Every finding on record at Via Christi Village Ridge

The facility reported a census of 69 residents. The sample included 17 residents, with one resident reviewed for pain and activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to ensure Resident (R) 55 remained free from neglect when the facility failed to provide necessary care and services staff were aware R55 needed and had multiple failures, which resulted in delayed healing, physical discomfort, and decreased quality of life. Findings included:- R55's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), contact dermatitis (skin rash), and overactive bladder. R55's 01/07/26 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R55's MDS documented no behaviors and minimal depression. R55 required total assistance with toileting hygiene, transfers, and bed mobility. R55 was always incontinent with bladder and had a colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body). R55 had frequent pain and did not receive pain medications as needed in the five-day look-back period. R55 had moisture-associated skin damage (MASD- inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucous). R55's 05/12/25 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R55 required assistance with toileting hygiene and transfers, and documented staff would monitor and assist R55 with peri-care to prevent infection. Staff would administer as-needed pain medications, and non-medication pain relief interventions were in place for her pain. Staff would encourage R55 to turn and reposition to avoid pressure injuries. R55's Care Plan, dated 11/22/24, revealed staff were instructed to provide perineal cleansing and apply a protective skin barrier after each incontinent episode, provide adult briefs, and report signs of impaired skin integrity or breakdown. Staff were to assist R55 to reposition every two to three hours using pillows to offload and for comfort. Staff were to provide treatments as indicated on the physician's orders. Staff were to provide medications for pain as ordered and report uncontrolled pain to the provider. R55's Care Plan, dated 09/29/25, directed staff to offer checks and change (of incontinence brief, if needed) upon getting R55 up for the day, before lunch, before supper, bedtime, and as needed during the night. R55's Care Plan, dated 11/21/25, instructed staff to follow the treatment orders for MASD from the wound care clinic. R55's Care Plan, dated 12/02/25, documented R55 received education on the importance of offloading her buttocks and allowing peri-care, as R55 often chose to spend long amounts of time seated in her wheelchair in urine incontinence. R55's 02/05/25 Physician's Orders documented an order for Tylenol 325 milligrams (mg), administer two tablets by mouth every 12 hours for pain. R55's 02/26/25 Physician's Orders documented an order for Tramadol (controlled narcotic pain medication) 50 mg, administer one tablet, by mouth three times a day as needed for pain. R55's 11/20/25 Physician's Orders documented an order to cleanse the bilateral buttocks, left and right posterior thighs twice a day with Vashe wound solution (wound cleanser containing pure hypochlorous acid to clean, irrigate, and debride acute and chronic wounds). Cleanse the perineal area with Baza cleanser (cleans and protects perineal area) and water with each incontinence episode, and apply Critic-aide clear or could substitute with A&D ointment for irritant contact dermatitis. R55's 01/27/26 Physician's Orders documented an order for Tramadol 50 mg, administer two tablets, by mouth, every eight hours for pain. R55's . Wound Healing Note (provided by the wound clinic), dated 09/16/25, documented the resident had irritant contact dermatitis to all skin areas. The left posterior thigh measured 6.8 centimeters (cm) by 3.1 cm by 0.1 cm with a moderate amount of serous (thin, clear) drainage. The left buttock measured 11 cm by 4.5 cm by 0.1cm with a low amount of serous drainage. The right buttock measured 10.8 cm by 5.9 cm by 0.1 cm with a low amount of serous drainage. The right posterior medial thigh measured 3.5 cm by 5.5 cm by 0.1 cm with a low amount of serous drainage. The areas appeared as chronic incontinence burn/incontinence dermatitis, with moisture and shearing contributing. The note documented goals which included a high-protein diet, vitamin supplementation, adequate hydration, and a return to the clinic in one week. R55's . Wound Healing Note, dated 09/23/25, documented no significant improvement to the buttocks. The resident and family were frustrated with the care at the facility. They were encouraged to discuss this with the facility. R55's . Wound Healing Note, dated 10/06/25, documented that the tissue remained red in appearance, but improvement was noted. The resident and family reported the facility had improved with more frequent incontinence care over the past week. R55's Skin Evaluation Form, dated 11/06/25, documented a MASD area on the resident's left groin with an original date for the skin area of concern on 08/21/25. The form documented left groin MASD, which was red in color and measured 10 cm by 15 cm. R55's Skin Evaluation Form, dated 12/10/25, documented a MASD area on the left posterior thigh with an original date of skin area of concern on 09/25/25. The form documented the left posterior thigh had MASD, which was red and irritated and measured 18 cm by 11 cm. R55's Skin Evaluation Form, dated 11/12/25, documented a MASD area on the right buttock with an original date of skin area of concern on 09/25/25. The form lacked a description of skin and recorded measurements of 11.5 cm by 5.5 cm. R55's . Wound Healing Note, dated 11/18/25, documented ulcers that were noted to be all similar in appearance that day. The writer conducted an examination for an ulcer that was resistant to healing despite numerous interventions. The plan was to examine any underlying conditions that impeded healing. The note documented R55 was incontinent of urine, was continuously dribbling, and a recommendation was made to the resident's family and resident, which included to talk to her provider about obtaining a Pure Wick (a non-invasive, external urine collection device designed to manage female urinary incontinence by using low-pressure suction to pull urine away from the body into a canister) or if unable to, consider placing a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). R55's . Wound Healing Physician's Orders, dated 12/05/25, noted the Advanced Practice Nurse Practitioner (APRN) ordered a Pure Wick for the use of diverting urine. The resident was incontinent of urine, and the Pure Wick was to be used when R55 was in bed. R55's EMR lacked evidence of the facility following up on the above recommendations and orders. R55's . Wound Healing Note, dated 12/09/25, documented the resident had severe pain from the irritant contact dermatitis at an eight on a scale of zero to 10. The pain was intermittent. The note documented that the APRN had ordered a Pure Wick system on 11/18/25, but the facility had not provided her with the Pure Wick system as of 12/09/25. The family would have a meeting with the facility's Director of Nursing. The note documented that it was unlikely for R55's skin to improve fully without diversion of urine. R55's Nurse Progress Note, dated 12/09/25 at 09:48 AM, documented staff received orders from the wound clinic that included an order for a Pure Wick. Administrative Nurse D called the wound clinic and spoke to the staff at the clinic. Administrative Nurse D informed the clinic that the facility was unable to complete the order as the facility did not have Pure Wick devices, and the resident did not have a diagnosis that was appropriate for a Pure Wick or a Foley catheter. A fax sent on 12/22/25 from the wound clinic to the facility included a medical letter of necessity for a Pure Wick system and documented the ongoing moisture exposure, which placed the resident at risk for worsening dermatitis and skin maceration, secondary skin infections, pain, and impaired quality of life. R55's Via [NAME] Wound Healing Note, dated 01/13/26, documented the left posterior thigh MASD on the resident measured 16.5 cm by 24 cm. The left buttock area measured 10 cm by 4.5 cm, and the right buttock measured 13 cm by 7.5 cm. The right posterior thigh area measured 6 cm by 9 cm. R55's .Urology Note, dated 01/28/26, documented the resident had chronic urine leakage worsening over three years and complicated skin wound healing due to constant moisture. The wounds located on her legs and bottom were managed by the wound clinic. The wound clinic emphasized the necessity of maintaining dry skin to facilitate healing, yet the nursing facility faced obstacles in implementing long-term solutions like a Pure Wick device. The treatment plan recommended Pure Wick for three months to support wound healing by keeping skin dry and listed an alternative plan, if Pure Wick was declined by the facility, was to consider an indwelling Foley catheter. R55's Nurse Progress Note, dated 1/28/26 at 11:53 AM, the resident returned from a urology consult with an order from the physician for a Pure Wick external catheter for 3-6 months on continuous suction. Staff called the physician at the urology office and left a message with the nurse that the facility was unable to complete the order at that time. The note indicated the order was reviewed with Physician Provider HH, who instructed staff not to complete the order for the Pure Wick at that time, and R55's family member was updated; R55's family member reported to the facility to watch for an order from the urologist for an internal (indwelling) catheter. R55's Skin Evaluation Form, dated 01/28/26, documented the right buttock MASD had redness and measured 11cm by 5 cm. R55's Skin Evaluation Form, dated 02/04/26, documented that the left groin MASD was red in color and measured 9 cm by 13 cm. R55's Skin Evaluation Form, dated 02/04/26, documented the left posterior thigh MASD was red with intact skin and measured 16 cm by 9 cm. During an observation on 02/09/2026 at 10:22 AM, R55 sat in her wheelchair and played the piano. R55 reported she had a sore on her left leg from her hip to her knee. That caused her a lot of pain, and the urologist and wound clinic she had been to recently ordered a catheter to heal the wounds. R55 reported that Physician Provider HH would not allow R55 to have a catheter. R55 was very teary-eyed when she spoke. During an interview on 02/09/26 at 10:30 AM, R55's family member reported R55 had been dealing with her wounds for the past six months and reported R55 went to the wound clinic and a urologist, who both recommended a Pure Wick system or an internal catheter. R55's family member reported the provider at the facility would not follow the recommendations. R55 and the family member were both crying when they spoke. They stated R55 was supposed to be in bed by 10:00 AM to offload. During an observation on 02/09/26 at 10:35 AM, Certified Nurse Aide (CNA) N answered the resident's call-light and told R55 it would be 30 minutes before staff could assist her back to bed because the lift was not available. During an observation on 02/09/26 at 11:05 AM, CNA N and CNA O assisted R55 into bed and began incontinence care. CNA N and CNA O provided incontinent care to R55. Observation revealed large, very bright red, shiny skin areas that covered the back of both thighs, inner thighs, buttocks, and coccyx area. R55 winced in pain and cried when CNA N cleansed and applied the A & D ointment to all the red areas. R55 asked CNA N to let the nurse know she was hurting badly and needed a pain pill. CNA N nodded her head yes. R55 asked CNA N to turn on the television to help her keep her mind off the pain. During an interview on 12/09/26 at 01:29 PM, CNA N reported she told Licensed Nurse (LN) H around 11:15 AM that R55 requested pain medication. CNA N reported that R55 would complain of pain every time she received incontinent care. During an interview on 12/09/26 at 01:34 PM, LN H reported the CNA N did not notify her that R55 requested pain medication around 11:00 AM and reported she had just administered R55 the scheduled pain medication about 20 minutes prior. During an interview on 12/09/26 at 01:42 PM, R55 reported she received pain medication about 20 minutes prior and reported it took the nurse a long time to get her pain medication. R55 was tearful when she spoke. During an interview on 02/10/26 at 10:22 AM, CNA N reported R55 never refused to go back to bed and always allowed the staff to complete incontinent care. CNA N reported sometimes R55 would not allow the CNAs to apply the A&D ointment after she was cleansed, but never refused to have incontinent care. During an interview on 02/10/26 at 10:30 AM, LN H reported R55's skin was the same for about six months. LN H reported R55 went to the wound clinic for about four months, had several different treatments ordered, and her skin had not healed. LN H stated any discussion about a Pure Wick or a Foley catheter would have to be with Administrative Nurse D. During an interview on 02/10/26 at 10:52 AM, Physician Provider HH reported the discussion about the Pure Wick and Foley catheter would have to be with Administrative Nurse D. Physician Provider HH reported she was told by Administrative Nurse D that she could not order a Foley catheter for R55 because R55 did not have an appropriate diagnosis. Physician Provider HH nodded her head yes when asked if she thought R55 would benefit from a Foley catheter. Physician Provider HH reported she expected the staff to administer pain medication as ordered and reported it was unacceptable that R55 had to wait two hours for a pain pill. During an interview on 02/10/26 at 04:30 PM, Administrative Nurse D reported R55 could not have a Pure Wick system at the facility because it would be unsafe for her to have one. Administrative Nurse D reported R55 did not have an appropriate medical diagnosis or a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) or higher wound to justify the Foley per her understanding of the state regulations. Administrative Staff A reported R55 would not be able to have the Pure Wick system at the facility, as they did not use those devices at the facility and had no way to have continuous suction. Administrative Staff A reported the Pure Wick and Foley orders, and the discussion was all coming from R55's family member, who just wanted things for R55 that she really did not need, and reported that the facility had several interdisciplinary meetings weekly with R55's family member about his concerns. Administrative Staff A reported R55 would refuse to have incontinent care provided and refused to offload the areas, and that R55 liked to be up in her wheelchair. Administrative Nurse D reported that she did not know if R55 had increased pain, but said she expected the nurse to administer pain medication as needed per orders. Administrative Nurse D reported that R55's skin had not improved with all the treatment changes ordered from the wound clinic. During an interview on 02/11/26 at 10:11 AM, Administrative Nurse D reported she had not spoken to the urologist who gave an order for a Foley catheter; she spoke to the nurse at the urology office, and a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) was discussed. Administrative Nurse D reported the supra-pubic catheter would be too invasive for R55 and that R55 did not qualify for a catheter. During an interview on 02/11/26 at 11:27 AM, Consultant Staff JJ (Wound Clinic LN) reported the provider at the wound clinic recommended and sent an order to the facility for a Pure Wick system, and the facility refused to allow the Pure Wick. Consultant Staff JJ reported R55 had a consultation with a urologist and thought R55 would have a Foley catheter placed and that the urologist would handle the urine diversion device to assist in healing R55's wounds. Consultant Staff JJ reported that a high-protein diet, vitamins, and supplements were a goal on R55's first visit, 09/16/25, and thought the facility would have ordered them. During an interview on 02/11/26 at 11:56 AM, Physician Provider II reported R55 could not use a Pure Wick system at the facility as it would not be beneficial for her and would cause more skin breakdown. Physician Provider JJ reported R55 was assessed by Physician Provider HH and was seen often and had adjusted R55's pain medication. Physician Provider II reported that the facility reported to her that R55 would refuse incontinent care and refuse to offload, and that was a concern. Physician Provider II reported R55 did not really qualify for a Foley catheter. Physician Provider JJ also reported that a catheter would cause more concerns, such as urinary tract infection (UTI- an infection in any part of the urinary system). Physician Provider JJ expected staff to administer as-needed pain medication if available, and was concerned that R55 waited two hours for pain medication. During an interview on 02/11/26 at 01:15 PM, Consultant Staff KK (Registered Dietitian) reported that he did not know that R55 had wound notes from the wound clinic that recommended a high protein diet. Consultant Staff KK reported that R55 was not on a high-protein diet and did not require a high-protein diet related to contact dermatitis. During an interview on 02/11/26 at 01:40 PM, Administrative Nurse D reported a resident who had unhealing wounds should receive high protein per provider orders/recommendations. Additionally, they should receive supplements and vitamins. Administrative Nurse D reported that the facility would normally not provide a high-protein diet and vitamins for residents with MASD, and she reported that R55 was not healing and did not know that the wound clinic notes had goals for high protein and vitamins. Administrative Nurse D reported she had not read the wound clinic notes and that the floor nurses would read the wound notes. The facility's Abuse Prevention Policy documented that the residents have the right to be free from abuse, neglect, and to be protected from abuse and neglect from community associates. The facility's policy Pain, dated 12/2025, documented that the physician and associates would identify individuals who have pain or who are at risk for pain. Administer pain drugs on a regular basis to maintain therapeutic levels and use as-needed medications for breakthrough pain.

The facility reported a census of 69 residents. The sample included 17 residents. Based on interviews, observation and record review, the facility failed to utilize 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) and failed to follow appropriate infection control practices related to hand hygiene, sanitization of shared equipment, and sanitary storage of respiratory equipment. Findings included:1. On 02/09/26 at 11:05 AM, Certified Nurse Aide (CNA) N and CNA O assisted R55 to bed using the mechanical lift. R55 had a colostomy (a surgical creation of an artificial opening on the stomach wall to excrete feces from the body). CNA N and CNA O did not apply a gown during this care. CNA N used her gloved hands to open R55's drawer to retrieve the hygiene wipes. She wiped the red areas of R55's inner thighs several times using that same wipe. Staff assisted R55 to her side, and CNA N washed the resident's buttocks. Wearing the same gloves, she sprayed perineal lotion into her gloved hand and then mixed A&D ointment on the same gloved hands and applied the mixture to R55's buttocks. Wearing the same gloves, CNA N grabbed the bottle of perineal lotion and the A&D ointment tube, mixed more up in her gloved hands, and applied it to the resident's coccyx (the area of the buttocks at the end of the spine). CNA N removed her gloves and reapplied new gloves without performing hand hygiene and proceeded with cleansing R55's front perineal area. CNA N and CNA O pushed the mechanical lift out of the resident's room into the hallway without sanitizing the lift or sanitizing their hands after removing their gloves. On 02/09/2026 at 01:29 PM, CNA N and CNA O agreed they should have worn a gown while providing care for a resident who required EBP. CNA N stated she did not realize she had used her gloved hand to touch the resident's dresser. Both CNA N and CNA O confirmed they should sanitize the mechanical lift after each use to prevent cross-contamination and the spread of infection. On 02/10/26 at 10:30 AM, Licensed Nurse (LN) H reported that she expected the staff to sanitize their hands when they remove gloves and expected staff to wear the required PPE for EBP, which includes gowns when providing direct care, such as incontinence care; additionally, staff should sanitize the mechanical lift between residents' use. 2. On 02/09/26 at 10:14 AM, R6 was in bed with his oxygen tubing wrapped around the concentrator and hanging without a cover. Her nebulizer mask mouthpiece lay directly on the table, uncovered, with clear liquid in it. On 02/09/26 at 01:54 PM, R6 reported she received breathing treatments last evening, but she did not know if the staff rinsed the equipment. Observation revealed the nebulizer mouthpiece remained touching the nightstand and still had clear liquid in the chamber. Her 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) mask lay directly on the nightstand. Her oxygen tubing was wrapped around the oxygen tank on the back of her wheelchair, with the nasal cannula touching the tank. On 02/10/26 at 04:13 PM, CNA P reported that a nasal cannula and CPAP mask should be placed in a bag, though sometimes the CPAP masks were placed in a sanitizer box if the resident had one. CNA P stated the nurse took care of the nebulizer equipment. On 02/10/26 at 04:18 PM, CNA P reported that R6 did not have a sanitizer box in her room for her CPAP mask and said the nasal cannula with oxygen tubing should be placed in a bag.On 02/10/26 at 09:17 AM, LN J reported that once a nebulizer treatment was administered by the nurse, the equipment should be taken apart, rinsed, and air dried; it usually would then be placed in a bag or a pencil box. She reported she had not yet given R6 breathing treatment that day. LN J reported that when a nasal cannula was not in use, it should be placed in a bag, and the same for a CPAP mask. On 02/11/26 at 04:25 PM, Administrative Nurse D reported she expected staff to wipe off the mechanical lift with a sanitizer wipe after each use. She expected the staff to wash their hands after they removed their gloves before applying new gloves, and not use gloves for personal care after touching drawers and handles on the resident's furniture. She expected the respiratory equipment to be stored in the correct way, which was in a bag or box, to prevent contamination and the spread of infection. Administrative Nurse D stated the staff should use EBP when giving direct care to residents who have an artificial opening in their body, such as a colostomy, including a gown. The infection Control Policy titled Personal Protective Equipment, dated 02/2025, included that personal protective equipment appropriate to specific task requirements should be used when indicated for isolation precautions to prevent the spread of infection, to protect wounds from contamination, and to protect hands from potential infectious material. The staff is to perform hand hygiene when removing gloves, and when the use of gowns is indicated, all personnel must put on gowns before treating a resident. The policy lacked addressing the storage of respiratory equipment and tubing when not in use and/or the sanitation of mechanical lifts between resident use.

The facility had a census of 69 residents. The sample included 17 residents with five reviewed for discharge and two for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy at the time of transfer for Resident (R)75 and R3. Findings included: 1. R75's Electronic Medical Record (EMR) recorded an admission Minimum Data Set (MDS) dated [DATE], which documented, per staff interview, that the resident had short-term and long-term memory problems. The resident admitted on [DATE]. R75's Nursing Progress Notes, dated 01/05/26 at 05:37 PM, documented the nurse called emergency services based on a physician order to send the resident to the hospital. The resident was transferred to the hospital on [DATE] at 05:15 PM. The Transfer Form, dated 01/05/26 at 04:03 PM, documented the facility would provide the resident and/or representative with a bed hold that included the daily room rate and duration of the bed hold prior to transfer. However, the documentation lacked evidence that a written bed hold was provided for the transfer. 2. R3's admission MDS, dated 07/19/25, documented a Brief Interview for Mental Status (BIMS) score of 13, indicating cognition intact. On 08/11/25 at 07:31 pm, the resident was sent to the hospital short of air/breath (SOA). On 02/10/26 at 08:13 AM, R3 was in bed. She stated she had transferred to the hospital on multiple occasions and went on to say she was not made aware of a bed hold policy. She reported she did not recall being provided with a written bed hold when she transferred to the hospital. On 02/10/26 at 03:56 PM, Licensed Nurse (LN) H reported that when a resident was transferred to the hospital, the nurse would send the Transform Form. She would not give the residents a written bed hold form, which included the room rate and duration of bed hold prior to transfer. LN H said Social Service X did that. On 02/10/26 at 05:04 PM, Social Service X reported that she would send the bed hold, which included duration and room rate, via certified mail, when a resident was sent to the hospital. She could not provide the documented evidence of a written bed hold sent to the residents and/or their representative. On 02/11/26 at 09:55 AM, Social Service X reported that she did not provide the bed hold when residents were transferred to the hospital; she stated the nurses would provide that prior to transfer to the hospital. On 02/11/2026 at 01:51 PM, Administrative Nurse D verified the lack of a written bed hold in the resident's EMR, which included the daily room rate and/or the duration of the bed hold. Administrative Nurse D stated she did not know who was responsible for providing the residents and/or representatives with a written bed hold policy. On 02/11/26 at 02:06 PM, Administrative Staff A reported that Social Service X did not provide the written information when residents transferred to the hospital because they were unaware that it was required for Medicaid residents. The undated facility Bed-Holds and Returns Policy documentation included that prior to transfer, written information will be given to the resident and the representatives, which explains in detail the duration of the bed hold, the reserve bed payment policy as indicated by the state plan.

The facility had a census of 69 residents. The sample included 17 residents. Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 7's Electronic Medical Record (EMR) contained appropriate documentation for the schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis. Findings included:- R7 's EMR revealed diagnoses of schizophrenia, and dementia (a progressive mental disorder characterized by failing memory and confusion). R7's Annual [NAME] Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R7's MDS revealed a diagnosis of schizophrenia. R7's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/30/25, documented R7 was at the facility for long term care. R7 had dementia and required staff to assist with activities of daily living. R7's Quarterly MDS, dated 07/28/25, documented a BIMS score of 12 and revealed a diagnosis of schizophrenia. R7's Care Plan, dated 09/22/21, documented R7 documented had a diagnosis of schizophrenia and would remain stable. Staff provided education to monitor behaviors, provide support as needed. R7's Care Plan, dated 09/22/21, documented R7 had a potential for drug related complications associated with use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use for schizophrenia. R7's Physician Orders ordered Zyprexa (antipsychotic medication), 5 milligrams (mg) by mouth every day, for schizophrenia, date ordered 11/23/21. R7's Psychological Evaluation, dated 09/10/1979, lacked schizophrenia as a diagnosis. R7's Basic Psychological Evaluation, dated 06/17/1982, lacked schizophrenia as a diagnosis. R7's Psychological Evaluation dated 09/29/2003, lacked schizophrenia as a diagnosis. R7's History and Physical dated 04/07/2017, lacked schizophrenia as a diagnosis. R7's Client, Assessment, Referral, and Evaluation, dated 04/18/2017, indicated R7 had not been diagnosed with a serious mental disorder. R7's Physician Orders ordered Zyprexa, (antipsychotic medication) 5 milligrams (mg) by mouth every day, for schizophrenia, date ordered 11/23/21. R7's Psychotropic Medications Risk, Benefit and Consent, dated 12/08/22, documented reason for use of medications diagnosis of schizophrenia. During an observation on 02/10/26 at 07:58 AM, R7 ambulated to the dining room with staff. He had a smile, and he was very friendly. During an interview on 02/11/26 at 08:36 AM, Administrative Nurse E reported that R7 did have a diagnosis of schizophrenia when he was admitted to the facility on [DATE]. Administrative Nurse E revealed an admission document Basic Psychological Evaluation, dated 06/17/1982, with a documented diagnosis of schizoid personality traits (personality disorder marked by a lack of desire for relationships and emotional coldness). Administrative Nurse F reported she thought it was a diagnosis for schizophrenia and had updated R7's diagnoses list in EMR on 09/03/21 with the diagnosis of schizophrenia. During an interview on 02/11/26 at 03:30 PM, Consultant Staff GG reported she thought R7 had the required documentation in his EMR for the diagnosis of schizophrenia. During an interview on 02/11/26 at 04:45 PM, Administrative Nurse D reported she expected the residents EMR to reflect their accurate diagnoses. The facility did not provide a policy for professional standards of care in diagnosing schizophrenia for use with antipsychotics.

The facility identified a census of 69 residents. The sample included 17 residents with two residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance with personal hygiene for Resident (R) 55 and R63, who did not receive fingernail care and facial hair removal, and R8 who did not receive staff assistance to get dressed. Findings included:1. R55's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), contact dermatitis (skin rash), and overactive bladder. R55's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 14, which indicated intact cognition. R55's MDS documented that she had no rejection of care during the observation period and minimal depression. R55's MDS documented that she required total assistance with personal hygiene. R55's Care Plan, dated 11/22/24, documented R55 had neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) to her hands. Staff were instructed to provide assistance with her ADL. During an observation on 02/09/26 at 10:31 AM, R55 had several long white facial hairs approximately half inch on her face. She reported she was unable to remove them and would like the staff to remove them but went on to say the staff would not do that for her. During an observation on 02/10/26 3:50 PM, R55 lay in her bed as she watched television. Several long white facial hairs remained on her face. During an observation on 02/11/26 at 09:20 AM, R55 sat in her wheelchair in the beauty shop. Her facial hairs were unchanged from previous observations. 2. R63's EMR recorded diagnoses of hemiplegia (paralysis of one side of the body) following a 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) which affected her right side, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with ADLs. R63's Annual MDS, dated [DATE], documented a BIMS of 14, which indicated moderately impaired cognition. R63's MDS documented that he had no rejection of care during the observation period and minimal depression. R63's MDS documented that he required maximal assistance with personal hygiene and had impairment of one upper extremity. R63's Care Plan, dated 09/23/25, documented staff instructed that R63 required extensive assistance with one person staff support for hygiene. During an observation on 02/09/26 at 10:47 AM, R63 was lying on his bed observed a right hand contracture (abnormal permanent fixation of a joint or muscle). R63 turned his arm and revealed long fingernails that were cutting into the right palm of his hand causing red marks. He reported that he could not cut his nails. A right arm/hand splint lay on his windowsill. During an observation on 02/10/2026 at 10:40 AM, R63 was seated upright in his bed with his right-hand splint on. He reported that staff had not cut his nails yet, and observation revealed long fingernails on his right hand. During an observation on 02/10/2026 at 12:30 PM, R63 was seated was seated in his wheelchair at the dining room table eating his lunch. R63's splint was off his right hand, Certified Nurse Aide (CNA) S asked R63 where his right-hand splint was. R63 pointed at CNA Q. CNA Q reported she had removed the splint to transfer R63. R63's right-hand fingernails remained long, and observation revealed red lines on the palm of his right hand. 3. R8's EMR revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acoustic neuroma (typically slow-growing tumor that develops on the main nerve connecting the inner ear to the brain) with hearing loss, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's Significant Change MDS, dated 06/05/25, documented the resident had a BIMS score of 12, which indicated moderately impaired cognition. The MDS documented R8 required moderate assistance with dressing. The MDS documented R8 had no rejection of cares during the observation period. R8's ADL Functional/Rehabilitation CAA, dated 06/10/25, documented R8 required moderate assistance with dressing related to cognition and fall risk. R8's Care Plan, dated 02/28/25, directed staff R8 required limited assist of one staff member for dressing. During an observation on 02/09/26 at 10:56 AM, R8 sat in his wheelchair in his room. He wore a blue long sleeve shirt and an incontinence brief. R8 reported he was sitting half naked. During an observation on 02/10/26 at 08:06 AM, R8 sat on the side of his bed with gripper socks on. He leaned towards his right side, propped up by his elbow. R8 wore the same blue long sleeve shirt from previous observation. During an interview on 02/10/2026 at 10:22 AM, CNA N reported that R55 did not refuse care and required assistance with all her ADLs. During an interview on 02/11/26 at 09:23 AM, CNA Q reported R55 would allow staff to remove her facial hair and would be provided on her shower days. CNA Q reported that fingernails were trimmed or filed on shower days too. During an interview on 02/11/26 at 09:30 AM, Licensed Nurse (LN) I reported that R8 could not dress himself but said the resident would allow staff to dress him. LN I reported that the residents would have their fingernails cleaned and cut when they have a shower, and they would have their facial hair removed on shower days and as needed. During an interview on 02/11/2026 at 04:10 PM, CNA P reported that R63 did not refuse care and required staff to assist with his personal hygiene. During an interview on 02/11/26 at 04:30 PM, Administrative Nurse F said she expected that staff to assist residents with removal for facial hair and filing/trim fingernails as resident/family preferred. The facility did not provide a policy for ADLs for dependent residents.

The facility reported a census of 69 residents. The sample included 17 residents with one reviewed for hearing aid use. Based on interview and record review, the facility failed to ensure Resident (R) 8 received the necessary services, including staff assistance, with his hearing devices. Findings included: - R8's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), acoustic neuroma (typically slow-growing tumor that develops on the main nerve connecting the inner ear to the brain) with hearing loss, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R8 required moderate assistance with personal hygiene. The MDS noted R8 had minimal difficulty with hearing and R8 used hearing aids. R8's Communication Care Area Assessment (CAA), dated 06/10/25, documented R8 had acoustic neuroma with hearing loss of his right ear and used a hearing aid for his right ear; R8 was deaf in the left ear. R8's Care Plan, dated 02/14/25, directed staff R8 wore a right ear hearing aid; staff were to place important items within his reach. During an observation on 02/09/26 at 10:56 AM, R8 sat in his wheelchair wearing only a brief and a blue long sleeve shirt. His hearing aid was in a dish on the table to the left of R8, outside of his reach. R8 reported he had a hearing aid and did not know where it was. R8 said he needed staff to put it in his ear. During an observation on 02/10/26 at 10:37 AM, R8 sat in his wheelchair. His eyes were closed and there was no hearing aid in his right ear. R8 reported he did not know where his hearing aid was. During an observation on 02/11/26 at 09:21 AM, R8 sat in his wheelchair eating breakfast as he watched television. He did not have a hearing aid in his right ear. His hearing aid was in the dish on the table to the left of R8 and outside of his reach. During an interview on 02/11/26 at 09:23 AM, Certified Nurse Aide (CNA) Q reported that R8 would play with his hearing aid, and the staff should apply it to his ear. CNA Q reported that R8 would usually lose the hearing aide in bed. CNA Q reported that the hearing aid was kept in the dish on R8's nightstand to keep track of it. CNA Q verified that R8 could not apply his hearing aid by himself. During an interview on 02/11/26 09:30 AM, Licensed Nurse (LN) I reported she expected the CNAs to follow R8's Care Plan and apply his hearing aid when they first got him up in the morning. LN I reported the residents kept their hearing aids in their rooms. During an interview on 02/11/26 at 04:10 PM, CNA P reported that R8 required assistance with his hearing aid and reported that she placed his right hearing aid in his right ear that afternoon. CNA P reported that R8 would not refuse his hearing aid. During an interview on 02/11/26 at 04:30 PM, Administrative Nurse F said she expected staff to assist residents with their hearing aids. The facility's policy Care of the Hearing-Impaired Residents, dated 01/2026, documented the purpose of this procedure was to provide guidelines when providing care to the residents with hearing impairment, motivate residents to use hearing aid if ordered, and assist residents to adjust the different sounds of a hearing aid.

The facility reported a census of 69 residents. The sample included 17 residents. Based on observation, interview and record review the facility failed to ensure Resident (R) 31 remained free from significant medications errors when staff held metoprolol without a physician's order and did not contact the physician regarding the held medication. Findings included: - R31's Electronic Medical record (EMR) revealed the following diagnosis: hypertension (elevated blood pressure). R31's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The medication section did not indicate hypertension. R31's Quarterly MDS, dated 02/02/26, indicated no changes to R31's BIMS or medications. R31's Care Plan, dated 11/06/25, noted R31 had hypertension and documented it would remain stable. Staff were to monitor R31's blood pressure and monitor and report side effects of medication. The plan directed staff to inform the physician of any concerns. R31's Physicians Orders, dated 11/06/25, noted an order for metoprolol (medication used to lower blood pressure), tab 25 milligrams (mg) by mouth twice a day for hypertension. R31's Nurses Notes, dated 01/03/26 at 10:01 AM, documented that metoprolol 25 mg was held for a blood pressure of 107/60 millimeters (mm) of Mercury (Hg). The notes lacked an indication that the physician was notified to obtain a hold order or to alert of the blood pressure reading. R31's Progress Notes, dated 01/21/26 at 09:01 AM, documented that R31's metoprolol 25 mg was held for a blood pressure reading of 98/63 mmHg. The notes lacked an indication that the physician was notified to obtain a hold order or to alert of the blood pressure reading. R31's Nurses Notes, dated 01/30/26 at 08:17 AM, documented that metoprolol 25 mg was held for a blood pressure reading of 94/78 mmHg. The notes lacked an indication that the physician was notified to obtain a hold order or to alert of the blood pressure reading. On 02/11/26 at 10:20 AM, Licensed Nurse (LN) G said that nurses should notify the physician if the metoprolol was held. LN G confirmed there was no order and no ordered parameters to hold the medication. On 02/11/26 at 10:50 AM, Administrative Nurse D said she expected the nursing staff to contact the physician and obtain orders for holding medications or for parameters if needed. On 02/11/26 at 03:46 PM, Consultant Staff GG said she reviewed the EMR for trends and to see if medications were being held. She said if medications were being held, the medications may need to be readjusted. She said staff should be contacting the physician with any medication that was held, and the facility should have a policy on this. The facility's policy Clinical Protocol: Guidelines for Notifying Health Care Providers (physicians) of Clinical Problems documented the guidelines are to help ensure that medical care problems are communicated to the health care provider efficiently and effectively, and all significant changes in resident status are assessed and documented in the medical record, immediate notification should occur as soon as possible, and the health care provider should be informed at the time of the event.

The facility reported a census of 69 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for residents and staff in the facility laundry. Findings included:- On 02/11/2026 at 12:30 PM, the tour of the facility laundry with Laundry/Housekeeping Staff U and Maintenance Staff V revealed the following concern. Three linen bins had soiled laundry, but were not covered. A 10-foot by four-inch area on the wall had peeling, unsealed, and unsanitary sheetrock. Two clean linen storage bins used for the delivery of clothes throughout the facility had frayed, unsanitary fabric around the top of the bins in an area that would have direct contact with clothes. On 02/11/26 at 12:53 PM, Laundry Staff U and Maintenance Staff V confirmed the above findings. They reported they were unaware that the soiled linen should be covered and were unaware of the inability to sanitize the clean clothes bins due to the frayed fabric. The staff verified that the sheetrock along the wall was unsealed and needed repair. Laundry Staff U reported the damaged sheet rock was due to the staff running the laundry carts into the wall. The facility did not provide a policy to address the above concerns.

The facility reported a census of 72 residents. Three residents were reviewed for privacy and confidentiality in their care at the facility. Based on observation, interview and record review, the facility failed to protect the privacy of Resident (R) 1 when Certified Nurse Aide (CNA) M took a video of R1 without R1's consent.Findings included:- The Electronic Medical Record (EMR) documented R1 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). R1's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status BIMS score of 99, indicating severely impaired cognition. The MDS noted R1 required the assistance of one staff member with activities of daily living (ADLs).R1's Quarterly MDS dated [DATE] indicated a BIMS score of 99, indicating severely impaired cognition. R1 required assistance from one staff member with all ADL. R1's Care Plan, revised 05/27/25, indicated R1 required extensive assistance from one staff member for bed mobility, toileting, transfers, and incontinent care. R1 had altered elimination due to her physical and cognitive status. The plan noted R1 had severe dementia and directed staff to observe for nonverbal cues that she needed assistance with toileting. The Investigation Report dated 09/22/25 indicated that night shift CNA M showed a video regarding R1 to CNA N during shift change. The video shows a fully clothed resident [R1] lying in bed, with bowel movement on her and the wall. CNA N reported the incident to Administrative Staff E. Administrative Staff A suspended CNA M until the investigation was completed. Administrative Staff A notified R1's representative, law enforcement, and the State Agency (SA) of the incident. On 09/23/25 at 09:35 AM, review of the camera footage in the facility for 09/22/25 at 06:08 AM showed the two CNA staff members at the nurses' desk. CNA M showed CNA N her phone. Zooming in on the video, observation revealed that it was unable to tell the identity of the resident in the video. On 09/23/25 at 09:56 AM, CNA N revealed she had come in for the shift. As she received the shift report from CNA M about R1, CNA M showed her a video of a resident from the chest down with BM on the resident and the wall. CNA N said she told CNA M to delete the video immediately and reported the incident to the Administrative Staff E. On 09/23/25 at 02:50 PM, CNA O revealed they had classes on protected health information. CNA O said staff were not to take pictures without the resident's consent, but they had not received any education recently regarding this incident. On 09/23/25 at 03:34 PM, Administrative Staff E said that after the incident, she had gone around to each of the houses and verbally reviewed the expectations on the residents' privacy. Administrative Staff E confirmed she did not have the staff sign off to verify that they had been educated. On 09/22/25 at 04:19 PM, Administrative Staff D stated the facility expected staff not to photograph or video the residents per facility policy. The facility policy Abuse Prevention dated 08/25, states that it is the policy of this community to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification, and verification of license. The community will provide training for associates at new hire orientation and through ongoing programs. Prevention protects the residents from invasion of privacy and or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other community activities.

The facility identified a census of 56 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to immediately implement interventions to prevent further falls for Resident (R) 1 after R1 had to be lowered to the floor when her left leg buckled underneath her. This failure led to another staff-assisted fall later the same day. As a result of this deficient practice, R1 sustained a severe fracture of the left ankle. This deficient practice also placed R1 at risk for pain, impaired mobility, and decreased independence. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dementia (progressive mental disorder characterized by failing memory, and confusion), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypertension (high blood pressure). R1's Entry Tracking Record Minimum Data Set (MDS) documented R1 admitted to the facility from the hospital on 05/16/24. No further MDS assessments were completed for this admission. R1's Care Plan dated 05/20/24, documented R1 required extensive assistance from one staff for transfers and toileting. The care plan documented R1 had a history of falls in the past and the resident would not have any major injuries from falls. The care plan directed staff to keep pathways clear and provide adequate lighting, keep the bed at an appropriate height, keep personal belongings within reach, transfer the resident per intake information until R1 was seen by therapy, and then follow therapy recommendations/plan of treatment. On 05/22/24, R1's transfer status changed to note the resident required a full lift. The undated Resident at Risk Review documented R1 had a fall risk score of 36 and was at risk for falls. The Nurse's Note, dated 05/17/24, documented R1 was alert and oriented. The Nurse's Note, dated 05/18/24, documented R1 was alert and oriented. The Nurse's Note, dated 05/21/24 at 07:51 AM, documented therapy was walking R1 to the bathroom in R1's room when R1 lost strength in her left leg and staff lowered her to the floor. Staff notified R1's provider who planned to see R1 that day. The note indicated R1's family would also be in that day and staff would notify them then. The nurse manager was notified of the event. The Occupational Therapy Treatment Note, dated 05/21/24, documented upon arrival R1 sat up in a recliner stating she needed to go to the bathroom. R1 completed a transfer from the recliner with minimal assistance using a front-wheeled walker to complete mobility from the recliner to the bathroom. R1 stood outside of the bathroom door when her left lower extremity buckled beneath her Therapy Staff GG slowly lowered R1 to the floor using Therapy Staff GG's leg as a guide and support with R1 sitting on Therapy Staff GG's foot. Staff assisted R1 to the wheelchair with a two-person assist. The note documented the skilled interventions included to stand pivot transfer R1 from her wheelchair to the toilet with the use of bilateral grab bars with minimal assistance, lower extremity clothing management with maximum assistance, and peri care with maximum assistance. R1 required a brief change and lower extremity clothing application with maximum assistance while seated and standing. Staff left R1 in a wheelchair with bilateral lower extremities on leg rests, call light and table within reach, and covered with a blanket. The Physical Therapy Treatment Note, dated 05/21/24, documented they performed therapeutic activities for transfer training to decrease caregiver burden post skilled stay. R1 presented in the recliner with a nasal cannula in place. R1 was very sleepy and required extra time to wake up. R1 was able to wake up and participate in mobility. R1 completed sit to stand activity from various surfaces with minimal assistance. R1 completed stand pivot transfers with cues for correct hand placement. R1 demonstrated a good ability to advance her feet during the stand pivot transfers. Note R1 had a non-injury fall when walking to the bathroom with Therapy Staff GG that morning. R1's legs gave out and she was assisted to the floor. R1's provider stated R1 had polypharmacy (multiple medications) and the provider planned to discontinue Haldol (antipsychotic medications used to treat major mental conditions that cause a break from reality), Baclofen (muscle relaxer), and Lyrica (a controlled substance used to treat muscle and nerve pain) in an effort to decrease tremors and improve alertness. The Nurse's Note, dated 05/21/24 at 09:30 AM, documented R1's daughter arrived and was informed of R1 being lowered to the ground. R1's daughter reported R1 was having pain in her left foot. The nursing staff reported the pain to the Physician's Assistant (PA). The Nurse's Note, dated 05/21/24 at 10:59 AM, documented R1's PA saw R1 and discontinued Lyrica, Baclofen, and Haldol due to R1 having decreased ability to communicate and twitching muscular movements. Staff notified R1's family of the new orders. The Nurse's Note, dated 05/21/24 at 01:29 PM, documented R1's PA ordered to hold R1's Lasix (diuretic used to promote formation and excretion of urine) for two doses, discontinue the lisinopril (medication used to lower blood pressure), place an intravenous (IV-directly into the vein) device and give R1 500 milliliters (ml) of normal saline at 75 ml's per hour. Staff notified R1's family of the order. The Nurse's Note, dated 05/21/24 at 08:00 PM, documented R1 received the ordered normal saline for dehydration. R1 was confused and pulled out her IV. R1 was unaware of what happened. Staff assessed the IV site and it was without bleeding or concern noted. The Nurse's Note, dated 05/21/24 at 11:00 PM, documented Certified Nurse Aide (CNA) M notified the nurse that R1 was unable to stand up for the bathroom and CNA M had assisted R1 to the floor. R1 stated her knees had given up and said she was unable to stand on her feet. R1 had no complaints of pain at that time. Staff performed a head-to-toe assessment, and no injury was noted. Staff assisted R1 up with a full lift, R1's brief was changed, and R1 was assisted to bed. R1 was talking to herself and pointing at stuff in her room. The Fall Scene Investigation Form, dated 05/21/24, documented Therapy Staff GG was walking R1 to the bathroom when R1's left leg gave out and PT lowered R1 to the floor with a gait belt on. R1 lost her strength while ambulating. R1 had gripper socks on. The fall intervention was for therapy to see R1 for strengthening. Therapy Staff GG's Witness Statement, dated 05/21/24, documented R1 was walking with therapy from the recliner to the bathroom. R1 was outside of the bathroom starting to turn in when R1's left lower extremity gave way and R1 was lowered to the floor with R1 ending up sitting on Therapy Staff GG's foot. R1 stated left ankle pain six out of ten. CNA N's Witness Statement, dated 05/21/24, documented R1 was working with therapy. Therapy came to get CNA N to help after R1's leg gave out on her. CNA N stated when she entered the room R1 was sitting on her bottom outside the bathroom door. The nurse was notified and assessed R1. CNA N and Therapy Staff GG helped R1 up from the floor and into her wheelchair. The Nurse's Note, dated 05/22/24 at 04:00 AM, documented R1 had purple bruising noted to her left ankle. R1 complained of pain and the note documented communication was placed for more evaluation. The Nurse's Note, dated 05/22/24 at 06:30 AM documented staff notified the on-call provider of R1's bruises and the provider ordered an x-ray of the left foot/ankle. The order was passed on to the on-coming nurse to notify the x-ray company. R1's Radiology Report, dated 05/22/24 at 05:14 PM, documented three views of the left ankle demonstrated a severe fracture dislocation of the left ankle. There was a transverse fracture (straight line fracture that runs in the opposite direction of the bone) at the medial (inner) malleolus (ankle bone). The distal (lower) fracture fragment as well as the talus (large bone of the ankle that connects with the tibia) were displaced laterally (to the outer side) by approximately 1.5 centimeters. Comminuted fractures (broken bones that have shattered into at least two pieces) were seen involving the distal fibula (lower leg bone) above the joint space. There was lateral angulation of the distal fracture fragment. The Nurse's Note, dated 05/22/24 at 06:15 PM, documented an order was received to send R1 to the hospital after the x-ray results came back. R1 exited the building at 06:15 PM. The Apparent Cause Analysis Report, documented R1 was admitted to the facility for skilled services on 05/16/24 with a primary diagnosis of CHF. On 05/21/24 at approximately 07:50 AM R1 was lowered to the floor by Therapy Staff GG during R1's therapy session. R1's left lower extremity buckled underneath her. Therapy Staff GG notified the charge nurse for assessment at the time of the fall. R1 complained of pain at a six on a scale of zero to ten, in her left ankle. R1 was seen by the PA and medication adjustments were made. The facility continued to manage R1's pain with routine pain medications. R1's weight-bearing status was not changed at that time by the PA or therapy. That evening at approximately 11:00 PM R1 was again lowered to the floor by clinical staff in her bathroom due to R1's legs giving out. R1 had no complaints of pain at the time of the second fall. On 05/22/24 at 04:00 AM, the nurse noted bruising on R1's left ankle and R1 complained of pain. R1's provider was notified via fax notification. At 06:30 AM, R1's PA was notified by phone of R1 having increased pain and bruising to the left ankle. The PA gave an order for an x-ray of the left ankle and foot. The x-ray results returned at 06:15 PM positive for lateral (to the side away from the center of the body) displacement relative to the tibia (lower leg bone). The facility received an order to send R1 to the emergency room for evaluation and treatment and R1 left the building. The facility concluded and documented that the fracture to R1's left lateral ankle appeared to be the result of R1 rolling her ankle when she was lowered to the floor with therapy and immediately complained of pain of six out of ten in her left ankle. The Nurse's Note, dated 05/23/24, documented that R1's daughter did not want to hold her bed at the facility. On 06/25/24 at 01:30 PM, Administrative Nurse D stated it was not up to nursing to determine R1's transfer status. Administrative Nurse D stated therapy determined R1 was a transfer with minimal assistance from one staff. Administrative Nurse D stated after R1's first fall, therapy did not change R1's transfer status so nursing continued to use a one-person assist. On 06/25/24 at 03:30 PM, Therapy Staff GG stated after she lowered R1 slowly to the ground. there was no deformity or bruising to R1's ankle. Therapy Staff GG said after the nurse assessed R1, she and another staff assisted R1 to her feet and to the wheelchair and then took R1 to the bathroom. Therapy Staff GG stated R1 did not complain of any increased pain when she stood and was able to completely bear weight. Therapy Staff GG stated physical therapy worked with R1 later that morning and R1 was able to bear weight and complete all exercises and did not complain of pain. Therapy Staff GG stated therapy staff leave it up to nursing staff to increase the level of assistance required for a resident's transfer status with a change of condition. The facility's Fall Policy, revised July 2023, documented the purpose of the policy was to provide guidelines for the evaluation of a resident in the event a fall occurred and to assist associates in the identification of potential causes of the fall. The [NAME] Fall Risk Assessment form should be utilized to complete the evaluation of the residents' potential for falls during the admission process. The [NAME] Fall Risk Assessment should be completed quarterly or with significant change MDS Assessment and after every fall. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as necessary. Direct care associates shall evaluate the area where the fall occurred for possible contributors. A Licensed Nurse shall document the fall in the resident's Attending Physician and Resident Representative of the event. The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall and document findings in the resident clinical record. The fall should be reviewed at the Daily Stand-Up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for resident falls by a Licensed Nurse after the fall occurs. The facility failed to initiate immediate interventions to prevent further falls for R1 after R1 was lowered to the floor when her left leg buckled underneath her. This led to another staff-assisted fall later the same day. As a result, R1 sustained a severe fracture of the left ankle. This deficient practice also placed R1 at risk for pain, impaired mobility, and decreased independence.

The facility reported a census of 72 residents. The facility identified four medication storage rooms and six medication carts used to administer medication to the residents. Based on observations, interviews, and record review, the facility failed to ensure that the medication administration error rate was no greater than five percent (%) when errors occurred with 22 of 27 observed medications had errors when the Licensed Nurse (LN) failed to confirm the medications administered against the physician's order or the eMAR (electronic medication administration record). The medication errors were due to failure follow nursing standard of care which resulted in an error rate of 81.48%. Findings include: - On 04/04/24 at 07:30 AM, LN D administered two medications to Resident (R) 8 by removing them from an outer wrapper (which was labeled with the identification of the contents) and removed the medications from their internal wrapping (which were also individually labeled with the identification of the contents) and failed to confirm the medications against the physician's order or the eMAR. On 04/04/24 at 07:35 AM, LN D confirmed that she had administered the medication without properly confirming the medication against the physician's order or the eMAR. On 04/04/24 at 07:37 AM, LN D administered a total of 13 medications to R15 by confirming the contents printed on the outer wrapper (which was labeled with the identification of the contents) and removing the medications from their internal wrapping (which were also individually labeled with the identification of the contents) without confirmation the individual medications against the physician's order or the eMAR. On 04/04/24 at 07:46 AM, LN D administered a total of seven medications to R3 by confirming the contents printed on the outer wrapper (which was labeled with the identification of the contents) and removing the medications from their internal wrapping (which were also individually labeled with the identification of the contents) without confirmation the individual medications against the physician's order or the eMAR. On 04/04/24 at 07:50 AM, LN D confirmed that she should have compared the individual medication identification labels to the physician's order or eMAR prior to administration to the residents. Additionally, LN D stated that the medication cart she was dispensing medication from serviced 20 residents. On 04/04/23 at 08:05 AM, Administrative Nurse B revealed that the facility's expectation is for staff to confirm the contents of each individual medication's identification label to the physician's order or the eMAR for accuracy since the outer packaging label could potentially be incorrect. The facility failed to provide a policy related to medication administration as requested on 04/04/24. The facility failed to ensure that the medication administration error rate was no greater than 5% when errors occurred with 22 of 27 observed medications had errors due to failure follow nursing standard of care which resulted in an error rate of 81.48%.

The facility census totaled 72 residents residing on four neighborhoods. Based on observation, interview, and record review. the facility failed to secure medications by the failure to lock two medication carts on two separate neighborhoods during administration of medications when nursing staff left the medication cart unlocked and unattended. This had the potential to affect 20 residents residing on neighborhood D2 and 20 residents on B2. Findings included: - On 04/03/24 at 11:35 AM, the medication cart on D2 neighborhood was unlocked with no nurse in the vicinity of the cart. On 04/03/24 at 11:35 AM, Licensed Nurse (LN) D reported there were 20 residents on the neighborhood who received medications from the medication cart. LN D stated the cart contained narcotics and insulins as well as other medications. LN D reported that all medication carts should be locked when unattended and confirmed that the medication cart was unlocked and unattended. On 04/04/24 at 09:12 AM, on B2 neighborhood, a medication cart was noted unlocked and unattended while LN C administered medications to a resident down the hallway. On 04/04/24 at 09:14 AM, LN C confirmed the medication cart was left unlocked and unattended, and stated he should lock the medication cart when he left the cart to give a resident their medications. On 04/04/24 at 09:37 AM, Administrative Nurse B stated that all medication carts should be locked when unattended. The facility policy named Storage of Medications dated 01/24 revealed compartments (including, but not limited to, drawers, cabinets, rooms refrigerators, carts and boxes) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility failed to secure medications by the failure to lock two medication carts on two separate neighborhoods during administration of medications when the nursing staff left the medication cart unlocked and unattended.

The facility reported a census of 72 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering meal trays to residents in the dining area, appropriately clean respiratory equipment for Resident (R) 8, R45 and R223 or perform hand hygiene between phases of wound care for R28. This deficient practice has the potential to lead foodborne illness, respiratory illness and wound infections. Findings include: - On 04/03/24 at 12:15 PM, Certified Nurse Aide (CNA) G and CNA H observed carrying multiple plates from satellite kitchen area in the D-200 neighborhood to resident tables with their thumbs over the edge of the plate and deep into the eating surface of the plates. On 04/03/24 at 12:25 PM, CNA G and CNA H revealed staff should carry resident plates by the bottom of the plate, without their fingers on the eating surface of the plates. On 04/03/24 at 12:36 PM, Dietary Staff I revealed that all staff, regardless of which department they work for, were expected to carry plates to residents by the bottom and keep their fingers off the eating surface of the plates. On 04/04/24 at 12:31 PM, Administrative Nurse F revealed that staff should carry plates to residents sitting at the tables by either using a tray, or by the bottom of the plate and ensure that their fingers do not contact the eating surface of the plates. The facility's 01/20/23 Preventing Food Borne Illness - Associate Hygiene and Sanitary Practices lacked instructions for staff on handling of resident plates. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering meal trays to residents in the dining area. This deficient practice had the potential to negatively impact the physical and psychosocial health of all 20 residents in the D-200 neighborhood. - R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and other disorders of the lung and obstructive sleep apnea (OSA - a sleep disorder that causes repeated breathing interruptions during sleep). R8's Physician Orders included: 1. Levalbuterol (a medication used to open and relax airway structures), 1.25 milligrams (mg) in 3 milliter (mL) to be inhaled orally, via nebulizer, two times per day, for asthma and breathing difficulty, related to COPD, ordered 12/12/23. 2. Trilogy Ventilator, (a CPAP device) at night or with sleep with oxygen at six liters per minute (LPM) supplementally added related to OSA, ordered 11/19/22. On 04/02/24 at 12:15 PM, an observation of R8's room revealed a nebulizer mask stored intact on an over the bed table with an unknown clear liquid inside the nebulizer chamber and a CPAP mask hung from the bedrail. On 04/03/24 at 09:10 AM, an observation of R8's room revealed a nebulizer mask stored intact on an over the bed table with an unknown clear liquid inside the nebulizer chamber and the CPAP mask hung from the bedrail. On 04/03/24 at 12:28 PM, an observation of R8's room revealed the nebulizer mask and CPAP mask remained in the same stored location. On 04/04/24 at 11:50 AM, an observation of R8's room revealed a CPAP mask remained intact and stored on the over the bed table. On 04/04/24 at 08:05 AM, Administrative Nurse B revealed that nebulizers should be cleaned after every use and set on a paper towel to dry. Additionally, staff have the availability of a cleaner to place CPAP masks in for cleaning. The expectation was for staff to clean nebulizers and CPAP masks after every use. On 04/04/24 at 12:31 PM, Administrative Nurse F revealed that staff should be cleaning nebulizers and CPAP equipment (masks/hoses/nebulizer chambers) after each use due to infection control concerns. The facility's 12/2022 Procedure: Respiratory Care - Prevention of Infection policy, documented that at the completion of therapy, staff were to remove the nebulizer container, rinse the nebulizer components with tap water and dry on a clean paper towel or gauze sponge. The policy lacked guidance for care/cleaning of CPAP equipment except to follow manufacturer's guidelines which were not provided by the facility as requested on 04/04/24 at 12:30 PM. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean respiratory equipment for R8. This deficient practice had the potential to lead to respiratory illnesses that could negatively affect the physical and psychosocial well-being of R8. - R45's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R45's Physician Orders included: 1. Ipratropium (a longer lasting medication used to open and relax airway structures), 0.5 milligrams (mg) and albuterol (a short- lasting medication used to open and relax airway structures) 3 mg in 3 milliter (mL), to be inhaled orally, via nebulizer, every two hours as needed, for COPD, ordered 09/14/22. 2. Brovana (a longer lasting medication used to open and relax airway structures),15 micrograms (mcg) in 2 mL solution, to be inhaled orally, via nebulizer, twice per day, for COPD, ordered on 09/14/22. 3. Budesonide (an inhaled steroid to reduce chronic airway inflammation) 0.5 mg in 2 mL suspension, to be inhaled orally, via nebulizer, twice per day, for COPD, ordered on 09/24/22. On 04/02/24 at 02:08 PM, an observation of R45's room revealed a nebulizer setup sat intact on the bedside table with an unknown clear liquid inside the nebulizer chamber and a second intact nebulizer setup stored inside a porcelain coffee cup. R45 revealed that staff would pre-load her as needed (prn) nebulizer with medications for her to use at her own discretion. On 04/03/24 at 09:16 AM, an observation of R45's room revealed a nebulizer setup stored intact on the bedside table with an unknown clear liquid inside the nebulizer chamber and a second intact nebulizer setup stored inside a porcelain coffee cup. On 04/04/24 at 11:47 AM, an observation of R45's room revealed the nebulizers storage unchanged from previous observations. On 04/04/24 at 08:05 AM, Administrative Nurse B revealed that nebulizers should be cleaned after every use and set on a paper towel to dry. Additionally, staff should not leave intact nebulizer equipment inside coffee cups. On 04/04/24 at 12:31 PM, Administrative Nurse F revealed that staff should be cleaning nebulizers after each use and should not leave intact nebulizer equipment inside coffee cups, due to infection control concerns. On 04/05/24 at 08:32 AM, Administrative Nurse B revealed that R45 did not have a self-administration safety assessment performed to be able to self-administer nebulized medications. The facility's 12/2022 Procedure: Respiratory Care - Prevention of Infection policy, documented that at the completion of therapy, staff were to remove the nebulizer container, rinse the nebulizer components with tap water and dry on a clean paper towel or gauze sponge. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards to appropriately clean respiratory equipment for R45. This deficient practice had the potential to lead to respiratory illnesses that could negatively affect the physical and psychosocial well-being of R45. - R28's diagnoses from the Electronic Health Record (EHR) documented personal history of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain) and 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), vascular dementia (a progressive mental disorder characterized by failing memory, confusion) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Physician orders documented the following: 1. On 03/22/24, staff were to cleanse the left upper buttock wound and the left lower buttock wound with wound cleaner, apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin), then cover wounds with hydrocolloid (an opaque dressing for wounds that is biodegradable, non-breathable, and adheres to the skin) On 04/04/24 at 11:15 AM, Licensed Nurse (LN) D performed wound care to areas of moisture associated skin damage (MASD) on R28's buttocks. Staff assisted the resident to the right side and removed R28's brief. LN D cleansed the buttock wounds and surrounding skin with bathing wipes. LN D changed gloves and failed to perform hand hygiene. LN D then cleaned upper buttock wound and surrounding skin with wound cleaner then skin prep and placed hydrocolloid dressing. LN D then changed gloves and failed to perform hand hygiene before the transition to wound care from the first treated wound to the second wound on the lower buttock. LN D then cleaned the second wound with wound cleaner then applied skin prep, changed gloves but failed to perform hand hygiene. LN D placed a hydrocolloid dressing on the second wound and changed gloves but failed to perform hand hygiene. LN D applied A&D ointment to the surrounding skin then, without glove change or hand hygiene, removed a permanent marker from her scrubs pocket and dated the dressings, then placed the marker directly onto the resident's bed. LN D then assisted the resident with placement of a new brief, then placed the marker on an over-the-bed table, then removed gloves and removed trash bag to bathroom and hand hygiene performed. LN D then returned to the resident's bedside to place a new trash bag and placed the contaminated marker back into her pocket and left the room. On 04/04/24 at 11:44 AM, LN D confirmed that she failed to perform hand hygiene when gloves were changed or when she transitioned between phases of wound care. On 04/04/24 at 12:28 PM, Administrative Nurse F stated that the expectation from staff is that hand hygiene is to be performed whenever gloves are changed during wound care and/or before transition from dirty phase to clean phase of wound care. The facility's 05/2023 Procedure: Wound Care/Dressing Change policy documented that staff were to perform hand hygiene whenever gloves were changed during wound care and/or dressing changes. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when staff failed to perform hand hygiene between phases of wound care for R28. This deficient practice had the potential to cause wound infections which would negatively affect R28's physical and psychosocial wellbeing.

The facility reported a census of 72 residents with 18 residents included in the sample. Based on interview and record review, the facility failed to ensure the five residents/ resident representatives acknowledged receipt related to COVID-19 (highly contagious respiratory virus) vaccination information/education for five of five residents, that included Resident (R)126, R124, R45, R6, and R16. Findings included: - On 04/04/24 at 12:20 PM, Administrative Nurse B provided an electronic spread sheet related to resident immunizations. The following were areas of concern: Resident (R)126 documentation revealed the COVID vaccination as Resident refused, however the facility was unable to provide declination information. R124 documentation revealed as resident refused, however the facility was unable to provide declination information. R45's documentation revealed the resident received a COVID vaccination on 10/13/23, however, lacked education for the risk verses benefits. Furthermore, the facility failed to provide a written consent to administer the vaccination. R6's documentation revealed the resident received a COVID vaccination on 10/13/23, however, lacked education for the risk verses benefits. Furthermore, the facility failed to provide a written consent to administer the vaccination. R16's documentation revealed the resident received a COVID vaccination on 10/13/23, however, lacked education for the risk verses benefits. Furthermore, the facility failed to provide a written consent to administer the vaccination. On 04/04/24 at 01:45 PM, Administrative Nurse B reported the facility lacked a no acceptance/declination consent form or an education information form, and verified the facility used verbal consents. The facility policy for Vaccination of Residents (Example: Pneumococcal, Influenza, COVID-19) dated 07/23 revealed residents will be educated about and offered vaccines in accordance to Center of Disease Control (CDC) and attending physician recommendations. Prior to receiving vaccinations, the resident or resident representative would be provided information and education regarding the benefits and potential side effects of the vaccines. Provision of education shall be documented in the resident record. Residents/resident representative may sign a consent/refusal form for vaccines. The resident or representative may refuse vaccines for any reason. Refusals for any immunizations offered will be documented in the medical record indicating the date of refusal. The facility failed to ensure these five residents/resident representatives acknowledged receipt related to COVID-19 vaccination information/education and/or signed consent verification.

The facility reported a census of 72 residents with 18 residents sampled, that included three residents reviewed for accident hazards. Based on observations, interviews, and record review, the facility failed to provide an environment as free of accident hazards as possible for Resident (R)28, when the facility failed to prevent multiple electrical cords plugged into two power strips next to R28's recliner from being strewn about the floor in the walking path between R28's recliner and R28's bed and the oxygen tubing on the floor in the walking path from the bathroom to R28's bed and recliner area. This deficient practice had the potential to create a trip hazard for R28 that could potentially lead to injury. Findings included: - R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), other disorders of the lung, and Parkinson's (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The 09/29/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance for all cares except eating and ambulation which were independent. The MDS documented no falls since admission and R8 mobility devices included a walker or wheelchair. The 09/29/23 Falls Care Area Assessment (CAA) documented R8 had a moderate risk for falls due to use of oxygen and long oxygen tubing. The 03/12/24 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident was independent with all cares except bathing, which required partial/moderate assistance of one staff and used a walker or wheelchair for locomotion. The 04/02/24 Care Plan documented an entry on 12/12/23 that R8 had a potential for falls related to change in environment with instructions for staff to keep pathways clear. On 04/02/24 at 12:15 PM, an observation of R8's room revealed two-four port power strips stored next to the recliner with seven items plugged in with cords that laid directly on the floor in the pathway between R8's recliner and R8's bed. R8's oxygen tubing looped on the floor between the resident's bathroom and down the pathway from the bathroom to R8's recliner. On 04/03/24 at 09:10 AM, an observation of R8's room revealed no difference from the previous observation. On 04/03/24 at 12:28 PM, observation of R8's room revealed the oxygen tubing and power cords remained in the same stored location. On 04/04/24 at 08:05 AM, Administrative Nurse B revealed that electrical cords and oxygen tubing on the ground in the walkway could be a trip hazard for residents. On 04/04/24 at 12:47 PM, Maintenance Staff E revealed the cords on the floor in R8's room were a trip hazard. The facility's 12/2017 Safety and Supervision of Residents policy documented that the facility would provide a safe environment for residents but failed to specifically address power cord or oxygen tubing placement. The facility failed to provide an environment as free of accident hazards as possible for R 28 when the facility failed to prevent multiple electrical cords plugged into two power strips next to R28's recliner from being strewn about the floor in the walking path between R28's recliner and R28's bed and the oxygen tubing on the floor in the walking path from the bathroom to R28's bed and recliner area. This deficient practice had the potential to create a trip hazard for R28 that could potentially lead to injury which would negatively affect the resident's physical and psychosocial wellbeing.

The facility reported a census of 72 residents with 18 residents selected for review, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment. for three Residents (R) 223 related to unlabeled nebulizer tubing and mask stored uncovered with unknown liquid remaining in the chamber, hanging on the side of the nebulizer machine and an undated oxygen tubing with nasal cannula, for R 45 with two nebulizers left with unknown clear liquid in nebulizer chambers, the second nebulizer lacked a date to indicate the tubing placement and was stored in an old coffee cup, and R 8 with an unknown clear liquid in the nebulizer chamber, continuous positive airway pressure (CPAP) mask left hanging on the bed rail with undated oxygen tubing/nebulizer/CPAP tubing. Findings included: - The Physician Orders, dated 03/26/24, revealed diagnoses that included intervertebral disc degeneration (a cushion of cartilage between the bones in the spine), fracture T11 and T12 (bones in the spine), and traumatic (injury) subdural hemorrhage (a pool of blood between the brain and its outermost covering). The Admission Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of seven, indicating moderate cognitive impairment. The resident received oxygen. The care plan, dated 03/26/24, directed staff the resident had potential for shortness of air (SOA) and/or respiratory complications related to pulmonary fibroids (scarring in the lungs which make it difficult to breath) with oxygen use. He had and upper respiratory infection present on admission. Staff should administer medications and oxygen as ordered. Review of the Physician Orders, dated 03/26/24, documented the following orders: 1. DuoNeb inhalation Solution (inhalation treatment), every 4 hours, while awake, for SOA, ordered 03/26/24. 2. Oxygen at two liters/minute per nasal cannula to keep oxygen saturation above 90 percent (%), every shift, ordered 03/25/24. 3. Change oxygen tubing and humidifier bottle weekly , ordered 03/31/24. On 04/03/24 at 10:02 AM, the resident's oxygen tubing and nasal cannula lacked a date to indicate the date it was placed. Additionally, the resident's uncovered, unlabeled handheld nebulizer inhalation administration appliance hung on the side of the nebulizer machine with an unknown liquid remaining in the medication chamber, while not in use. On 04/03/24 at 10:12 AM, Certified Nurse Aide (CNA) J, verified the above findings. She stated the CNAs monitor residents with oxygen to make sure the oxygen is on them, and it is going at the right setting. The humidifier bottle on the oxygen concentrator should be filled. The tubing should be labeled with the date it is placed by the third shift. Additionally, the nursing staff should label the oxygen tubing and cannulas when they change them on Sunday nights, and when if the tubing needs to be replaced. If she saw an issue with the oxygen, she would replace the oxygen set up to prevent the spread of infection. On 04/03/24 at 10:22 AM, Licensed Nurse (LN) C stated staff should change the oxygen and nebulizer tubing weekly on Sunday night. The nurse should date the tubing when initiating or replacing the tubing and or humidifier. The nebulizer medication chamber should be disassembled, cleaned, and left to air dry on a paper towel after each use, to prevent cross contamination and prevent the spread of infection, and should have a date and a time to indicate when last changed. On 04/03/24 at 10:32 AM, Certified Medication Aide (CMA) K, entered the resident room to administer the resident's 10:00 . She verified the resident's oxygen tubing and nasal cannula lacked a date to indicate the date it was placed. Additionally, the resident's uncovered, unlabeled handheld nebulizer inhalation administration appliance hung on the side of the nebulizer machine with an unknown liquid remaining in the medication chamber, while not in use. She stated the CMAs administer the breathing treatments for residents. The nurses were responsible for dating the tubing and humidifier bottles when initiated or changed. The nebulizer medication chamber should be cleaned and air dried after each treatment. CMA verified the above findings were still present. On 04/03/24 at 01:12 PM, Administrative Nurse B, stated she expected the nursing staff to rinse the nebulizer medication administration appliance and air dry on a paper towel after each use to prevent respiratory infection after each use. Additionally, she stated the oxygen tubing should be changed weekly and the tubing and respiratory equipment should be labeled with the date when initiated or changed. The facility's 12/2022 Procedure: Respiratory Care - Prevention of Infection policy, documented that at the completion of therapy, staff were to remove the nebulizer container, rinse the nebulizer components with tap water and dry on a clean paper towel or gauze sponge. The facility failed to provide respiratory care consistent with professional standards of care for the resident, regarding the use and cleaning of the nebulizer equipment. This deficient practice had the potential to lead to respiratory illnesses that could negatively affect the physical and psychosocial well-being for the resident. 46960 - R8's diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), other disorders of the lung and obstructive sleep apnea (OSA - a sleep disorder that causes repeated breathing interruptions during sleep). The 09/29/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance for all cares except eating and ambulation which were independent. The MDS documented no falls since admission and R8 received oxygen and a non-invasive mechanical ventilator via CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). The 09/29/23 ADL (activities of daily living, such as combing/brushing hair, brushing teeth, dressing and toileting) Functional / Rehabilitation Potential Care Area Assessment (CAA) documented R8 had significant COPD and required continuous oxygen and utilized a CPAP machine while sleeping. The 03/12/24 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident was independent with all cares except bathing which required partial/moderate assistance of one staff. R8 received oxygen and a non-invasive mechanical ventilator via CPAP. The 04/02/24 Care Plan documented an entry on 12/12/23 that R8 had altered respiratory status related to diagnosis of COPD and instructed staff to administer breathing treatments, oxygen and CPAP as ordered, and to monitor the resident for changes in respiratory status. Staff were to wash and dry the CPAP mask after each use and wash and dry the nebulizer after each use. R8's Physician Orders included: 1. Levalbuterol (a medication used to open and relax airway structures), 1.25 milligrams (mg) in 3 milliter (mL) to be inhaled orally, via nebulizer, two times per day, for asthma and breathing difficulty, related to COPD, ordered 12/12/23. 2. Trilogy Ventilator, (a CPAP device) at night or with sleep with oxygen at six liters per minute (LPM) supplementally added related to OSA, ordered 11/19/22. On 04/02/24 at 12:15 PM, an observation of R8's room revealed a nebulizer mask stored intact on an over the bed table with an unknown clear liquid inside the nebulizer chamber and a CPAP mask hung from the bedrail. On 04/03/24 at 09:10 AM, an observation of R8's room revealed a nebulizer mask stored intact on an over the bed table with an unknown clear liquid inside the nebulizer chamber and the CPAP mask hung from the bedrail. On 04/03/24 at 12:28 PM, an observation of R8's room revealed the nebulizer mask and CPAP mask remained in the same stored location. On 04/04/24 at 11:50 AM, an observation of R8's room revealed a CPAP mask remained intact and stored on the over the bed table. On 04/04/24 at 08:05 AM, Administrative Nurse B revealed that nebulizers should be cleaned after every use and set on a paper towel to dry. Additionally, staff have the availability of a cleaner to place CPAP masks in for cleaning. The expectation was for staff to clean nebulizers and CPAP masks after every use. On 04/04/24 at 12:31 PM, Administrative Nurse F revealed that staff should be cleaning nebulizers and CPAP equipment (masks/hoses/nebulizer chambers) after each use due to infection control concerns. The facility's 12/2022 Procedure: Respiratory Care - Prevention of Infection policy, documented that at the completion of therapy, staff were to remove the nebulizer container, rinse the nebulizer components with tap water and dry on a clean paper towel or gauze sponge. The policy lacked guidance for care/cleaning of CPAP equipment except to follow manufacturer's guidelines which were not provided by the facility as requested on 04/04/24 at 12:30 PM. The facility failed to provide respiratory care consistent with professional standards of care for R8, regarding the use and cleaning of the nebulizer and CPAP equipment. This deficient practice had the potential to lead to respiratory illnesses that could negatively affect the physical and psychosocial well-being of R8. - R45's pertinent diagnoses from the Electronic Health Record (EHR) documented chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 05/11/23 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required extensive assistance for all cares except eating which was independent. The resident did not receive special treatments or therapies. The 05/11/23 Care Area Assessment (CAA) lacked documentation related to nebulized medication use. The 01/25/24 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The resident required extensive assistance for all cares except eating which was independent. The resident did not receive special treatments or therapies. The 04/02/24 Care Plan documented an entry on 05/09/23 that R45 had the potential for shortness of breath and respiratory complications related to diagnosis of COPD and instructed staff to administer breathing treatments, and to wash and dry the nebulizer after each use. R45's Physician Orders included: 1. Ipratropium (a longer lasting medication used to open and relax airway structures), 0.5 milligrams (mg) and albuterol (a short- lasting medication used to open and relax airway structures) 3 mg in 3 milliter (mL), to be inhaled orally, via nebulizer, every two hours as needed, for COPD, ordered 09/14/22. 2. Brovana (a longer lasting medication used to open and relax airway structures),15 micrograms (mcg) in 2 mL solution, to be inhaled orally, via nebulizer, twice per day, for COPD, ordered on 09/14/22. 3. Budesonide (an inhaled steroid to reduce chronic airway inflammation) 0.5 mg in 2 mL suspension, to be inhaled orally, via nebulizer, twice per day, for COPD, ordered on 09/24/22. On 04/02/24 at 02:08 PM, an observation of R45's room revealed a nebulizer setup sat intact on the bedside table with an unknown clear liquid inside the nebulizer chamber and a second intact nebulizer setup stored inside a porcelain coffee cup. R45 revealed that staff would pre-load her as needed (prn) nebulizer with medications for her to use at her own discretion. On 04/03/24 at 09:16 AM, an observation of R45's room revealed a nebulizer setup stored intact on the bedside table with an unknown clear liquid inside the nebulizer chamber and a second intact nebulizer setup stored inside a porcelain coffee cup. On 04/04/24 at 11:47 AM, an observation of R45's room revealed the nebulizers storage unchanged from previous observations. On 04/04/24 at 08:05 AM, Administrative Nurse B revealed that nebulizers should be cleaned after every use and set on a paper towel to dry. Additionally, staff should not leave intact nebulizer equipment inside coffee cups. On 04/04/24 at 12:31 PM, Administrative Nurse F revealed that staff should be cleaning nebulizers after each use and should not leave intact nebulizer equipment inside coffee cups, due to infection control concerns. On 04/05/24 at 08:32 AM, Administrative Nurse B revealed that R45 did not have a self-administration safety assessment performed to be able to self-administer nebulized medications. The facility's 12/2022 Procedure: Respiratory Care - Prevention of Infection policy, documented that at the completion of therapy, staff were to remove the nebulizer container, rinse the nebulizer components with tap water and dry on a clean paper towel or gauze sponge. The facility failed to provide respiratory care consistent with professional standards of care for R45, regarding the use and cleaning of the nebulizer equipment. This deficient practice had the potential to lead to respiratory illnesses that could negatively affect the physical and psychosocial well-being of R45.

The facility reported a census of 59 residents with two residents reviewed for abuse. Based on record review and interview, the facility failed to ensure Resident (R) 1 was free from the inappropriate sexual behaviors/advances of R2, who had a history of inappropriate sexual behaviors; both verbal towards the staff in the facility and physical towards R1 on 11/05/22. R2 was treated with medication to help reduce sexual behaviors and the care plan directed staff to monitor R2 and encourage him not to sit within arm's length of female residents. However, on 12/06/22, due to lack of staff supervision, R2 spent an unknown amount of time in R1's room and put his hand up her shirt and down her pants, touching R1's chest and genitals. This deficient practice placed R1 in immediate jeopardy and at risk for psychosocial and physical harm. Findings included: - The Physician Orders (PO), dated 11/29/22, for R2, included a diagnosis of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). The Annual Minimum Data Set (MDS), dated [DATE], documented R2 with a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had verbal behavioral symptoms directed at others for one to three days during the seven-day lookback period. R2 required extensive assistance of two staff members for bed mobility, transfer, and toilet use. The resident used a wheelchair for mobility and received antidepressant medication during the lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/06/22, documented the resident with a diagnosis of dementia and experienced negative behaviors during the assessment period that was directed at others. The Quarterly MDS, dated [DATE], documented R2 with a BIMS score of 15, indicating intact cognition, and exhibited no behaviors. R2 required extensive assistance of two staff members for bed mobility, transfer, and toilet use. The resident used a wheelchair for mobility and received antianxiety and antidepressant medication during the seven-day lookback period. The Care Plan, updated 12/06/22, advised the staff R2 had a history of a stroke and memory problems and they were to provide cues to promote the resident's independence and ensure his safety. The resident required two staff members to assist with bed mobility, toileting, and transfer and R2 used a wheelchair for mobility. The resident had behaviors due to restlessness and made sexual comments towards the staff. Staff were to redirect and let R2 know it was not ok to speak to staff in that manner 09/28/22. Staff educated R2 not to touch female residents in inappropriate areas 12/06/22. Staff were to monitor resident and encourage him not to sit within arm's length of a female resident 09/28/22. The resident received medication for inappropriate behaviors and moved to another unit to separate R2 from the female resident that he sought out 12/06/22. A Behavior Note, dated 11/05/22 at 01:18 PM, written by Licensed Nurse (LN) G documented R2 touched a female table neighbor during the mid-day meal. Staff immediately separated R2 and the female table neighbor to separate tables for the remainder of the meal. Staff notified LN G as acting Manager on Duty and Director of Nursing (DON) in a timely manner. When questioned about this incident, R2 denied the incident happened and denied touching any female neighbors in a private or inappropriate manner. R2 then verbalized understanding that inappropriate touching of any other resident was not an acceptable action or behavior. A Facility Investigation, dated 11/11/22, documented on or about 11/07/22 at lunch time, staff reported R2 appeared to reach over and attempt to fondle the breast of female resident, R1. R1 reported R2 tried to fondle her breast and it made her uncomfortable. A Physician Communication, dated 11/28/22 at 06:07 PM, by LN H revealed a communication to the physician regarding R2 asking multiple staff to perform sexual acts with him in his room and to lay on his bed. R2 made those requests frequently throughout the day with any of the staff members. R2's family member requested information about any medication that would reduce the behaviors. A Nursing Note, dated 11/29/22 at 07:49 AM, revealed Administrative Nurse E spoke to R2 privately concerning very inappropriate sexual comments made to the staff earlier in the shift. R2 was alert and oriented with a BIMS score of 15. Administrative Nurse E educated R2 on the proper way to communicate with the staff and he was made aware that the comments he made to the staff were making them uncomfortable. A Nursing Note, dated 12/06/22 at 04:53 PM, by Administrative Nurse D documented at approximately 01:00 PM, staff witnessed R2 leaving a female resident's room. The female resident (R1), reported R2 fondled her breast and genitals under her clothing. She said that was the first time he had come to her room and done this. Staff reported the incident to the DON, state agency, local police department, and the emergency contacts for both residents. R2 denied fondling the female resident and stated he only went in there to talk to her. Police officers informed him it was not appropriate to touch other female residents that lived in the unit, and he needed to stay away from the female resident that reported this situation. R2 verbalized understanding. A Witness Statement, dated 12/06/22, by Administrative Nurse F, revealed she was assisting clinical staff members to find R2 as he was scheduled for therapy. Administrative Nurse F observed R2 leaving R1's room in his motorized wheelchair. Administrative Nurse F immediately went into R1's room and found her sitting in her recliner with her feet elevated. Administrative Nurse F inquired about her visitor and R1 stated R2 liked to come into her room sometimes. The nurse asked R1 what happened during their visit and R1 grabbed her breasts and stated that R2 touched them and tried to help her get her pants down. Administrative Nurse F asked R1 if she was okay and R1 stated she was and that she didn't need anything before Administrative Nurse F left the room to immediately notify the DON about the situation. A Witness Statement, dated 12/06/22, by Administrative Nurse D, revealed Administrative Nurse F informed her that she witnessed R2 leaving R1's room. Administrative Nurse F immediately went into R1's room and asked why R2 was visiting her and R1 informed Administrative Nurse F that R2 fondled her. Administrative Nurse D went directly to R1's room and inquired about the situation. R1 reported R2 was getting a feel while she motioned towards her breast area. R1 reported R2 fondled her breast and genital area. Administrative Nurse D asked if it happened above or underneath her clothing. R1 reported R2 touched her under her clothes. R2 told her he needed to get under them. R1 did not give the resident permission to touch her or want him to touch her. She stated, I just wanted him to get it over with so he would calm down. R1 also stated that R2 had never done that to her before. Interview on 12/04/22 at 10:48 AM, with Administrative Nurse D verified the above statements. She was not sure why R2 singled out and targeted R1. R2 had always been inappropriate with the staff and did not bother the residents. R2 was on daily behavior monitoring and charting due to behaviors towards staff. She educated R2 about inappropriate sexual behaviors towards others and he understood as he had a BIMS of 15. Nothing else happened between the residents until the incident on 12/06/22. The resident could move about in the unit in his wheelchair and staff did not see him go into R1's room. When she talked to R1 about it, R1 stated that she lifted up her shirt so he could touch her and also moved her pants and brief so he could put his hand in them. Nothing else happened and R2 left her room after he touched her genitals. R2 was moved downstairs into a different room and nothing else has happened since. The facility policy, Abuse Prevention, approved 06/22, documented .Our residents have the right to be free from abuse, neglect .This includes .sexual or physical abuse .Sexual Abuse is non-consensual sexual contact of any type with the resident . b. Does not want the contact to occur . 2. Any forced, coerced, or extorted sexual activity with a resident .Training .5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond .These symptoms, include but are not limited to .b. Wandering . The facility failed to ensure R1 was free from the inappropriate sexual behaviors/advances of R2, who had a history of inappropriate sexual behavior. On 12/06/22, due to lack of staff supervision, R2 spent an unknown amount of time in R1's room and put his hand up her shirt and down her pants, touching R1's chest and genitals. This deficient practice placed R1 in immediate jeopardy and at risk for psychosocial and physical harm. The facility provided their plan of removal on 12/14/2022 at 06:40 PM, which included the following implementation. 1. On 12/06/22 at 01:50 PM, the police and the medical director were notified. 2. On 12/06/22, R2 was moved to a different unit/floor of the facility and away from R1. 3. On 12/07/22, residents in the facility were reviewed by Administrative Staff A and residents reported they had not had any unwanted male visitors in their rooms or unwanted physical touching from others. Residents reported they felt safe in the facility. 4. Education of staff regarding ANE policies and reporting of incidents of Abuse, Neglect, and Exploitation to Administrative staff immediately was completed on 12/14/22 at 08:00 PM. Any remaining staff were contacted by the facility and advised they would be unable to work until education was completed. 5. Resident was put on one-on-one status on 12/14/22 at 08:30 PM The facility completed the removal plan on 12/14/22 at 08:30 PM.

The facility reported a census of 61 residents with 15 sampled. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to empty a suction canister for Resident (R) 10, which contained yellow liquid and was visible to all visitors who entered the room, through three days of observations. Findings included: - Review of R10's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/25/21 Significant Change Minimum Data Set (MDS) documented a staff assessment indicated long and short-term memory problem with severely impaired cognition. R10 received hospice services. The 01/28/22 Quarterly MDS documented R10 received hospice services and suctioning. The 01/22/22 Care Plan documented R10 received hospice services and as of 10/29/21 the resident had suctioning available, as needed (PRN). The EHR documented an order on 10/16/21 for orally suction PRN. The January through April 2022 Treatment Administration Record (TAR) documented only one suctioning documented as completed on 01/15/22. On 04/04/22 at 03:32 PM observed R10's room with a suction canister on suction machine. There was yellow liquid in the canister, which sat on the bedside table. The tubing and a [MEDICATION(S)] (an oral suctioning tool used in medical procedures) suction catheter tip were set directly on the bedside table, with no barrier noted, and visible to anyone who entered the room. On 04/05/22 at 01:09 PM observed R10's room with a suction canister on suction machine. There was yellow liquid in the canister, which sat on the bedside table. The tubing and a [MEDICATION(S)] suction catheter tip were set directly on the bedside table, with no barrier noted, and visible to anyone who entered the room. On 04/06/22 at 09:33 AM observed R10's room with a suction canister on suction machine. There was yellow liquid in the canister, which sat on the bedside table. The tubing and a [MEDICATION(S)] (an oral suctioning tool used in medical procedures) suction catheter tip were set directly on the bedside table, with no barrier noted, and visible to anyone who entered the room. Interview on 04/05/22 at 01:21 PM with Certified Nurse Aide (CNA) K revealed she did nothing with the suctioning for R10. Interview on 04/06/22 at 09:35 AM with Licensed Nurse (LN) D revealed she had not suctioned R10. LN D said she believed the canister and [MEDICATION(S)] suction catheter should be cleaned and stored covered after each use. Interview on 04/06/22 at 10:24 AM with Administrative Nurse B confirmed following suctioning, the canister and [MEDICATION(S)] should be cleaned and stored next to the bed. Administrative Nurse B confirmed she would not expect the [MEDICATION(S)] to be set on the bedside table with no barrier and she expected the canister to be cleaned and not contain any fluids. The 12/2021 Quality of Life- Dignity policy documented each resident should be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The 01/2022 Suctioning the Upper Airway (oral pharyngeal Suctioning) documented the purpose of the procedure was to clear the upper airway of mucous secretions and prevent the development of respiratory distress . staff were to empty and rinse the collection container, if necessary, or as indicated by community protocol and place catheter in a clean, dry area. The facility failed to promote dignity for R10 when staff did not empty the suction canister.

The facility reported a census of 61 with 15 residents in the sample. Based on observation, interview, and record review the facility failed to revise a care plan for one Resident (R) 30 regarding the use of a nebulizer (a respiratory treatment). Findings included: - The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set, dated dated dated [DATE] indicated R30 received oxygen therapy. The 03/07/22 Care Plan indicated R30 had a potential for shortness of breath and/or respiratory complications related to pneumonia and chronic [CONDITION(S)]. Staff were to provide treatment per physicians' orders and monitor the resident for response. The 03/07/22 Care Plan lacked interventions related to the use of the nebulizer and/or the care of the nebulizer after each treatment The 03/07/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/04/22 at 04:45 PM revealed the nebulizer set next to the equipment, with the face mask and tubing still attached, and not in use at the time of observation. Observation on 04/06/22 at 11:33 AM revealed the nebulizer equipment remained attached to the tubing and not in use. The medication bowl had clear fluid in the bottom of the bowl, and not in use at the time of observation. Observation on 04/06/22 at 11:22 AM revealed the nebulizer equipment had tubing and mask attached with liquid from the treatment in the base of the bowl, and not in use at the time of observation. Interview on 04/06/22 at 11:34 AM with Licensed Nurse (LN) I indicated the correct process included rinsing the nebulizer after each treatment and to place it on a towel to air dry. Interview on 04/06/22 at 11:53 AM with Administrative Nurse B indicated the facility did not include the nebulizer on the care plan because it was considered a standard of practice. The facility's 07/2020 Care Plans policy revealed the plan of care included the instructions needed to provide effective and person-centered care of the resident. The baseline care plan should include a review of the health care provider's orders and be implemented to meet the resident' immediate care needs until a comprehensive assessment can be developed. The facility failed to revise R30's care plan to include the care of the nebulizer after each treatment.

The facility reported a census of 61 residents with 15 sampled. The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for three residents. The facility failed to notify the provider of weight fluctuations greater than two pounds (lbs.) as ordered and failed to document the application of ace wraps and [MEDICATION(S)] bandages (an elasticated tubular bandage used for support) for Resident (R) 16. The facility also failed to document treatments as ordered by the provider for R15 and failed to change the wound dressing daily, as ordered for R25. Findings included: - Review of R16's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of two staff for all activities of daily living (ADL). R16 received a diuretic medication for six days of the seven-day look back period. The 04/28/22 Quarterly MDS documented a BIMS of 15, indicating intact cognition. The 02/05/22 Care Plan for R16 documented staff were to apply ace wraps/tubigrips as ordered. The Orders in the EHR documented on 02/01/19 the staff were to obtain weights daily and notify the provider of fluctuation of two lbs in 24 hours. On 01/31/19 staff were to apply ace wraps to both legs in the morning and remove at hour of sleep, discontinued on 03/23/22. On 03/23/22, the staff were to apply tubigrips to both of R16's legs in the morning and remove them at hour of sleep. The January through April 2022 Treatment Administration Record (TAR) documented 14 occasions of a fluctuation of two lbs. or greater, with the highest fluctuation of five lbs. noted. The TAR lacked documentation on 15 occasions to apply or remove ace wraps, and four occasions for application or removal of tubigrips. R16's EHR for January through April 2022, lacked documentation of provider notification for the 14 occasions of weight fluctuations. On 04/05/22 at 10:30 AM R16 sat in her wheelchair in her room with tubigrips to both legs and declined staffs offer to sit in her recliner and elevate her legs at the time. On 04/30/21 at 10:20 AM Certified Nurse Aide (CNA) C revealed staff were to apply the tubigrips in the morning and removed at bedtime. CNA C stated she did not document this but informed the nurse of the need. CNA C stated R16 was compliant with the tubigrips, but R16 did not like the ace wraps. On 04/06/22 at 09:35 AM Licensed Nurse (LN) D revealed R16's weights were obtained daily and if ordered, staff reported to the physician. When the staff reported the weights to the physician, the staff made a note in the EHR. LN D stated R16 had ace wraps she stated hurt and she would refuse to have them applied. LN D said R16 did better with the tubigrips. On 04/11/22 at 10:57 AM Administrative Nurse B revealed she expected the treatments to be initialed in the TAR. She expected resident weights to be obtained and staff to notify the physician when ordered. If the treatment was out of the Certified Medication Aid (CMA) scope of practice, she would expect them to contact the on-call nurse to complete the task. There were nurses on other units the CMA could also inform to complete the task. The 12/2021 Clinical Protocol: Heart Failure policy documented that the physician would review and make recommendations for relevant aspects of the nursing care plan, such as weight monitoring and when to report findings to the physician, etc. The facility failed to provide R16 care and treatment in accordance with standards of practice by the failure to apply and remove ace wraps/tubigrips, as ordered and the failure to notify the physician for out of parameter weights as ordered. - Review of R15's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/07/21 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, indicating severely impaired cognition. The 02/05/22 Care Plan for R15 documented staff were to administer treatments as ordered. The Orders in the EHR documented on 03/11/20 staff were to check R15's skin weekly and apply skin prep to both heels at bedtime (HS). The 09/02/21 order instructed staff to apply skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to medial (the middle) skin on knees where they touch for wound prevention. The February through April 2022 Treatment Administration Record (TAR) lacked documentation on three occasions to check R15's skin weekly, lacked documentation on 12 occasions to apply skin prep to medial skin on knees where they touch for wound prevention, and lacked documentation on 12 occasions to apply skin prep to both heels at HS. On 04/05/22 at 12:26 PM R15 sat in her wheelchair in her room having her noon meal. R15 wore shoes and her knees were touching at the time. R15 had no open skin wounds visible. On 04/06/22 at 09:35 AM Licensed Nurse (LN) D revealed treatments were documented in the TAR when completed. She stated she completed her tasks and the on-call nurses were available when needed, as well. On 04/11/22 at 08:25 AM Administrative Nurse B revealed she expected the treatments to be initialed in the TAR. If the treatment was out of the Certified Medication Aid (CMA) scope of practice, she expected the CMA to contact the on-call nurse to complete the task, and there were nurses on other units the CMA could also inform to complete the task. The 01/2022 Wound Care/ Dressing Change policy documented staff were to document treatments in the resident's medical record. The facility failed to provide R15 care and treatment in accordance with standards of practice when staff failed to document treatments as ordered. - R25's signed Physician Orders dated 04/05/22 revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/11/21 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The resident required extensive assistance of two staff for all daily care. The resident had one non-injury fall and one minor injury fall. The Annual MDS dated [DATE] revealed a BIMS score of three, indicating severely impaired cognition. The resident received limited assistance of one staff for all daily care. The resident had two non-injury and two minor injury falls. The Falls Care Area Assessment (CAA) dated 03/27/22 revealed the resident had a walker for mobility assistance. He would often rise and ambulate by himself without his walker. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan dated 05/26/21 revealed the resident would have falls related to desire for independence. The approaches included the resident wanted to remain free from injury related to falls over the next review period and the resident stated he wished to complete ADLs independently and preferred to risk falling rather than ask for staff assistance. The Nurse's Progress Notes dated 03/27/22 at 11:31 PM revealed the resident fell and sustained a skin tear to the right arm. The Nurse's Progress Notes dated 03/28/22 revealed the resident's right arm with a dressing clean, dry, and intact. The Physician Order dated 04/05/22 revealed wound care every day and directed the facility to cleanse the resident's right arm skin tear with wound cleanser, apply non-adherent dressing, cover with [MEDICATION(S)] (stretchy gauze roll wrap), and change daily. The Treatment Administration Record (TAR) revealed a CMA initialed the dressing was changed on 04/04/22 and 04/05/22. Observation on 04/05/22 at 12:20 PM revealed the resident sat at the dining table eating. The resident had a large dressing on his right arm with a date of 03/30/22. The dressing appeared dry and intact. On 04/06/22 at 07:33 AM the resident sat at the ding table in a wheelchair and had a large bandage on his right arm with date of 03/30/22. The dressing appeared clean and dry. On 04/06/22 01:07 PM Licensed Nurse (LN) E went in the resident's room to change the dressing on the resident's right arm. The dressing was dated 03/30/22. With gloves on the Allevyn ([MEDICATION(S)] wound) dressing was peeled back and removed to reveal an open wound on his arm approx 2.5 centimeters. An area of scab on one side of the wound and the other side open and bleeding. The wound was cleaned with wound cleaner and skin prep around the wound and an Allevyn dressing applied. (No order to apply that type of dressing found). During an interview on 04/05/22 at 10:00 AM Certified Nurse Aide (CNA) F reported the resident wants to do things by himself. CNA F said the staff try to sit him in the living room where we can keep a closer eye on him and R25 would not use his call light and tried to get up on his own if he is in his room. During an interview on 04/06/22 at 12:35 PM LN E reported it was a job to keep the resident from falling. He refused to ask for assistance and was determined to get up on his own. LN E said she put a dressing on the wound but did not call for an order the day she put it on. She assumed the dressing in place was the right dressing so that is what she replaced the old one with. She did not check the order for the correct dressing. On 04/06/22 at 02:30 PM Administrative Nurse B reported the dressing that was on the resident was a seven- day dressing and that was probably why it was not changed. The CMA could not change the dressing and she did not know why the CMA signed the TAR. Administrative Nurse B stated she expected the CMA to notify another nurse of treatments that needed done and verified that did not happen. Review of the facility policy for Wound Care dated 08/21 revealed nurses were to review and verify physician orders for dressing changes. The facility failed to provide wound care in a timely manner and according to physician orders.

The facility census totaled 70 residents with 7 included in the sample and 3 of the 7 were sampled 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, interview and record review the facility failed to plan and consistently implement interventions to prevent pressure ulcer development for 2 of 3 residents who were at risk and entered the facility without pressure ulcers (#1 and #3). Resident #1 admitted on [DATE] from an acute care hospital with no pressure ulcers and staff discovered a suspected deep tissue injury (SDTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) on the resident's right heel and a mushy red left heel on 12/27/17. Resident #3 admitted on [DATE] without pressure ulcers, but at risk based on assessment and developed a blister to the left heel on 12/7/17 which staff later assessed as a suspected deep tissue injury. Findings included: - Review of the Inter-Agency Transfer (IAT) record signed by the physician on 12/22/17 revealed the following [DIAGNOSES REDACTED].), [MEDICAL CONDITION] status/post repair, and left elbow fracture. Review of the Nursing Comprehensive Admission Observation/Evaluation form dated 12/23/17 at 3:25 PM revealed the resident arrived to the facility by wheelchair. Staff/therapy staff assisted the resident with weight bearing during the transfer from the wheelchair to the bed. Nursing staff assessed the resident's functional abilities to need substantial or maximal assistance with mobility from sitting to lying/lying to sitting; the resident did not walk and needed substantial or maximal assistance with toileting, eating and oral hygiene. His/her cognition was alert with short-term memory deficits and difficulty answering yes/no questions with aphasic speech (an impairment of language affecting the production or comprehension of speech and the ability to read or write) and hearing impaired. The section for Skin/Nails directed staff to complete smart chart skin condition form for all skin documentation including skin check completed with no skin issues). His/her oral mucosa was pink, moist and intact. Review of the skin condition assessment form dated 12/23/17 at 6:52 PM revealed an area marked on the body portion indicated an issue with the right hip and the notes read surgery 12/18/17 dressing in place for 10 days. A second skin condition dated 12/23/17 at 6:54 PM indicated the resident had a circular red area on the middle right back, which measured 1 centimeter (cm) by 1 cm by less than 0.2 cm. The record did not indicate any conditions involving the resident's feet or heels. The admission minimum data set (MDS) completed on 1/3/18 included a brief interview for mental status (BIMS) score of 7 indicating severe cognitive impairment with no behaviors. He/she required total assistance of 2 staff to transfer between surfaces and walking did not occur. He/she required extensive assistance of 2 staff for bed mobility, dressing, toilet use and personal hygiene. The resident was at risk for pressure ulcer development and had 1 Suspected Deep Tissue Injury (SDTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) unhealed pressure ulcer. The facility interventions included pressure reducing chair and bed, pressure ulcer care and application of dressing to the feet. The MDS indicated the pressure ulcer did not have pressure ulcer(s) present on admission. The care area assessment (CAA)s dated 12/30/17 triggered for cognitive function, activities of daily living (ADLs), urinary incontinence/catheter, nutrition, pressure ulcer and pain. All of the CAAs had the same information as follows: severe cognitive impairment, speech was clear and he/she was able to make him/herself understood and understood conversation. The resident admitted to the facility [MEDICAL CONDITION] related to a complicated UTI he/she experienced prior to hospitalization following a fall which resulted in a right [MEDICAL CONDITION] and left elbow fracture. His/her hip was repaired surgically. He/she admitted to receive services for safety, strengthening and mobility. He/she needed assistance with ADLs and extensive assistance from two staff members with bed mobility, dressing and toileting. He/she required two staff members for transfers and required a total body mechanical lift. He/she was at risk for skin breakdown and developed pressure related areas to his/her heels per skin assessment and clinical notes. To mediate his/her risk of breakdown related to pressure he/she used an air mattress while in bed and a pressure-relieving cushion in his/her wheelchair. He/she reported experiencing some left arm, right hip and right foot pain during the 14 day observation period. He/she stated the pain made it hard to sleep at night and limited his/her day-to-day activities and rated his/her pain at a 10 on a scale of 1-10 at its worst over the 14 day observation period. He/she denied pain at the time of the pain interview and received pain medication during the observation period. The ADL care plan initiated on 12/23/17 directed staff to provide extensive assistance of 2 persons with transfers, bed mobility, toileting and dressing. He/she used a wheelchair for mobility. The pressure ulcer care plan dated 12/23/17 directed staff to complete a Braden scale (pressure ulcer risk assessment), keep bed linens wrinkle free and do not use excess pads. Staff would observe skin for redness and breakdown during routine care. Staff should use pressure relieving devices as indicated and provide treatments as indicated (see physician order [REDACTED]. He/she had a deep tissue injury to the right heel and staff should provide treatment per treatment administration record (TAR). On 12/28/17 staff revised the care plan with provision of an air mattress to reduce the risk of skin breakdown. Review of the skin condition reports revealed the following: The next skin condition report was dated 12/27/17 at 4:47 PM which indicated the resident had a reddened boggy (soft or mushy) left heel which measured 3 cm x 3 cm of intact skin caused from pressure. A second skin report dated 12/27/17 at 4:50 PM which indicated staff found the resident with a popped blister to the right heel. The whole area measured 6.8 cm by 6.0 cm with the blister part measuring 3.5 cm by 3.5 cm and described the area as dark purple with serosanguinous drainage and caused by pressure. Staff identified the treatment plan to include off-loading the resident's heels with a HeelZup wedge (a large foam based wedge which goes under the resident's calves to allow the heels to float and not touch the mattress). On 12/28/17 at 6:59 PM staff recorded the right heel popped blister measured 8.5 cm by 7.5 cm which was dark purple with redness around and undermined depth. On 1/3/18 staff recorded the left heel as resolved. On 1/3/18 at 12:41 PM the right heel remained 7.5 cm by 7 cm and with a dark purple center of the center aspect of heel with dark redness surrounding and undetermined depth. Review of the interdisciplinary progress notes between 12/23/17 and 1/9/18 revealed the resident admitted on [DATE] at about 2:00 PM and noted the resident had his/her right [MEDICAL CONDITION] repaired on 12/18/17 and had a fractured left elbow as well. The resident was non-weight bearing on the left upper extremity and weight bearing as tolerated on bilateral lower extremity. Staff planned to reposition the resident every 2 hours. On 12/24/17 at 4:48 AM staff indicated the resident required total assistance with bed mobility and transfers. Staff placed pillows between the resident's thighs and under the left arm. He/she was alert and oriented to self only, very lethargic, weak and hard to arouse. The nurse and direct care staff made frequent checks on the resident who rested quietly in bed. The nursing note did not indicate if staff placed any pillows or other off-loading device under the resident's heels. On 12/25/17 at 11:56 PM staff indicated the resident continued to require assist of 2 staff for bed mobility and transfers to the wheelchair. His/her pedal pulses were present (but did not include a skin assessment of the feet/heels). The nursing note indicated staff checked and changed the resident every 2 hours or more and he/she rested quietly in bed. The note did not include any information regarding repositioning or intervention for prevention of pressure ulcers. On 12/26/17 at 2:31 AM staff recorded at 1:45 AM the resident unwrapped the ace bandage from his/her left arm splint and was attempting to remove the splint. He/she did not answer questions inquiring as to why he/she wanted to remove the splint. A thick absorbent pad (ABD) was placed between his/her arm and the hard edges of the splint for comfort, splint rewrapped with ace wrap. An ABD was also taped to the neck strap for comfort. The resident was alert and oriented times 2 and told the nurse about his/her previous work before retirement. He/she denied pain and rested quietly in bed. On 12/27/17 at 4:58 PM the nursing note indicated direct care staff notified the nurse of the resident having a popped blister to the right heel. The entire area measured 6.8 cm by 6.0 cm with dark purple center measuring 3.5 cm by 3.5 cm. The area is blanchable and noted with a large amount of serosanguinous drainage. The nurse cleaned the area, applied [MEDICATION NAME] (foam padded adhesive dressing) and indicated it should be changed every 3 days and as needed (PRN), and direct care staff were to float heels with HeelZup wedge when in bed. The nurse notified the physician and family. Observation on 1/9/18 at 9:34 AM observation revealed the resident attended morning exercise group and actively participated with the ability to perform all the exercises independently. He/she wore a non-skid sock on the right foot and a house slipper on the left foot. There were no foot pedals on the wheelchair and he/she kept his/her toes on the floor and tapped the heels up and down with no signs of pain or discomfort. Observation on 1/10/18 at 7:00 AM revealed licensed nurse B removed the dressing from the right heel. Observation of the heel revealed an area of dark purple skin with splotches of pink and beige (normal skin tone) and covered the entire heel with intact skin. The nurse said the area was less purple in color and estimated it at a half dollar size. Interview with family member G and family member H on 1/9/18 at 4:35 PM revealed the family (one or the other) was present in the room from about 9:00 AM to well after supper 6:00 PM). He/she indicated the resident wore the non-skid socks continuously, the socks were not changed, and he/she did not get a bath or even out of bed the first weekend. He/she said the wedge was not in place until after the pressure ulcer developed. The staff would put a pillow between his/her knees and under the left arm. Interview on 1/10/18 at 5:53 AM with direct care staff F revealed he/she provided care for the resident on 12/24/17 at 10:00 PM until 12/25/17 6:00 AM. He/she remembered the resident having a bandage on his/her left arm with no other devices in place, used a full body mechanical lift to transfer, would turn and reposition every 2 hours. He/she did not remember there being a wedge for the heels on that night but the next time he/she worked there was one. He/she indicated the care plan would direct the care the resident needed and he/she did not know of anything special for the resident prior to the pressure ulcer development. Interview on 1/11/18 at 10:11 AM with direct care staff E revealed the family had told staff the resident used something to float his/her heels at home. He/she reported going to the supply room and not finding a HeelZup wedge; he/she checked the other houses and could not find one. He/she reported placing pillows and blankets under the resident's lower legs to off-load the heels from the bed. He/she did not know if the care plan directed staff to off-load the resident's heels. He/she has a care sheet in the electronic record which indicated what care the resident needed and he/she would ask the nurse. Interview on 1/9/18 at 2:52 PM licensed nurse J revealed on 12/27/17 when direct care staff went to assist the resident to bed from the wheelchair staff saw drainage on the bed. He/she was made aware at that time which was the first he/she knew of any areas. Assessment revealed the resident wore non-skid socks and house slippers. The slipper was wet with a moderate to large amount of serosanguinous drainage. He/she asked the direct care staff about it at that time and staff reported they had trouble getting the slipper on his/her right foot that morning but the resident did not report having any pain. Nurse J remembered the resident being on a turn and reposition program but did not remember when the wedge was started. Interview on 1/11/18 at 9:24 AM licensed nurse K reported doing a partial skin assessment while the resident sat in the wheelchair upon arrival and could view most of the body due to him/her wearing a hospital gown. He/she wore non-skid socks at the time and the family present in the room requested pillows for under his/her heels. The nurse reported he/she and direct care staff E looked for a heel wedge but could not locate one in the facility so he/she directed staff E to put pillows under the resident's heels. He/she indicated completing the skin assessment later in the 12-hour shift and both heels were pale in color with no open areas. He/she reported initiating the resident's care plan and confirmed the care plan did not include elevating or off-loading of the heels. He/she reported on 12/26/17 the physical therapist worked with the resident and provided a HeelZup wedge. He/she confirmed the wedge was not added to the care plan by which all staff would know what care to provide the resident. Interview on 1/11/18 at 11:03 AM with administrative nurse C revealed he/she expected staff to follow the care plan to provide the resident with the care he/she needed. He/she confirmed the resident's care plan did not include pressure ulcer prevention interventions for the heels related to the risk due to dependence of staff for bed mobility prior to the development of the left heel being soft and the right heel having a suspected deep tissue injury. Interview on 1/10/18 at 12:05 PM with physician L revealed the resident had a lot of risk factors and he/she did not off-load every resident at risk but certainly a post-op [MEDICAL CONDITION] repair had a higher risk factor. He/she believed there was a 50/50 chance of the pressure ulcer being avoidable. The facility's policy titled Prevention of Pressure Injuries dated (YEAR) directed staff the most common site of a pressure injury was where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes. Staff should complete a pressure injury risk assessment upon admission. Staff should perform routine skin inspections (with daily care). Because a resident at risk could develop a pressure injury within 1 to 4 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helped to define those initial care approaches and interventions. The facility failed to plan and consistently implement interventions to prevent pressure ulcer development for cognitively impaired resident #1 who was at risk and entered the facility without pressure ulcers. The resident entered the facility on 12/23/17 from an acute care hospital with no pressure ulcers and staff discovered a SDTI on 12/27/17 to the resident's right heel. - Review of the history and physical form signed by the physician on 10/24/17 revealed the following [DIAGNOSES REDACTED]. insulin (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The admission minimum data set ((MDS) dated [DATE] indicated staff assessed the resident with moderately impaired cognition and he/she had no behaviors. He/she required extensive assistance of 2 staff for bed mobility, dressing, toilet use and transfers. The resident was at risk for pressure ulcer development based on formal and clinical assessment with no history of a pressure ulcer. The care area assessments (CAAs) dated 11/16/17 included cognition, activities of daily living (ADL), urinary incontinence, and nutrition and pressure ulcer. Review of the CAAs revealed they included the same information as follows: the resident admitted from the hospital post fall with right thigh bone fracture which was surgically repaired. He/she had a history of [REDACTED]. Staff could not determine a true baseline for cognition, however he/she could nod to answer yes or no questions and to make some choices. He/she required total staff performance for all transfers, extensive to dependent assistance for all ADLs. He/she was at risk for developing pressure ulcers related to poor mobility, incontinence and required staff assistance for all repositioning. Review of the Braden scale for pressure ulcer risk assessment dated [DATE] revealed a score of 10 (if a resident scored 12 or less, consider him/her high risk for pressure ulcer development). The ADL care plan dated 11/2/17 directed staff to provide total assistance of 2 staff for bed mobility, ADLs and transfers using a total body mechanical lift. The pressure ulcer/skin prevention care plan dated 11/2/17 directed staff to complete a Braden Scale risk assessment, keep bed linens wrinkle free and do not use excess pads, inspect skin for signs and symptoms of breakdown. Staff updated the care plan on 11/16/17 to include the use of a pressure relieving cushion for his/her wheelchair. Staff revised the care plan on 12/7/17 with directions to off-load heels with a wedge while in bed due to deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) to the left heel. See the treatment administration record (TAR) for care of the DTI to the heel. The diabetes care plan dated 11/16/117 directed staff to check the resident's feet daily for redness, breakdown or pain and report conditions to the physician. Keep the resident's feet dry and skin lubricated. Review of skin condition assessments revealed on 12/1/17 at 5:30 PM licensed nursing staff indicated a general skin check was performed and identified dry skin which staff applied lotion applied and an incision site scar on the right knee. Nothing was marked on the body picture and the nurse's notes section was blank. On 12/6/17 at 1:02 PM the skin condition assessment was marked as a rash in the perineum and staff applied a zinc based moisture barrier. The peri-area was also marked on the body picture and nothing else marked. The nurses note section was blank. On 12/8/17 at 10:17 AM licensed nursing staff completed a general skin check/skin condition assessment which indicated on 12/7/17 staff discovered an unstageable wound to the resident's left outer heel which was non-blanchable explain had a dark red/purple center and measured 2.7 centimeters (cm) by 2.5 cm. Staff off-loaded the area from pressure by using an [MEDICATION NAME] dressing (a foam padded adhesive dressing) and a positioning wedge. On 12/14/17 at 4:19 PM licensed nursing staff completed a skin condition assessment and noted a non-blanchable area to left outer heel which was dark red/purple and measured 2.5 cm by 2 cm. On 12/15/17 at 3:29 PM licensed nursing staff recorded on a skin condition assessment the area on left outer heel was a full thickness pressure ulcer which measured 2.5 cm by 2 cm of non-blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation) dark red/purple skin. On 12/28/17 at 3:58 PM licensed nursing staff recorded on a skin condition assessment the area on the left heel was a partial thickness pressure ulcer with purple coloring and a thick dry eschar (dead tissue) from the past blister which had the edge of eschar lifting form skin and measured 2.9 cm by 3.5 cm and undeterminable depth. On 1/4/18 at 3:01 PM licensed nursing staff identified the left heel as a partial thickness pressure ulcer and indicated the eschar/dried blister fell off leaving a stage 2 (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) partial thickness open area light of red and pink [MEDICATION NAME] (new skin growing in a superficial wound) tissue with the outer bed wound blanchable. The area measured 1.4 cm by 1.3 cm and no depth recorded. The treatment changed to cleanse with normal saline, apply skin prep (a liquid film-forming dressing which applied to intact skin forms a protective film) to the peri-wound, apply [MEDICATION NAME] AG (a type of wound dressing which transforms into a soft, [MEDICATION NAME] biodegradable gel which inhibits bacteria growth and supports epithelization) cut to size, moisten the [MEDICATION NAME] with normal saline and cover with bordered dressing and change every other day. On 1/8/18 at 1:20 PM licensed nursing staff recorded on the skin condition assessment the left heel was a partial thickness pressure ulcer measuring 2.1 cm by 2.2 cm with less than 0.2 cm in depth. Review of the interdisciplinary notes between 11/15/17 and 1/10/17 revealed no additional information regarding the pressure ulcer development or prevention measures prior to development. Observation on 1/9/18 at 10:23 AM revealed the resident seated in a high back wheelchair with physical therapy staff M and direct care staff N completing morning cares. The resident's wheelchair had a foam foot buddy across the wheelchair pedals. Physical therapy staff M reported he/she just changed the resident from a pillow to the foot buddy and added a trough for the left arm to aid with proper body alignment. The resident wore double sided gripper socks on both feet. Observation at 10:40 AM, 10:53 AM, 11:10 AM, 11:25 AM revealed the resident remained in the same position in the wheelchair in his/her room watching TV. At 11:45 AM licensed nurse A was in the room providing the resident's feeding by stomach tube of liquid nutrition and the resident remained in the same position as when last observed at 11:25 AM. Between 11:45 AM and 12:10 PM no staff entered the resident's room. At 12:14 AM the resident remained in the same position in the wheelchair in his/her room watching TV. At 12:35 PM the resident remained in the same position. Between 12:35 PM and 1:17 PM no staff entered the resident's room and the resident remained in the same position. At 1:17 PM the surveyor approached licensed nurse A and requested a skin check. At this time direct care staff N and direct care staff O used a total body mechanical lift to transfer the resident from the wheelchair to the bed. Observation of the resident's buttocks revealed blanchable redness with deep linen creases. Licensed nurse A found the dressing on the left heel coming off and returned at 1:38 PM to change the dressing. The left heel had an area about 2 cm by 3 cm of redness/discoloration and along one edge an open area approximately 0.6 cm by 1 cm with superficial depth. Interview on 1/9/18 at 1:17 PM with direct care staff N confirmed the resident had not been repositioned since transferred to the wheelchair at 10:23 AM (approximately 2 hours and 57 minutes). He/she reported the resident should be repositioned at least every 2 hours. He/she believed the heel pressure ulcer resulted from the resident's heels being on the mattress too long. He/she said staff would put a pillow behind the feet for support when the resident was up in the wheelchair but not when he/she was in bed. Now the resident had the positioning wedge which staff placed under his/her calves so the heels float and do not rest on the mattress. He/she said the care plan would indicate if a resident needed a positioning device or special needs. Interview on 1/9/18 at 4:53 PM with direct care staff P revealed the resident required total care for all ADLs. He/she reported the resident's heels were not elevated before the pressure ulcer developed. Staff used a pillow behind the feet when he/she was up in the wheelchair for positioning. He/she reported knowing how to care for the resident from the electronic record plan of care. Interview on 1/9/18 at 12:55 PM with licensed nurse A revealed the resident pressure ulcer was about half dollar size of dark red/purple skin with what looked like a scab 2 weeks ago and then last week on the resident's bath day the scab just fell off and now it was about 1.8 cm by 3 cm of redness. Interview on 1/10/18 at 5:00 PM with licensed nurse Q revealed the resident was at risk for pressure ulcers since admission due to his/her limited mobility. Staff repositioned the resident every 2 hours but did not have a positioning device under his/her calves to prevent pressure ulcer development. Staff placed a pillow behind his/her feet when he/she was in the wheelchair for positioning purposes. He/she reported the direct care staff should look at all the skin during cares and report any redness or other skin issues to the nurse. Interview on 1/11/18 at 11:30 AM with administrative nurse C confirmed he/she expected staff to follow the resident's care plan to provide care. He/she confirmed the resident was at risk for pressure ulcer development and the facility used mattresses which redistributed pressure including the heel area. The facility's root cause analysis included leaning towards the left, poor tissue perfusion and confirmed staff off-loaded the heels with a pillow while he/she was in the wheelchair. Interview on 1/10/18 at 12:09 PM with physician L revealed the resident's pressure ulcer was probably positioning related and avoidable. The facility's policy titled Prevention of Pressure Injuries dated (YEAR) directed staff the most common site of a pressure injury was where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes. Staff should complete a pressure injury risk assessment upon admission. Staff should perform routine skin inspections (with daily care). Because a resident at risk could develop a pressure injury within 1 to 4 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helped to define those initial care approaches and interventions. The facility failed to develop and consistently implement interventions to prevent pressure ulcer development for this resident identified at risk and who entered the facility without a pressure then developed a SDTI on 12/7/17.

The facility reported a census of 74 residents with 14 residents reviewed for narcotic medication discrepancies. Based on interview and record review, the facility failed to ensure 1 of 14 residents reviewed for narcotic medication discrepancies remained free of a significant medication error. Staff administered 10 times the prescribed amount of an [MEDICATION NAME] (a medication that contains almost all of the [MEDICATION NAME] alkaloids, including [MEDICATION NAME] and [MEDICATION NAME], and its high [MEDICATION NAME] concentration makes it a potent narcotic) to resident #4, for severe diarrhea. The opioid overdose resulted in the resident receiving 2 doses of [MEDICATION NAME] (a medication used to block and reverse the effects of opioids, especially in overdose) to combat the side effects of the overdose. Findings included: - Review of the resident #4's [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE], revealed a BIMS (brief interview for mental status) score of 15, indicating intact cognition. The resident received scheduled and as needed (PRN) pain medication and received non-medication intervention for pain. The resident reported occasional pain over the past 5 days rated a 5/10 that did not affect his/her function. The resident had bowel continence. Review of the cognitive loss/dementia care area assessment (CAA) dated 2/7/17 revealed the resident admitted to the facility for skilled care (a term that refers to a resident's need of care or treatment that can only be provided by licensed nurses) and had a personal history of ulcerative [MEDICAL CONDITION] and diarrhea. The resident could make his/her needs known to staff without difficulty. The staff assessed the resident's BIMS and the resident scored a 14/15, indicating intact cognition. Review of the 1/3/17 resident care guide revealed the resident maintained bowel continence. Review of the 1/31/17 signed physician's order revealed the physician prescribed [MEDICATION NAME] of [MEDICATION NAME] at 10% (contains 10% powdered [MEDICATION NAME] by weight), and staff were to administer 0.5 milliliters (ml) orally every 6 hours, PRN, for diarrhea. Review of the EMAR (electronic medication administration record) revealed staff administered the opioid [MEDICATION NAME] on 2/6/17 at 3:55 p.m. Review of the nurse to physician faxed communication order dated 2/7/17 (no time listed) revealed the facility nurse reported the medication error to the physician by fax which stated staff administered the [MEDICATION NAME] prescribed at a dose of 0.5 ml in error at 5 ml administered. Physician D ordered by telephone for staff to administer [MEDICATION NAME] (a medication used to block the effects of opioids, especially in overdose) STAT (immediately) and to notify physician D of the result in 10 minutes, monitor vital signs every 15 minutes for 3 hours and closely monitor the resident throughout the night, especially until 12:00 a.m. and staff were to obtain at least 3-4 doses of [MEDICATION NAME] in case the resident needed more. Review of the daily skilled care nursing note dated 2/7/17 at 12:03 a.m. lacked documentation of specific vital signs. (no oxygen saturation levels (level of oxygen in the blood), no respirations, no pulse, no blood pressure, and no temperature)). Review of the nurse's note from 2/7/17 at 12:16 a.m. revealed the resident's family member approached the staff around 6:00 p.m. and asked the medication aide a question about the medication given to the resident. The family member stated the resident exhibited extreme lethargy (state of tiredness) and decreased responsiveness. Moments later, the medication aide informed the licensed nurse, he/she gave the resident 5 ml of [MEDICATION NAME]. The staff notified physician D at approximately 6:15 p.m. and physician D instructed to give a dose of [MEDICATION NAME] to the resident and contact him/her in 10 minutes with the response. The staff administered the [MEDICATION NAME], SQ (subcutaneous- below the skin) from the emergency medication kit. Staff obtained the resident's vital signs and staff noted no labored breathing and oxygen saturation (O2- percentage of oxygen in the blood) saturations were in the middle 90's in percentage of oxygen in the blood on room air. The resident quickly became more responsive and could sit up in bed and answer questions. The staff notified physician D and he/she instructed the staff to obtain vital signs every 15 minutes for 3 hours and to monitor the resident closely through the night. Staff D also instructed staff to obtain at least 3-4 more doses of [MEDICATION NAME] to have on hand to administer, if needed. The nurse last checked on the resident around 9:00 p.m. when the night shift nurse arrived and the resident sat in his/her recliner, remained alert and able to answer questions correctly at that time. Staff assisted the resident to the restroom and back to bed and the resident voiced no complaints. Review of the vital signs record revealed staff documented vital signs for resident #4 on 2/6/17 every 15 minutes from 6:15 p.m. until 9:15 p.m. and the next documented vital signs were at 4:29 a.m. on 2/7/17 (over 7 hours later). Review of the 2/7/17 at 4:20 a.m. nurses note revealed the resident's family member stated to the licensed nurse around 10:00 p.m. on 2/6/17 the resident was not as awake as he/she should be and the resident's oxygen saturation levels decreased to 83% (normal range: 95% - 100%). Physician D instructed staff to administer a repeat [MEDICATION NAME] and stated the medication would be worn off within the next hour. The staff gave [MEDICATION NAME] SQ. The staff placed the oxygen per nasal cannula on the resident and the resident's oxygen levels came up to 96%. Interview with direct care staff F on 2/23/17 at 3:32 p.m. revealed he/she administered 5 ml of [MEDICATION NAME] to resident #4, instead of the prescribed 0.5 ml. Staff F stated he/she looked for the licensed nursing staff on duty to verify, but could not find him/her and assumed it looked correct. Staff F stated he/she saw a syringe near the [MEDICATION NAME], but he/she poured 5 ml into a measuring cup and said it was his/her first time administering the [MEDICATION NAME]. Staff F stated a few hours later a family member approached him/her and questioned the dosage and then he/she realized the medication error. Staff F stated he/she worked until 10:00 p.m. on 2/6/17 and said the resident got really tired from the opioid. During an interview on 2/22/17 at 11:24 a.m., licensed nursing staff E revealed he/she worked the day after the medication error and the resident remained very tired and by the middle and end of the day, the resident became more alert and able to eat. Staff E stated the staff checked his/her oxygen levels a lot and they were within normal limits. Staff E stated he/she had never administered the [MEDICATION NAME] medication before, but did administer it to the resident the next day after the incident because the family wanted the resident to have it. Staff E stated the medication was clearly labeled. During an interview with administrative nursing staff B on 2/22/17 at 8:15 AM revealed he/she agreed staff made a medication error. Staff B stated the medication aide administered too much [MEDICATION NAME] to the resident. Staff B said when the medication aide realized the mistake he/she notified the charge nurse, staff notified the physician, and gave [MEDICATION NAME] just to counter the side effects. Interview with administrative nursing staff B on 2/23/17 at 9:55 a.m. revealed the facility could not locate the [MEDICATION NAME] nor the narcotic log (a medication log used to track the inventory of narcotic medication for each resident). Interview with consultant staff H on 2/23/17 at 11:12 a.m. revealed the pharmacist destroyed medications at the facility once a month and had last destroyed on 2/20/17 and did not recall destroying [MEDICATION NAME]. Staff H stated he/she would remember destroying [MEDICATION NAME], because it was a medication that he/she did not see that often and all of the liquid medications he/she destroyed on 2/20/17 had sheets with them. Interview with physician D on 2/23/17 at 3:21 p.m. revealed staff administered a significant medication error to resident #4. Physician D reported the staff needed to monitor the resident very closely for up to 6 hours after the medication error due to the possible side effects of an opioid overdose (decreased oxygen levels, decreased respirations, and decreased levels of consciousness). According to the FDA (Food and Drug Administration) safety page, dated 7/7/2003, the FDA had received cased of medication errors, which involved [MEDICATION NAME] and resulted in fatal outcomes. .these medication error reports indicate the risk for patient harm and injury is increased if [MEDICATION NAME] is dispensed or administered in error. Review of the facility policy on administration of medication revised on 10/30/12 revealed medications must be administered in accordance with the written orders of the ordering physician and the staff administering should contact the physician if a dose seemed excessive. The policy also stated the staff administering the medication should compare the drug and dosage schedule on the resident MAR indicated [REDACTED]. The facility failed to ensure resident #4 remained free from a significant medication error, when staff administered a dosage of [MEDICATION NAME] at 10 times the ordered dose.

The facility census totaled 69 residents. The sample included 12 residents with 1 resident reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to follow and implement interventions to prevent the reopening of stage 2 ulcers on the resident's buttocks and the development of new unstageable pressure ulcers for 1 of 1 resident sampled for pressure ulcers. (#104) Findings included: - Review of resident #104's signed physician order [REDACTED]. Review of the admission MDS (minimum data set) dated 11/29/15 revealed the resident had a BIMS (brief interview for mental status) score of 13, indicating no cognitive impairment. The MDS further included the resident required extensive assistance of two staff for bed mobility, transfers, and was frequently incontinent of bladder and bowel. The resident was at risk for pressure ulcers, and had one unhealed stage 2 pressure ulcer present upon admission. Review of the 30 day MDS dated [DATE] assessment revealed the resident had a BIMS score of 14 indicating no cognitive impairment. The MDS identified no change in ADL (activities of daily living) status, urinary incontinence and remained at risk for pressure ulcers. The resident had a history of [REDACTED]. The resident used a pressure reducing device for his/her chair and bed, had a turn and repositioning program, and received nutritional interventions for skin management. Review of the quarterly MDS dated [DATE] revealed the resident did not complete a BIMS interview but had long and short term memory deficit. The resident had no change in ADL assistance, urinary incontinence and remained at risk for pressure ulcers. The resident had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar (a layer of dead tissue in a wound) that measured 0.7 cm (centimeters) in length, 0.4 cm in width, and had no depth with the most severe tissue type for any pressure ulcer being eschar. The resident used a pressure reducing device to his/her chair and bed, was on a turn and repositioning program, nutrition or hydration intervention to manage skin problems, and received pressure ulcer care. Review of the 12/4/15 Pressure ulcer CAA revealed the resident had a healed stage 2 pressure ulcer. The resident had boggy heels and mushy elbows because he/she was thin and spent much time in bed. Staff provided Skin Prep (a type of liquid dressing) to the resident's heels and elbows twice a day and off-loading (relieved the pressure). Staff discussed bringing a recliner so the resident would be out of bed more with the resident's family. The resident required staff assistance to move sufficiently to relieve pressure over any one site. The resident was confined to the bed or chair most of the time and needed a special mattress and seat cushion to reduce pressure, and required a regular schedule of turning and repositioning. The resident was at risk for poor nutrition and needed staff to feed the resident due to he/she became easily fatigued. The resident required extensive assistance of 2 staff with bed mobility, transfers, dressing and toileting. Review of the care plan last reviewed on 3/7/16 revealed the following interventions related to pressure ulcers: The resident received a multivitamin supplement, and vitamin C daily to improve skin issues. The resident received [MEDICATION NAME] daily as an appetite stimulant. The resident had a history of [REDACTED]. Staff needed to cleanse coccyx area after each incontinent episode and apply moisture barrier. Staff needed to apply [MEDICATION NAME] 2 times a day until healed. Staff needed to check the resident's skin with each bath and report any concerns to the charge nurse. The resident had a significant weight loss and received a fortified foods program The resident received bene-calorie (caloric additive) in his/her supercereal daily for additional calories and to improve his/her ability to heal and prevent skin issues. Family provided boost for the resident to drink 3 times a day. The resident received a mechanical soft diet with nectar thickened liquids. Staff needed to provide assistance with toileting, transfers and changing positions. Staff needed to provide assistance of 2 people with turning and repositioning in bed at least every 2 hours. Staff needed to use the stand-up lift for transfers. Review of the physician's orders [REDACTED]. Such motions cause tissues and blood vessels to move in such a way that blood flow may be interrupted, placing the patient at risk for pressure ulcers) injury to right inner buttock measured 0.6 X 0.4 cm with an order to cleanse, apply thin layer of [MEDICATION NAME] to affected area twice a day until resolved. Record revealed the wound was acquired in the facility. Review of the physician's orders [REDACTED]. The resident had a new left upper medial buttock shearing ulcer that presented as beefy red, scant bloody drainage and measured 0.3 X 1 cm. The resident also had an unstageable wound to the bony prominence on his/her left outer knee, with yellow eschar over 100% of the wound. The wound measured 1.5 X 0.7 cm. Treatment orders: left buttocks - cleanse, pat dry and apply skin prep to periwound, Z guard (a type of ointment) to wound bed daily and as needed. Left knee treatment: cleanse, pat dry, apply Thera-honey gel (a type of wound gel), cover with [MEDICATION NAME] border after applying skin prep to perimeter change every 3 days and as needed. Review of the physician's orders [REDACTED]. Cleanse the wound, pat dry; apply hydroguard (a type of ointment) to wound, skin prep to perimeter change every 3 days and as needed. Review of the left outer knee wound measurements revealed the following: 4/28/16 - Unstageable left outer knee pressure ulcer acquired in house measured 0.7 X 1.5 cm with yellow eschar in wound bed, periwound is irregular with no drainage and noted pain to area. (wound was identified on 4/28/16) 5/2/16 unstageable wound to left outer knee measured 1.1 X 2.0 cm with 90% yellow slough in wound bed and 10% tan eschar, scant bloody drainage with pain. Measurements revealed the wound became larger in size since 4/28/16. Review of the right upper buttocks wound measurements revealed the following: 4/28/16 measured 0.3 x 1.1 cm with scant bloody drainage (new wound acquired in the facility and identified on 4/28/16) 5/2/16 measured 0.7 x 1.0 cm and now had a second area above the first that measures 0.3 cm diameter. (both areas were acquired in the nursing facility) Review of the TAR (Treatment Administration Record) revealed the following: November 2015 - No treatment to coccyx but directed staff to apply skin prep to both heels twice a day. February 2016 - 2/1/16 started a treatment for [REDACTED]. April 2016 - 4/3/16 updated with an order to cleanse and apply a thin layer of [MEDICATION NAME] to right buttock open area two times a day until resolved. The order was discontinued on 4/28/16. On 4/28/16 an order was placed on the TAR to treat the left upper medial buttock. Staff needed to cleanse, pat dry, apply skin prep to perimeter, Z-guard to wound bed, and apply opti-foam. Change daily and as needed. On 4/28/16 an order was placed on the TAR to treat the left outer knee. Staff needed to cleanse, pat dry and apply thera-honey gel. The area was covered with opti-foam border and skin prep was applied to the perimeter, changed every 3 days and as needed. May 2016 TAR revealed left outer knee ulcer - cleanse, pat dry, apply Hydroguard (a type of ointment) to wound bed, skin prep to perimeter [MEDICATION NAME] to cover change every 3 days. Review of the May 2016 Medication Administration Record [REDACTED]. Observation on 5/10/16 at 5:39 AM revealed the resident lay in bed with the head of the bed elevated, resident slouched down in the bed and his/her and left knee bent up had 4 foam pad at the end of his;/her bed. At 6:12 AM direct care staff A walked into the resident's room and then walked right back out. At 6:15 AM the resident lay in bed, with his/her head of bed elevated and the resident scooted down in the bed with his/her legs extended on a 4 square cushion to keep his/her heels off the bed. At 6:23 AM and 6:36 AM the resident lay in the same position as he/she did at 6:15 AM. At 6:40 AM - left knee pulled up and foot on the blue pad other leg out straight. At 6:49 AM same position. At 7:07 AM legs extended, left leg off the cushion and on the bed with foot turned outward. At 7:18 AM and 7:32 AM the resident remained in the same position. At 7:49 AM -Direct Care Staff B went into the resident's room and had a bottle of Boost in his/her hand -- staff said the resident's name twice - resident did not wake up and the staff walked out of the resident's room. At 7:50 AM the resident lay in bed with both knees slightly bent upward, feet on the edge of the bed, resident legs uncovered, observed incontinent brief was wet, and had a dressing on the resident's left outer knee. At 7:51 AM licensed nursing staff C went into the resident's room and said he/she would be right back. At 8:01 AM licensed nursing staff C went back into the resident's room and stated he/she would have to get assistance to move the resident up in bed. Direct care staff D came into the room to assist staff C and the nurse explained to staff D that the resident needed a clean bed pad and sheets. At 8:07 AM direct care staff A and staff D came into the resident room put on gloves, and then raised the height of the resident's bed. Staff A and D took hold of the bed pad and lifted the resident up in the bed sliding his/her bottom across the bed during the process. Staff then rolled the resident onto his/her right side revealing 2 open areas on the resident's right buttock without a protective dressing. The open areas were about the size of a pencil eraser and had red wound beds. The skin surrounding the wounds had a reddish purple color that extended about ¼ inch around each wound and the resident's skin was wet from urine. Direct care staff D proceeded to provide incontinent care using proper technique. At 8:18 AM staff C put on gloves and cleansed the wound areas with wound cleanser and then applied Z-guard to both wounds and surrounding skin and then covered the area with an [MEDICATION NAME] dressing. While providing cares observation revealed the resident's right inner knee was reddened from when he/she laid on his/her side for incontinence care and for nurse C to apply the dressing. The redness disappeared after 10 minutes. The dressing on the resident's left outer knee area had a small amount of blood drainage at the lower edge of the dressing but staff C stated the dressing did not get changed today. Staff did not reposition the resident until after 2 hours and 25 minutes. Observation on 5/10/16 at 12:01 PM staff served the resident 2 cups of thickened juice and 1 cup of thickened water. Staff served the resident Caribbean pork, mashed potatoes, green beans and a piece of pie. Direct care staff D sat beside resident and assisted him/her with eating the meal. The resident ate 100% of his/her meal. Observation on 5/11/16 at 8:38 AM licensed nursing staff C proceeded to change the dressing to the resident's outer left knee. Observation revealed the pressure ulcer was about an inch below the knee joint. Staff C cleansed the area with wound cleanser and revealed an open area with the appearance of a popped blister that was the size of a dime. Above that area was another area staff C stated had healed that presented as a red area that was approximately 1 cm x .2 cm. Staff C reported the blistered area was new and he/she would let administrative nursing staff I know about it. An observation on 5/11/16 at 9:52 AM revealed licensed nursing staff C went to the medication room and brought out a bottle of Boost (nutritional meal supplement), opened it, put a straw in it and gave it to the resident. Staff sat at the table and assisted the resident to drink the Boost. During an interview on 5/10/16 at 5:34 AM direct care staff F reported he/she knew the resident needed 2 staff for cares, he/she used the sit to stand lift for transfers, and the resident was incontinent of urine but staff F did not know anything about positioning for the resident to prevent pressure ulcers. During an interview on 5/10/16 at 12:37 AM direct care staff A reported the staff needed to make sure they turned the resident every 2 hours and kept the resident's heels/legs on the cushion to prevent pressure ulcers on the resident's heels. During an interview on 5/10/16 at 3:11 PM direct care staff E reported staff repositioned the resident every 2 hours or more often if the resident had a bad pressure ulcer. If the resident had an ulcer on his/her feet then staff kept feet lifted off the bed. Staff E reported the resident would try and help when staff lifted the resident up in bed and would scoot' him/herself up with some staff assistance. Staff E stated the resident currently had an ulcer on his/her bottom. During an interview on 5/11/16 at 7:56 AM dietary staff G reported the resident received scrambled eggs, sausage and regular oatmeal for breakfast. Staff stated the resident did not get supercereal. During an interview on 5/11/16 at 10:01 AM dietary staff G stated if a resident received bene-calorie or bene-protein the dietary staff would add it to their meal. Staff G looked at the resident's diet card and it revealed the resident received a regular meal and regular oatmeal with breakfast. During an interview on 5/11/16 at 11:54 dietary staff H reported the nurse filled out a diet slip for any change in diet orders and gave it to the dietary aide and staff H would fill out the plastic meal card. Staff H stated if the resident received bene-calorie it would be on his/her meal card. Observation of the meal card revealed it did not have supercereal or the bene-calorie supplement. During an interview on 5/11/16 at 1:13 PM direct care staff B reported that up until about a week or so ago he/she put the bene-calorie in the resident's boost because the resident had difficulty with dropping his/her oatmeal before getting it into his/her mouth. Staff B stated he/she had reported to the nurse what he/she did and asked for the order to be changed but guessed it just did not happened yet. Staff stated the resident started to eat the oatmeal better and thought that the dietary staff put the bene-calorie in the oatmeal so he/she stopped putting it in the Boost. During an interview on 5/11/16 at 9:54 AM licensed nursing staff C reported the sores on the resident's bottom were there when he/she came from the hospital and thought that it had healed once and then came back again. Staff C stated staff offloaded the areas and keep the resident repositioned but his/her visitors would always put the resident on his/her back and remove the pillows. Staff C stated the left outer knee area was there in March when he/she came back from vacation. Thought it might have been from the sit to stand lift but it is padded and now wonder if it was from when his/her legs laying on the bed and turned outwards that caused it. The family brought in a wider bed because he/she thought it might have been from the bed and how the resident laid his/her legs off to the side. Staff C stated they applied lotion twice a day, and the resident drank boost at least daily if not more often. The resident also received [MEDICATION NAME] to stimulate his/her appetite. Staff C stated the resident liked honey buns and so they give him/her whatever he/she liked to eat. Staff C stated the kitchen put the bene-calorie in the resident food or if a resident received a fortified diet the kitchen provided that as well. During an interview on 5/11/16 at 2:01 PM administrative nursing staff I reported he/she would expect staff to reposition the resident every 2 hours would expect for 2 staff to lift the resident up in bed by using a turn sheet. Staff I stated he/she talked to the nursing staff C and decided the ulcer on the resident's outer left knee was from when he/she would slide his/her leg off the cushion and onto the bed or if he/she crossed his/her legs. During an interview on 5/11/16 at 12:12 PM nurse practitioner consultant M reported he/she expected staff to follow the plan for nutritional supplements and repositioning as planned to promote healing and prevent further pressure ulcers. Review of the skin and wound care prevention protocol dated 4/28/10 directed staff to reposition residents at least every 2 hours while in bed and every 1 hour when in wheelchair and to utilize draw/transfer sheet for positioning and turning. (Do not drag heels) The facility failed to ensure staff provided repositioning and nutritional supplements as planned in order to prevent/promote healing for a resident who developed recurring stage 2 pressure ulcers on his/her buttocks and developed a new unstageable pressure ulcer on his/her left outer knee which developed in the facility.

The facility census totaled 76 residents with 3 included in the sample, including one closed record. Based on observation, interview, and record review, the facility failed to ensure a resident remained as accident-free as possible by the failure to investigate to determine adequate supervision, as well as the failure to follow planned interventions for the resident to prevent a fall requiring sutures. (#1-a closed record) Findings Included: - Review of resident #1's signed physician note dated 1/23/15 revealed the following Diagnoses: [REDACTED]. Review of resident #1's quarterly MDS (minimum data set) dated 9/20/14, revealed a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident did not have any behaviors. The resident required extensive assistance of one staff for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, toileting, and personal hygiene. The resident was not steady and only able to stabilize with human assistance for moving from a seated to standing position, walking, for turning around and facing the opposite direction while walking, moving on and off the toilet, and surface-to-surface transfers. The resident did not have functional limitation in range of motion (ROM). The resident used a walker and wheelchair for mobility. The resident was frequently incontinent (inability to control the flow of urine) of bladder and always continent of bowel and was on a toileting program. The resident had no falls since admission. The resident received training and skill practice in walking 6 of 7 days of the observation period. The resident admitted [DATE]. Review of resident #1's annual MDS dated [DATE] revealed no change in his/her cognitive or behavioral status from the previous assessment. The resident required extensive assistance of two or more staff for bed mobility, transfers, and toileting, extensive assistance of one staff for walking in the room and corridor and locomotion on and off the unit, and limited assistance of one staff for personal hygiene. The resident did not have any change in abilities for transitions during walking, ROM, or assuasive devices for mobility. The resident did not have any change in continence status and did not fall since the previous assessment. The resident received 265 minutes of occupational therapy (OT) and 190 minutes of physical therapy (PT) 5 of 7 days of the observation period. Review of resident #1's ADL (activities of daily living) Functional/Rehabilitation Potential CAA (care area assessment) dated 12/19/14 revealed the resident resident #1 continued to be incontinent and was on a toileting program. Resident #1 received Zoloft (an antidepressant medication) for depression daily, Ativan (an antianxiety medication) as he/she needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and he/she did not display signs or symptoms of adverse reactions to his/her medications. Resident #1 had vision and hearing deficits. Resident #1 needed staff assistance with his/her daily cares. Resident #1 had confusion and impaired cognition related to dementia (a progressive mental disorder characterized by failing memory and confusion). Review of resident #1's Falls CAA dated 12/19/14 revealed resident #1 needed extensive help of staff with bed mobility, transfers, standing, and walking. He/she forgot his/her limits and tried to do tasks without help. Resident #1 continued to be incontinent of urine and was on a toileting program. Review of resident #1's Psychotropic Drug Use CAA dated 12/19/14 revealed resident #1 was unsteady with walking, transfers, and mobility as was the resident's normal. Resident #1 was at risk for falls because of his/her impaired cognition, his/her lack of safety awareness, and his/her unsteady balance. He/she needed staff help with walking and movement. Review of resident #1's significant change MDS dated [DATE] revealed he/she had a BIMS score of 10, indicating moderate cognitive impairment. The resident did not have any behaviors. The resident required extensive assistance of two or more staff for bed mobility and transfers, extensive assistance of one staff for walking in his/her room, locomotion on and off the unit, and personal hygiene, did not walk in the corridor, and the resident required total dependence on two or more staff for toileting. The resident did not have a change in balance during transitions in walking, mobility devices, or continence. The resident had functional limitation in range of motion on one upper extremity. The resident fell on ce since the previous assessment with injury. The resident did not receive any therapy or restorative nursing programs. Review of resident #1's Falls CAA dated 2/2/15 revealed resident #1 recently had a fall on 1/23/15 at 3:00 PM. Staff found the resident on the floor in the bathroom face down. He/she had a laceration to his/her left forehead and received 7 sutures. The resident reported he/she was going to the bathroom at the time of the fall. Resident #1 had poor balance, but because of his/her impaired cognition, he/she did not remember he/she could not walk without help. The resident had impulsive behavior and attempted to walk on his/her own. Resident #1 needed extensive help with bed mobility, transfers, walking in his/her room, locomotion on the unit and off, and personal hygiene. The resident was dependent with toileting. The resident's gait and balance were poor. He/she had a BIMS score of 10/15 as compared to 11/15 on the previous assessment. Review of resident #1's care plan, initiated 10/16/13 (last reviewed 1/7/15), revealed interventions directed staff to provide assistance of 2 staff for transfers as the resident could stand and pivot but had poor balance, provide assistance of 2 staff to go to the bathroom as the resident was incontinent at times, toilet the resident at the following times: when the resident got up each morning, between 10 AM-11 AM, between 2 PM-3 PM, between 6 PM-7 PM, before assisting the resident to bed, as well as anytime the resident asked to be toileted, place Dysem (anti-slip surface) in the resident's wheelchair to prevent him/her from sliding out, provide an anti-thrust cushion to reduce pressure and prevent the resident from sliding out of the wheelchair as he/she moved around, provide a scoop mattress (mattress with raised edges) on the bed to help define the edges of the bed, provide adjustable arm rests on the wheelchair to prevent sliding/falling out of the chair and to help the resident to have something to push against when staff helped him/her to stand, keep the bed in the low position when he/she lay down, place a mat beside the bed, encourage the resident to call and wait for staff assistance before trying to transfer him/herself as he/she had a history of [REDACTED]. On 12/4/14, staff added an intervention to be alert the resident tried to take him/herself to the bathroom if no one was available to help him/her. On 1/23/15, staff added an update to the care plan to provide staff education to assist the resident to the bathroom after he/she returned from activities. On 2/4/15 , staff added an intervention to place a fall stop sign on the resident's door to remind him/her not to go into his/her room by him/herself due to poor safety awareness. Review of resident #1's fall risk assessment score on 12/4/14, 12/8/14, 1/23/15, and 2/4/15 revealed each time the resident had a score of 32 with greater than 14 indicating at risk for falls. Review of the resident's incident investigation dated 12/4/14 revealed at 7:20 PM staff found the resident sitting on the floor with his/his/her back against the wheelchair (between the foot pedals) without injury. The resident was awake, alert, and incontinent. Staff last toileted the resident at 6:20 PM. The resident's wheelchair brakes were not locked, the call light was not in reach, and it was not on. Staff encouraged the resident not to transfer without assistance and was instructed on how to use the call light for assistance. The investigation did not indicate if staff had visualized the resident after toileting at 6:20 PM and prior to the fall. Review of a nurse's note dated 12/10/14 at 9:29 AM revealed the resident required assistance of 2 staff for transfers with toileting. The resident went to most activities and became quite anxious if he/she was not there 25-30 minutes ahead of the start time. After dinner, he/she acted similar if staff were unable to help his/her immediately to get ready for bed. The resident was a fall risk and in spite of fall precautions, fell about once every 1-2 months. Review of a nurse's note dated 1/23/15 at 2:51 PM revealed the nurse was called to resident #1's unit because of a fall. Upon entering the scene, the nurse visualized resident #1 in bathroom, laying face down with his/her head facing the right side, and a moderate amount of blood under his/her head. The resident was alert and oriented to person, answered questions appropriately, and wiggled all fingers and toes upon request. The resident complained of left leg, right shoulder, and his/her head hurting. The resident did not lose consciousness. The resident had a large wound to the left side of forehead. The nurse instructed staff to find the physician extender who was in the building. The physician extender went and gathered resident information and held pressure to the resident's forehead wound. The nurse took vital signs and called emergency medical services (EMS). Staff did not move the resident and stayed with him/her until EMS arrived and assessed resident. Review of resident #1's emergency room (ER) report dated 1/23/15 revealed the resident presented after a fall when he/she tried to go to the bathroom by him/herself and was not supposed to move anywhere by him/herself. The resident had a pressure dressing applied to the head with a laceration to the left forehead. The laceration measured 4.5 cm (centimeters) and required 7 sutures/staples. The resident did not have any fractures. Review of the facility investigation for the resident's fall dated 1/23/15 revealed at 1:30 PM, staff found the resident on the floor in his/her bathroom. The resident had a laceration to his/her left forehead. The facility's investigation determined the resident was previously toileted at 8:00 AM prior to breakfast. At 9:50 AM, the resident went to exercise, which was completed at 11:00 AM and the resident went back to his/her neighborhood. The resident ate lunch at noon. The activities staff saw the resident propelling him/herself to his/her room at 1:25 PM. The resident reported he/she took him/herself to the bathroom to toilet self and when he/she stood up, he/she could not quite make it to the toilet and fell and hit his/her head. The report acknowledged the resident was to be toileted between 10 AM and 11 AM per the care plan, because he/she was in activities during that time. Per the report staff reported the resident did not voice the need to use the bathroom prior to the incident. The investigation did not include if staff had offered to toilet the resident from 8:00 AM-1:30 PM. Review of a physician note dated 1/23/15 revealed the physician extender examined resident #1 for a fall. Staff came and got him/her when the resident fell in his/her bathroom. The resident reported he/she had attempted to toilet him/herself because people were eating lunch and staff were busy. The resident sustained [REDACTED]. Review of a nurse's note dated 1/24/15 at 12:02 AM revealed resident #1 returned from the ER at 11:20 PM transported by his/her family via wheelchair with new orders. Two staff assisted the resident to the bathroom with a gait belt and staff performed a skin assessment and noted 3 scabbed areas on left outer eye that measured 1.5 cm by 1.5 cm, 0.6 cm by 0.6 cm, and 0.5 cm by 0.5 cm. The resident's left forehead and eye were bruised and he/she had sutures to the laceration on the left forehead. Review of a nurse's note dated 1/31/15 at 12:01 AM revealed staff removed the sutures from resident #1's left forehead. Review of a resident incident investigation dated 2/4/15 at 6:15 PM revealed staff found the resident lying on his/her right side on the floor in his/her room. The resident was alert. The resident reported he/she attempted to go to the bathroom. Staff toileted the resident previously at 5:30 PM. The resident had received a rectal suppository earlier that afternoon causing the resident to have abdominal cramps without producing a bowel movement. The resident went to the bathroom about every 30 minutes all afternoon in an attempt to have a bowel movement. The resident self-propelled his/her wheelchair to his/her room and fell just inside the door. The resident stated the little bump he/she rolled over,(the threshold) had caused him/her to fall out of the wheelchair. The resident had 3 large skin tears and a small laceration to his/her right forehead. Interview with direct care staff B on 2/23/15 at 1:20 PM revealed the resident was a fall risk because he/she was very confused and tried to self-propel his/her wheelchair him/herself. Staff B reported to prevent falls, staff educated the resident about asking for help, offered to toilet him/her, encouraged activities, put the resident in a recliner in the common areas, did not keep him/her in his/her room by him/herself in the wheelchair, kept his/her bed in the low position when he/she lay in it, kept the call light within reach, offered fluids, and kept items within reach. Staff B reported he/she remembered the resident's fall with the injury and reported the resident fell because he/she had to go to the restroom and tried to take him/herself. Staff B reported he/she did not remember asking to toilet the resident that day. Staff B reported sometimes staff asked the resident if he/she needed to use the bathroom and he/she would say no, but then tried to take him/herself. Interview with direct care staff C on 2/23/15 at 4:04 PM revealed the resident required a 1-2 person assist depending on the time of day or the resident's mood. Staff C reported the resident could use his/her call light, but rarely did. Staff C reported if staff asked the resident if he/she needed to go to the bathroom, he/she could tell them, and the resident also told staff when he/she wanted to go to the bathroom. Interview with licensed nursing staff D on 2/23/15 at 4:27 PM revealed the nurses started the fall investigation after the resident was safe after a fall and then then DON followed up on the investigation. Staff D reported the reason for the fall investigation was to look at why the fall occurred and the big picture for causal factors. Staff D reported he/she did not work the day of the resident's fall with injury. Staff D reported the resident was very non-compliant with calling for help and did not call 9 out of 10 times. Staff D reported the resident had many falls and many interventions, and had even suggested to the family to get someone to sit with the resident during busy times. To prevent falls, staff D reported staff tried to keep the resident out in the commons areas and kept a floor mat on the floor when the resident lay in bed. Staff D reported staff toileted the resident after every meal and at bed time, mid-morning, and mid-afternoon. Staff D reported he/she expected staff to make sure to toilet the resident before activities because the resident attended them frequently. Staff D reported the resident sometimes told staff when he/she needed to use the toilet, and sometimes did not, but he/she received a diuretic (medication used to rid the body of excess fluids) and had to urinate frequently. Staff D reported the resident could not toilet him/herself and required 1-2 staff assistance for transfers. Interview with administrative nursing staff A on 2/2315 at 4:45 PM revealed the resident had a major fall on 1/23/15 when he/she did not go to the bathroom before exercise, had lunch, and then staff found the resident after lunch and when he/she stood up from the wheelchair and hit his/her head on the granite countertop. Staff A confirmed staff did not toilet the resident per his/her care plan between 10 and 11. Staff A reported the resident was the type of person who did what he/she wanted to do when he/she wanted to do it. Staff A reported he/she did not know if it would have prevented the fall with injury if staff had toileted the resident per the care plan. Review of the facility policy for Fall Risk Identification-Mitigation, last revised 4/28/10, revealed the facility would identify each resident who was at risk for falls and implement interventions to mitigate accidents. Review of the facility policy for Fall Investigation and Management, revised 4/28/10, revealed causative factors should be addressed to improve resident safety outcomes. The Director of Nursing, with the assistance of the Quality Assurance Team should attempt to make determination of the cause of the fall. The facility failed to implement the care plan for resident #1. The resident fell and suffered injuries from the fall.