Every finding on record at Villa Maria

Based on interview and record review the facility failed to transmit five resident's Minimum Data Set (MDS) assessments, within the CMS required timeframe. [Resident (R)10, R41, R22, R18, and R27] Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of timely submission of MDS information for residents as follows: R10's 04/15/2026 Admission MDS was marked as In Progress and noted an ARD [Assessment Reference Date]: 4/22/2026 140 days overdue.R10's admission MDS lacked evidence of completion and submission (almost 5 months later). R41 admitted on [DATE] and discharged on 05/15/2026. R41's 05/04/2026 Admission MDS was marked as In Progress R41's 05/15/2026 Discharge Return Not Anticipated MDS was marked as In ProgressThe MDS page noted the Discharge - ARD: 5/15/2026 103 days overdue and ARD: 5/11/2026 121 days overdue. R22's Annual MDS with an ARD date of 06/24/2026, completed on 06/29/2026, and locked on 08/20/2026, was not accepted until 08/21/2026 (almost 2 months later). R18's Annual MDS with an ARD 06/19/2026 was not locked until 07/08/2026 (19 days later). R27's Annual MDS with an ARD of 05/08/2026, was not locked and accepted until 06/02/2026 (25 days later). During an interview with Administrative/MDS Nurse C on 09/09/2026 at 03:56 PM, revealed she had worked at this facility for almost a year. Administrative/MDS Nurse C stated she knew of late MDS submissions and completion issues. She stated she was playing catch up and working on getting those completed, and was working her way back. She stated there were newer administrative staff and mentioned changes in the facility and spoke of having to wait on others to sign off on sections before she can lock an assessment. Administrative/MDS Nurse C stated she was the only MDS nurse for the facility and stated she was very busy. She said she had signed some MDS assessment's but then forgot to submit some, lost track, and then wished she had submitted them. She stated CMS would give her a warning is the MDS did not have a Medicare number and she then would not lock it. She stated that is what it boiled down to, she was the one MDS nurse and was playing catch up. The facility provided a MDS Policy, revised October 2025, which indicated it is the policy of this Community to maintain a comprehensive, accurate, timely, and interdisciplinary Minimum Data Set (MDS) for all residents in accordance with CMS guidelines as outlined in the Resident Assessment Instrument (RAI) User's Manual. The policy included guidance which included:3. Comprehensive Assessments are initiated for residents by the 14th day in accordance with CMS guidelines, and other required assessments completed per the RAI Manual.4. MDS Assessments are used by the Interdisciplinary Assessment Team to develop a plan of care in accordance with CMS guidelines and the RAI Manual.

Based on interview and record review the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed within the required 14 calendar days for the following five residents: Resident (R)10, R41, R22, R18, and R27 Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of completed comprehensive MDS assessments for residents as follows: R10's 04/15/2026 Admission MDS was marked as In Progress (almost 5 months). R41's 05/04/2026 Admission MDS was marked as In Progress (over 4 months). R22's Annual MDS with an Assessment Reference Date (ARD) date of 06/24/2026, completed on 06/29/2026, and locked [to indicate completed] on 08/20/2026 (almost 2 months). R18's Annual MDS with an ARD 06/19/2026 was not locked until 07/08/2026 (19 days later). R27's Annual MDS with an ARD of 05/08/2026, was not locked until 06/02/2026 (25 days later). During an interview with Administrative/MDS Nurse C on 09/09/2026 at 03:56 PM, revealed she had worked at this facility for almost a year. Administrative/MDS Nurse C stated she knew of late MDS completion issues. She stated she was playing catch up and working on getting those completed and was working her way back. She stated there were newer administrative staff and mentioned changes in the facility and spoke of having to wait on others to sign off on sections before she can lock an assessment. Administrative/MDS Nurse C stated she was the only MDS nurse for the facility and stated she was very busy. She said she had signed some MDS's but then forgot to submit some, lost track, and then wished she had submitted them. She stated CMS would give her a warning is the MDS did not have a Medicare number and she then would not lock it. She stated that is what it boiled down to, she was the one MDS nurse and was playing catch up. The facility provided a MDS Policy, revised October 2025, which indicated it is the policy of this Community to maintain a comprehensive, accurate, timely, and interdisciplinary Minimum Data Set (MDS) for all residents in accordance with CMS guidelines as outlined in the Resident Assessment Instrument (RAI) User's Manual. The policy included guidance which included:3. Comprehensive Assessments are initiated for residents by the 14th day in accordance with CMS guidelines, and other required assessments completed per the RAI Manual.4. MDS Assessments are used by the Interdisciplinary Assessment Team to develop a plan of care in accordance with CMS guidelines and the RAI Manual.

Based on interview and record review the facility failed to implement physician's orders for Resident (R) 9 on 06/29/26 when they identified a wound to her coccyx. Findings included:- Review of R9's EHR revealed she had diagnoses of hidradenitis suppurativa (inflammation in the body that results in abscesses and nodules, which usually occur where skin rubs together), pressure ulcer of the sacral region stage 3 (full thickness pressure injury extending through the skin into the tissue below). Review of the 07/11/26 Quarterly Minimum Data Set revealed R9 had a Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. The assessment documented R9 had an unhealed pressure injury but lacked any indication of stage and/or notation of a deep tissue injury or unstageable wound. The assessment further lacked indication of additional open lesions other than ulcers. Review of the 06/29/2026 Skin Issues Note revealed the resident had a chronic abscess to her left lower abdomen. The note further indicated the resident had a new wound to her coccyx, which was identified in the note as a pressure injury. The wound measured 1.26 centimeters (cm) by 0.68 cm. The wound would be cleaned with normal saline, and the writer indicated a primary antibacterial dressing to the area was utilized. Review of the 06/29/2026 Team Health Wound Care Follow Up revealed the resident had a new wound secondary to her diagnosis of hidradenitis suppurativa. The wound identified in the note as coccyx hidradenitis would be treated by cleansing the site with normal saline, silver alginate, and border foam to the site. Staff would change the dressings daily and as needed due to soilage or dislodgement. The resident's physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for June and July 2026 lacked evidence of the treatment orders put in place by the resident's provider on 06/29/2026 for the resident's coccyx wound until 07/23/26. Review of the weekly wound documentation in the EHR from 06/29/2026 through 07/20/2026 revealed the resident's coccyx wound was cleansed with normal saline and treated with a primary dressing, however the residents MAR/TAR continued to lack evidence the facility implemented the wound treatment order put in place by the resident's provider on 06/29/2026. Review of the resident's Physician's Orders revealed an order dated 07/23/26, which instructed staff to cleanse the resident's abdominal and coccyx wounds with soaked gauze for five minutes then rinse with normal saline. Staff were to apply an antibacterial dressing and foam border every day shift every Monday, Wednesday, and Friday for wound care. Staff would also change the dressing as needed for saturation and dislodgement. During an interview on 09/09/2026 at 04:38 PM Administrative Nurse B stated nurse's documented wound treatments in the TAR. Administrative Nurse B reviewed the TAR and confirmed it lacked evidence of the treatment order.

Based on interview and record review the facility failed to ensure required Quarterly Minimum Data Set (MDS) assessments were completed every 3 months for Resident (R) 10. Findings included:- Review of the Minimum Data Set (MDS) assessment information in the Electronic Health Record revealed concerns regarding the lack of completed comprehensive MDS assessments for R10 as follows: R10's 04/15/2026 Admission MDS was marked as In Progress and noted an ARD [Assessment Reference Date]: 4/22/2026 140 days overdue. The MDS section lacked evidence of any Quarterly MDS assessment completed for R10 (who was a current resident of the facility) in the past 5 months (quarterly MDS assessments are required at least every 3 months). During an interview with Administrative/MDS Nurse C on 09/09/2026 at 03:56 PM, revealed she had worked at this facility for almost a year. Administrative/MDS Nurse C stated she knew of late MDS completion issues. She stated she was playing catch up and working on getting those completed and was working her way back. She stated there were newer administrative staff and mentioned changes in the facility and spoke of having to wait on others to sign off on sections before she can lock an assessment. Administrative/MDS Nurse C stated she was the only MDS nurse for the facility and stated she was very busy. She said she had signed some MDS's but then forgot to submit some, lost track, and then wished she had submitted them. She stated CMS would give her a warning if the MDS did not have a Medicare number and she then would not lock it. She stated that is what it boiled down to, she was the one MDS nurse and was playing catch up. The facility provided a MDS Policy, revised October 2025, which indicated it is the policy of this Community to maintain a comprehensive, accurate, timely, and interdisciplinary Minimum Data Set (MDS) for all residents in accordance with CMS guidelines as outlined in the Resident Assessment Instrument (RAI) User's Manual. The policy included guidance which included: 3. Comprehensive Assessments are initiated for residents by the 14th day in accordance with CMS guidelines, and other required assessments completed per the RAI Manual.4. MDS Assessments are used by the Interdisciplinary Assessment Team to develop a plan of care in accordance with CMS guidelines and the RAI Manual.

Based on interview and record review the facility failed to accurately code Resident (R) 9's Minimum Data Set. Findings included: - Review of R9's EHR revealed she had diagnoses of hidradenitis suppurativa (inflammation in the body that results in abscesses and nodules, which usually occur where skin rubs together), pressure ulcer of the sacral region stage 3 (full thickness pressure injury extending through the skin into the tissue below). Review of the 07/11/26 Quarterly Minimum Data Set revealed R9 had a Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. The assessment documented R9 had an unhealed pressure injury but lacked any indication of stage and/or notation of a deep tissue injury or unstageable wound. The assessment further lacked indication of additional open lesions other than ulcers. Review of the 06/29/2026 Skin Issues Note revealed the resident had a chronic abscess to her left lower abdomen. The note further indicated the resident had a new wound to her coccyx, which was identified in the note as a pressure injury. Review of the 06/29/2026 Team Health Wound Care Follow Up revealed the resident had a new wound secondary to her diagnosis of hidradenitis suppurativa. The wound was identified in the note as coccyx hidradenitis and new orders were placed for treatment of the wound. The note further identified the resident continued to have an abscess to the abdomen, which the facility was actively treating. Review of the weekly wound documentation in the EHR from 06/29/2026 through 07/20/2026 identified the resident's abdominal wound as an abscess and the coccyx wound as a pressure injury, with no staging present. During an interview with MDS Nurse C on 09/09/2026 at 03:57 PM revealed the facility underwent some administrative changes and was working on ensuring she had the information she needed to code the MDS accurately. MDS Nurse C stated she claimed wounds that were over a boney prominence as pressure, which included coding the resident's abdominal wound as an unhealed pressure injury on the 07/11/2026 assessment. She stated she was not made aware of the injury to the resident's coccyx until after the coding of the most recent quarterly assessment. MDS Nurse C said she was working with the facility wound nurse to ensure she was made aware of wound as soon as they are identified so she could code them on the MDS assessment. Review of the Resident Assessment Instrument Manual revealed Open Lesion(s) Other than Ulcers, Rashes, Cuts would be coded for open lesions that develop as part of a disease or condition and are not coded elsewhere on the MDS. Areas of concern such as wounds, boils, cysts, and vesicles would be considered for this section. The RAI Manual further stated for MDS assessments, initial numerical staging of pressure ulcers, and the initial numerical staging of ulcers after debridement, or DTI that declares itself, should be coded in terms of what is assessed (seen or palpated, i.e. visible tissue, palpable bone) during the look-back period. Pressure ulcer/injury staging is an assessment system that provides a description and classification based on visual appearance and/or anatomic depth of soft tissue damage. This tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer/injury staging also informs expectations for healing times.

The facility reported a census of 57 residents; the sample included three residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from accidents when staff failed to assess Resident (R) 1's ability to safely manage hot liquids resulting in a hot liquid spill. This deficient practice placed R1 at risk for burns and pain.Findings included:- R1's Electronic Health Record (EHR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), and Parkinsonism (a clinical syndrome characterized by a group of symptoms including resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R1's 01/06/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R1 required set-up assistance for eating and oral care. The MDS documented R1 was dependent for toileting, bathing, dressing, and transfers. The MDS documented R1 had no skin conditions present.R1's 01/21/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R1required assistance with activities of daily living (ADL) and mobility. The CAA noted the care plan would address her need for assistance with personal care and mobility.R1's 06/24/25 Quarterly MDS documented R1 had disorganized thinking and an altered level of consciousness. The MDS documented R1 required moderate assistance for eating, oral care, and personal hygiene. The MDS documented R1 was dependent for toileting, bathing, dressing, wheelchair mobility, and transfers. The MDS documented R1 had no skin conditions present.R1's Care Plan dated 04/19/23 instructed staff to provide assistance with meals as needed. The plan directed staff to set up R1's tray and assist her with bites and sips as she was not consistently feeding herself. R1's Care Plan did not address the handling or management of hot liquids.R1's EHR lacked evidence the facility assessed R1's ability to safely manage hot liquids.The 06/08/25 Villa [NAME] Physician Communication documented R1 had declined and was unable to eat on her own again. On 06/11/25, the physician responded, Labs pending.R1's Progress Note dated 06/15/25 at 04:37 PM documented at approximately 10:25 AM, R1 lay in bed while staff cleaned her neck; there was a family member in the room. The note documented Licensed Nurse (LN) G assessed R1 and noted a large burn to her neck, shoulder, and ear on her right side. LN G noted a sticky substance on R1's neck, ear, and in her hair, along with a brown wet spot on the pillowcase that looked like coffee. At 10:50 AM, R1 requested a pain pill. The note documented staff were educated about not leaving hot drinks in reach of residents who were not able to safely handle them or who needed assistance with them.R1's Physician Orders dated 06/15/25 ordered Silvadene external cream (topical antibiotic medication primarily used to prevent and treat wound infections in patients with burns), apply topically two times a day to burns on the neck, shoulder, and ear. The Silvadene was discontinued on 06/18/25.R1's Physician Orders dated 06/18/25, ordered A&D ointment (a topical skin protectant ointment containing vitamins A and D, typically used to help heal and protect minor cuts, and burns) to the area of dryness on the right shoulder/neck and up into the hairline two times a day for exacerbation of skin condition.The 06/18/25 Physician Progress Note documented R1 sustained a burn to her right neck while trying to drink coffee in bed. The note documented orders were received for Silvadene topically, and the burn appeared to be improving at that time. The note documented that Administrative Nurse D had a discussion with the nursing staff regarding hot beverages and R1. The note documented that the burn appeared to be a first-degree burn (a burn that affects the first layer of the skin).R1's Skin/Wound Evaluation dated 06/18/25 at 04:28 PM documented a red scaly pink area measuring 13.61 centimeters (cm) by 5.85 cm and an area dimension of 59.59 cm.R1's Progress Note dated 6/18/25 at 05:16 PM documented after a review of updated pictures of the burn area with the physician and finding the area to be dry and scaly with no appearance of a burn, it was believed that the area might be more of an underlying skin condition that the resident had and not a burn. R1 will no longer get Silvadene cream on the area and will now get A&D ointment on the area per the physician, who agreed the area was not a burn at all.During an observation on 07/30/25 at 12:30 PM, CNA N picked up a cup of coffee that sat on the counter next to the coffee carafe, put a lid on the cup, and placed it on a resident's room tray. CNA N then started to walk out of the dining area. CNA N hesitated and then stated that she obtained a temperature reading of 120 degrees Fahrenheit (F.) prior to the service. Upon request, CNA N obtained a thermometer from a small cup on the counter and placed the thermometer in the coffee without sanitizing the thermometer. The coffee was 100 degrees F. Further observation of the dining area revealed a large sign with instructions for staff to obtain temperature readings of all hot liquids prior to service, and that the hot liquid temperature could not exceed 120 degrees F.On 07/30/25 at 10:10 AM, Certified Nurse Aide (CNA) M reported that she gave R1 her breakfast tray while R1 was in bed the morning of 06/15/25. CNA M reported the coffee mug had a lid on it. CNA M said she was not aware that R1 required assistance with meals. CNA M reported that she noted R1's sheets had a brown stain on them near the resident's head when she assisted R1 with care. CNA M reported that she then observed the coffee mug had no lid on it; there was coffee in the cup, and the lid was on the table. CNA M said she noted reddened skin on the right side of R1's neck and her right ear, so she got the nurse. CNA M stated that all confused residents required lids on their hot beverages, and should be in the dining room to eat, but if a resident refused, the staff would assist the residents. CNA M reported that R1 had become more confused in the past month.On 07/30/25 at 10:19 AM, CNA N reported that if a resident was not fully aware of their surroundings, shaky, and/or confused, the resident would have a lid on their hot beverage. CNA N reported some residents were care planned for covered hot beverages.On 07/30/25 at 10:25 AM, LN H stated she was unsure what the policy was regarding hot liquids before R1 spilled the hot coffee, but stated now every resident would have a lid placed on all hot beverages. LN H said if a resident was alert and oriented, they could take the lid off themselves.On 07/30/25 at 12:40 PM, Administrative Staff A and Administrative Nurse D acknowledged that none of the staff signed that they received education regarding hot liquids, except for the immediate education provided on 06/15/25, signed by the four staff members on duty at the time. Administrative Staff A reported they sent out an alert on 06/15/25 via text and email to all staff, which directed that, effective immediately, all hot liquids must have a temperature taken prior to serving and the liquid must be 120 degrees F. or lower before placing the lid on the cup and serving. Administrative Staff reported that the facility did not have a policy implemented for hot beverages yet, as she had to finish it after she completed her research. Administrative Staff A reported that there was a posting of the education for all the staff about temperatures and lids in the facility in several locations.On 07/30/25 at 01:00 PM, Administrative Nurse D reported she expected the staff to apply a lid on all hot beverages. Administrative Nurse D reported she expected staff to not serve R1 in her room as R1 had good days and bad days when she fed herself.On 07/30/25 at 01:15 PM, Administrative Staff A reported that no residents had been assessed for safety with hot liquids and reported every resident was required to have a lid placed on their hot beverages.The facility did not provide a policy for safety related to hot beverages.

The facility had a census of 57 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R16 and R146 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care. Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility failed to provide R29 the completed form 10055, which estimated the cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled services ended on 10/09/22. The facility failed to provide R48 the completed form 10055, which estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 11/04/22. The facility failed to provide R157 the completed form 10055, which the estimated cost for the services to be able to make an informed choice whether or not the resident wanted to receive the items or services, knowing he/she may have to pay out of pocket. The resident's skilled nursing services ended on 08/17/22. On 02/04/23 at 11:25 AM, Social Services X verified the facility staff had not provided the resident and/or their representative the CMS form 10055. On 02/08/23 at 1:30 PM, Administrative Staff A verified the facility had lacked providing the resident and/or their representative the CMS 10055 form. The facility's Advance Beneficiary Notice of Non-Coverage policy, undated, documented ABN is a notice to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. Notifiers including physicians, providers, practitioners and suppliers' pain under Part B, as well as hospice providers and religious non-medical health care institutions pain under Part A. They must complete the ABN and deliver notice to affected beneficiaries or their representatives before providing the item or services that are the subject of the notice. The ABN will be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. A copy is given to the beneficiary or representative, and the facility retains the original copy. The facility failed to provide R29, R48, and R157, or their representatives, the completed ABN 10055 form when discharged from skilled care, which placed them at risk to make uninformed decisions about their skilled care.

The facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to care plan the use of beds rails for Resident (R) 30. This deficient practice placed R30 at risk for impaired safety due to lack of staff direction for the use of the bed rails. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and obesity (abnormal or excessive fat accumulation that presents a risk to health). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero. The MDS documented R30 required extensive assistance of one staff for eating, hygiene, two staff for bed mobility, and total assistance for transfers, dressing, toileting. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair for mobility, and had no falls. The Fall Care Area Assessment (CAA), dated 12/12/22, documented R30 had been readmitted from the hospital and at times she became resistant to cares by pushing back when staff are trying to provide cares or repositioning. Staff transferred her with a full body lift, and she was dependent on staff for transfers, dressing, incontinent cares, mobility, and had no falls in the past quarter. The Fall Care Plan, dated 12/24/22, directed staff to ensure her call light was placed within reach at all times, use a full body lift for all transfers, and a wheelchair for all mobility. The care plan directed staff to use two-person assistance with bed mobility, repositioning and dressing. The care plan lacked direction for the use of side rails. The facility lacked a side rail assessment for R30. The Fall Risk Assessment, dated 12/07/22, documented R30 was a high risk for falls. On 02/06/23 at 08:46 AM, observation revealed R30's bed side rails had long gaps approximately 4.5 inches by 26 inches between the bars. On 02/06/23 at 09:30 AM, observation revealed R30 sat in her wheelchair in her room watching television. On 02/06/23 at 10:40 AM, Administrative Nurse D checked the side rails on the R30's bed. She stated hospice brought the bed to the facility. The rail gaps measured 4.5 inches tall by 26 inches wide. Administrative Nurse D verified the gap was more than 4.75 inches wide. She stated the resident used the side rails to hold herself on her side during care. The DON moved the right-side rail back and forth approximately 3 inches and then attempted to tighten the pin holding the rails. Administrative Nurse D stated staff normally do a side rail assessment and verified the facility had not assessed R30 for the use of side rails or the hospice-provided bed rails. The facility's Comprehensive Care Plan policy, dated 03/18/2018, stated the facility would develop and implement a person-centered care plan for each resident to meet a resident's medical, nursing, and psychosocial needs and would include resident specific interventions. The facility failed to care plan the use of beds rails for R30, placing R30 at risk for impaired safety due to lack of staff direction for the use of the bed rails.

The facility had a census of 57 residents. The sample included 15 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)5, placing the resident at risk for embarrassment and an undignified living environment. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnoses of post-polio syndrome (polio, or poliomyelitis, is an infectious viral disease that can harm the nervous system. post-polio syndrome (PPS-usually occurs 15-[AGE] years after the infection and recovery. PPS is believed to be the result of a deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction), and paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). R5's Significant Change Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact), and an indwelling urinary catheter (a tube in the bladder to drain urine). R5's Care Plan dated 12/16/22, recorded a private duty nurse would change the catheter monthly and the resident would not allow any facility staff to change her catheter. The care plan recorded staff were to provide catheter care every shift, and monitor and document output. The care plan lacked any guidance for staff to cover the urinary catheter bag. On 02/03/23 at 02:30 PM, observation revealed R5 rested in bed, with the uncovered urinary catheter bag hanging on the left side of the bed frame, visible from the hall. On 02/06/23 at 08:15 AM, observation revealed R5 rested in bed, with the uncovered urinary catheter bag hanging on the left side of the bed frame, visible from the hall. On 02/08/23 at 09:45 AM, Administrative Nurse E stated the resident's urinary catheter bag should be covered at all times. The facility's Respect and Dignity policy, undated, stated the residents have the right to be treated with respect and dignity which includes personal privacy including accommodations, medical treatment and personal cares. The facility failed to cover R5's urinary catheter bag, placing the resident at risk for embarrassment and an undignified living environment

The facility had a census of 57 residents and the sample included 16 residents, in which one resident was reviewed for weight loss, Resident (R) 33. Based on observation, record review, and interview, the facility failed to implement dietician's recommendations which placed the resident at risk for further weight loss, malnutrition, and delayed in wound healing. Findings included: -The Medical Diagnosis section within R33's Electronic Medical Record (EMR) included diagnoses metabolic encephalopathy (inflammatory condition of the brain ), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), overactive bladder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain )with agitation, intertrochanteric(hip area of large thigh bone) fracture of left femur , muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care. R33's Admission Minimum Data Set (MDS), dated [DATE], lacked a cognition assessment, but documented R33 had inattention, disorganized thinking, other behavioral symptoms not directed toward others, and rejected evaluation or care behaviors which occurred one to three days during look back period. The MDS further documented R33 required extensive assistance of two staff for bed mobility and transfers and required extensive assistance of one staff for eating. R33 had incontinence of urine and bowel, weighed 121 pounds (lbs.), received as need pain medication for daily indicators of pain with vocal and facial expressions. The MDS further documented an unhealed stage two pressure ulcer (break in the top two layers of skin) a deep tissue injury (DTI- a pressure related injury to tissue under intact skin) were present on admission. R33 had pressure reducing devices for the bed and chair, turning/repositioning program, pressure ulcer/injury care, and application of ointment/medication other than to feet. The Nutritional Status Care Area Assessment (CAA), dated 01/25/23, documented R33 was a few weeks post operation to repair a left hip fracture, required extensive assistance of one staff with eating and drinking. The CAA noted constipation was present and risk factors of falls, dehydration related to use of daily diuretic and the need for intake assistance, worsening of pressure ulcer status. The Baseline Care Plan dated 01/12/23 documented R33 was at risk for dehydration, on a regular diet, and required total feeding assistance. The Comprehensive Nutrition Care Plan dated 02/01/23 directed staff to obtain weight monthly, the Dietician to assess annually and as needed, help with intake of meals and fluids, to provide a mechanical soft diet with thin liquids. The Progress Notedated 01/26/23 documented R33 lacked intake the last few days; the physician approved a mechanical soft diet. R33 had been lethargic, not very responsive. The facility drew lab and administered a bag of normal saline intravenously (into vein). On 01/30/23 the EMR documented R33 weighed 113 lbs. The Admission Nutrition Assessment date 01/31/23, documented R33 had a mechanical soft diet, no supplements, poor intake. R33 weighed 113 lbs. which was a loss of seven percent (%) since 01/14/23 (two weeks post admission). The document further documented wound issues to left buttock and heel. Due to weight loss, decreased intake, and wound healing recommended nutritional interventions for Prostat (supplement to treat pressure ulcers) 30 milliliters (ml) twice a day, Gelatin (protein derived from collagen) twice a day or other supplement if not available. The recommendation also included super cereal (calorie and nutrient dense meal) at breakfast and encouraged R33 to come to dining room and directed staff to offer encouragement at meals. The Progress Note, dated 02/01/23, documented R33 had dark brown emesis and the physician order administration of normal saline intravenously. On 02/06/23 the EMR documented R33 weighed 111 lbs. On 02/06/23 at 07:48 AM, observation revealed R33 sat in her wheelchair, the wheelchair had a pressure reducing cushion. R33 wore padded boots to both feet, and was dressed and groomed for the day. Speech therapy was om the room assisting R33 to eat. The breakfast meal consisted of scrambled eggs, French toast with syrup, and two containers of orange juice. R33 did not receive super cereal. On 02/06/23 at 08:15 AM observation revealed speech therapy was no longer in the room. R33 ate a few bites of scrambled eggs and a few bites of French toast, drank one of the orange juices. R33 remained in the wheelchair. On 02/06/23 01:12 PM observation revealed R33 sat in her wheelchair, in her room. Staff were present in the room for dining. The meal consisted of a noodle entree, peas, and a peach cobbler desert. R33 was fed by staff. On 02/06/23 01:31 PM observation revealed staff removed R33's lunch tray from her room. R33 only ate 25% of the meal. R33 remained in her wheelchair and staff brought her out to the nurse's station area. On 02/06/23 the EMR documented R33 weight 111 lbs. On 02/07/23 at 07:58 AM observation revealed R33 in the dining room, in her wheelchair being fed by staff. R33 had scrambled eggs, a pancake with syrup, and a large glass of orange juice. Staff inquired about added salt to eggs and R33 said that tasted good. No super cereal was provided to R33. On 02/07/23 at 04:13 PM observation revealed Licensed Nurse (LN) I and Administrative Nurse E measured R33's wound. Wound measured 5.4centimeters (cm) in length by 3.5 cm in width, R33 reacted with a pain complaint while staff measured wound. LN I and Administrative Nurse E verified resident left buttock wound continued to worsen. They verified R33 remained in her wheelchair over two hours with occassional position changes and verified R33 lacked off-loading interventions and had continued weight decline. Staff reported they were not aware of the dietician's recommendations of supplements or super cereal recommendations. Administrative Nurse E reported discussion with R33's family to involve wound care consultation and care, and review dietician's recommendations. The facility's Nutritional Management policy, dated 06/2021, documented the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. A systematic approach is used to optimize each resident's nutritional status and risk factors. Evaluating/analyzing the assessment information, developing consistently implementing pertinent approaches. The facility failed to implement dietician's recommendations which placed the R33 at risk for further weight loss and delayed in wound healing.

The facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to assess Resident (R) 30 for risk of entrapment from bed rails, obtain informed consent, and ensure the bed rail dimensions were within recommended safe dimensions. This deficient practice placed R30 at risk for entrapment in the bed rail and potentially serious injury. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), and obesity (abnormal or excessive fat accumulation that presents a risk to health). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of zero. The MDS documented R30 required extensive assistance of one staff for eating, hygiene, two staff for bed mobility, and total assistance for transfers, dressing, toileting. The MDS documented R30 had no range of motion (ROM) impairment, used a wheelchair for mobility, and had no falls. The Fall Care Area Assessment (CAA), dated 12/12/22, documented R30 had been readmitted from the hospital and at times she became resistant to cares by pushing back when staff are trying to provide cares or repositioning. Staff transferred her with a full body lift, and she was dependent on staff for transfers, dressing, incontinent cares, mobility, and had no falls in the past quarter. The Fall Care Plan, dated 12/24/22, directed staff to ensure her call light was placed within reach at all times, use a full body lift for all transfers, and a wheelchair for all mobility. The care plan directed staff to use two-person assistance with bed mobility, repositioning and dressing. The care plan lacked direction for the use of side rails. The facility lacked a side rail assessment for R30. The Fall Risk Assessment, dated 12/07/22, documented R30 was a high risk for falls. On 02/06/23 at 08:46 AM, observation revealed R30's bed side rails had long gaps approximately 4.5 inches by 26 inches between the bars. On 02/06/23 at 09:30 AM, observation revealed R30 sat in her wheelchair in her room watching television. On 02/06/23 at 10:40 AM, Administrative Nurse D checked the side rails on the R30's bed. She stated hospice brought the bed to the facility. The rail gaps measured 4.5 inches tall by 26 inches wide. Administrative Nurse D verified the gap was more than 4.75 inches wide. She stated the resident used the side rails to hold herself on her side during care. The DON moved the right-side rail back and forth approximately 3 inches and then attempted to tighten the pin holding the rails. Administrative Nurse D stated staff normally do a side rail assessment and verified the facility had not assessed R30 for the use of side rails or the hospice-provided bed rails. The facility's Bed and Bed Rail Use policy, dated 03/01/2018, stated the facility would conduct regular inspections of all bed rails as part of a regular preventative maintenance program to identify and avoid areas of possible entrapment. The policy stated bed frame, mattress, and bed rail inspections would be conducted upon each item entering the facility. Bed rail gap measurements would be performed to ensure safety following Food and Drug Administration (FDA) guidelines. The policy included the FDA guideline for gaps within the rails and recommended a space of less than 4.75 inches. The policy stated a restraint assessment including a bed rail assessment and bed rail gap measurements would be completed initially and at least quarterly. The facility failed to assess R30 for risk of entrapment from bed rails, obtain informed consent, and ensure the bed rail dimensions were within recommended safe dimensions, placing R30 at risk for entrapment in the bed rail and potentially serious injury.

The facility had a census of 57 residents. The sample included 16 residents. Based on observation, interview and record review the facility's staff failed to safely discard a fentanyl (controlled, narcotic pain medication at high risk for abuse, addiction, or overdose) patch properly for Resident (R)10, per facility policy. This deficient practice created a risk for diversion, illicit use and accidental overdose. Findings included: - R10's Electronic Medical Records (EMR) documented diagnoses of chronic pain, Parkinson's (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R10 required extensive assistance with bed mobility, toilet use, and personal hygiene. The MDS documented R10 had frequent pain, received scheduled and as needed pain medication; her pain limited day to day activities. She received opioid medication three days of the lookback period. The Pain assessment dated [DATE] with a score of 8 (a score of 8 -10 indicated severe pain). The Pain Care Plan, dated 11/14/22, directed staff to administer as needed pain medication for pain management and review the Medication Administration Record (MAR) for current medications. A Physician Order, dated 04/21/22, directed Fentanyl transdermal patch, 25 micrograms(mcg), apply topically and change patch every 72 hours. On 02/06/23 at 12:20 PM, observation revealed Certified Medication Aide (CMA) R removed a Fentanyl patch from R10's right upper scapula (back shoulder), then discarded the patch in the resident's trash can. CMA R applied a new Fentanyl patch 25 mcg to R10's left upper scapula. Continued observation revealed CMA R took the plastic bag from the trash can, with the Fentanyl patch in the plastic bag from the trash can, tied the plastic bag in a knot and placed the bag at the bottom of the trash can, CMA R then placed a new plastic bag over the old trash bag. On 02/06/23 at 12:25 PM, CMA R verified R10's Fentanyl patch was the first patch she had removed and/or applied, and she had to get verification from the Administrative Nurses as to what rotate the patch site meant. CMA R verified she was not aware of proper disposal protocol of the Fentanyl patch or the facility policy for Fentanyl patch removal. On 02/06/23 at 12:35 PM, Administrative Staff D stated CMA R should fold the old patch in half and discard the patch in a sharps container and have a nurse witness the disposal. Administrative Nurse D verified she would have an in-service with the staff for proper disposal of the patches. The Disposal of Medications and Medication Related-Supplies policy, dated June 2022, documented Fentanyl patch medication remained in the patch after removal, created a potential for abuse, misuse, diversion, or accidental exposure. Due to life threatening risk associated with exposure to or ingestion of the patch, the Food and Drug Administration (FDA) and manufacture instructions recommend consumers dispose of used Fentanyl patches by folding in half with the sticky sides together and flushing the patch down the sink or toilet. This method may not be appropriate for nursing homes, particularly in areas that state or federal laws restrict flushing of pharmaceuticals, Nursing homes may use drug disposal products or systems for Fentanyl patches and other controlled medications as long as the facility can show the product or system minimizes accidental exposure or diversion. The facility failed to ensure staff disposed of R10's Fentanyl patch per standrards and facility protocol, creating the risk for diversion, illicit use and accidental overdose.

The facility had a census of 57 residents. The sample included 16 residents of which four residents were reviewed for pressure ulcers (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, record review, and interview, the facility failed to implement interventions to prevent Resident (R) 33's left buttock pressure ulcer from worsening and failed to implement treatment for R34's facility acquired pressure ulcer when identified. These deficient practices placed R33 and R34 at risk for delayed healing or worsening pressure ulcers. Findings included: - The Medical Diagnosis section within R33's Electronic Medical Record (EMR) included diagnoses metabolic encephalopathy (inflammatory condition of the brain ), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), overactive bladder, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain )with agitation, intertrochanteric (hip area of large thigh bone) fracture of left femur , muscle weakness, other abnormalities of gait and mobility, and need for assistance with personal care. R33's Admission Minimum Data Set (MDS), dated [DATE], lacked a cognition assessment, but documented R33 had inattention, disorganized thinking, other behavioral symptoms not directed toward others, and rejected evaluation or care behaviors which occurred one to three days during look back period. The MDS further documented R33 required extensive assistance of two staff for bed mobility and transfers and required extensive assistance of one staff for eating. R33 had incontinence of urine and bowel, weighed 121 pounds (lbs.), received as needed pain medication for daily indicators of pain with vocal and facial expressions. The MDS further documented an unhealed stage two pressure ulcer (break in the top two layers of skin) a deep tissue injury (DTI-a pressure related injury to tissue under intact skin) were present on admission. R33 had pressure reducing devices for the bed and chair, turning/repositioning program, pressure ulcer/injury care, and application of ointment/medication other than to feet. The Pressure Ulcer Care Area Assessment (CAA), dated 01/25/23, documented R33 had surgical repair of a left hip fracture, required extensive assistance of two staff for bed mobility and transfers, used wheelchair for mobility, had three areas of skin impairment: a surgical wound, stage two pressure ulcer, and a suspected DTI. R33 had a low air loss mattress and a cushion in the wheelchair. The CAA further documented worsening of the PU related to the need for repositioning assistance. The Baseline Care Plan, dated 01/12/23, documented R33 had a moderate risk of developing pressure ulcers, and had heel protectors to elevate heels. It directed staff to provide barrier cream, reposition every two hours and documented R33's wounds were located on the left buttock and the left heel. The facility Skin/Wound Documentation form, dated 01/12/23, documented a buttock stage two pressure ulcer which measured 1.0-centimeter (cm) in length by 0.5 cm in width, Chamosym (moisture barrier) cream twice a day (BID) and as needed. R33's left heel DTI measured 3 cm in length by 0.6 cm in width; staff were to cover with bordered foam dressing and change daily. The Weekly Wound Assessment, dated 01/23/23, documented the physician was notified on admission of R33's left pressure area and DTI and R33 had padded boots. The left heel overall impression was unchanged, dry, dark purple in color, not open, hard to touch, and did not blanch. The left heel measured 4.1 cm in length by 2.1 cm in width, the periwound (tissue surrounding a wound) was dry and irregular shaped. The assessment directed to apply skin prep (liquid skin barrier) to the wound, cover with bordered foam, and change daily. The left buttock stage two pressure ulcer was noted as worsening. The assessment noted epithelial (new skin growing in a superficial wound) tissue was present, measured 4 cm in length x 2 cm in width. The w periwound was dry, flaky, and slow to blanch. The left buttock wound was to be cleansed every three days and as needed, with normal saline and covered with a foam dressing. The Physician Progress Note, dated 01/25/23, documented nursing noted a left buttock pressure area, about half-dollar size open area with some erythema (redness or inflammation of the skin) and shallow. The physician plan was to use foam dressing and off-loading pressure and consider a low air loss mattress if worsening. The Admission Nutrition Assessment date 01/31/23, documented R33 had a mechanical soft diet, no supplements, and poor intake. R33 weighed 113 lbs. which was a loss of seven percent (%) since 01/14/23 (two weeks post admission). The assessment further documented wound issues to left buttock and heel. The assessment noted that due to weight loss, decreased intake, and wound healing, the registered dietician (RD) recommended nutritional interventions for Prostat (supplement to treat pressure ulcers) 30 milliliters (ml) twice a day, Gelatin (protein derived from collagen) twice a day or other supplement if not available. The recommendation also included super cereal (calorie and nutrient dense meal) at breakfast and encouraged R33 to come to dining room and offer encouragement at meals. The Weekly Wound Assessment, dated 02/01/23, documented R33's left heel DTI was worsening, and had opened. There was granulation tissue present, scant bloody drainage, and measured 0.8 cm in length by 2.4 cm in width. The assessment directed to apply skin prep to wound, cover with bordered foam, and change daily. The left buttock stage two pressure ulcer was worsening and had 95 percent (%) slough (dead tissue, usually cream or yellow in color), and the periwound did not blanch. Treatment was noted to cleanse with normal saline, cover with bordered foam dressing, and change every three days and as needed. The assessment included a new observation of a suspected DTI to the left lateral (outside edge) foot, which was dark purple, hard, did not blanch, measured 1.2 cm in length by 1.4 cm in width, and directed to apply skin prep twice a day. The Physician Progress Note, dated 02/01/23, documented R33 was seen, and nursing reported episode of dark emesis. Left buttock wound discussed with nursing; wound had foam dressing. Orders noted to off load pressure and administered normal saline intravenously, again. On 02/06/23 at 07:48 AM, observation revealed R33 sat in her wheelchair, the wheelchair had pressure reducing cushion. She wore padded boots to both feet and was dressed and groomed for the day. Speech therapy was in the room assisting R33 to eat. The breakfast meal consisted of scrambled eggs, French toast with syrup, and two containers of orange juice. No super cereal was present. On 02/06/23 at 08:15 AM observation revealed speech therapy was no longer in room. R33 ate a few bites of scrambled eggs and a few bites of French toast, drank one of the orange juices. R33 remained up in the wheelchair. On 02/06/23 at 10:25 AM observation revealed nursing staff in room, R33 sat on the footrests of her wheelchair. Resident had remained in her wheelchair up to this time, over two hours. Licensed Nurse (LN) G and Certified Medication Aide (CMA) S assessed the resident and placed R33 back in the wheelchair. On 02/06/23 at 10:48 AM observation revealed staff brought R33 to the nurse's station area. Administrative Nurse D inquired how R33 was doing and R33 reported she was not good. On 02/06/23 at 11:23 AM observation revealed Certified Nurse Aide (CNA) O and LN G placed R33 in her bed and used a full body mechanical lift. Staff explained they were going to provide incontinent check and laid R33 in bed. R33 had not voided in brief, R33 rolled to her right side with pillow against R33's back (off-loading buttocks) and continued padded boots to feet. On 02/07/23 at 07:58 AM observation revealed R33 in the dining room, in her wheelchair being fed by staff. R33 had scrambled eggs, pancake with syrup, and large glass of orange juice. Staff inquired about added salt to eggs and R33 said that tasted good. No super cereal was provided to R33. On 02/07/23 at 08:45 AM observation revealed staff had brought R33 to her room where she remained in her wheelchair covered with blankets and her TV on. On 02/07/23 at 12:00 PM observations revealed CNA N and O transferring R33 from wheelchair to bed using a full body lift. CNA N and O stated the resident required extensive assistance with all activities of daily living, was to be repositioned every two hours, was incontinent of urine and bowel. Staff provided cleansing of peri rectal area, the dressing to left buttocks was removed, and a clean brief provided. Staff reported the nurse would place a new dressing to R33 after the shower. Further observation revealed left buttock wound with slough covering majority of the open wound and a dark black area at the top of the wound. Staff finished care and left R33 laying on her back. On 02/07/23 at 04:13 PM observation revealed LN I and Administrative Nurse E measured the wound. The wound measured 5.4 cm in length by 3.5 cm in width, slough covering most of the wound and eschar at 10 o'clock to 12 o'clock wound top. The periwound was red and irritated. R33 reacted with pain complaint while staff measured wound. LN I and Administrative Nurse E verified resident left buttock wound continued to worsen, and that R33 remained in her wheelchair over two hours with position changes but lacked off-loading interventions. The staff reported they were not aware of the dietician's recommendations of supplements or super cereal recommendations. Administrative Nurse E reported discussion with R33's family to involve wound care consultation and care, and review dietician's recommendations. On 02/08/23 at 07:41 AM observation revealed R33 being pushed by staff from the dining room to halfway point of Harmony Lane with padded boots. R33's left foot was dragging the floor behind the foot pedal on the floor until staff stopped and placed left foot on foot pedal. The facility's Pressure Injury Prevention and Management policy, dated 03/28/18, documented the facility is committed to prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). The facility established and utilized a system for pressure injury prevention and management , starting with prompt assessment and treatment, including efforts to identify at risk , stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Licensed nurses would conduct a pressure injury risk assessment on all residents upon admission /re-admission, after a change of condition, after any newly identified pressure injury, and quarterly. Assessments of pressure injuries be performed by a licensed nurse and documented in the resident's medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Nursing assistants would observe skin during bathing/personal cares and would report any concerns to the charge nurse immediately after the task. Interventions would be for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. Interventions would be documented in the care plan and communicated to all relevant staff. Interventions on the resident's care plan would be modified as needed. The facility failed to provide off-loading and repositioning or follow dietician recommendations for R33's wound care and treatment. This placed R33 at risk for worsening of the wound and/or delayed healing. 27168 - R34's Electronic Medical Record (EMR), recorded a diagnosis of morbid obesity (a person is at least 100 pounds overweight), venous insufficiency peripheral (failure of the veins to adequately circulate blood, especially in the lower extremities), and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). R34's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R34 had a Brief Interview for Metal Status (BIMS) score of 15, indicating intact cognition. The assessment revealed R34 required extensive staff assistance of two for bed mobility, personal hygiene, dressing, repositioning and transfers. The resident was at risk for pressure ulcer development with moisture associated skin damage (MASD). The Activities of Daily Living (ADL) Care Plan, dated 11/02/22, recorded R34 required a full body lift for transfers, used a wheelchair for all mobility and the resident was dependent on staff for propelling. The Skin Integrity Care Plan, dated 11/02/22, documented R34 was at risk for skin breakdown and had MASD related to morbid obesity with excess skin folds, incontinence, and prolonged sitting. The Braden Scale for Predicting Pressure Ulcer Risk Admission Assessment, dated 12/12/22 documented a score of 12.0, which indicated the resident was at high risk for pressure ulcer development. The Braden Scale dated 02/01/23 documented a score of 13 which indicated the resident at moderate risk for pressure ulcer development. The Nurse Progress Note, dated 01/25/23 at 05:06 PM, documented R34 had a bath and the nurse aide identified an open area on R34's coccyx (skin over the tailbone) but the note failed to document if a treatment was implemented or if the physician was notified. A 02/02/22 Physician Order documented wound treatments for the left and right buttocks. The Weekly Wound Assessment, dated 02/03/23 (added during the survey after surveyor requested assessment) documented R34 had a stage two facility acquired pressure ulcer (pressure injury which extends deeper into the skin, may appear like a scape, blister or shallow crater in the skin) on her left buttocks 5.5 centimeters (cm)length, by 2.0 cm width, no tunneling or undermining. The current treatment plan directed staff to cleanse the wound with normal saline or wound cleanser, pat dry with gauze, apply skin prep (skin barrier)to the peri wound (skin around the wound) and cover with a foam border dressing; change the dressing three times a week and as needed for soiling or dislodgement. The wound assessment documented the resident had a stage two facility acquired pressure ulcer on her right buttocks 4.0 cm by 1.3 cm, no tunneling or undermining. The treatment plan included to cleanse with normal saline or wound cleanser, pat dry with gauze, apply skin prep to the wound and cover with foam border dressing, change the dressing three times a week and as needed for soiling or dislodgement. On 02/02/23 at 03:10 PM, observation revealed R34 laid in bed on her back. Administrative Nurse D and Administrative Nurse E assisted the resident to position on her right side and removed the resident's brief. Administrative Nurse E verified an open area on the residents left and right buttocks that was facility acquired. On 02/02/23 at 01:30 PM, Administrative Nurse D stated she was not aware of the resident having a pressure ulcer. Administrative Nurse D said she would observe the resident skin and get back with the surveyors. On 02/02/23 at 3:00 PM, Administrative Nurse D verified the nurse had documented in the progress notes on 01/25/23 the resident had open areas on her coccyx but failed to inform administrative staff of the skin concerns. Administrative Nurse D verified the resident did not have any treatment until staff were questioned during the facility health resurvey on 02/02/23. The facility's Pressure Injury Prevention and Management policy, dated 03/28/18, documented the facility is committed to prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). The facility established and utilized a system for pressure injury prevention and management , starting with prompt assessment and treatment, including efforts to identify at risk , stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. Licensed nurses would conduct a pressure injury risk assessment on all residents upon admission /re-admission, after a change of condition, after any newly identified pressure injury, and quarterly. Assessments of pressure injuries be performed by a licensed nurse and documented in the resident's medical record. The staging of pressure injuries would be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Nursing assistants would observe skin during bathing/personal cares and would report any concerns to the charge nurse immediately after the task. Interventions would be for prevention would be implemented for all residents who are assessed at risk or who have a pressure injury present. Interventions would be documented in the care plan and communicated to all relevant staff. Interventions on the resident's care plan would be modified as needed. The facility failed to prevent the development of facility acquired pressure ulcers for R34 and failed to implement treatment and interventions upon identification of the skin injury placing the resident at risk for further skin breakdown, pain, and infection.

The facility reported a census of 44 residents. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions, for the residents of the facility. Findings included: - On 04/13/2021 at 11:07 AM, an initial tour of the kitchen with Dietary Staff (DS) BB, revealed seven frying pans with a brown substance and irregular cooking surfaces, which made them unsanitizable. On 04/13/2021 at 11:07 AM, DS BB verified the above and stated the seven frying pans were not the ones provided by the facility. He explained that the facility cooks brought in these seven personal frying pans from home to cook for the residents. He agreed the pans all had irregular cooking surfaces, and brown debris inside which came into direct contact with the food cooked in them. These seven pans were unsanitizable and should not be used. The facility failed to provide a policy to address the procurement and use of appropriate cookware to ensure sanitation and safe cooking practices. The facility failed to prepare and serve food under sanitary conditions for the residents of the facility.

The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly. Findings included: - On 04/19/21 at 11:40 AM, during a Kitchen tour with Dietary Staff (DS) BB, revealed the lack of a trash can adjacent to the hand washing sink in the food preparation area. An open barrel located approximately 10 feet away from the handwashing sink sat next to the bread rack. The open barrel had paper towels overflowing from the top of the barrel. On 04/19/21 at 11:40 AM, DS BB verified the above findings. He reported the kitchen staff used the barrel to dispose of the paper towels used to dry their hands after washing them. He stated they previously had a foot operated trash can adjacent to the handwashing sink, in the food preparation area, but the staff used the barrel instead. DS BB agreed the trash receptacle did not adequately contain the trash and that it should not be located next to the bread rack. Additionally, he stated the handwashing sink should have a foot operated trash receptacle at the handwashing sink for staff to dispose of paper towels and to prevent any cross contamination. The facility policy for Garbage and Refuse, dated 03/18/2021 documentation included the center shall properly dispose of garbage and refuse. Garbage and refuse containers should not be overfilled, have lids, and be covered when not in use. The facility policy for Handwashing Guidelines-Dietary Employees, dated 03/01/2018, documentation included handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink when preparing food, especially when changing preparation procedures, and when working with different raw foods during preparation. After engaging in any activities that may contaminate the hands. Staff should dispose of paper towels in a pedal opening trash can (do not touch the trash can lid with clean hands). The facility failed to maintain and/or dispose of kitchen garbage and refuse properly for the residents of the facility.

The facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of the pandemic COVID-19 virus. The facility failed to ensure staff were answering screening questions appropriately at the beginning of the shift, failed to quarantine residents when a staff member tested positive for COVID-19 that previously worked two shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in place to provide instruction on the steps the facility should take when an outbreak occurred. The above practices increased the risk of transmission of COVID-19 to the residents of the facility. Findings included: - On 04/13/21 at 09:30 AM, the Administrative Staff B reported they were in outbreak testing due to one employee that was positive for COVID-19. On 04/13/21 at 04:42 PM, Administrative Staff A confirmed the facility was currently in outbreak testing due to one positive employee. Currently no residents tested positive and no other staff tested positive. On 04/14/21 at 09:58 AM, Licensed Nurse (LN) J stated a staff member previously tested positive, staff were being tested twice a week, and staff were wearing surgical style masks right now. On 04/14/21 at 10:02 AM, residents were in the sitting area between the hallways for exercise activity had a cloth or surgical mask in place and the staff wore surgical masks. On 04/14/21 at 03:30 PM, Administrative Nurse D stated that Certified Nurse Aide (CNA) M complained of cough and runny nose on 04/08/21 for her 2:00 PM to 10:00 PM shift screenings. A rapid COVID-19 test done at that time was negative, and staff collected a PCR (polymerase chain reaction) at that time too. The PCR test returned with a positive result for COVID-19 on 04/09/21 at 06:50 AM. CNA M worked her scheduled shift on 04/08/21 since the rapid test was negative. On 04/14/21 at 03:35 PM, Administrative Staff B stated staff are allowed to perform their own screening and Administrative Staff A monitored the screening forms for completion. If someone had symptoms or an increased temperature, they would not be allowed to enter, the director of nursing (DON) or charge nurse would be contacted to recheck their temperature, and they would probably do a COVID-19 test at that time. On 04/14/21 at 03:44 PM, Certified Medication Aide (CMA) R stated the residents were not quarantined to their room right now, and a couple of weeks ago the facility updated the guidelines that there can be two residents to a table in the dining room. On 04/14/21 at 05:47 PM, residents sat in the dining room, two tables had two residents sitting there less than six feet apart and the other tables had one resident to a table. Review of the schedule for CNA M revealed on 04/06/21 and 04/08/21 the facility assigned her to work on the 2:00 PM to 10:00 PM shifts. Review of the staff screening logs, dated 04/06/21 and 04/08/21, revealed that CNA M answered No in response to the symptom questions on the screening form. Her temperature was 98.2 degrees Fahrenheit on 04/06/21 and 98.6 degrees Fahrenheit on 04/08/21. The [CONDITION(S)]-CoV-2 (COVID-19) result summary, dated 04/09/21 at 06:49 AM, revealed that CNA M had a positive result for date of specimen collection on 04/08/21 at 02:03 PM and received in the laboratory on 04/08/21 at 05:32 PM. An electronic communication dated 04/09/21 at 09:11 AM, from Administrative Staff D to the local county health department, revealed that during routine testing on 04/08/21 that CNA M tested positive on a PCR test. CNA M reported to work with complaints of a sore throat and a mild cough and did not have a fever. A rapid test completed on 04/08/21 was negative and she worked her scheduled shift on 04/08/21 from 02:00 PM to 10:00 PM. The [CONDITION(S)]-CoV-2 (COVID-19) result summary, dated 04/09/21 at 06:03 PM, revealed that CNA M had a positive result for date of specimen collection on 04/09/21 at 02:51 PM. On 04/15/21 at 12:00 PM, CNA M stated that she was in quarantine/isolation until she could return to work. On 04/06/21 when at home she started having symptoms of a stuffy nose, cough, and scratchy throat. She thought it was just allergies and did not report those symptoms on the screening form and worked her assigned shift from 02:00 PM to 10:00 PM that day. She reported that she walked around everywhere in the building except the dining room and provided cares to residents of one hallway of the facility. CNA M stated on 04/08/21 the facility was doing routine testing and she felt her symptoms were a lot worse than on 04/06/21. She felt like she had a fever, her throat was sore, and she had a cough. CNA M reported she requested a rapid test be done because she did not feel well and wanted to make sure it was not COVID-19, even though she thought it was just allergies. The symptoms on the screening form were answered no as she was used to circling no to the questions on the form. She was then tested and waited for results before going to her assigned area of the facility. CNA M stated she worked one hall until 06:30 PM then was moved to another hall to provide cares until 10:30 PM on 04/08/21. She wore a surgical mask during her shift. On 04/15/21 at 12:27 PM, Administrative Nurse D stated on 04/08/21, CNA M was sniffling, so we tested her to make sure she was not positive, she was in the screening area at that time. LN G assessed her. Administrative Nurse D stated if a staff feels like they have a fever and a cough or sore throat they should not report to work. A policy regarding facility response to when a staff tests positive was not available at this time, the management company was assisting to obtain one. On 04/15/21 at 12:35 PM, LN G stated he assessed CNA M on 04/08/21, conducted the rapid testing, he assessed her lung sounds and there were no issues and she had allergy-like symptoms of runny nose and sore throat. She was given the option if she wanted to work her shift or not and she did not want to go home that he recalled. An electronic communication dated 04/15/21 at 12:41 PM, from Administrative Nurse D to the local county health department, revealed that when CNA M tested positive, the facility instructed her to self-quarantine and all residents testing conducted on 04/09/21 was negative results. The facility restricted movement within the facility, suspended in room visitations, and suspended group activities. Staff repeated testing on 04/12/21 which was negative. Since that time, the facility lifted the restriction for residents to remain in their room, group activities, and allowing staff to wear surgical/cloth masks at all times, based on criteria for positivity rates in the two counties below five percent, greater than 70 percent of all residents vaccinated, first-round testing of both residents and staff resulted negative, and twice a day resident screenings revealed no indication of abnormal signs and symptoms. The local county health department returned an electronic communication back to Administrative Nurse D indicating they had no further suggestions, to keep the routines and monitoring going, and hope that this would be just an isolated case. On 04/19/21 at 09:29 AM, Administrative Nurse D stated that testing for all staff and residents completed on 04/15/21 had negative results. On 04/20/21 at 10:38 AM, Administrative Nurse E, responsible for the infection control program, stated that on 04/09/21 when the facility received the positive result for CNA M, the facility stopped visitation in the facility, stopped some of the larger group activities, continued to use the dining room, and the residents were not quarantined to their room. Administrative Nurse E stated that the facility was still in outbreak mode, and the staff continued to wear a cloth or surgical mask. On 04/20/21 at 02:46 PM, Administrative Nurse D revealed the facility lacked a policy on the steps the facility needed to take when there was an outbreak, and they follow multiple guidelines from the CDC. The health department did not respond to her electronic communication sent on 04/09/21. The facility policy Group Activities During COVID-19 Policy, dated 03/29/21, indicated it was the policy that alterations are made in programming within the Center during COVID-19 outbreaks and to meet the Center's COVID-19 prevention protocols and local, state, and federal guidelines. The facility policy, Coronavirus Surveillance Policy, dated 03/23/20, included that screening for visitors and staff included signs and symptoms of a respiratory infection, such as fever, cough, shortness of breath, or other symptoms of coronavirus (i.e. chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, diarrhea). Staff who have signs and symptoms of respiratory infection should not report to work. The facility policy Coronavirus Testing, revised 09/08/20, indicated an outbreak was a new COVID-19 infection in any healthcare personnel or any nursing-home onset COVID-19 infection in a resident. Staff who do not test positive for COVID-19 but have symptoms will follow the facility policy to determine when they can return to work. The facility policy Novel Coronavirus Prevention and Response, revised 07/30/2020, included the Infection Preventionist (IP) or Director of Nursing (DON) will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility. When a threat is detected, the facility will respond promptly and implement emergency and/or outbreak procedures. The policy lacked a procedure on response of a positive employee but addressed response of a positive resident or if COVID-19 is suspected in a resident. The CDC recommendations, titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 03/29/21, included residents that have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Healthcare personnel should wear an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Any new identified [CONDITION(S)]-CoV-2 infected healthcare personnel or resident should be evaluated as a potential outbreak. Residents should generally be restricted to their rooms. Consideration should be given to halting social activities and communal dining. Recommended precautions should be continued for residents until no new cases of [CONDITION(S)]-CoV-2 infection have been identified for at least 14 days. The facility failed to ensure staff answered screening questions appropriately at the beginning of their shifts, failed to quarantine the residents to their room when they received a positive test result for COVID-19 for a staff member who worked two previous shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in place to provide instruction on the steps the facility staff were to take when an outbreak occurred. The above practices increased the risk of transmission of COVID-19 to the residents of the facility.

The facility reported a census of 44 residents with 12 selected for review including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to provide appropriate cleaning and storage of two of the three sampled residents respiratory equipment including, Resident (R)34's nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) administration kit. R13 with the facility failure to clean the oxygen concentrator filter, failed to label the oxygen tubing when changed, and failed to label the distilled water container when opened and store appropriately. These practices increased the risk for R34 and R13 of developing a respiratory infection. Findings included: - The Order Summary Report, dated 03/03/21, for Resident (R)34, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], assessed R34 with a Brief Interview of Mental Status (BIMS) score of zero, indicating severe cognitive impairment and that she did not receive any respiratory services. The Quarterly MDS, dated [DATE], revealed no changes in assessment from the prior MDS, dated [DATE]. The Care Plan, dated 03/31/21, lacked any instructions for respiratory interventions or treatments. The Order Summary Report, dated 03/03/21, included an order dated 09/03/20, for [MEDICATION(S)]-[MEDICATION(S)] (a bronchodilator medication-used to relax and open the air passages to the lungs to make breathing easier) solution, 0.5-2.5 milligrams (mg)/three milliliters (mL), inhale one vial, via nebulizer, three times a day, related to other specified symptoms and signs involving the circulatory and respiratory symptoms. The electronic medical record (EMR), in the order section, lacked any instructions on cleansing or storage of the resident's nebulizer administration kit. On 04/14/21 at 01:51 PM, R34's nebulizer machine was directly sitting on the floor by her recliner, the nebulizer administration kit was on the floor with condensation noted in the medicine cup of the kit. The Treatment Administration Record, (TAR), dated 04/14/21, revealed that R34 received her second treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/15/21 at 11:40 AM, R34's nebulizer machine and her administration kit were on the floor by her recliner, connected, with the administration kit mask in direct contact with the floor. On 04/15/21 at 02:47 PM, R34's nebulizer machine and administration kit continued to be stored directly on the floor. On 04/19/21 at 12:29 PM, Licensed Nurse (LN) H disconnected the nebulizer administration kit once the treatment was done, placed the mask on the table next to the nebulizer machine, rinsed out the medicine cup with water, then placed it on a paper towel to air dry. LN H failed to clean the nebulizer administration mask. On 04/19/21 at 12:49 PM, LN H, revealed that sometimes she would rinse the mask too with water and let it air dry on a paper towel if it looked like it needed it. When the administration kit was dry staff would put it back together and hook it onto the machine. On 04/19/21 at 01:39 PM, Administrative Nurse D, confirmed when the nebulizer treatment was done. She explained that the mouthpiece or mask and medicine cup of the administration kit should be rinsed immediately after the treatment was done and placed on a paper towel to air dry next to the machine. The machine or administration kit should not be stored on the floor. The facility policy, Nebulizer Therapy Policy, dated 03/01/18, indicated after the nebulizer treatment, staff are to disassemble and rinse the nebulizer cup and mouthpiece with water and allow to air dry on an absorbent towel. The facility failed to provide appropriate cleaning and storage of Resident (R)34's nebulizer administration kit, increasing the risk of R34 developing a respiratory infection. - Review of Resident (R)13's physician orders, dated 04/01/202, documentation diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission, Minimum Data Set (MDS) dated [DATE], documented she admitted on [DATE], with the Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitively impairment. The resident received oxygen after admission to the facility. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/22/2021, documentation the resident had a stroke and was not able to return home to live with her spouse due to concerns which included the use of oxygen. The care plan (CP), dated 02/22/2021, directed staff the resident required oxygen at two liters a minute by way of nasal cannula, as needed, for shortness of air/breath or oxygen saturation (oxygen concentration in the blood) less than 90 percent. Change oxygen tubing, mask, and humidifier bottle and clean filter every Sunday night shift. On 04/14/2021 at 10:20 AM, the resident's oxygen tubing and nasal cannula was laying directly on the floor. There was not a container present for sanitary storage of the cannula or tubing to prevent cross contamination. The concentrator humidifier bottle lacked a date when when last changed by staff and the air filter screen was covered with a thick layer of dust. Additionally, there was a third full gallon jug of distilled water that sat directly on the floor in the resident's room. On 04/14/21 10:22 AM, Licensed Nurse (LN) G verified the findings above. He stated the staff should check the residents with oxygen for storage of tubing at each shift and throughout the day. They should use zip lock bags to store the tubing when not in use to prevent cross contamination. He stated the third shift nurse should change the tubing and humidifier bottles out every week and date the bottle and tubing when they changed them. He reported the nurses used the distilled water to fill the humidifier bottle on the oxygen concentrator. LN G reported the distilled water bottle should be dated when opened and staff should not leave the container on the floor. He verified the collection of dust on the concentrator filter and stated the filter needed cleaning. On 04/15/2021 at 1:34 PM, the concentrator humidifier bottle lacked a date when changed and the air filter was not in place on the concentrator. The concentrator air filter was laying on a paper towel on the resident's dresser. A one third full open container of distilled water, which lacked a date when opened, sat directly on the floor. On 04/15/2021 at 1:41 PM, CNA Q, stated the nurse was responsible for maintaining the oxygen and respiratory equipment in a safe and sanitary condition. She stated if she saw the resident's oxygen tubing on the floor, she would report it to the nurse. CNA Q stated the distilled water should be marked with the date when opened and should be kept in the supply closet and not in the resident's room. She stated she did not think the distilled water should be left setting on the floor. On 04/19/2021 at 10:22 AM, a gallon bottle of distilled water, was one third full, sat directly on the resident's room floor. On 04/19/2021 at 01:16 PM, CNA O, stated third shift changed out the oxygen nasal cannulas weekly. Charge nurses should check for proper storage and change the tubing if needed. Staff should label the cannulas and humidifier bottles when changed and the cannulas and tubing should be stored in bags when not in use. The distilled water should be labeled the day staff opened it and staff should not place the container on the floor. On 04/19/2021 at 4:04 PM, LN H reported the facility oxygen room had oxygen equipment supplies which included tubing and humidifier bottles. She stated tubing and humidifier bottles should be changed out weekly by the night shift nurse. The equipment should be labeled with the dates when changed. The distilled water should be stored in the clean utility room underneath the sink and not left in the resident's room. The staff should date the gallon containers of distilled water when they are opened and when they change the tubing and humidifier bottles. Oxygen tubing should be stored in a bag when not in use to prevent cross contamination. On 04/20/2021 at 9:38 AM, Administrative Nurse D stated she expected the nursing staff to monitor for proper storage of oxygen tubing in a bag when not in use. She stated the oxygen tubing and humidifier bottles should be changed and the concentrator filters should be cleaned weekly by the third shift staff. The staff should date the oxygen tubing and humidifier bottles with the date when staff changed them. The staff should keep the distilled water stored in the clean utility room and they should date the gallon jugs when they open them. They should keep the open jugs at the nurse's station and not in the resident's rooms. The distilled water containers should never be stored on the floor. The facility policy for Oxygen Concentrator, dated 03/01/2018, documentation included: .1. Wash filters weekly and as needed. 2. Change tubing weekly. 3. Change humidifier bottle weekly or as recommended by the maker. 4. The main body cabinet should be dusted when needed and can be wiped clean with a damp cloth and mild household cleaner if necessary. 5. Fill the humidifier container to the correct level with distilled water and attach to the concentrator; or use disposable humidifier. 6. Attach oxygen delivery device ordered by the physician to the concentrator . The policy did not address storage of tubing when not in use, labeling equipment with the date when put in place and/or the appropriate storage of distilled water used to fill the humidifier bottle. The facility failed to provide appropriate sanitary respiratory care in maintaining respiratory equipment to prevent the spread of infection for this resident that required oxygen, related to storage and labeling of oxygen concentrator tubing, cannula, humidifier bottle, and distilled water.

The facility reported a census of 44 residents with 12 residents selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to keep the catheter tubing from touching directly on the floor for one of the two residents reviewed, Resident (R)38, creating a risk for developing urinary tract infections. Findings included: - The Order Summary Report, dated 04/02/21, for Resident (R)38, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS), dated [DATE], assessed R38 with a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. R38 required extensive assist of one staff for toilet use and had an indwelling urinary catheter in place. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 10/15/20, revealed R38 had a long term indwelling catheter that was managed by the staff and he was at risk for a urinary tract infections related to the long term indwelling catheter use. The Quarterly MDS, dated [DATE], assessed R38 with a BIMS score of five, indicating severe cognitive impairment. He continued to require extensive assist of one staff for toileting and continued to have an indwelling catheter in place. The Care Plan, dated 01/21/21, revealed that R38 had a long-term indwelling catheter, the staff were to monitor the tubing to ensure there were no kinks present, and measure the output from the catheter every shift. The Order Summary Report, dated 04/02/21, included an order dated 11/12/20, to check R38's tubing to ensure no kinks for accurate and safe flow of urine four times daily. On 04/14/21 at 10:28 AM, R38 was sitting up in his wheelchair in his room and his urinary catheter tubing was touching directly on the floor. On 04/15/21 at 11:36 AM, R38 was sitting up in his wheelchair in the dining room and his urinary catheter tubing was touching directly on the floor. On 04/19/21 at 12:59 PM, Certified Mediation Aide (CMA) S was preparing to drain the resident's catheter urine collection bag, when she repositioned R38's feet off of the footrests of the wheelchair and onto the floor, the urinary catheter tubing again touched directly on the floor. The tubing remained on the floor during the drainage process until she placed his feet back on the footrests of the wheelchair. CMA S failed to clean the tubing after it had contact with the floor. On 04/20/21 at 09:39 AM, Consultant Nurse GG, stated the resident's urinary catheter tubing should not touch on the floor. On 04/20/21 at 09:50 AM, Licensed Nurse (LN) I stated the urinary catheter tubing should not be on the floor, and it if was it should be cleaned by the staff. On 04/20/21 at 11:03 AM, Administrative Nurse D stated the urinary catheter tubing should not be on the floor and if it was the staff should adjust the bag's positioning to keep it off of the floor. The facility policy Catheter Care Policy, dated 03/01/18, indicated the center will provide catheter care to all residents with an indwelling catheter in an effort to reduce bladder and kidney infections. The policy lacked instruction on keeping the tubing from having contact with the floor. The facility failed to keep R38's urinary catheter tubing from touching directly on the floor increasing his risk for developing a urinary tract infection.

The facility reported census of 44 residents, with 12 residents selected for review, which included one reviewed for discharge summary. Based on record review and interview the facility failed to complete a discharge summary which included a recapitulation of stay, reconciliation, and disposition of medications for the one sampled resident (R)44, as required. Findings included: - Review of Resident's (R)44's undated Physician Orders, documentation revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission, Minimum Data Set (MDS) dated [DATE], documented the resident entered the facility on 12/22/2020. The documentation included the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident participated in the assessment and expected to be discharged to the community. He had an active discharge plan in place and a referral was not needed. The Discharge Return Not Anticipated MDS, dated [DATE], documentation included the resident with an unplanned discharge to the community on 02/01/2021. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 01/04/2021, documentation included the resident would discharge home after completion of short-term rehabilitation (therapy) and completion of intravenous (IV-in the vein), antibiotics. The care plan (CP), dated, 01/22/2021, documentation included the resident to discharge to home with his wife. He would receive additional services, as needed, upon completion of his rehabilitation therapies. The Nurse's Note, dated 02/01/2021 at 03:45 PM, documented the resident discharged home at 02:40 PM. The medical record lacked a discharge summary to include medication reconciliation, disposition, and/or a discharge summary which documented recapitulation of the residents stay at the facility. On 04/15/2021 at 02:45 PM, Certified Nursing Assistant (CNA) P, stated the discharging nurse should provide the resident and /or their representative with discharge instructions and complete all documentation at the time of discharge. On 04/19/2021 at 01:16 PM, CNA O, stated the nurse completed the paperwork associated with a resident's discharge. On 04/19/2021 at 04:04 PM, Licensed Nurse (LN) H, reported when she discharged a resident she would count the medications document the disposition of the medications, which included the medication count and whether the medications were sent to the pharmacy , destroyed, and/or sent with the resident. The discharging nurse should complete a discharge summary which includes a recap of the resident's stay and the course of treatment while here. On 04/20/2021 at 12:28 PM, Administrative Nurse D, confirmed the medical record lacked documentation of a discharge summary to include a recapitulation of stay, reconciliation, and disposition of medications for the resident. The facility failed to provide a policy for completion of a discharge summary, to include the recapitulation of the resident's stay and/or reconciliation/disposition of medications at the time of discharge from the facility. The facility failed to complete a discharge summary which included a recapitulation of the resident's stay, and reconciliation/disposition of medications for resident (R)44, as required.

The facility reported a census of 44 residents with 12 selected for review including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure equipment was in proper working condition, failed to implement a new intervention following falls, failed to implement appropriate interventions following two falls for one of the three residents, Resident (R)16. Findings included: - The Order Summary Report, dated 04/06/21, for R16, included diagnoses of [CONDITION(S)] to her right knee, pain in her right hip, cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, unsteadiness on feet, difficulty in walking, muscle weakness, low back pain, dementia (progressive mental disorder characterized by failing memory, confusion), history of falling, and repeated falls. The Significant Change in Status Minimum Data Set (MDS), dated [DATE], assessed R16 with a Brief Interview of Mental Status Score (BIMS) of 11, indicating moderate cognitive impairment and she had no falls since the prior assessment. She required limited assistance of one staff for bed mobility, transfers, walking, toilet use, and personal hygiene. She required extensive assistance of one staff for dressing and her balance was unsteady requiring staff assistance to stabilize. She used a wheelchair and a walker for locomotion and was occasionally incontinent of urine. The Falls Care Area Assessment (CAA), dated 08/26/20, revealed that R16 had severely impaired cognition and regularly not able to tell you where she was or what the current situation in her life was. She has had a significant decline in function related to a past fall with a fracture but was a very determined person and progressed back to an improved level of functioning. The CAA indicated she required limited assistance of one staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene, and was working with therapy. The Quarterly MDS, dated [DATE], assessed R16 with a BIMS score of 4, indicating severe cognitive impairment and had two or more noninjury falls since the last assessment. She required limited assistance of one staff for bed mobility, transfers, dressing and personal hygiene. She required extensive assistance of one staff for toilet use, and walking occurred one or two times. There were no changes in her balance or bladder continence from the prior significant change MDS. The Quarterly MDS, dated [DATE], assessed R16 with a BIMS score of 11, indicating moderate cognitive impairment and she had two or more non injury falls and one injury fall that was not major since the last assessment. She required extensive assistance of one staff for bed mobility, transfers, and dressing, and limited assistance of one staff for walking, toilet use, and hygiene. R16 was frequently incontinent of urine, and there were no changes in her balance or bladder incontinence from the prior MDS. The Care Plan, dated 03/04/21, initiated on 07/08/20, included R16 had a history of frequent falls due to her impaired cognition, unsteady gait and medications. The staff were to arrange her overbed table to keep frequently used items in reach, keep her call light in easy reach, and give her household tasks such as folding laundry to do as a keep busy task. She was to have shoes on with increased traction, one person to assist her with transfers, and non-skid socks on at all times. Her bed was to be up against the wall to give fewer objects to maneuver around and the staff were to make her bed upon awakening. The Morse Fall Scale, dated 12/01/20, indicated that R16 had a high risk for falling. The electronic medical record revealed R16 had 10 various falls from 10/29/20 to 04/09/21. There were concerns with her fall on 12/02/20, and both falls that occurred on 01/19/21 as follows. The progress notes, dated 12/02/20 at 08:30 PM, revealed R16 had a witnessed fall from the low bed to the floor and that she continued to be impulsive and would get in and out of her bed and into her wheelchair and recliner or go to the restroom on her own. The facility fall investigation, for R16's fall on 12/02/21, indicated that she complained of feeling dizzy and was trying to get up to use the restroom. The intervention for the fall was for Physical Therapy and Occupational therapy to evaluate and treat the resident. However, the facility failed to put an immediate intervention in place prior to the therapy evaluation to prevent further falls. The progress notes, dated 01/19/21 at 04:04 PM, revealed that R16 reported she had fell trying to get out of bed. The facility fall investigation, for R16's fall on 01/19/21 at 11:25 AM, revealed the intervention for the fall was to put in place a three-day incontinence analysis to evaluate the need for individualized toileting times to aide in fall prevention. This was also not an immediate intervention to prevent further falls. The progress notes, dated 01/20/21 at 03:28 AM, revealed that R16 fell in front of her bathroom at 09:45 PM. The facility fall investigation, for the fall on 01/20/21 at 09:45 PM, indicated the intervention from the earlier fall was still in progress and instructed the staff to continue the plan of care. The facility failed to implement a new intervention to prevent further falls. The progress notes, dated 02/03/2021 at 02:28 AM, indicated that at 08:15 PM R16 had an unwitnessed fall. The progress note, dated 2/11/2021 at 04:05 PM, revealed the interdisciplinary team reviewed the fall, from 02/03/21, and the intervention was the addition of anti-roll back brakes to her wheelchair. The Care Plan, dated 03/04/21, included an intervention dated 02/02/21 for anti-roll back brakes to be placed on R16's wheelchair. On 04/15/21 at 11:14 AM, Certified Nurse Aide (CNA) N revealed that the anti-roll back brakes were to prevent the wheelchair from rolling backwards when she was not sitting in it. CNA N attempted to move the wheelchair while R16 was not sitting in it and the chair rolled backwards. CNA M stated it should not do that. She then attempted to move a lever on the brakes and tried moving the chair back again and stated there it works now except it was not catching on one side like it should. CNA N confirmed that the brakes needed to be looked at with this malfunction. On 04/15/21 at 11:28 AM, Licensed Nurse (LN) I stated the anti-roll back brakes should prevent the wheelchair from rolling backwards when she was not sitting in it. After knowledge that the brakes were not functioning properly, LN I stated she would enter a maintenance request for them to be repaired. On 04/19/21 at 11:58 AM, Certified Medication Aide (CMA) S attempted to roll R16's wheelchair backwards while the resident was not sitting in it and the wheelchair rolled backwards easily. CMA S stated that the anti-roll back brakes were not functioning, that the purpose was to keep the chair from rolling backwards when she was not sitting in it. CMA S was not aware of who monitored the functioning of the brakes, and then tried to adjust the lever on the back of the brakes without success. CMA S reported she would let someone know that the anti-roll back brakes were not working. On 04/20/21 at 03:09 PM, R16's wheelchair moved backwards without her in it, to check if the anti-roll back brakes were functioning and the wheelchair rolled easily backwards. On 04/20/21 at 03:10 PM, CMA R revealed that R16 was not good about locking her wheelchair brakes and the staff had to keep a good eye out on her. On 04/20/21 at 03:13 PM, Administrative Nurse D stated that a work order was not placed for maintenance to look at her anti-roll back brakes and did not have an answer on who monitored them for functioning. Administrative Nurse D confirmed that each fall needed a new intervention to prevent further falls and that Physical and Occupational Therapy and bowel and bladder analysis were more long-term interventions and not immediate interventions to prevent falls. The facility policy Accidents and Supervision, dated 03/01/18, indicated it was the facility policy that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents. This includes implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The facility failed to monitor the functioning of R16's anti-roll back brakes and failed to act timely (five days), when they had knowledge of them malfunctioning, and failed to implement a new immediate intervention for three of her falls, to prevent further falls for the resident.

The facility reported a census of 36 residents with four sampled for review. Based on observation, interview, and record review the facility failed to follow the care planned interventions to prevent falls for one of the four sampled residents. Staff left Resident (R) 1 unattended in the bathroom, the resident attempted to reposition herself with the wheelchair when she fell and experienced a fractured (broken) nose and a large hematoma (a solid swelling of clotted blood within the tissues) with bilateral blackened eyes. Findings included: - The signed physician's orders [REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. Her short and long-term memory were ok. She required extensive assistance of two for transfers and toileting. She required extensive assistance of one for locomotion, dressing, and hygiene. She was unsteady and was only able to stabilize with staff assistance for standing and moving on and off the toilet. She had limited range of motion (ROM) on one side of the lower extremities and she used a wheelchair for mobility. She had falls prior to admission in the last month which resulted in a fracture and right hip replacement. R1 was a fall risk on admission. The CAA (Care Area Assessment), for Cognition, Activity of Daily Living (ADL) and Falls, dated 11/25/19, revealed the resident had moderate cognitive impairment with a BIMS score of 10. She admitted with a right hip surgical wound. She was to remain toe touch weight bearing for six weeks post-operative. This was a difficult task for her to do and she needed extensive assistance of one with dressing, personal hygiene, and bathing. The Care Plan for ADL, dated 11/20/19, documented the resident required one person with stand by assistance to maintain balance once standing. She required two person maximum assistance with verbal cues to maintain toe touch weight bearing status. The Care Plan for Falls, dated 11/20/19, documented the resident was a fall risk and needed one to two-person assistance with transfers and staff were to encourage the resident to use the call light. Additional update added on 11/26/19, documented the resident was not to be left alone in the bathroom. The Progress Note, on 11/30/2019 at 20:55 PM documented the nurse was in the dining room when a nurse aide said that a resident fell off the toilet and was bleeding. The staff found the resident on the bathroom floor, face down, bleeding from her nose and had a large sized hematoma on her crooked nose. She was sent to the hospital per ambulance and found to have a fractured nose. The Fall Investigation, dated 11/29/19, documented the resident was sitting on the toilet and the nurse aide left the bathroom and went to get help. The resident tried to reposition herself reaching for the unlocked wheelchair and was found lying face down. Her nose was crooked with a large amount of blood coming from her nose. There was a large hematoma on the bridge of her nose with throbbing pain, rated at a five on a scale of 1-10 . With one being no pain and 10 being the worse pain ever felt. On 12/17/19 at 10:42 AM, R1 was in bed in her room. She stated she did not remember what caused the fall when she broke her nose. She knew she went to the hospital, had an x-ray, and they found a broken nose. The resident remembered there was a lot of blood. On 12/17/19 at 12:10 PM, Certified Nurse Aide (CNA) M entered the resident's room, transferred her from the bed to the wheelchair with use of a gait belt, and took the resident into the bathroom. Nurse Aide N came into the room and they both assisted the resident onto the toilet. Staff stayed with the resident until she finished and assisted her back into her wheelchair. On 12/27/19 at 01:20 PM, CNA M stated the resident care was always to have one person with her while on the toilet. On 12/18/19 at 10:20 am, CNA O, I was in with the resident the morning she fell , she had pushed her call light to use the bathroom, I went to get help to reposition her as she was sitting crooked on the toilet and not wanting to move her by myself with her given hip issues. I heard a noise as I was reaching her room doorway, when I got back into the bathroom, the resident was laying on the floor, face down, in a pile of blood. I then went to get help. On 12/18/19 at 12:10 PM, Administrative Nurse D reported that it was her expectation that all staff were to follow the plan of care. The facility failed to follow the care planned interventions for fall preventions, of not leaving the resident alone in the bathroom. R1 fell when left unattended in the bathroom and sustained a fractured nose.

The facility reported a census of 44 residents. The sample included 13 residents with 2 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a functioning bed and planned interventions to keep 1 (#15) of the 2 sampled residents, as safe as possible, to prevent repeated falls. Resident #15's bed malfunctioned, and the facility failed to change that bed for a bed that would lower, to prevent falls. The resident fell from the bed and sustained a fracture of his/her tibia and fibula (the bones of the lower leg). Findings included: - The signed physician order [REDACTED].#15, documented the resident admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 4/10/19, documented the resident had a BIMS (brief interview for mental status) score of 2, indicating he/she had severely impaired cognition. The resident required total assistance with bed mobility. The resident was 64 inches tall and weighed 228 pounds. He/she had no falls since the previous MDS assessment. The falls CAA (care area assessment), dated 4/23/19, documented the resident was on hospice services after hospitalized from [DATE] to 3/9/19, for [MEDICAL CONDITION]. The falls care plan, dated 12/8/18, directed staff to keep personal items within reach at all times. Hi/lo bed would be kept in the low position with a fall mat next to his/her bed (door side of the room). On 3/14/19 the resident fell and staff would request a bolstered cover for the resident's air mattress from hospice. The care plan lacked interventions after the resident fell on [DATE]. Review of the nurse's notes, dated 6/18/19, documented this as a late entry for 6/13/19, evidenced night shift nursing staff reported the resident's bed remote controls failed to function. The bed remained in a raised position and would not lower. Licensed nursing staff K notified maintenance staff G later in the day regarding the broken bed. Maintenance staff reported the resident would have to be out of the bed for a repair, and the repair of the bed would not be a simple fix. Nurse's notes, on 6/14/19 at 4:05 am, revealed the resident fell . The resident attempted to get out of his/her bed to toilet. The resident complained of pain to his/her left leg. Staff completed an physical assessment and documented the resident lacked signs of left lower leg extremity injury. The resident had a hematoma (collection of blood trapped in the tissues of the skin, resulting from trauma) to his/her right shin. Staff notified the durable power of attorney, and he/she opted to wait on X-rays and follow-up later. On 6/15/19, the resident continued to complain of 7 out of 10 pain (pain scale of 1 at minimal pain and 10 at severe pain) and yelled out with cares. The bed did not go very low when the bed was at the lowest position. Staff contacted hospice services about a possible different bed. On 6/16/19, the resident screamed in pain when staff moved his/her left leg and the physician ordered X-rays due to the increased pain. On 6/17/19, orders were obtained to transfer the resident to the hospital for evaluation. The resident returned on 6/18/19 with a [MEDICAL CONDITION] tibia and fibula. Nurse's notes, on 6/14/19 at 6:52 pm, after the fall staff replaced the resident's broken bed, however the new bed did not adjust to a low position. Nurse's notes, on 6/18/19, staff requested a second fall mat for the fall intervention. In addition, on 6/24/19, documentation revealed the intervention for the fall included bolster parameters on the resident's bed, however, when staff contacted hospice for the bolster parameters, they were unavailable. Review of the facility fall investigation, dated 6/21/19, revealed the facility was aware of the resident's broken bed controls, and the bed was stuck in a moderately elevated position at the time of the resident's fall. Review of the notarized witness statement, dated 6/18/19, of maintenance staff G, revealed the resident's hand pendant malfunctioned, and he/she did not have the parts to repair the bed, and would have to order parts from the manufacturer, the licensed nursing staff would have to order another bed for the resident. On 6/18/19 at 12:28 pm, the resident was in his/her bed. The resident's mattress height was approximately 3 feet high from the floor level. The resident had one fall mat next to the bed, closest to the resident's window, however, the care plan documented the resident's fall mat should be on the side by the door. The resident's phone was located on his/her bedside drawer, approximately 5 feet from the resident, out of his/her reach. On 6/18/19 at 3:15 pm, the resident remained in his/her bed. The resident's bed and fall mat remained unchanged. On 6/19/19 at 8:00 am, the resident was in his/her bed, with no change in the height of the bed. Two fall mats were at the bedside, one on each side of the bed. The resident's phone remained out of his/her reach. On 6/25/19 at 9:20 am, the resident was in his/her bed, and the resident's mattress remained elevated at approximately 3 feet from the floor. One fall mat, closest to the window, was 3/4 under the resident's bed, and one fall mat leaned against the resident's wall. On 6/25/19 at 12:39 pm, direct care staff V and direct care staff L, transferred the resident from his/her wheelchair to the resident's bed. The resident complained of leg discomfort when staff provided cares. On 6/19/19 at 2:26 pm, direct care staff M, identified he/she worked on 6/13/19, and reported the resident's bed control malfunctioned and the bed was stuck in a high position. On 6/24/19 at 12:24 pm, licensed nursing staff I, reported the resident had a history of [REDACTED]. He/she verified the resident was not in a hi/lo bed, and the bed was not in a low position, as care planned. On 6/24/19 at 12:55 pm, direct care staff L, reported staff had not transferred the resident from his/her bed since the resident fell and broke his/her leg. Since the resident's fall, staff replaced the broken bed. Direct care staff L verified the resident used his/her phone, but the phone was out of the resident's reach. Various telephone attempts were made to contact staff members identified present at the time of the resident's fall and surveyor was unable to visit with the staff members, however, the notarized witness statements revealed the following: 1.) Direct care staff O, reported on 6/14/19 at approximately 12:45 am, he/she heard the resident yelling for help, and the resident fell out of his/her bed, onto the floor. 2.) Licensed nursing staff K, identified night shift staff reported the resident's bed controls brok on 6/13/19. The bed was stuck, and staff were unable to change the resident's bed position. Later in the day he/she notified maintenance staff regarding the broken bed controls and was told that the repair would not be easy to fix. Another bed was unavailable at that time and would not be available until the following day. 3.) Licensed nursing staff P identified the resident fell from his/her bed, on 6/14/19 at approximately 12:45 am. The resident attempted to use the toilet by him/herself, however, the resident required a total body lift for transfers. He/she was aware of the resident's broken bed controls. On 6/25/19 at 9:11 am, administrative nursing staff B, reported the resident's previous bed was stuck in an elevated position when the resident fell out of the bed. After the fall, staff placed the resident on a mattress directly on the floor, until a different bed was delivered the next day. Staff should have called a DME (durable medical equipment) company and staff should have replaced the bed immediately. He/she verified the resident's current bed was not a hi/lo bed and verified the bed's lowest position was approximately 3 feet from the floor. Staff should have moved the resident's mattress to the floor until the resident's bed could have been replaced, for the resident's safety. He/she reported one of the resident's fall interventions was to have a bolsters on the sides of the resident's mattress as a parameter for the bed, and was unaware the resident's bed lacked the bolsters. He/she verified the current bed lacked the bolsters for bed parameters. In addition, administrative nursing staff B verified staff failed to properly place the resident's fall mats on each side of the bed. The facility's policy for accidents and incident reporting and investigating, dated 3/1/18, documented when an accident or incident occurred, implementation of any corrective action would be completed, and would be reviewed by the safety committee related to the accident or safety hazard and would analyze any individual resident vulnerabilities. The facility failed to ensure the resident's bed functioned properly, and the planned interventions were in place to keep this resident, with repeated falls, as safe as possible. The resident fell from the higher broken bed and experienced a fracture to his/her left tibia and fibula.

The facility reported a census of 54 residents. The sample included 16 residents with 4 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices with safe ambulation for 1 (#65) sampled resident to prevent a fall, which resulted in a fractured arm and hip. Furthermore, the facility identified 31 residents as self mobile and confused. Based on observation and record review, the facility failed to maintain hazardous chemicals in a manner to prevent accidents for these 31 residents. Findings included: - Resident #65's POS (Physician order [REDACTED]. The quarterly MDS (Minimum Data Set), dated 11-14-16, documented the resident had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident had severe impairment in cognition. The resident had no functional limitation in ROM (range of motion) and used a walker for ambulation. The resident required limited assistance of 1 for ambulation. The resident had 1 non-injury fall since the prior assessment. The significant change MDS, dated [DATE], documented the resident had a BIMS score of 2, which indicated severe cognitive impairment. The resident had impairment in functional ROM on one side of the upper and lower extremities and used a wheelchair for locomotion. The resident did not walk in his/her room or corridor during the assessment period. The resident had a fall resulting in a fracture during the month prior to re-admission. Review of the fall assessment, dated 10-27-16, identified the resident was at risk for falls. The CAA (Care Area Assessment) for falls, dated 8-15-16, documented the resident had compromised balance, but was able to steady him/herself with assist from others. The care plan, dated 10-26-16, instructed staff to assist the resident to walk to dine with the use of a walker. The revised care plan, dated 1-17-17, instructed staff must transfer the resident with a gait belt (a device used to transfer people from one position to another, from one thing to another or while ambulating people that have problems with balance) at all times. Review of the facility's self-reported investigation, dated 1-30-17, revealed the resident had a fall in his/her room on 1-17-17. Agency direct care staff Q walked the resident to his/her room with the use of the resident's walker. Staff Q failed to use a gait belt. Upon arriving at the resident's room, staff Q left the resident, unattended at the entrance doorway to his/her room, entered the resident's room, opened the bathroom door and lifted the lid of the toilet. When staff Q turned around, he/she heard the resident fall to the floor, into the room. The facility sent the resident to the emergency room for evaluation. X-rays revealed the resident had a right humerus comminuted supracondylar fracture of the distal humerus (The more distant part of the long bone in the upper arm) with fracture line entering the intercondylar (notch of the femur) area and right forearm fracture noted at the elbow. The hospital admitted the resident and surgically repaired the fractures. On 2-09-17 at 9:45 a.m., direct care staff K and L transferred the resident from his/her wheelchair to the bed using the hoyer (full body) lift. Staff explained cares to the resident during the transfer. On 2-09-17 at 9:45 a.m., direct care staff K stated, the resident is now transferred with the Hoyer lift due to several fractures. The resident previously ambulated with the staff using a gait belt and his/her walker. Staff K stated all staff were to have a gait belt with them at all times. Staff also had a pocket care plan which described the care and assistance each resident required. Staff were given these at the beginning of each shift so they know how to care for each resident. On 2-13-17 at 11:17 a.m., direct care staff M stated, he/she updated the pocket care plans each day. On 2-13-17 at 2:13 p.m., agency direct care staff J stated, he/she always had a report of the routine of each resident and what each resident required. He/she would be given a pocket care plan which explained what each resident's needs were and what level of care was required. 2-13-17 at 3:30 p.m., agency direct care staff Q stated, he/she had walked with the resident back to his/her room on the day of the fall. Staff Q stated he/she could not remember if he/she had used a gait belt with the resident. Staff Q stated he/she left the resident standing at the doorway of the bedroom door with his/her walker while he/she opened the bathroom door and lifted the lid of the toilet. When staff Q turned around, he/she heard the resident fall to the floor. On 2-14-17 at 2:26 p.m., therapy staff V stated, the resident received therapy before the fall. Staff were to use a gait belt and his/her walker when ambulating with the resident. He/she was not to be left alone without a staff member. On 2-14-17 at 3:13 p.m., direct care staff W stated, staff were to have gait belts with them when walking with residents. On 2-13-17 at 10:57 a.m., licensed nursing staff H stated, staff Q stated he/she had a gait belt at the beginning of the shift. At the time of the fall, the resident was able to walk with limited assistance with his/her walker and the use of a gait belt. The facility sent the resident to the hospital following his/her fall for evaluation and treatment of [REDACTED]. On 2-13-17 at 12:41 p.m., administrative nursing staff C stated agency direct care staff Q should not have walked the resident without a gait belt and should not have left the resident unattended in the doorway of the room. On 2-15-17 at 2:07 p.m., the resident's physician BB, nurse AA, stated the physician was aware of the injuries and stated physician BB had no comment regarding the fall in the facility or if a gait belt could have prevented the fall with injury. The facility policy for fall investigation and management, revised 4-28-10, included: It is the policy of the facility to investigate each fall to ensure that risk from falls is decreased for the individual resident and is used to improve the overall performance according to current standards of practice and in conjunction with state and federal guidelines. The facility failed to provide supervision and assistive devices (gait belt) with ambulation for this cognitively impaired dependent resident. Staff failed to use a gait belt during ambulation and the resident fell when left unattended, standing in his/her room doorway. The resident sustained [REDACTED]. - Observation revealed, on 2/8/17 at 3:11 pm, a one quart bottle of no burn fabric fire protection, on the hand rail in the hallway of the 100 hall. The label on the bottle documented to keep out of reach of children. On 2/8/17 at 3:31 pm,maintenance staff E, verified the chemical was left in the hallway unattended, and should not have been left where a resident could get the chemical. On 2/9/17 at 4:30 pm, administrative staff A, verified the staff should not have leave chemicals out where confused residents have access to them. On 1/13/17 at 12:00 pm, consultant staff B, reported the facility had 31 confused and self- mobile residents. The facility's policy for chemical safety, dated 3/1/11, included documentation of chemical storage would be conducted in a manner to reduce risk of personal exposure, and included appropriate security of storage location. The facility failed to ensure hazardous chemicals not accessible to these 31 confused, self-mobile residents.

The facility reported a census of 62 residents, with 3 residents selected for sample review of medication error. Based on observation, interview, and record review the facility failed to ensure 1 resident (#1) of the 3 reviewed, received only necessary medications, of the correct dose. Furthermore, as a result of the resident receiving too much medication the resident suffered a decline in cognitive and physical ability. Findings included: - The facility admitted resident #1 on 8/20/16, with a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. An admission MDS (Minimum Data Set), dated 8/20/16, included the staff assessed the resident with long and short term memory impairment and severely impaired of decision making. The assessment further indicated the resident with a [DIAGNOSES REDACTED]. A quarterly Minimum Data Set, dated dated [DATE], lacked a Brief Interview for Mental Status assessment, and included the resident needed extensive assistance of staff for most ADL's (activities of daily living) with aphasia (condition with disordered or absent language function) and seizure disorder documented. A Care Area Assessment for cognition, dated 8/29/16, included the resident with a [DIAGNOSES REDACTED]. The care plan, dated 8/22/16, lacked inclusion of the intervention to monitor the resident's Keppra level, or any interventions related to the resident's [DIAGNOSES REDACTED]. Review of nursing notes, from 10/1/16 to current included the following: On 10/5/16 at 2:25 PM -- Resident receiving PT/OT/ST (physical, occupational, and speech therapy) for transfers, ambulation, ADL's, ROM (range of motion), strengthening, and speech; required assist with ADL's, and ambulated with assistance of 1 staff using a gait belt and a walker, was easily distracted and required prompting with staying focused on the task being performed, goes to the dining room for meals, and was cooperative with therapies and staff. On 10/23/16 at 2:15 AM - Resident cooperative and alert this PM, confused as per baseline, unable to state name or place. On 10/24/16 at 4:00 PM - The staff faxed the physician the resident was unable to swallow the medication whole and requested to have a liquid Keppra ordered. On 10/26/16 at 1:18 PM - The physician wrote an order for [REDACTED]. On 10/31/16 at 1:42 PM - The resident was capable of ambulating 120 feet, using a FWW (front wheeled walker) and CGA (contact guard assist). The resident required a maximum amount of cueing and directions to keep moving, with constant reminders to pick up his/her feet while walking, as he/she tended to drag the right foot. The resident was very resistive due to the current level of cognition, but displayed an adequate amount of ROM to all extremities. On 11/10/16 at 11:46 AM - Telephone order received to decrease the Keppra and ordered a laboratory level of Keppra. On 11/11/16 at 1:23 PM -- A telephone order from the resident's neurologist, returned the resident to the prior dosage of 500 mg (5 ml) of Keppra in the AM, and 1000 mg (10 ml) of Keppra at HS. On 11/11/16 at 2:30 PM -- Keppra level lab results received and faxed to the neurologist. On 11/14/16 at 2:41 PM -- The resident ambulated about 160 feet, using a front wheeled walker and contact guard assistance of staff. Most days, the resident required 2 person assist with standing up, as he/she did not follow direction and was very resistive. Review of the MAR's (medication administration records) identified the facility staff administered the resident the Keppra medications as ordered by the primary care physician, which included: October 2016: Keppra, 1000 mg, once daily, tablet at HS, by mouth, for convulsions, ordered 8/19/16; staff administered 10/1/16 to 10/25/16. Keppra, 500 mg, once daily, tablet in AM, by mouth, for convulsions, ordered 8/19/16; staff administered 10/1/16 to 10/26/16. Keppra Oral Solution, 100 mg/ml (20.5 ml), two times daily, starting on 10/26/16, for epilepsy; staff administered 10/26/16 (HS) to 10/31/16. November 2016: Keppra Oral Solution, 100 mg/ml (20.5 ml), two times daily, starting on 10/26/16, for epilepsy; staff administered 11/1/16 to 11/11/16 (AM). Keppra Oral Solution, 100 mg/ml (5 ml) orally daily starting 11/11/16, for seizures; staff administered 11/12/16 to 11/28/16 (except when noted out of the building). Keppra Oral Solution, 100 mg/ml (10 ml) orally once daily, starting 11/11/16, for seizures; staff administered 11/11/16 to 11/28/16 (except when out of the building). A review of a 60 day plan of correction notice, dated 11/29/16, by the facility included the facility staff failed to verify a medication order, which was incomplete. The bottle of liquid Keppra, failed to identify how many milligrams of medication per milliliter of liquid, the staff should administer to the resident. The medication was given to the resident and at one point staff noted the resident acted inappropriately. At that time, further assessments were done and discovered the problem was with the dosage of the Keppra medication the resident received. Failure to follow-up on the medication the resident received did endanger the resident. The plan of correction, continued to stress the importance of medication orders being specific and complete to avoid any adverse reactions or consequences to the resident. Review of the resident's laboratory results, lacked a Keppra (Levetiracetam) therapeutic level, prior to 11/10/16. The 11/10/16 Levetiracetam level tested at 130, with a therapeutic reference range of 12-46. This resulted in a flagged high range. The facility tested the resident on 11/18/16 after lowering the Keppra dose of medication on 11/11/16, and the Levetiracetam level dropped to therapeutic range of 38.5 (with 10-40 being specified as therapeutic.) Observation of the resident on 12/7/16 at 10:05 AM, identified the resident awakened for a brief period of time during a conversation with his/her spouse, however, did not make any type of acknowledgement of the visit. At 10:45 AM, the resident continued asleep in the chair. At 12:30 PM the resident sat in a wheel chair, propelled by the resident's spouse to the dining room, with his/her eyes open, not making any eye contact or acknowledgement. At 1:30 PM, the resident continued in the wheelchair, talking with his/her spouse, looking out the window. At 3:00 PM, the resident sat in his/her recliner, with his/her spouse at chair side. The resident smiled and waved from his/her room. On 12/14/16 at 9:35 AM, the resident sat in the dining room in his/her wheelchair with his/her spouse seated with the resident. At 10:40 AM, the resident ambulated with assist of 2 staff members providing extensive assistance and cueing to the resident to ambulate. The spouse pushed the wheelchair behind the resident. On 12/7/16 at 10:05 AM, the resident's family member reported he/she was pleased with the residents (spouse's) care, and was aware the facility had received an incorrectly labeled bottle of medication for the resident. The family explained he/she reported to the facility of the resident behaving differently following the change in the medication and noted some additional bruising to the resident's skin. The spouse indicated the facility reported to the family of the pharmacy filling the prescription in the wrong dosage, but fortunately the change in the resident was only temporary and he/she was returning to his/her normal status. The spouse was unaware how long the change in the resident's behavior occurred. 12/7/16 at 10:30 AM, direct care staff I reported he/she worked at the facility as a medication aide. The staff reported the resident had taken Keppra for quite some time, and had begun having problems with swallowing the pills. Staff I talked to the nurses when the medication changed to a liquid form and reported the concern over the dose seeming like a large amount. The nurse replied the pharmacy and doctor figured the dose to be given and instructed the staff to give the medication. Sometime later, staff I again asked about the dose and the nurse checked this time, as the resident began acting differently, concurred and checked with the doctor who reported it was too much medicine. Staff I reported the resident did not walk like usual, did not perform ADL's as normal for the resident, and was not aware of any behavior charting occurring. On 12/7/16 at 10:40 AM, licensed nursing staff E reported that any medication staff reported a changed dose of medication that seemed too high or low, would indicate the nursing staff needed to double check the order. If the licensed staff suspected an error in the order, then that nurse would notify the physician of the need for a clarification. If the doctor indicated the medication in fact, had a discrepancy, then the pharmacy would be notified and the MAR indicated [REDACTED] On 12/7/16 at 3:50 PM, licensed nursing staff F reported he/she took the order from the physician. The staff reported they were not that familiar with Keppra and did not question the order, simply noted the order; put it into the computer for the update of orders and MARs. The staff reported a triple check should have been completed then, however, review of the order identified staff F actually completed the triple check of the order his/her self, without the next shift having the opportunity to complete the review. Direct care staff G, reported on 12/14/16 at 12:56 PM, the resident did change from being cooperative and alert, to more confused, resistant to care and sleeping most of the time. The staff reported they were unclear as to the time frames of this medication problem. On 12/14/16 at 1:50 PM, administrative nursing staff B verified the resident began changing after several days of the increased dose of Keppra. At the time, the staff were not aware of what caused the change, however, had since realized it was due to the increased Keppra. Staff B further verified the medication was increased on 10/26/16 and the error was not found until 11/11/16. Staff B verified the facility triple check of medication orders failed to identify the error in dosage and strength of the medication administered. On 12/14/16 at 2:05 PM, licensed nursing staff D reported the pharmacist made a recommendation to change the resident's Keppra to liquid due to the resident's inability to swallow the pills. The staff notified the PCP (primary care physician) of the need to change the form of the medication. The PCP responded with an order for [REDACTED]. Staff D notified administrative nursing staff K of the change in the resident, and thought the issue would be followed through. On 12/14/16 at 2:55 PM, consultant staff H reported the error in the medication appeared to be a combined error of the facility staff F and H, who accepted an order from the physician without a strength of the dose in milliliter to the milligrams and the pharmacy filled the medication, without the correct information. Additionally, the facility staff then administered the liquid medication without the correct strength and quantity to be dispensed. On 12/15/16 at 8:05 AM, consultant staff J, verified the physician mistakenly ordered the 20.5 ml of Keppra twice daily for the resident (an equivalent intake of 4100 mg per day). The facility policy, dated 4/30/10, for Medication Orders, directed staff to identify the dosage - including the amount of the drug and the strength, when and how often. The facility failed to ensure the resident received the correct dose of a prescribed medication from 10/26/16 to 11/11/16, when the facility staff failed to clarify an order taken by telephone. The resident experienced a decline in his/her cognition and physical ability during the time from 10/26/16 to 11/11/16 when the resident received Keppra, 20.5 ml twice daily, (an equivalent intake of 4100 mg per day) instead of the correctly ordered dose of 5 ml in the AM and 10 ml at HS (an equivalent intake of 1500 mg per day.)

The facility identified a census of 53 residents. The sample included 24 residents, including 1 resident reviewed for pain and 2 residents reviewed for non-pressure related skin conditions. Based on observation, interview and record review, the facility failed to adequately treat pain for the 1 resident (#23) and failed to assess, treat and monitor a skin tear for 1 of the two residents reviewed for skin concerns. (#40) Findings included: - Resident #23's POS (physician order [REDACTED]. The annual MDS (minimum data set), dated 7-7-15, identified the resident with moderately impaired cognition. The resident was able to make self understood and had clear speech. The resident had physical and verbal behavioral symptoms directed toward others which occurred 1-3 days of the assessment period. The resident's current behavior status was worse than the previous assessment. The resident required total dependence of two for bed mobility, transfers, toilet use, dressing and personal hygiene. The pain assessment revealed the resident did not report any pain. Scheduled pain medications were given, but no as needed pain medications or non-medical pain interventions were used. No CAA for pain was available. The care plan, dated 7-22-15, documented the resident was totally dependent for all cares. He/she used a wheelchair for locomotion on and off of the unit. Staff were instructed to use a full body lift for transfers as the resident was not able to stabilize his/herself without staff assistance. The care plan documented the resident had chronic pai[DIAGNOSES REDACTED] and received a [MEDICATION NAME], 75 mcg (micrograms), every 3 days, for pain and Tylenol 1000 mg (milligrams), every 8 hours, as needed for pain (PRN). The POS documented a physician's orders [REDACTED]. Review of the June 2015 MAR (medication administration record), revealed the resident was not given any PRN medications. Review of the July 2015 MAR, revealed the resident received PRN Tylenol 1000 mg for complaints of pain on 7-2-15, 7-3-15, 7-12-15, 7-16-15, and 7-28-15. Staff documented on these dates that the PRN medication was effective. The pain assessments documented on the TAR revealed the resident had not had been having any pain. On 7-27-15 at 10:45 a.m., direct care staff Q requested the resident turn to face the wall so that they could change his/her brief. The resident stated, No, I can't and hit at the staff member with their fist. Staff Q continued to change the resident's brief and the resident continued to cry out with pain and hit at the staff member stating, You're hurting me. On 7-27-15 at 2:04 p.m., direct care staff P and Q were repositioning the resident. The resident stated, Ow repeatedly throughout repositioning and continuously pinched staff Q's arm. On 7-27-15 at 3:01 p.m., direct care staff P and Q were repositioning the resident. The resident cried out in pain stating, ow and stop it repeatedly and grimacing while being moved. On 7-28-15 at 2:52 p.m., direct care staff P and S, transferred the resident from his/her wheelchair to the bed using the hoyer lift. The resident cried out in pain during the transfer and while being positioned in bed. The resident stated, You're hurting me and Ow and had facial grimacing. On 7-29-15 at 7:03 a.m., licensed staff J, administrative nursing staff A and I were giving cares to the resident. While cares were being given, the resident cried out in pain and stated, Ow and You're hurting me multiple times during the cares. The resident also had facial grimacing and would moan and groan. During an interview, on 7-29-15 at 11:10 a.m., direct care staff Q stated, the resident always says Ow and That hurts when cares are being delivered. It is one of the behaviors that the resident had. Staff Q stated he/she has not really considered that the resident may be in pain. On 7-29-15 at 11:39 a.m., direct care staff R stated, the resident always screams out and tells staff that they are hurting him/her. According to staff R, the resident cries out because his/her legs hurt. Staff R continued to state that staff have a hard time getting his/her legs pulled apart far enough, due to contractures, to get a pillow in between his/her knees. On 7-28-15 at 2:02 p.m., direct care staff O stated, the resident has a pain patch on his/her shoulder. The resident has had behaviors such as hitting and scratching the staff and will call them names while cares are given. The resident complained of hurting whenever staff move him/her. On 7-28-15 at 11:09 a.m., licensed nursing staff V stated, the resident has a pain patch that is worn at all times. Staff do not like to give the resident the PRN Tylenol because they do not want to go over the amount that he/she can have in a 24 hour period. Staff V continued to state that the resident always acts out while cares are given, trying to hit or pinch staff. Staff V stated it is part of the resident's behaviors. On 7-29-15 at 7:03 a.m., licensed nursing staff J stated, it is a typical behavior for the resident to say Ow. This is one of the behaviors he/she has. If staff touch him/her, he/she says Ow. The resident has a pain patch and also a PRN pain medication. On 7-29-15 at 1:09 p.m., administrative nursing staff A stated, that they believe the reason the resident was crying out was because he/she had pain when moved. On 7-29-15 at 9:47 a.m., consultant staff AA stated, he/she was not aware the resident was having increased pain and that it is the expectation for staff to give PRN pain medication when needed. The facility policy for pain, revised 5-3-10, documents it is the policy to ensure that every resident is adequately assessed for the presence of pain and that appropriate interventions are implemented to bring pain to an acceptable level. Non-verbal residents and residents with dementia should be assessed using the non-verbal residents assessment portion on the Pain Assessment. Staff shall be trained to observe residents for non-specific signs and symptoms that suggest the presence of pain, and report observations to charge nurse. The facility failed to adequately assess and treat this dependent resident's pain and deliver effective pain management. The resident cried out in pain anytime the staff had physical contact with the resident to provide cares. - Resident's #40's annual MDS (minimum data set) assessment, dated 8/28/14, identified the resident scored 3/15 on the Brief Interview for Mental Status, indicating severely impaired cognition, and needed extensive assist of 1-2 staff for ADL's (activities of daily living), including 2 for transfers, bed mobility, dressing, and toilet use; with use of a walker and a wheel chair for mobility, without any range of motion impairment or skin concerns. A quarterly MDS (minimum data set) assessment, dated 5/13/15, identified the resident unable to complete the Brief Interview for Mental Status and staff identified the resident with short term memory problems, long term memory intact and severely impaired of decision making skills. The assessment further identified the resident required total dependence of staff for ADL's including grooming, toileting, eating, transfers and bed mobility, without any range of motion impairment, needed a wheelchair for mobility, and lacked identification of any skin concerns. The resident's care plan, dated 5/20/15, instructed staff the resident required extensive assistance of staff for ADL's, and reminders to the resident not to pick at his/her skin, as it tore very easily. The care plan further instructed staff to inspect the resident's skin during showers and routine cares and to report abnormal findings to the charge nurse. Review of the resident's clinical record lacked evidence of monitoring and/or treatment, to a skin tear, noted with steri strips intact, to the resident's right forehand. Observation on 7/26/15 at 3:54 PM, identified a skin tear to the resident's right hand, approximately 3.5 centimeters, across the top of the resident's hand with steri strips in place. On 7/27/15 at 3:40 PM, direct care staff C and D, transferred the resident into the high backed wheelchair, using a 2 person transfer with the gait belt. Direct care staff C reported being unaware of how the skin tear occurred to the resident's hand and reported the resident required total assistance for all ADL's. On 7/28/15 at 7:44 AM, direct care staff E assisted the resident with arising cares. Observation identified the resident able to move their arms and legs in non-purposeful movements, with staff providing total care for the resident. At that time, the staff member reported being aware the resident had received a skin tear to the left upper arm, a while back, during showering, but was not aware of the newer skin tear to the resident's right hand. On 7/29/15 at 11:45 AM, licensed nursing staff F examined the residents right hand and confirmed the presence of an unreported and undocumented skin tear with steri strips in place. At that time, the charge nurse indicated staff are required to notify the physician of a wound, to obtain a treatment order, then continue to monitor, until the wound healed. The staff confirmed, following review of the resident's clinical record, this did not occur. On 7/28/15 at 5:12 PM, direct care staff G, reported the resident was totally dependent, of staff for all ADL's and reported the resident had very fragile skin, and did not know what happened to the resident's hand. Interview on 7/29/15 at 4:00 PM, with administrative nursing staff A, reported all nursing staff had received in-service and were expected to report all incidents for investigation and monitoring/treatment of [REDACTED]. The staff expressed a lack of knowledge of the residents skin tear. The facility policy for Reporting and Investigating Resident Accidents/Incidents, dated 4/29/10, included that accidents/incidents involving residents must be reported to the director of nursing services and to the administrator and must be thoroughly documented in the resident's medical record. The facility failed to monitor, obtain a treatment order, and assess the resident's wound to ensure adequate healing.