurse N verified he/she used the care plan to know how to transfer the resident, and any changes were discussed during report. On 5/11/15 at 11:19 AM, Nurse SS stated staff used a sit to stand lift to transfer the resident. On 5/11/15 at 12:24 PM, Nurse X verified staff had used the sit to stand lift to transfer the resident, and verified staff should use a sling lift. On 5/11/15 at 12:40 PM, Nurse Aide Z verified the care plan stated the resident required 2 staff assistance using a full body lift, and the care plan instructed staff not to use the sit to stand lift for transfers. On 5/12/15 at 2:45 PM, Administrative Nurse A verified the sit to stand lift should not have been used on the resident, and verified agency staff do not have access to the computers to review the care plan. Upon request, the facility failed to provide the policy for use of a mechanical lift. The facility failed to use the appropriate transfer device to ensure safety for resident #34, who had muscle weakness, not always able to stand, and totally dependant on staff for cares. - The 4/16/15 physician's progress note indicated Resident #103 had the following Diagnoses: [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 1/1/15, indicated the resident had severe cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 7, and the resident required extensive assistance of 2 staff for bed mobility, transfers, walking in the room and corridor, dressing, toileting and personal hygiene. The MDS further indicated the resident was frequently incontinent of bowel and bladder, his/her balance was not steady, and was only able to stabilize with staff assistance. The MDS indicated the resident had no range of motion impairment or falls. The 7/14/14 Fall (CAA) Care Area Assessment indicated the resident had fallen at home, was pinned against the wall for 3 days, and suffered extensive wounds to his/her chest and shoulder. The 12/30/14 care plan instructed staff to assess the resident for falls and to implement the fall prevention plan. The care plan further instructed staff to place a fall mat on both sides of his/her bed, keep the resident's wheelchair out of reach, frequently assess for needs, and ensure no pad in his/her wheelchair. The care plan instructed staff to provide transfer assistance of 2 staff, transfer to the recliner after meals and toileting, and provide resident assistance to go to bed at 7:30 PM. The 1/11/15 nurse's note indicated the resident leaned forward in his/her wheelchair and fell forward. The note further indicated staff found the resident kneeling with his/her head down on the floor near the hand rail and entry way of his/her room. The note continued to indicate the resident had a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the right side of his/her forehead with a scant amount of bleeding, which measured 6 (cm) centimeters x 3 cm and the resident was lethargic (feeling a lack of energy or lack of interest). The note further indicated staff sent the resident to the emergency room . The 1/11/15 hospital discharge instructions informed staff the resident was diagnosed with [REDACTED]. The 1/12/15 physician fax communication indicated staff informed the physician the resident fell out of his/her wheelchair and obtained a hematoma to his/her head, and complained of back pain. The fax further indicated staff obtained an order from the on call physician to send him/her to the emergency room . The 1/14/15 nurse's note indicated the resident had bruising around his/her eyes, complained of discomfort to his/her knees, and staff noted edema to his/her right ankle. Upon request, the facility provided no fall investigation for the 1/11/15 fall. The 4/25/15 at 1:08 PM, nurse's note revealed staff found the resident on the floor next to his/her wheelchair, and had some movies in his/her hands. The note further revealed no injuries were noted and the resident had no complaints of pain. The 4/25/15 facility fall investigation further indicated the resident had no apparent injuries, and no root cause analysis identified to prevent further falls done by the facility. The report further indicated the intervention was to have staff keep an eye on the resident at all times. On 5/6/15 at 9:53 AM, observation revealed staff assisted the resident to a seated position on the bed, with a gait belt loosely applied. Nurse Aide JJ and Nurse Aide KK lifted the resident, without assistance from the resident,and observation revealed the resident stiffened his/her body with the transfer. On 5/17/15 at 9:19 AM, observation revealed the resident seated in a recliner, asleep, and hunched over to the left. Continued observation revealed Nurse Aide F and Nurse Aide KK appplied a gait belt, assisted the resident to stand, and the resident pivoted to sit in his/her wheelchair. Further observation revealed staff propelled the resident to the bathroom, and assisted the resident to stand, and pivot to sit on the toilet. Observation revealed staff attempted to stand the resident to cleanse him/her, and the resident was unable to stand. Further observation revealed staff stood the resident up and down several times to cleanse the resident, and the resident grabbed at an unlocked wheelchair several times while he/she stood by the staff. Continued observation revealed Medication Aide MM arrived to assist staff to stand and cleanse the resident. Observation revealed staff had to hold the resident up as they cleansed him/her. Continued observation revealed the resident could not stand and he/she was 1/2 way to the floor, as the staff cleansed him/her. Further observation revealed staff pivot transferred the resident to the wheelchair and changed his/her socks to gripper socks. On 5/6/15 at 9:53 AM, Nurse Aide KK stated staff provide total care to the resident and he/she does not request to go the bathroom. Nurse Aide KK stated staff toilet him/her upon awakening and after lunch (which is not every 2 hours). On 5/6/15 at 4:49 PM, Nurse Aide QQ, stated the resident required two staff to transfer and he/she does not move his/her legs and physical therapy does work with him/her. On 5/7/15 at 3:50 PM, Administrative Nurse A verified staff failed to prevent falls by identifying the root cause, and review and revise the care plan. On 5/12/15 at 4:10 PM, Administrative Nurse A verified physical therapy should evaluate a resident's ability to transfer, and staff should notify therapy when a resident had a decline. The facility failed to prevent further falls for Resident #103, who had multiple falls, including injury which required emergency treatment. - The 12/24/14 progress note indicated Resident #54 had the following Diagnosis: [REDACTED]. or widespread generalized pain) , post traumatic stress disorder (a person is exposed to one or more traumatic events), coronary artery disease (abnormal condition that may affect the flow of oxygen to the heart) status [REDACTED]. The admission (MDS) Minimum Data Set assessment, dated 12/26/14, indicated the resident had intact cognition with a (BIMS) Brief Interview for Mental Status score of 13, and required limited assistance from 1 staff for transfers, dressing, toilet use, and personal hygiene. The MDS further indicated the resident's balance was not steady, but able to stabilize without staff assistance, had frequent bowel incontinence, and frequent level 5 moderate pain. The MDS further indicated the resident had a less than 6 month life prognosis, had no falls, and had 1 venous and arterial ulcer. The 12/31/14 pressure ulcer (CAA) Care Area Assessment informed staff the resident had an open right femoral aneurysm, which was bulging and pulsating. The CAA further indicated the resident had anemia secondary to chronic blood loss. The 1/1/15 care plan instructed staff to provide standby assistance before ambulating the resident, and to remind the resident to use his/her call light. The 1/5/15 care plan update instructed staff to remind the resident to use his/her call light. The 1/5/15 at 3:32 AM, nurse's note indicated at 2:10 AM, staff found the resident on the floor, covered in blood. The note indicated staff applied pressure to the resident's aneurysm and stopped the bleeding, and the resident returned to bed. The 1/5/15 at 5:01 PM, nurse's note indicated staff found the resident on the toilet with blood oozing from his/her femoral artery aneurysm, and the resident had transferred him/herself without staff assistance. The note indicated staff applied pressure to the wound in order to stop the bleeding. The note indicated the resident was gasping, had apneic breathing, and his/her skin tone was ashen. The note further indicated staff transferred the resident to his/her bed, and he/she continued to be unresponsive, with the apnea increasing in length. The note indicted at 7:45 AM, the resident was without a pulse and respiration. On 5/11/15 at 4:51 PM, Nurse Aide LL stated the resident would get up independently and stand in his/her doorway, needing pain medication. On 5/12/15 at 9:00 AM, Nurse G verified the resident frequently would get up without assistance of staff, and staff would just keep an eye on him/her. On 5/12/15 at 4:10 PM, Administrative Nurse A verified the facility failed to prevent a fall that resulted in injury. The facility failed to prevent falls for Resident #54 who was known to frequently ambulate without assistance.

The facility had a census of 90 residents. The sample included 22 residents of which 6 were reviewed for nutrition. Based on observation, record review, and interview the facility failed to ensure necessary assistance at meals to maintain adequate nutritional status, and provide interventions to prevent significant weight loss for 1 resident reviewed for nutrition (#16) who had an 11.5% weight loss in 180 days, and weight loss for 1 of 6 residents reviewed for nutrition. (#116) Findings included: - Resident #16's quarterly (MDS) Minimum Data Set assessment, dated 1/22/15, indicated the resident had moderate cognitive impairment with a (BIMS) Brief Interview for Mental Status score of 8. The MDS further indicated the resident required extensive assistance of 1 staff for eating, bed mobility, locomotion on and off the unit, and total dependence on staff for transfers. The MDS further indicated the resident weighed 200 pounds, and received a (NAS) no added salt diet. The 4/11/14 nutrition (CAA) Care Area Assessment, indicated the resident had an inability to perform (ADL) Activities of Daily Living without significant physical assistance. The CAA further indicated the resident was independent with eating, and needed cueing at times. The CAA further indicated the resident was on a therapeutic diet, (NAS) no added salt, due to the [DIAGNOSES REDACTED]. The CAA further indicated the care plan would include to monitor weight and ensure adequate nutrition, due to alterations in nutritional status. The 1/30/15 care plan instructed staff to record food intake at each meal, offer appropriate substitutes for uneaten food, and weigh the resident as ordered. The last blood laboratory report that included a (CBC) Complete Blood Count, dated 7/2/14, revealed an [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, and used in part to determine a person's nutritional status) of 3.3 (normal range: 3.4-5.0), and a protein of 6.8 (normal range: 6.4-8.2). The last nutritional assessment, dated 8/7/14, indicated the resident weighed 200 pounds, was on a (NAS) no added salt diet, required 1995 calories and 65 grams of protein per day, and the resident's weight was stable for the past six months. Review of the medical record revealed the following weights: 11/2014-200# 12/2014-194# 1/2015-190# 2/3/2015-194# 3/2/2015-186# 4/5/2015-181# 5/1/2015-177# (11.5% significant weight loss in 180 days) The Nurse/Physician faxed communication dated, 3/26/15, stated the resident had a current weight of 183.2 pounds and was 195.8 pounds on 3/1/15. The communication further stated the resident was on a diuretic but was needing more assistance with eating and that it would be added to the care plan to assist with meals and to continue to monitor. The 4/30/15 (POS) Physician order [REDACTED]. The meals intake record from 5/11/14 - 5/10/15 revealed the resident was trending downward in consumed percentage of meals (from 80% to 60%) and increased in the number of substitutes offered (with 0-25% of the substitute being consumed) during this time period. The intake record from 3/5/15-5/9/15 revealed (19 days) no documentation of intake, except for one meal. The 5/4/15 (RD) Registered Dietician note, recommended protein powder three times a day, included in meals, and a multivitamin. (The note had not been submitted to the physician). On 5/6/15 at 7:40 AM, observation revealed the resident sat in a wheelchair at the dining table. Continued observation revealed staff served 2 pancakes with butter, syrup, and 8 ounces of cranberry/orange juice to the resident. Continued observation revealed staff did not offer cueing or assistance with the meal and resident hadn't eaten or drank as of 8:30 AM. At 8:31 AM, the staff assisted the resident with eating. At 8:38 AM, the resident consumed 75% of his/her meal and 7 ounces of juice. On 5/7/15 at 8:11 AM, observation revealed the resident sat in a wheelchair, at the dining table with an apron on and an untouched plate of food in front of him/her. At 8:15 AM, staff assisted the resident with eating and drinking. Continued observation at 8:23 AM revealed the staff left the resident's side and the resident continued to take infrequent bites, thereafter, with the resident consuming 75% of the pancakes and 8 ounces of orange/cranberry juice. On 5/11/15 at 11:35 AM, observation revealed the resident sat in a wheelchair in the dining room. At 11:48 AM, staff served the resident lunch and he/she consumed small infrequent bites and drank independently. The staff walked by and asked the resident if he/she needed assistance, the resident shook his/her head no and the staff walked away. Continued observation at 12:11 PM revealed the resident sat in front of his/her plate of food and not eating. The resident started eating again and by 12:20 PM the resident consumed 50% of scalloped potatoes, 25% of chicken and dumplings, and 4 ounces of water. On 5/7/15 at 1:30 PM, Nurse B stated the staff did assist the resident with eating and the resident had been eating on his/her own recently. Nurse B stated the resident required a lot of cueing and prompting and the staff were to obtain the resident's daily weights. On 5/12/15 at 2:45 PM, Administrative Nurse A verified the staff should have known continuity of cares with meals, and meal assistance, through review of the care plan, nurse observation, and from weekly weight meetings. Administrative Nurse A verified the resident had lost over 20 pounds since November 2014 and was unsure on the policy regarding weight loss. Administrative Nurse A verified the care plan should have been current. On 5/14/15 at 8:15 AM, Physician Nurse S verified the resident had not been seen in the physician's office since 2/10/15. Physician Nurse S stated the physician's office did not weigh the resident due to the resident being in a wheelchair, the office did not have wheelchair scales, and the office relied on the facility weights. Physician Nurse S further stated the physician's office would expect to be notified of the resident's weight changes, as ordered. Physician Nurse S stated the last time the staff notified the physician's office was on 3/26/15, when the resident had a 12 pound weight loss. On 5/14/15 at 1:00 PM, Registered Dietician I stated that he/she was aware the resident had lost weight and had not made any recommendations. On 5/20/15 at 1:20 PM, Physican CCC verified he/she would had expected the facility to notify him/her of the weight loss. Physician CCC further verified he/she had not been notified of the Registered Dietician's 5/4/15 recomendations until 5/13/15. The facility's Significant Weight Loss/Gain policy stated the staff would re-weigh all resident's with a weight change of 5 pounds or greater to determine an accurate monthly weight, and record the resident's weight into the weight tracking program. The policy defines a significant weight change as a weight loss or gain of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. The doctor should be notified of any significant weight change that was unexplainable or in which the registered dietician had requested a nutritional intervention. The facility failed to provide sufficient interventions to prevent further weight loss for Resident #16, who had significant weight loss. - Resident #116's readmission (MDS) Minimum Data Set assessment, dated 3/20/15, indicated the resident had intact cognition, with a (BIMS) Brief Interview for Mental Status score of 13, required extensive assistance of 1 staff with bed mobility, transfer, toilet use, independent with set up assistance for eating, and had coughing or choking during meals. The MDS indicated the resident received a mechanically altered diet, was at risk for pressure ulcers, on a turning/repositioning program, received antipsychotic, diuretic medications, and received oxygen therapy. The 3/20/15 Nutritional (CAA) Care Area Assessment indicated the resident had fair-good intake with nursing staff cueing. The 3/16/15 care plan directed the staff to encourage high protein snacks and supplements, the resident received a mechanical soft diet per physician's orders [REDACTED]. Review of the medical record revealed the resident had a significant weight loss while hospitalized which indicated the resident was a severe risk for poor nutrition. On 2/22/15 the resident weighed 164 pounds and upon reentry to the facility on [DATE], the resident weighed 134 pounds (30 pound weight difference). The 3/24/15 nutrition assessment stated the resident had a weight loss since previous admission, meal intake varied between 25-100% and he/she received Ensure Plus, 1 can, three times a day, for added calories/protein. Review of the medical record revealed on 4/9/15 the staff identified the resident had a pressure ulcer on the left gluteus (buttock) which measured 3 (cm) centimeters x 2 cm x 0.2 cm, was open with a reddened, hard 10 cm x 8 cm area around the pressure ulcer. The 4/9/15 Dietician Nutrition Progress note indicated the staff were to provide the resident [MEDICATION NAME] supplement in his/her food at each meal due to varied oral intake and weight loss. The progress note did not mention the resident's pressure ulcer. Review of the resident's March, April and May meal intake indicated the resident's meal percentage varied from 0-100% and no documentation of the percentage of intake of the Ensure. On 5/6/15 at 11:58 AM, observation revealed the resident ate approximately 50% of his/her lunch meal with no staff encouragement, to eat more of his/her meal. On 5/7/15 at 8:33 AM, observation revealed the resident ate approximately 25% of his/her breakfast meal, with no staff encouragement to eat more of his/her meal. On 5/12/15 at 8:48 AM, observation revealed a can of Ensure with the date provided to the resident of 5/11/15, written on the top of the Ensure label, approximately 1/2 full, on the resident's side table. On 5/11/15 at 11:20 AM, Court Assistant T stated the resident gets [MEDICATION NAME] added to the food at each meal and the resident's intake varied. On 5/11/15 at 11:09 AM, Medication Aide U stated he/she provided the Ensure to the resident, the resident sometimes accepts the Ensure, and the staff did not keep track of how much of the Ensure the resident consumed. On 5/11/15 at 4:35 PM, Nurse D stated the resident did not eat well and did not always drink his/her Ensure. On 5/12/15 at 10:39 AM, Administrative Nurse A stated the facility did not keep track of the percentage of Ensure the resident consumed making it difficult for staff to determine if the supplements are effective or not. The 4/27/10 facility Snack and Supplement Intake policy stated nursing staff should offer residents supplements at ordered times and residents who required assistance with supplements would be assisted at the time the supplement was delivered to the resident. The facility failed to effectively monitor interventions to determine further needs to prevent additional weight loss for Resident #116, who had a significant weight loss during hospitalization .

The facility had a census of 88 residents with 3 residents selected for sample. Based on interview and record review, the facility failed to ensure one of 3 sampled residents remained free of significant medication errors. The facility failed to administer medications to former resident #1 as ordered by the physician/mid-level practitioner which resulted in the resident's need for hospitalization for treatment of [REDACTED]. Findings included: - Resident #1's electronic clinical record noted admission to the facility on [DATE] and discharge to the hospital on [DATE]. Resident #1 did not return to the facility after 5/28/13. admission orders [REDACTED]. The 5/22/13 Admission MDS (Minimum Data Set) identified resident #1 with no cognitive impairment. CAAs (care area assessments) dated 5/24/13 noted resident #1's use of a diuretic (medication used to promote the formation and excretion of urine) daily, and the resident's lack of cognitive impairment. Resident #1's 5/28/13 care plan did not include goals or interventions related to resident #1's use of diuretic medication. Laboratory tests done on 5/10/13 at a hospital prior to resident #1's admission to the facility showed a slightly low blood sodium level of 131 (normal range of 135-145). Physician orders [REDACTED]. A telephone order from a mid-level practitioner on 5/19/13 directed staff to administer metalozone ([MEDICATION NAME]) 2.5 mg. every morning. According to the FDA (Food and Drug Administration) information posted on the website, "Drugs.com", [MEDICATION NAME] ([MEDICATION NAME]) is classified a a diuretic which should be used cautiously with [MEDICATION NAME]. According to this reference, "All patients receiving therapy with [MEDICATION NAME] tablets should have serum electrolyte measurements done at appropriate intervals and be observed for clinical signs of fluid and/or electrolyte imbalance, namely [MEDICAL CONDITION] (low sodium), and hypokalemia (low potassium).....When [MEDICATION NAME] is used with other antihypertensive drugs, particular care must be taken to avoid excessive reduction of blood pressure, especially during initial therapy...." A dictated note written after a visit by the mid-level practitioner on 5/23/13 included, "....reassured pt (patient) that medications orders were changed so that (he/she) was receiving [MEDICATION NAME] coated ASA (aspirin) and [MEDICATION NAME] only if weight gain > (greater than) 5 pounds..." Progress Notes/Orders from the mid-level practitioner on 5/23/13 included, "Change to [MEDICATION NAME] 2.5 mg. 1 time daily for weight gain > 5 lbs (pounds)....BMP (basic metabolic panel, a blood test)...." May 2013 MARs (medication administration records) documented staff administered [MEDICATION NAME] 2.5 mg on 5/21, 5/22, 5/24 and 5/25 with one resident refusal of the medication noted on 5/23/13. During this time period, resident #1 continued to receive [MEDICATION NAME] 40 mg. daily. According to May 2013 TARs (treatment records), daily weights recorded from 5/23/13 - 5/28/13 revealed no weight gains of greater than 5 lbs which would justify the use of [MEDICATION NAME] as ordered by the mid-level practitioner. Laboratory results indicated the facility failed to obtain the laboratory testing/BMP ordered by the mid-level practitioner on 5/23/13 in a timely manner. According to the record, the facility drew blood for the BMP on 5/28/13, 5 days after receiving the order. The results of that 5/28/13 were a "critical low" sodium level of 117 (normal range of 135-145). Upon hearing of the critical low sodium level, resident #1's physician ordered transfer to the local hospital emergency room for evaluation. A 5/28/12 "emergency room Note" from the physician in the emergency room noted a serum sodium level of 118 and a [DIAGNOSES REDACTED]. The emergency room physician ordered resident #1's admission to the hospital for treatment of [REDACTED]. During an interview on 6/18/13 at 3:10 p.m., Administrative Nurse A confirmed staff failed to administer [MEDICATION NAME] to resident #1 as ordered by the mid-level practitioner on 5/23/13, and actually gave the resident a total of four doses of [MEDICATION NAME] in error. Nurse A also confirmed the facility failed to obtain lab tests (BMP) as ordered by the mid-level practitioner until several days after the order. According to Administrative Nurse A, resident #1 required admission to the hospital on [DATE] for treatment of [REDACTED]. Attempts to reach Mid-level Practitioner B on 6/19/13 at 9:00 a.m. were unsuccessful and, according to the practitioner's office staff, he/she would not be available until the week of June 24th, 2013. The facility failed to ensure resident #1 remained free of significant medication errors when staff failed to administer medications to the resident as ordered by the mid-level practitioner. The resident subsequently required hospitalization for treatment of [REDACTED].

The facility had a census of 92 residents with 28 residents selected for sample. The sample included review of pressure ulcers for three residents. Based on observation, interview and record review, the facility failed to provide the timely, effective interventions to prevent pressure ulcers for one sampled resident (#45), failed to provide the planned supplements to prevent further development of pressure ulcer for one sampled resident (#80) and failed to ensure that one of 3 residents sampled for pressure ulcers did not develop ulcers after admission. Staff failed to complete a comprehensive assessment of resident #34 after he/she began to decline, and failed to implement appropriate interventions to prevent the development of pressure ulcers. Resident #34 developed multiple pressure ulcers of varying stages ( One Stage 2 and three unstageable ulcers due to eschar) since admission in September 2012. Findings included: - Resident #34's clinical record included a 9/27/12 Admission MDS (Minimum Data Set) which noted admission to the facility on [DATE]. The Admission MDS identified resident #34 with severely impaired cognition, the need for extensive assistance of one staff member for transfers, ambulation, dressing and toileting, independence with eating, use of a walker or wheelchair, total bowel and bladder continence, no weight loss, no pressure ulcers and no other skin problems. The Admission MDS triggered the area of pressure ulcers for further investigation. The clinical record included no subsequent MDS assessments since the admission assessment on 9/27/12. The 9/29/12 CAAs (Care Area Assessments) included a CAA for pressure ulcers. The pressure ulcer CAA did not include additional assessments related to the potential for pressure ulcer development and did not include a summary/analysis of all findings. Resident #34's 10/15/12 care plan did not include interventions related to pressure ulcer prevention. On 11/12/12, staff added an intervention to apply barrier cream to bruise on right buttock daily and prn (as needed). On 12/4/12, staff added an intervention to measure, clean and dress lower extremity wounds as ordered. A 9/20/12 Braden skin assessment identified resident #34 as "low risk" for skin breakdown. The clinical record included no evidence of completion of a Braden assessment since 9/20/12. According to clinical nursing notes dated 10/20/12, resident #34 was admitted to the hospital on that date for treatment of [REDACTED]. Clinical nursing notes dated 10/30/12 described resident #34's readmission to the facility on [DATE]. Skin assessments completed after readmission from the hospital included: *10/30/12 - described multiple areas of bruising on the upper and lower arms as well as a bruise to the right outer leg from the hip to the knee and extensive bruising to the lower legs. The skin assessment also noted a dark purple area on the buttocks, the presence of a soft and red to pink left heel and toes with small red areas. The readmission skin assessment did not identify any areas of skin breakdown at the time of readmission to the facility. * 11/8/12 - described bruises to the arms and the dark purple bruise to the buttocks. This skin assessment did not mention the resident's heels or toes. The clinical record included no evidence of skin assessment from the time of the 11/8/12 assessment until 11/30/12, a time period of three weeks. * 11/30/12 - described a 7 cm (centimeter) by 6 cm bruise to the buttocks and bruises on the knees. This skin assessment did not mention the resident's toes or heels. * 12/5/12 - described a "necrotic and undermining" area to the resident's left heel, a necrotic would to the right heel, and an open wound to the coccyx measuring 1.3 cm by 1.4 cm by 0.1 cm. This skin assessment did not mention the resident's toes. Review of the clinical record revealed no evidence staff implemented appropriate interventions to prevent skin breakdown, such as use of heel protectors, after staff first noted the soft and pink/red left heel and toes on 10/30/12. During an observation on 12/3/12 at 10:00 a.m. resident #34 sat in a recliner in his/her room. The resident had a bandage to the left foot/ankle area and a bandage to the right calf. The resident lacked the ability to respond meaningfully to simple questions. During an observation on 12/4/12 at 4:06 p.m., resident #34 sat in the recliner in his/her room with both feet hanging down. The resident's feet did not touch the floor and dangled approximately 2 inches from the floor. The resident did not wear shoes or socks, and the toes on both feet were purplish red in color. The resident had a gauze wrapped bandage to the left heel/ankle area. The resident did not have a pressure reduction cushion in the recliner. During an observation on 12/5/12 at 9:20 a.m., resident #34 had knee high stockings on both feet. The left stocking had a large hole which exposed several toes. The great toe on the left foot had a black area of skin near the outside edge of the toe nail. Toes of the left foot continued to have a reddish colored discoloration. On 12/6/12 at 10:15 a.m., Administrative Nurses B and C examined resident #34's skin. At that time, resident had an open wound on the left inner buttock. Administrative Nurse B described the area as a Stage 2 pressure ulcer. The entire left heel (approximate size of a tennis ball) had a black, thick covering of eschar. The right heel had a smaller area of blackened eschar (approximate size of a quarter). Administrative Nurse B described the heel wounds as unstageable. Resident #34's left great toe had a blacked area near the toe nail at the outer border with Nurse B also described as unstageable. Administrative Nurses B and C confirmed staff did not know of the multiple areas of skin breakdown prior to 12/5/12 when survey staff inquired about it. Neither Nurse B or C could determine who placed the dressing/bandage on the left heel which had been observed since 12/3/12. During an interview on 12/4/12 at 5:30 p.m., Licensed Nurse SS reported resident #34, "has circulation problems" and should have his/her feet elevated at all times. Nurse SS confirmed the presence of "an area" on the left heel and indicated staff floated the heels when the resident lay in bed. Nurse SS also confirmed resident #34 experienced significant declines since admission in September 2012, and currently had total dependence on staff for all ADLs (activities of daily living), including transfers and repositioning. During an interview on 12/5/12 at 11:20 a.m., Administrative Nurse C reported resident #34 had only one open area on his/her skin and that was on the right calf. Nurse C lacked awareness of additional skin breakdown or the reason for the dressing on the left heel. Administrative Nurse C also confirmed staff failed to complete weekly skin assessments as per facility policy in the 3 week time period between 11/8/12 and 11/30/12. During an interview on 12/6/12 at 1:00 p.m., Administrative Nurse B confirmed staff failed to identify the skin breakdown on resident #34's heels, toes and buttock prior to 12/5/12. Additionally, Nurse B stated the heel wounds had obviously been there for awhile in order to get to the condition they were currently in, including thick eschar to both heels. Upon review of the clinical record, Nurse B determined the left heel problem started back on 10/30/12 when staff first noted the presence of a soft left heel, and the breakdown continued from there. Nurse B could not verbalize any interventions put into place after 10/30/12 to prevent further skin breakdown. Nurse B also confirmed staff failed to complete weekly skin assessments during the three week time period from 11/8/12 to 11/30/12. During a subsequent interview on 12/11/12 at 8:40 a.m., Nurse B reported the facility placed an air mattress on resident #34's bed after his/her return from the hospital on [DATE]. According to the facility's "Skin Care Protocol" policy dated 2/20/03 with a revision date of 4/28/10, a resident's skin should be assessed weekly by the Skin/Wound nurse. Additionally, a Braden Skin Risk Assessment should be completed by a licensed nurse upon readmission to the facility. The facility failed to ensure that resident #34 did not develop pressure ulcers after admission, and failed to provide the necessary treatment and services (weekly skin assessments per facility policy, implementation of appropriate interventions to prevent skin breakdown after the resident experienced significant declines in his/her medical/physical condition) to promote healing, prevent infection, and prevent new sores from developing. Resident #34 developed one Stage 2 pressure ulcers and three unstageable pressure ulcers due to eschar after admission to the facility. - Resident #45's admission Minimum Data Set 3.0 dated 11/12/12 revealed a Brief Interview of Mental Status score of 15, cognitively intact, required extensive assistance with bed mobility, transfers, dressing, personal hygiene, at risk for development of pressure sores, had one stage one or higher pressure sore with slough (tissue), present on admission. The Care Area Assessment for pressure sores dated 11/26/12 lacked the causative factors of why the resident had a pressure sore on his/her right foot. The temporary care plan dated 11/26/12 listed the interventions for the resident to wear slippers or different shoes, and soak right foot for 20 minutes with Epsom salt before dressing the toe. The physician order [REDACTED]. The physician order [REDACTED]. The weekly skin assessment dated [DATE] (on admission), 11/16/12, 11/23/12, 11/30/12 revealed the resident had a 0.5 centimeter (cm) by 0.5 cm wound to the right foot bunion. The Skin/Wound Documentation dated 11/2/12 revealed the resident had a Stage II to the right foot bunion which measured 0.5 by 0.5 cm with slough present and the wound with a white appearance. The Skin/Wound Documentation dated 11/16/12 revealed the resident had a Stage II to the right foot bunion that had and off white center tissue appearance with no drainage. The Wound team's skin measurements of the right foot pressure sore began on 11/30/12 and measured 0.4 by 0.7 cm and on 12/6/12 measured the same. The registered dietician's nutritional assessment dated [DATE] documented the resident did not have skin breakdown and no current labs. The nurse's note dated 11/30/12 and timed 12:48 A.M. revealed the resident continued to have two plus [MEDICAL CONDITION] (depth of 2 finger placed on top of each other) to the bilateral lower legs and feet while up in the wheel chair. The [MEDICAL CONDITION] decreased to one plus when the resident was in bed. The Skin Integrity Guidelines dated 11/2/12 was blank. Observation on 12/4/12 at 4:08 P.M. revealed the resident sat in a wheel chair in his/her room with ted hose (hose to improve circulation) and shoes on, [MEDICAL CONDITION] to both feet, and the feet hanging downward. Observation on 12/5/12 at 7:24 A.M. revealed the resident sat in his/her wheel chair with ted hose and shoes on, [MEDICAL CONDITION] noted to both ankles and feet. The resident's feet were in the downward position. Observation on 12/5/12 at 9:55 A.M. revealed the staff wheeled the resident to church services and no change in position of the legs and feet. Observation on 12/5/12 at 12:20 P.M. revealed no change in position of the legs and feet. Observation on 12/6/12 at 6:48 A.M. revealed the resident sat in his/her wheel chair and ted hose and shoes on. The legs were positioned downward. Observation on 12/6/12 at 7:20 A.M. revealed licensed nurse H and direct care staff M provided a dressing change to the right foot. Observation revealed a circular area which measured 0.4 by 0.7 centimeters. The resident had [MEDICAL CONDITION] to both feet which pushed out over the strap of the shoes. The resident stated during the dressing change on 12/6/12 at approximately 7:30 A.M. stated he/she felt the ted hose made the [MEDICAL CONDITION] worse. Licensed nurse H on 12/6/12 at approximately 7:30 A.M. asked the resident if he/she would leave his/her shoes off until the [MEDICAL CONDITION] went down and the resident stated he/she would. This nurse instructed the direct care staff to place the resident in the recliner during the day and raise his/her legs. The resident stated he/she would. Licensed nurse L on 12/5/12 at 4:20 P.M. stated the resident was admitted to the facility with the pressure sore on his/her right foot. This staff stated staff should elevate the resident's legs and take the ted hose off when the legs were elevated and use one or two pillows to elevate the legs on. Licensed nurse H stated on 12/6/12 at 7:50 A.M. that the charge nurses do weekly skin assessments on all the residents and that was documented in the computer under weekly skin assessments. The charge nurse assessed all wounds on a weekly basis and documented that information on the Skin/Wound Documentation forms. Wound rounds were done weekly by the MDS coordinators and assistant director of nursing and that was documented in the computer on their skin sheets. The policy for Skin Care Protocol dated 4/28/10 - included the interventions to completed the Skin Integrity Guidelines upon admission and implement specific individualized Plan of Care as appropriate. The facility failed to provide timely and effective interventions for the presence of a pressure sore to the right foot. - The 10/19/12 signed physician ' s note indicated Resident #80 ' s [DIAGNOSES REDACTED]. The admission (MDS) MInimum Data Set 3.0 assessment, dated 11/12/12, indicated the resident scored 9 on the (BIMS) Brief Interview Mental Status which indicated moderately impaired cognition and reported feeling tired and having little energy. The MDS indicated the resident required total staff assistance for bed mobility and extensive assistance for transfers, dressing locomotion, toileting and personal hygiene. The resident was able to eat independently. The resident had no weight loss or swallowing difficulties and received a therapeutic diet. The MDS indicated the resident had one or more pressure ulcers and one Stage 2 pressure ulcer not present on admission. The assessment revealed the resident had two Stage 3 pressure ulcers and one unstageable pressure ulcer on admission. The resident had 1 venous/arterial ulcers and infections of the foot. The current skin treatments included: pressure relief for the bed/chair, turning, reposition, nutrition/hydration programs, ulcer care, and application of nonsurgical dressings. The 11/1612 (CAAs) Care Area Assessment Summary for Nutritional Status, Pressure Sores and Urinary Incontinence indicated the resident triggered dehydration due to constipation. The resident had a 3 pound weight loss since admission possibly due to fluid. The resident does have a [DIAGNOSES REDACTED]. The dietician indicated due to the resident ' s skin issues he/she receives a multivitamin and Ensure Plus supplement three times a day. At the time of admission the resident is independent with meals. Upon admission to the facility the resident had a pressure ulcer to the sacrum and to the right great toe. The resident is at risk for impaired skin integrity due to being wheelchair bound, impaired mobility, dehydration, Diabetes Mellitus and impaired cognition. The summary indicated the wound care team assesses and measure wounds weekly and the resident would be seen at the wound clinic on 11/21/12 for the sacral wound. Current interventions included: air mattress, cushion in wheelchair, turn/reposition every 1.5 - 2 hours, and the staff were initiated a foot cradle. . Death report indicated the resident passed 11/24/12. The 11/1/12 care plan directed the staff to: check the resident for incontinence every 2 hours and change as needed ensure the placement of a chair pad/cushion to reduce pressure reposition redistribute weight every 1.5 to 2 hours, assess and record the size (Length by width by depth) amount and characteristics of exudates and pain status 1x weekly perform complete skin assessment and record once per week perform nutritional screening and adjust diet/supplements as indicated to reduce the risk of skin breakdown use pilows, pads, or wedges to reduce pressure on heels and pressure points use pressure-reducing mattress and pads when sitting assess resident for presence of pain at frequent routine intervals and before wound treatment The care plan notes indicated the resident's spouse and daughter were present at the meeting. The note indicated the resident received Ensure Plus 3 times a day. The November 2012 (MAR) Medication administration revealed the resident provided House Supplement three times a day. The MAR revealed the staff initiated the physician's order [REDACTED]. On 12/6/12 at 1:05 pm certified medication aide I reviewed the MAR and indicated the house supplement was 2-cal and the staff always provide 60 cc unless the physician specified a different amount. On 12/6/12 at 4:15 pm, administrative nurse B reviewed the November 2012 MAR and stated the staff are to write what supplement the physician ordered and the resident ' s MAR only stated house supplement. Nurse B indicated the resident had received Ensure Plus although it was not documented. Nurse B further verified the MAR was blank on 11/16 and 11/18 and indicated the staff are to write " R " if the resident refused it. In summary, the facility failed to ensure and document the staff provided the physician ordered supplement to Resident #80 in order to prevent further pressure ulcer development and to promote healing.

The facility had a census of 54 residents, with 4 residents selected for sample, including one resident who no longer resided in the facility. Based on observation, interview and record review, the facility failed to provide the necessary care and services (timely, thorough nursing assessments following resident complaints of chest pain) to maintain one of 4 residents' highest practicable physical well-being. Resident #1 expired within approximately 3 hours of reporting symptoms of chest pain to staff. During that 3 hour time period, licensed nurses failed to notify resident #1's physician of the change in the resident's condition, failed to complete thorough nursing assessments and then document the findings of those assessments in the clinical record. Findings included: - Resident #1's clinical record included a [DATE] signed physician's orders [REDACTED]., [MEDICAL CONDITIONS], nausea with vomiting, muscle weakness, backache, [MEDICAL CONDITIONS], pneumonia, [MEDICAL CONDITIONS], chronic pain, [MEDICAL CONDITION], shortness of breath, dementia with behavior disturbance, [MEDICAL CONDITION] reflux, sleep hypoventilation, hypoxemia, dementia with behavior disturbance, [MEDICAL CONDITION], long term use meds, and arthropathy of the hand. An [DATE] Annual MDS (Minimum Data Set) identified resident #1 with some cognitive impairment and a BIMS (Brief Interview Mental Status) score of 12, no signs/symptoms of [MEDICAL CONDITION], no moods/[MEDICAL CONDITION], no behaviors, the need for extensive assist of two staff persons for ADLs (activities of daily living) except eating, frequent mild pain, and not enrolled in Hospice. The [DATE] Care Plan noted resident #1's preferences/directive for DNR (do not resuscitate) status. The care plan also included goals and interventions related to chronic pain from RA ([MEDICAL CONDITION] arthritis). The care plan did not include interventions related to other acute pain not related to RA. physician's orders [REDACTED]. o [MEDICATION NAME] 50 mg. (milligrams) twice daily for treatment of [REDACTED]. o [MEDICATION NAME] 0.125 mg. daily for [MEDICAL CONDITION] o [MEDICATION NAME] 40 mg. daily for [MEDICAL CONDITION] o Klor Con, a potassium supplement, 20 mEqs (miliequivelents) twice daily for treatment of [REDACTED]. Nurses Notes included: o The entry dated/timed [DATE] at 11:00 a.m. by Licensed Nurse D, "Res. (resident) c/o (complained of) chest pain/indigestion. Gave [MEDICATION NAME] 30 cc (cubic centimeters). " Time and date stamps on the computerized charting entry showed Licensed Nurse D actually entered this note on [DATE] at 2:18 p.m. o The entry dated/timed [DATE] at 12:00 p.m. by Licensed Nurse D, "Res. stated that [MEDICATION NAME] was helping." Time and date stamps on the computerized charting entry showed Licensed Nurse D actually entered this note on [DATE] at 2:20 p.m o The entry dated/timed [DATE] at 3:00 p.m. by Licensed Nurse D, "Mortuary here to pick up res." Time and date stamps on this computerized charting entry showed Licensed Nurse D entered this note on [DATE] at 4:25 p.m. According to vital sign records, staff took resident #1's vital signs one time on [DATE], at 12:57 p.m., nearly 3 ,[DATE] hours after the resident told Direct Care Staff F he/she had chest pain. The vital signs at that time were as follows: blood pressure ,[DATE], pulse 78, respirations 20, temperature 97.3 degrees Fahrenheit. The clinical record included no evidence staff notified resident #1's attending physician of the onset of chest pain and/or indigestion on [DATE] at 9:35 a.m. when Direct Care Staff F said he/she first told Licensed Nurse D about the chest pain, or at 10:30 a.m. when Licensed Nurse D said he/she first learned of the chest pain, as cited at F157. During observations on [DATE] from 10:30 a.m. to 12 noon and 12:45 p.m. - 5:00 p.m., two licensed nurses were on duty to provide care to the 54 facility residents. Additionally, there were sufficient numbers of nurse aides on duty to respond to the needs of facility residents in a timely manner. During an interview on [DATE] at 2:00 p.m., Direct Care Staff F reported he/she worked on [DATE] and had several interactions with resident #1. According to Staff F, resident #1 started to complain of chest pain, "right after breakfast...probably about 9:15 or 9:30 a.m." Staff F said he/she immediately told Licensed Nurse D about resident #1's complaints because, to his/her knowledge, resident #1 never complained of chest pain before. Staff F said Nurse D replied to the report of chest pain by saying something like, "It's probably just indigestion" and he/she would make sure the medication aide gave resident #1 some [MEDICATION NAME]. Direct Care staff F reported he/she did not see Nurse D enter resident #1's room to assess the chest pain. Then, at approximately 10:15 a.m., Direct Care Staff F again entered resident #1's room and the resident reported continuing chest pain. Staff F said resident #1 had a hand over the left side of his/her chest at the time, and that concerned him/her. At that time resident #1 requested a drink of water. Since resident #1 had a fluid restriction, Direct Care Staff F went to ask Nurse D if the resident could have additional water. Staff F said she told Nurse D again about the resident's chest pain. Licensed Nurse D approved of some ice water for resident #1 but did not comment on the continued chest pain. According to Staff F, he/she gave resident #1 the requested water and then left the room to provide care to other residents. Direct Care Staff F recalled that resident #1 went to the dining room for lunch with his/her spouse, but sometime after lunch, "probably around 1:00 p.m.," resident #1 told Direct Care Staff G about continuing chest pain. Staff F and G then approached the other nurse on duty, Licenses Nurse E, and advised him/her of resident #1's complaints of chest pain. According to Staff F, Nurse E did not go to resident #1's room, and instead advised Direct Care Staff F and G to get a full set of vital signs. Staff F said they took the vital signs and then, because neither Nurse D or E were at the desk, just laid the paper with the vital signs on the desk where Nurse D usually sat. The next thing Direct Care Staff F recalled occurred sometime after 1 p.m. when another staff member yelled they needed help in resident #1's room. When Staff F entered the room, there were already several staff there, and resident #1 was unresponsive. Direct Care Staff F reported resident #1 died after EMS (emergency medical staff) arrived at the facility. Upon review of his/her entries into the Nurses Notes on [DATE], Licensed Nurse D confirmed he/she failed to document thorough nursing assessments of resident #1's chest pain. During an interview on [DATE] at 9:30 a.m., Direct Care Staff G reported he/she had several interactions with resident #1 on [DATE]. According to Staff G, she knew resident #1 complained of chest pain during the morning hours of [DATE]. Then, after lunch on that day, Staff G said she wheeled resident #1 from the dining room to his/her room and resident #1 asked, "Does it hurt to have a [MEDICAL CONDITION]?" Staff G recalled that resident #1 rubbed his/her chest when he/she made that comment, and the resident reported the chest area, "feels kind of funny." Direct Care Staff G reported he/she took resident #1 to the bathroom, assisted him/her to bed, and then immediately went to the desk to tell the nurse about the resident's symptoms. Staff G did not find Licensed Nurse D at the desk, so he/she told Licensed Nurse E about resident #1's complaints of chest pain. Staff G recalled that Nurse E directed him/her to go get a full set of vital signs. Staff G did not recall Nurse E going to resident #1's room at that time. Direct Care Staff G recalled the previously described events happened just before 1:00 p.m., and he/she got off duty at 1:00 p.m.. During an interview on [DATE] at 2:12 p.m., Licensed Nurse D confirmed he/she worked at the facility on [DATE] and had the responsibility for several residents on that day, including resident #1. Nurse D recalled that Direct Care Staff F approached him/her at approximately 10:30 a.m. and said resident #1 complained of chest pain. According to Nurse D, he/she immediately went to resident #1's room and completed a full assessment. Nurse D recalled the chest pain was located mid-sternum, and resident #1 denied radiating pain or back pain. After completing the assessment, Nurse D determined the resident had indigestion and asked the medication aide to administer [MEDICATION NAME] 30 cc. Nurse D reported resident #1 did not say he/she had indigestion, but he/she (Nurse D) determined the pain was due to indigestion since it did not radiate anywhere and did not extend to the back. Nurse D also recalled resident #1 reported some relief of the chest pain symptoms within an hour of administration of [MEDICATION NAME]. Nurse D reported he/she had no additional interaction with resident #1 until sometime after 1:00 p.m. when staff found the resident unresponsive. Nurse D confirmed resident #1 expired just before 2:00 p.m. Licensed Nurse D confirmed resident #1 never complained of chest pain prior to [DATE], and confirmed he/she did not consider the sudden onset of chest pain a significant change in the resident's condition. Nurse D confirmed he/she did not notify resident #1's physician of the onset of chest pain until staff found the resident unresponsive in the afternoon hours of [DATE]. Upon review of his/her entries into the Nurses Notes on [DATE], Licensed Nurse D confirmed he/she failed to document thorough nursing assessments of resident #1's chest pain. During an interview on [DATE] at 9:50 a.m., Licensed Nurse E confirmed staff advised him/her of resident #1's complaints of chest pain after lunch on [DATE]. Nurse E confirmed he/she did not assess the resident at that time, and did not notify the resident's physician. According to Nurse E, resident #1 expired sometime around 2:00 p.m. on [DATE], approximately 1 hour after staff advised him/her of resident #1's chest pain. The facility provided a copy of resident #1's death certificate which noted the date/time of death as [DATE] at 1:55 p.m.. The death certificate listed the cause of death as, "[MEDICAL CONDITION], hypertension, [MEDICAL CONDITIONS], deep vein [MEDICAL CONDITIONS], and abdominal wall hematoma." The facility provided evidence of mandatory staff nurse education completed on [DATE], two days after the previously described incident involving resident #1. The educational topics covered included assessments, prioritization and emergency care. Additionally, the facility provided evidence of ongoing competency assessments of nurses, with mandatory requirement planned based on individual nurses competency testing results. During an interview on [DATE] at 10:30 a.m., Licensed Nurse C confirmed the facility identified lack of adequate nursing assessments following resident #1's complaints of chest pain on [DATE]. Due to the deficits identified, Nurse C reported the facility immediately began to educate licensed nursing staff about appropriate response to emergency situations, when and how to notify physicians of changes in a resident's condition. As requested, the facility provided copies of policies related to physician notification. According to a, "Change In a Resident's Condition Or Status" policy, number NURADMIN004 dated [DATE] with a revision date of [DATE], "The Licensed Nurse will notify the resident's attending physician when...there is a significant change in the resident's physical, mental or psychosocial status." The facility also provided a "Change of Condition" policy, number NURCARE034 dated [DATE] with a revision date of [DATE], which directed staff to, "make accurate and timely assessments of a resident's condition and provide notification of any change in that condition to appropriate parties." The facility failed to provide the necessary care and services (timely, thorough nursing assessments following resident complaints of chest pain) to maintain resident #1's highest practicable physical well-being. Resident #1 expired within approximately 3 hours of reporting symptoms of chest pain to staff. During that 3 hour time period, licensed nurses failed to notify resident #1's physician of the change in the resident's condition, failed to complete thorough nursing assessments and then document the findings of those assessments in the clinical record.