Every finding on record at Villa St Francis Catholic Care Center Inc

The facility identified a census of 136 residents. The facility identified 19 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use and further failed to ensure all oxygen cannulas and nebulizer masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 12/23/24 at 07:07 AM on the initial walk-through of the facility, Resident (R) 1's nebulizer mask laid directly on her dresser on a box next to her bed, and a rolled-up nasal cannula laid directly on the bedside table. On 12/24/24 at 07:18 AM, a tour through the laundry room revealed wet linens were left in the washer overnight. On 12/30/24 at 07:21 AM R1's nasal cannula laid over her oxygen canister next to her bed, unbagged. On 12/30/24 at 07:40 AM Certified Medication Aide (CMA) R obtained an unidentified residents' vital signs. CMA R did not sanitize the blood pressure cuff, pulse monitor, and oxygen saturation equipment before or after the resident's vital signs were obtained. On 12/30/24 at 02:32 PM, R39 was asleep in his electric wheelchair. R39's nasal tubing was thrown over the nightstand in his room and was not in a bag. On 12/31/24 at 08:09 AM, Licensed Nurse (LN) G stated nasal cannulas were stored in a bag when not in use and were changed weekly. LN G stated nebulizer masks were rinsed and laid on a paper towel, and then the mask was put into a bag. LN G stated blood pressure cuffs should be sanitized with wipes before the cuff after each resident's use. On 12/31/24 at 08:41 AM, Housekeeping Supervisor U stated the evening shift would wash a load of linens each evening before they would leave, and this practice helped the laundry department. She stated damp laundry could not be left in the dryer, but it could be left overnight in the washer. On 12/31/24 at 10:01 AM, Administrative Nurse D stated the blood pressure cuff and shared resident equipment should be sanitized after staff used it on a resident. He stated nasal cannulas, if not in use, are placed in a bag. Administrative Nurse D stated nebulizer bulbs and masks were to be rinsed and laid to dry before being bagged. The facility's Infection Control policy dated 11/01/24 documented that the facility will facilitate safe care of all residents and staff with known or suspected communicable diseases by establishing and maintaining an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transition of communicable diseases and infections. The policy applies to all staff members from all departments of this facility, including direct and indirect care staff, contracted staff, consultants, volunteers, and others who provide care and services to residents on behalf of the facility. The facility failed to ensure shared equipment was sanitized after each resident's use and further failed to ensure respiratory equipment was stored in a sanitary manner. These deficient practices placed the residents at risk for infection.

The facility identified a census of 136 residents. The sample included 27 residents with four reviewed for pressure ulcers (localized injury to the skin or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 66's low air-loss mattress was set to the appropriate weight settings for pressure reduction. This deficient practice placed R66 at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R66's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, dysphagia (difficulty swallowing), and type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R66's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS noted bilateral lower extremity impairment. The MDS indicated R66 used a wheelchair for mobility. The MDS indicated R66 required substantial to maximal assistance with bed mobility, transfers, bathing, personal hygiene, dressing, and toileting. The MDS noted R66 was at risk for developing pressure injuries. The MDS indicated R66 weighed 202 pounds (lbs.). The MDS indicated R66 was placed on hospice services. R66's Pressure Injuries Care Area Assessment (CAA) completed 12/10/24 indicated he was at increased risk for pressure ulcers related to his history of incontinence weakness, and immobility. The CAA noted he started hospice services on 11/18/24 due to his cognitive decline and a care plan would be implemented to minimize the risks. R66's Care Plan initiated on 01/07/22 indicated he was at risk for alterations in skin integrity related to his medical diagnoses. The plan noted R66 required extensive assistance from staff for his Activities of Daily Living (ADLs). The plan instructed staff to complete skin inspections during his ADLs. The plan instructed staff to keep R66's linen clean, dry, and wrinkle-free. The plan instructed staff to educate him not to sit for prolonged periods in his wheelchair. The plan instructed staff to offload R66's heels while in bed. R66's EMR under Physician's Orders instructed staff to ensure R66's air mattress was set to his current weight each shift. The order instructed staff to ensure the power unit was on and working. The order instructed staff to ensure the mattress was not set to static. R66's EMR under Vitals noted he weighed 195.9 lbs. on 12/24/24. A review of the low air-loss mattress manufacturer's operation guide (Drive Model 14530) indicated the pump and mattress were intended to reduce the incidence of pressure ulcers while optimizing comfort. The guide indicated that firmness can be adjusted based on the recommendations of the health care professional and the patient's weight. On 12/23/24 at 07:05 AM R66 rested in his bed. R66's low air-loss mattress control panel was set to 350 lbs. (maximum weight setting). The Drive low air-loss mattress system range was between 50-350 lbs. adjustable weight increments. The panel indicated the mattress was set to the static setting. On 12/23/24 at 12:45 PM, R66 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in his room. R66's low air-loss mattress panel was still set to 350 lbs. R66 stated he was not sure about the weight settings or if staff asked him if he wanted it adjusted. On 12/24/24 at 09:54 AM an inspection of R66's low air-loss mattress revealed it was set between 125 lbs. and 150 lbs. On 12/31/24 at 10:02 AM Certified Nurse's Aide (CNA) O stated the low air-loss mattresses should be set to the closest weight setting and staff should check on them each shift. On 12/31/24 at 08:30 AM Licensed Nurse (LN) G stated the air mattresses should be set per the resident's current weight. She stated the mattresses should not be too firm or too soft to be effective at preventing skin injuries. On 12/31/24 at 10:05 AM Administrative Nurse D stated staff were expected to set the pumps per the resident's current weight. The facility's Pressure Ulcer Prevention policy revised 11/2024 indicated the facility will implement preventative interventions to minimize the risk associated with skin breakdown and pressure injuries. The policy noted the facility will utilize pressure redistribution surfaces deemed appropriate based on the resident's risk factors and care needs. The facility's Low Air Loss Mattress policy dated 11/2024 indicated the facility would ensure pressure settings were adjusted to match the resident's current weight as closely as possible. The policy indicated proper use of the air mattresses was essential to prevent pressure injuries and promote resident comfort. The facility failed to ensure R66's low air-loss mattress system was set to his appropriate weight. This deficient practice placed R66 at risk for complications related to skin breakdown and pressure ulcers.

The facility had a census of 136 residents. The sample included 27 residents, with five residents reviewed for accidents and, or hazards. Based on observation, record review, and interview, the facility failed to secure areas containing hazardous materials to keep them out of reach of 28 cognitively impaired, independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - On 12/23/24 at 07:10 AM, a walkthrough of the facility was completed with the following observation: An inspection of the 100-unit (secured unit for severely cognitively impaired residents) revealed unlocked closets in the sitting area of the left-side dining room. Both closets contained purple disinfectant wipe containers and tile cleaner spray bottles. All products contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, and harmful if swallowed. An inspection of the facility's HM -hallway revealed a spray bottle of window cleaner in the kitchenette sink. The spray bottle contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, and harmful if swallowed. An inspection of the facility's 600 and 700 hall's lift storage rooms revealed purple disinfectant wipes stored in the rooms. The room's doors were propped open. The wipe's containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, and harmful if swallowed. An inspection of the 600-hallway revealed an unlocked electrical panel room. An inspection of the room revealed boxed supplies of personal protective equipment (PPE) and eight large unlocked electrical panels. The panels contained the warning, high voltage - danger of electric shock. At 07:45 AM, Certified Nurse's Aide (CNA) P secured the door and stated all the rooms with potential hazards should remain locked. On 12/31/24 at 08:24 AM, CNA M stated chemicals and electrical rooms should be locked. CNA M stated cleaning materials should never be left out for residents to access. On 12/31/24 at 08:30 AM, Licensed Nurse (LN) G stated the residents should not have access to areas with potential hazards. On 12/31/24 at 10:05 AM, Administrative Nurse D stated staff should never leave potentially hazardous materials within reach or access to the residents. Staff were expected to lock all products and areas with potential hazards. The facility's Accidents policy revised 11/2024 documented the facility will ensure a safe environment for all residents. The policy indicated staff will assess each resident's potential risks, including functional abilities, potential falls, assistive devices, and environment, to ensure resident safety. The facility failed to secure rooms containing hazardous materials out of reach of 28 cognitively impaired, independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents.

The facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to provide services in a dignified manner for Resident (R) 1 when staff stood over R1 while feeding her a pudding cup. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial well-being. Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent feelings of sadness), aphasia (condition with disordered or absent language function), respiratory failure ( not enough oxygen passes from your lungs to your blood), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R1 should not have an interview for mental status, as she was rarely understood. The MDS documented R1 was dependent on staff for oral hygiene, toileting, dressing, eating, and showers. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/28/24 documented R1 had alterations in her activities of daily living (ADL) function related to a diagnosis of cerebral palsy, and R1 was dependent on staff for ADLs. R1 used nonverbal cues, and staff anticipated R1's needs. R1's Care Plan dated 05/27/21 documented R1 needed assistance with eating. R1 required a pureed diet, with pudding thick fluids. R1's plan of care documented R1 was at nutritional risk due to cerebral palsy and dysphagia. R1's plan of care documented she was at risk for dehydration due to thickened liquids, she had a good appetite since admission and needed total assistance from staff for eating. On 12/30/24 at 01:12 PM R1 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room while Licensed Nurse (LN) H stood over R1 and fed her a pudding cup. On 12/31/24 at 08:09 AM LN G stated staff should always sit and be at eye level with the resident. LN G stated staff should be engaged with the resident in conversation, even if the resident cannot communicate. On 12/31/24 at 08:22 AM Certified Nurse Aide (CNA) M stated staff should always sit next to the resident and never stand over the resident while helping the resident eat or drink. On 12/31/24 at 10:01 AM, Administrative Nurse D stated all staff members should sit next to the resident when they helped any resident with eating. The facility's Dignity policy dated 11/01/22 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall always be treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed hairstyles, nails, facial hair, etc.). Residents shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns. The facility failed to ensure R1's dignity when staff stood while feeding R1 a pudding cup. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial well-being.

The facility identified a census of 136 residents. The sample included 27 residents. Three residents were sampled for reasonable accommodations of resident needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 16's call light was within her reach. This deficient practice left R16 vulnerable to unmet care needs due to the inability to call for staff assistance. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), cardiac arrhythmia (a condition where the heart beats abnormally), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented a mental status interview should not be conducted as R16 was rarely or never understood. The MDS documented R16 was dependent on staff for toileting, bathing, dressing, and eating. The Cognitive Loss/Dementia (CAA) dated 02/19/24 documented R16 was at risk for cognition decline due to her diagnosis of Alzheimer's disease. The Urinary Incontinence and Indwelling Catheter CAA dated 02/19/24 documented R16 was started on a toileting diary on admission, and a toileting pattern was not noted. R16 required staff assistance for toileting. R16's Care Plan dated 02/14/22 documented R16 was at risk for falls due to confusion and poor safety awareness. She was impulsive and tried to do for herself when she was unable. Staff were to ensure R16's call light was within her reach and anticipate her needs such as toileting and snacks. On 12/23/24 at 07:27 AM, R16 laid on her bed, her call light was dangling off the bed on the floor, and R16's call light was not within her reach. On 12/30/24 at 08:02 AM R16 laid in her bed, R16's call light was clipped to the room dividing curtain, and R16's call light was not within her reach. On 12/31/24 at 08:09 AM Licensed Nurse (LN) G stated call lights should be within the resident's reach. On 12/31/24 at 08:22 AM, Certified Nurse's Aide (CNA) M stated residents' call lights should be pinned to the resident or be within their reach. On 12/31/24 at 10:01 AM Administrative Nurse D stated the resident's call light was to be placed within the resident's reach. The facility's Accommodation of Needs policy dated 11/01/24 documented each elder has a right to reside and receive services at this facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the elder or other elders would be endangered. The facility maintains a safe, functional environment for all elders residing in the facility. Interior spaces meet the needs of each elder and the elder population in its entirety for safety and suitability for the care, treatment, and services provided. It is understood that interior spaces contain necessary equipment and therapeutic activities required to accomplish each eider's goals, but the environment will be arranged and maintained in a way that does not compromise the safety of the environment and will not detract from the environment of home provided by the facility. The facility failed to ensure R16's call light was within her reach. This deficient practice left R16 vulnerable to unmet care needs due to the inability to call for staff assistance.

The facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Centers for Medicare and Medicaid Services (CMS) form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form was provided to Resident (R) 117. This placed R117 at risk of uninformed treatment decisions and unexpected costs. Findings included: - A review of R117's Electronic Medical Record (EMR) documented that her Medicare Part A episode began on 10/01/24 and ended on 10/09/24. R117 remained in the facility for custodial care. R117 was provided the CMS form-10123 Notice of Medicare Non-Coverage (NOMNC) on 10/07/24. R117 was not issued the SNF ABN, form CMS-10055 as required. On 12/31/24 at 10:29 AM Social Services X stated she had been issuing the ABNs except for residents on managed care as their insurance directed the care and would send the documents. Social Services X stated to her understanding, the ABN was not made mandatory until after 10/31/24. The Medicare Denial Notices (Advance Benefit Notification- ABN) policy dated 11/01/24 documented: The SNF ABN would be issued to the resident or representative by the facility staff in the following situations- In the situation the facility believed Medicare would not pay for extended care items or services that the physician had ordered, the facility would provide a SNF ABN to the resident or representative prior to furnishing the non-covered extended care items or services to the resident. In the situation in which the facility recommended a reduction to the resident's extended care items or services because other facility anticipated that Medicare would not pay for a subset of extended care items or services, or for any items or services at the current level and or frequency of care that a physician had ordered, the facility would provide a SNF ABN to the resident or representative prior to reducing the items or services to the resident. Or in the situation in which the facility proposed to stop furnishing all extended care items or services to the resident because the facility expected that Medicare would not continue to pay for items or services that the physician had ordered and the resident would like to continue receiving the care, the facility would provide a SNF ABN to the resident/representative prior to terminating extended care items or services. The facility failed to ensure a CMS-10055 SNF ABN form was provided to R117. This placed R117 at risk of uninformed treatment decisions and unexpected costs.

The facility identified a census of 136 residents. The sample included 27 residents with three residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 1 with grooming and failed to ensure R1's fingernails were cut short and kept clean. This deficient practice placed R1 at risk for impaired dignity, comfort, and further decline in ADL. Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent feelings of sadness), aphasia (condition with disordered or absent language function), respiratory failure ( not enough oxygen passes from your lungs to your blood), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R1 should not have an interview for mental status, as she was rarely understood. The MDS documented R1 was dependent on staff for oral hygiene, toileting, dressing, eating, and showers. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/28/24 documented R1 had alterations in her ADL function related to a diagnosis of cerebral palsy R1 was dependent on staff for ADLs. R1 used nonverbal cues and staff anticipated R1's needs. R1's Care Plan dated 05/27/21 documented R1 preferred to take a shower, on Tuesdays and Fridays during the day. R1's plan of care documented R1 required assistance with eating. R1 required a Hoyer (total body mechanical lift) lift assist of two staff with transfers. Staff were to keep R1's nails short, and to ensure her safety with hand movements. On 12/23/24 at 08:22 AM R1 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room, and staff assisted her with eating. R1's fingernails were not trimmed short and R1 had a dark substance under her nails. R1's hair appeared greasy and was uncombed. On 12/30/24 at 8:12 AM, R1 sat in the dining room while staff assisted her with eating breakfast. R1's fingernails were not trimmed and there was a dark substance under her fingernails. R1's hair was greasy and uncombed. On 12/31/24 at 08:09 AM Licensed Nurse (LN) G stated R1 got a bed bath twice a week. She stated staff should have looked at R1's fingernails to ensure they were clean and cut short. She stated R1's fingernails were kept short to ensure she was not scratching herself. LN G stated the resident's hair should have been washed when she needed it. On 12/31/24 at 08:22 AM Certified Nurse Aide (CNA) M stated she would talk to the nurse before cutting anyone's fingernails. She stated the charge nurse let her know if anyone needed their nails trimmed and she would trim them. CNA M stated she would give baths or showers if they were to be done on her shift. On 12/31/24 at 10:10 AM, Administrative Nurse D stated all nursing staff have access to the care plan and would know which residents required their fingernails to be trimmed short. All nursing staff should have monitored residents to ensure each resident's fingernails were kept clean. Administrative Nurse D stated CNAs fill out a shower sheet for each resident on his or her shower day. He stated this was also documented in the resident's EMR. The facility's ADLs policy dated 11/01/24 documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including: bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, and communication including using speech, language, or other functional communication systems specific to the needs of the individual resident. The facility failed to ensure staff assisted R1 with grooming and failed to ensure her fingernails were cut short and clean. This deficient practice placed R1 at risk for impaired dignity and further decline in ADLs.

The facility identified a census of 136 residents. The sample included 27 residents with five residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1's washcloth was applied to her hands. This deficient practice placed the resident at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings Included: - R1's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle weakness, dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hyperlipidemia (condition of elevated blood lipid levels), major depressive disorder (major mood disorder that causes persistent feelings of sadness), aphasia (condition with disordered or absent language function), respiratory failure ( not enough oxygen passes from your lungs to your blood), and insomnia (inability to sleep). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R1 should not have an interview for mental status, as she was rarely understood. The MDS documented R1 was dependent on staff for oral hygiene, toileting, dressing, eating, and showers. R1's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 05/28/24 for R1 had alterations in her activities of daily living (ADL) function related to a diagnosis of cerebral palsy. R1 was dependent on staff for ADLs. R1 used nonverbal cues and staff anticipated R1's needs. R1's Care Plan revised 09/02/24 documented R1 would have passive ROM to maintain her current level of ADL level without avoidable decline. R1's plan of care documented passive range of motion to the right wrist. R1's right wrist presented with contracture (abnormal permanent fixation of a joint or muscle). Staff were to apply a clean washcloth to R1's right hand to prevent contracture daily, the washcloth was acceptable to use in place of a splint. On 12/23/24 at 08:22 AM R1 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room, and staff assisted her with eating. R1 did not have a washcloth in her right hand. R1's right hand was closed tight. On 12/30/24 at 8:12 AM, R1 sat in the dining room staff assisted her with eating breakfast. R1 did not have a washcloth in her right hand. R1's hands were closed tight. On 12/31/24 at 08:09 AM Licensed Nurse (LN) G stated if a resident's care plan states there should be a washcloth in their hand for contracture, all nursing staff would be responsible for ensuring the washcloth was placed daily. LN G stated all nursing staff have access to a summary of care for each resident. She said she was unsure if the Certified Nurse Aide (CNA) had full access to the care plan. On 12/31/24 at 08:22 AM, CNA M stated she goes by what the charge nurse tells her to do, and the summary of the resident's care paper that was handed to her each morning. CNA M stated she did not know if she could see the full resident's care plan. On 12/31/24 at 10:01 AM, Administrative Nurse D said all nursing staff and CNAs can pull the full care plan up on their phones at any time. He stated each CNA was given a care summary every morning, but they do have access to the care plan. He stated the charge nurse was responsible for ensuring each resident received care as ordered. The facility's Range of Motion policy documented Based on the comprehensive assessment of an elder, facility staff will ensure that each elder who enters the facility without a limited range of motion does not experience a reduction in range of motion unless the elder's clinical condition demonstrates that a reduction in range of motion is unavoidable and an elder with a limited range of motion receives appropriate treatment and services to increase range of motion and, or to prevent further decrease in range of motion. Authorized personnel will use specific protocols when performing a range of motion exercises on elders. Elders of this facility will be provided care to prevent the formation and progression of contractures and deformities. Active and passive ROM exercises are therapeutic activities that are implemented by nursing order. The facility failed to ensure R1's washcloth was applied to her hands to treat her contracture. This deficient practice placed R1 at risk for discomfort and decreased ROM.

The facility identified a census of 136 residents. The sample included 27 residents, with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 66. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs. Findings included: - The Medical Diagnosis section within R66's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive-communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle weakness, dysphagia (difficulty swallowing), and type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R66's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS noted bilateral lower extremity impairment. The MDS indicated R66 used a wheelchair for mobility. The MDS indicated R66 required substantial to maximal assistance with bed mobility, transfers, bathing, personal hygiene, dressing, and toileting. The MDS indicated R66 was placed on hospice services. R66's Pressure Injuries Care Area Assessment (CAA) completed 12/10/24 indicated R66 was at increased risk for pressure ulcers related to his history of incontinence, weakness, and immobility. The CAA noted R66 started hospice services on 11/18/24 due to his cognitive decline, and a care plan would be implemented to minimize the risks. R66's Care Plan initiated on 01/07/22 indicated he was at risk for skin breakdown, falls, incontinence, and a decline of his Activities of Daily Living (ADLs) related to his medical diagnoses and cognitive decline. The plan noted R66 required assistance from staff for all transfers and his ADLs. The plan noted R66 began hospice services on 11/19/24 and instructed staff to encourage him to express his feelings and allow family support. The plan instructed staff to provide non-judgmental acceptance and compassion. The policy indicated equipment and medication will be provided by hospice per the admission agreement. The plan lacked documentation related to the staff and services provided by his assigned hospice. R66's EMR under Miscellaneous revealed his Hospice Admission form was completed on 11/18/24. The form indicated he was admitted to hospice for senile degeneration (age-related cognitive decline). The form indicated he was assigned a hospice nurse, social worker, and health aide but failed to indicate the date, time, and frequency of the hospice visits. The documentation indicated hospice would provide his low air-loss mattress, Broda chair (specialized wheelchair with the ability to tilt and recline), and incontinence products. The agreement failed to identify which medications the hospice provided. On 12/24/24 at 10:44 AM R66 sat in a Broda chair in his room. R66 stated he was put on hospice services and had no concerns with the care provided to him. On 12/31/24 at 08:12 AM Certified Nurse's Aide (CNA) M stated the care plan should include the services provided by hospice, medications, visit frequency, and equipment. On 12/31/24 at 08:25 AM Licensed Nurse (LN) G stated the facility's care plans should indicate the hospice selected, but she was not sure if the care plan identified staffing, equipment, and medications. She stated the hospice admission paperwork should show that information. On 12/31/24 at 10:05 AM Administrative Nurse D stated the facility holds frequent care plan meetings with hospice services to ensure each resident's hospice choices are reflected in the care plan. He stated the plan should notify staff of the hospice service information, equipment, medications, and staff services. He stated staff may also refer to the hospice admission agreement. He stated the agreement should show what service hospice provided and how often they were provided. The facility's Hospice Program policy 01/2023 indicated the facility will create a management program with contracted hospice services to provide quality care for terminally ill residents. The policy indicated the facility will ensure coordinated care planning with each resident, family, and hospice service. The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-provided services and medication for R66. This deficient practice placed both residents at risk for delayed services and uncommunicated care needs.

The facility identified a census of 118 residents. The sample included one resident reviewed for pressure-related injuries. Based on record review and interviews, the facility failed to ensure staff provided the appropriate level of assistance, as directed by Resident (R) 1's care plan, for bed mobility. This deficient practice placed R1 at risk for unwarranted physical complications. Findings included: - R1 admitted to the facility for respite care (short term health services to the dependent adult) on 07/12/23 and discharged home on 07/17/23. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with agitation. The Activities of Daily Living (ADL) Care Plan, dated 07/12/23, directed R1 needed assistance of two staff for bed mobility. The Notes tab of R1's EMR revealed a Hospice/Palliative/Terminal Prognosis Note on 07/17/23 at 01:36 PM that documented a new skin issue was reported to hospice case manager by the nurse. In a Witness Statement on 07/19/23, Certified Nurse Aide (CNA) M stated he took care of R1 overnight on 07/16/23 and he was told she required one person for cares but that was not the case. He stated he was not given a care plan on 07/15/23 and 07/16/23. CNA M stated he changed R1 regularly and repositioned her as well. On 07/27/23 at 01:29 PM, CNA N stated R1 required two people for bed mobility and when a resident was moved up in bed, they were lifted up instead of slid up in bed. She stated CNAs were required to carry a Kardex (CNA care plan) on them at all times. On 07/27/23 at 01:39 PM, Licensed Nurse (LN) G stated CNAs carried a Kardex on them at all times and the charge nurse was in charge of giving the CNAs the Kardex at the beginning of the shift. She stated R1 was a two person assist with bed mobility. On 07/27/23 at 02:10 PM, Administrative Nurse D stated R1 was a two person assist for bed mobility including changing and repositioning. He stated when CNAs showed up for work, they received report and any updates were added to the Kardex then the nurse printed the Kardex off for the CNAs. Administrative Nurse D stated CNAs were expected to follow the Kardex and have it with them at all times. On 07/28/23 at 11:57 AM, CNA M stated he was never informed that R1 was a two person assist with bed mobility. He stated he should have read the care plan and followed the care plan. CNA M stated the nurse usually printed the Kardex off and gave it to him. He stated he did not receive a Kardex on 07/15/23 and 07/16/23. He said he could have asked for it, but he did not think about it. He stated the nurse was with him one or two times for R1's repositioning but he repositioned her by himself about five times. The facility's Care Plan and Kardex Policy, not dated, directed the Kardex was printed by the charge nurse at the beginning of the shift and given to the CNAs. If a CNA was not given a Kardex, they looked up the Kardex for each individual resident. The facility's Bed Mobility Policy, not dated, directed staff always followed the resident's interim/comprehensive care plan schedule and positioning instructions. The facility failed to ensure staff provided the adequate level of assistance required by R1 for bed mobility. This deficient practice placed R1 at risk for unwarranted physical complications.

The facility had a census of 118 residents. The sample included 25 residents. Based on observation, interview, and record review, the facility failed to provide food prepared in puree form (to chop or grind into a thick paste), from a standardized recipe for eight residents who received pureed meals which placed the residents at risk to not receive essential nutrients. Findings included: - On 05/18/23 at 11:10 AM, observation revealed Dietary Staff (DS) CC prepared the noon meal of which one of the menu items consisted of zucchini. DS CC placed the zucchini, with the liquid it had been prepared with, into the facility's blender. DS CC initiated the blender, added tap hot water and a commercial thickening agent. The facility's Pureed Seasoned Zucchini recipe instructed to place prepared, drained, vegetables in food processer and blend until a smooth consistency. The recipe instructed to add prepared hot broth if product needed thinning. The recipe specifically directed not to use water. On 05/23/23 at 08:09 AM, DS BB verified DS CC had not followed the zucchini pureed recipe, by adding water, which changed the nutrient value. The facility's Food Preparation and Service policy, dated 03/13/23, documented food will be prepared and served in accordance with resident wishes and/or diets ordered. Diets may include but not limited to mechanically soft, puree, fortified foods, supplements, etc. The facility failed to follow pureed diet recipe which placed eight residents at risk to not receive essential nutrients from the facility's kitchen.

The facility had a census 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed store, prepare, and serve food, in a sanitary condition for residents who received meals from the facility kitchen, which placed them at risk for food borne illness. Findings included: - On [DATE] at 11:00 AM, during observation of the kitchen, Dietary Staff (DS) BB reported the main kitchen dishwasher had not been working since [DATE]. DS BB stated the repair required a part that had not been received. The kitchen was utilizing the three-compartment sink for washing cook and prep ware. The Hydrion Micro Essential sanitation test strip had an expiration date of [DATE]. DS BB reported she was not aware the testing strips had an expiration date. The facility's Sanitation policy, dated [DATE], documented manual washing and sanitizing will employ a three-step process for washing rinsing and sanitizing. Quaternary ammonium compound for time designated by the manufacturer. The facility failed to store, prepare, and serve food in a sanitary condition by using expired sanitation test strips which placed the residents at risk for food borne illness.

The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one resident, Resident (R) 69, when another resident urinated on her while in the dining room. This placed R69 at risk for impaired dignity and psychosocial wellbeing. Findings included: - The Electronic Medical Record (EMR) for R69 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), documented R69 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and extensive assistance of one staff for eating and personal hygiene. R69's Care PLan dated 05/03/23 documented R69 was at risk for altered mood related to depression and directed staff to monitor for agitation, and behaviors. The care plan directed staff to honor her interpersonal space, maintain a distance, do not crowd or touch her. The plan directed staff to always prepare R69 if staff were going to touch her, and report to the physician any changes in mental health status. The Nurse's Note, dated 02/26/23 at 07:10 AM, documented R69's colleague urinated on her at the common area in the dining room. The resident was cleaned up and taken away. The EMR lacked any follow-up related to the incident. On 05/22/23 at 03:35 PM, observation revealed R69 sat in her Broda chair (positioning chair), at the dining room table. On 05/18/23 at 01:00 PM, Certified Nurse Aide (CNA) O stated R69 had been urinated on when R69 was in bed but CNA O did not know about the incident in the dining room; CNA O stated it had happened more than once. On 05/18/23 at 01:30 PM, Administrative Nurse E stated she had not been made aware of the incident in the dining room butsaid she would investigate and talk with staff. At 03:00 PM, Administrative Nurse E stated the incident would be thoroughly investigated, reported, and the resident that urinated on R69 would be placed with staff 1:1. Administrative Nurse E further stated the physician and family were made aware and R69's family had not seen any changes in R69's mood or psychosocial well being. Administrative Nurse E said staff would be educated on reporting after any incidents. On 05/22/23 at 10:09 AM, Licensed Nurse (LN) K stated there had not been a change in R69's behaviors since the incident and there had not been any further incidents between the two residents. LN K further stated, if residents were in the dining room, a staff member was always present. On 05/22/23 at 03:16 PM, Social Services X stated she had contacted the physician and family regarding the incident and R69's family visited quite often and had not seen any changes in the resident's behavior or demeanor. On 05/23/23 at 10:11 AM, Administrative Nurse D stated he had reported the incident and staff were educated on reporting. Administrative Nurse D further stated the facility was taking precautions so this would not happen again. The Quality of Life-Accommodation of Needs policy, dated 03/28/23, documented the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and well-being. The facility failed to promote care in a manner to maintain and enhance dignity and respect for R69 when another resident urinated on her while in the dining room. This placed R69 at risk for impaired dignity and psychosocial wellbeing.

The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide a comfortable table height while dining for Resident (R) 65. This placed the resident at risk for discomfort and weight loss. Findings included: - The Electronic Medical Record (EMR) for R65 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, pain, and need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R65 had severely impaired cognition and required extensive assistance of two staff for transfers, extensive assistance of one staff for bed mobility, ambulation, dressing, and personal hygiene. The assessment documented R65 required supervision and set-up assistance for eating. The Care Plan, dated 04/21/23, documented R65 was at risk for self-care deficit and emotional well-being and directed staff to monitor for poor appetite, and used a pedal Broda chair (positioning chair) for mobility. On 05/17/23 at 12:14 PM, observation revealed R65 in her Broda chair at the dining room table. Further observation revealed the edge of the table was at [NAME] level of the resident. Continued observation revealed R65 took the top of the croissant (roll) with her fork and tried to eat it. On 05/18/23 at 12:12 PM, observation revealed R65 at the dining table. The table was at her shoulder level and she had to take the bowl of fruit off the table and hold it so she could eat it. On 05/22/23 at 12:01 PM, observation revealed R65 in her Broda chair at the dining table waiting for the noon meal. Further observation revealed the edge of the table was at the residents shoulder. On 05/22/23 at 12:13 PM, Licensed Nurse (LN) J stated that if staff sat R65 at a bedside table instead of a dining table,, it would isolate her. LN J was not sure if the dining tables could be lowered. On 05/23/23 at 10:44 AM, Administrative Nurse D stated the facility would look at the tables to see if they could be adjusted for R65 so she would be able to eat better and be more comfortable. The facility's Quality of Life-Accommodation of Needs policy, dated 03/28/23, documented the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The facility failed to ensure the dining room tables were are a comfortable height for R65. This placed the resident at risk for discomfort and weight loss.

The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility staff failed to report to administration a resident to resident incident for one sampled resident, Resident (R) 106, who urinated on another resident. This placed the residents at risk for unidentified abuse and/or ongoing mistreatment. Findings included: - The Electronic Medical Record (EMR) for R106 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set (MDS), dated [DATE], documented R106 had severely impaired cognition and required extensive assistance of one staff for bed mobility, toileting, dressing, personal hygiene, and required supervision and one staff for ambulation. The assessment further documented R106 had inattention, disorganized thinking and wandered daily. R106's Quarterly MDS, dated [DATE], documented R106 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The assessment further documented R106 had inattention, disorganized thinking, rejection of care one to three days, and other behavioral symptoms one to three days. R106 wandered daily, and his wandering significantly intruded on the privacy or activities of others. R106 received an antidepressant (medication used to treat depression) medication daily. The Admission Assessment, dated 12/22/21, documented R106 had a history of wandering and was anxious and restless. The Mood and Behavior Care Plan, dated 03/03/23, initiated on 12/22/21, documented R106 wandered around the special care unit and would go into other resident rooms at times. R106 would mimic the staff and follow them around. The update, dated 01/07/22, directed staff to give R106 time and space to ambulate and self sooth. R106 liked music and to sing. The update, dated 11/14/22, directed staff to give R106 items to fidget with, redirect as possible when wandered, and refer to the physician for review as needed. The update, dated 05/15/23, documented, when R106 declined cares, staff were to ensure he was safe and reapproach later or try other staff to approach. The Bowel and Bladder Care Plan, dated 03/03/23, initiated on 12/22/21, documented R106 often pulled at his brief as a warning he needed to void or that he felt wet from already voiding. When he was wandering and staff were unable to redirect to the bathroom, staff were to give R106 time and space, redirect back as able, and when R106 paced, it was a warning for the need to be toileted. The care plan directed staff to offer assistance with toileting/check and change upon rising, before and after meals, bedtime, at 01:00 AM, 03:00 AM, at 05:00 AM rounds and as needed. The Nurse's Note, dated 02/26/23 at 07:00 AM, documented R106 urinated on a fell ow resident in the dining room area. The note further documented R106 was seen walking around the dining room prior to him urinating on the resident. The note documented staff took the resident to the bathroom and talked to him about boundaries. On 05/18/23 at 08:30 AM, observation revealed R106 independently wandered in the dining room, singing. R106 approached the surveyor, and tapped the outside of the computer. On 05/18/23 at 01:00 PM, Certified Nurse Aide (CNA) O stated R106 had urinated on another resident when the other was in bed but CNA O did not know about the incident in the dining room on 02/26/23. CNA O stated it had happened more than once. On 05/18/23 at 01:30 PM, Administrative Nurse E stated she had not been made aware of the incident in the dining room on 02/26/23 but said she would investigate and talk with staff. At 03:00 PM, Administrative Nurse E stated the incident would be thoroughly investigated, reported, and R106 would be placed 1:1 with staff. Administrative Nurse E further stated the physician and family were made aware and staff would be educated on reporting after any incidents. On 05/22/23 at 10:09 AM, Licensed Nurse (LN) K stated, since R106 urinated on the other resident there had not been any further incidents between the two residents. LN K stated R106 had urinated on his roommates bed and on the floor of another resident's room. LN K further stated staff tried to redirect R106 but he could get agitated; staff kept trying. On 05/22/23 at 03:16 PM, Social Service X stated she had contacted the families involved and the physicians. Social Services X further stated she had also contacted the psychologist and he did visit with R106 and gave recommendations. On 05/23/23 at 09:51 AM, LN L stated staff were educated on reporting events and the staff in the Special Care Unit were provided with extra education on behaviors and dementia by outside sources and through computer training. On 05/23/23 at 10:11 AM, Administrative Nurse D stated he had reported the incident and staff were educated on reporting. Administrative Nurse D further stated, the facility was taking precautions so this would not happen again. On 05/23/23 at 11:11 AM, Administrative Staff A stated they have reeducated staff on reporting incidents and are utilizing a report from the computer that would be generated daily to see if there were any incidents or behaviors so they can make sure nothing like the incident with R106 would happen again. The facility Abuse Prevention Policy and Procedure dated 09/07/22, documented each resident had the right to be free from abuse and must not be subjected to abuse by anyone, including other residents. The policy further documented, mandated reporters are to immediately report to their onsite supervisor when they have reasonable cause to believe abuse has occurred. The Director of Nursing and/or administrator shall be immediately notified of all allegations of abuse and neglect. Any incidents of abuse or injuries of unknown origin and resident to resident altercations would be reported to the state. The facility staff failed to report a resident to resident incident to administration awhen R106 urinated on another resident. This placed the residents at risk for unidentified and ongoing abuse and mistreatment.

The facility had a census of 118 residents. The sample included 25 residents with two residents reviewed for range of motion difficulties. Based on observation, interview, and record review, the facility failed to provide care and services to maintain range of motion for Resident (R) 61 who had contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in both hands. This deficient practice placed R61 at risk for complications resulting from contracted hands. Findings included: - R61's Electronic Medical Record documented diagnoses of diabetes mellitus (group of diseases that result in too much sugar in the blood (high blood glucose), hypertension (high blood pressure), atrial fibrillation (irregular and often very rapid heart rhythm), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and contractures. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The MDS documented R61 required extensive staff assistance with all activities of daily living (ADLs), had range of motion (ROM) impairment in all extremities, and received passive ROM therapy. R61's ADL Care Plan, dated 04/06/23, directed staff to provide palm protectors in both hands at all times except with hand hygiene. The plan directed staff to provide range of motion (passive) to maintain current ADL level without avoidable declines. An intervention dated 08/2/21 directed a splint/brace was needed to maintain R61's current level of function of range of motion and further contracture prevention, 5-7 days a week, 15 minutes a day. Another intervention dated 02/22/2023 directed staff R61's splint was on hold at that time due to a skin tear to her hand. On 05/17/23 at 09:58 AM, observation revealed R61 in bed with severe contractures to both hands and no palm protectors in either hand. A sign from therapy services, on the wall by her bed, directed staff to place the right-hand palm protector with the black line facing out, and the left-hand protector with the line facing out. The sign also stated Please wear these at all times except during hand hygiene. On 05/18/23 at 08:09 AM, observation revealed R61 in bed while Certified Nurse Aide (CNA) M fed her. R61 wore a hospital gown and had no palm protectors in either hand. On 05/18/23 at 12:20 PM, observation revealed CNA M fed R61, who laid in bed with a hospital gown on. R61 had no palm protectors in either hand. On 05/18/23 at 12:50 PM, upon surveyor request, Licensed Nurse (LN) H checked the resident's palms which had no redness but did have some odor. R61 complained of pain when the nurse gently tried to open her hand. LN H used a moist wipe and slowly drew it through R61's contractured palms to clean them and even that slight movement caused R61 pain. On 05/18/23 at 12:20 PM, CNA M verified the resident did not have the hand splints or palm protectors on and stated he did not know where they were. On 05/18/23 at 12:33 PM, LN H verified the resident should have something in her hands due to the contractures. She stated R61's hand splints had been on hold since February 2022 due to a skin tear. On 05/22/23 at 09:55 AM, Consultant GG stated therapy ordered palm protectors to both R61's hands in February 2022. She stated the resident tilted her head to the side and sometimes food or drink dribbled down to her neck crease, and she had a history of yeast buildup there. Consultant GG stated therapy had provided staff education for ROM and staff were to ensure palm protectors were in at all times. She stated the resident was able to lift her left arm a little and had use of her left thumb. On 05/23/23 at 10:25 AM, Administrative Nurse D verified staff should have placed the palm protectors on the resident at all times. The facility's Treatment of Contractures policy, dated 02/01/23, stated restorative staff, nursing staff and therapy staff will work closely to prevent the progression of contractures with treatment of slow, gentle stretching and massage. Contracture treatment plans would be developed and supervised by skilled therapy and the restorative coordinator. Handrolls should be considered part of the routine care of all dependent residents and staff was responsible for keeping the skin clean and dry under the handroll. Staff were to remove the handroll each shift, wash the hand with soap and water, dry the hand well and then reapply the handroll. The facility failed to ensure palm protectors were in place for R61's contractures in both hands, placing R61 at risk for complications resulting from contracted hands.

The facility had a census of 118 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 104, who had incontinence, with toileting opportunities in an effort to avoid incontinence and related complications. This placed the resident at risk for skin breakdown and infections. Findings included: - The Electronic Medical Record (EMR) for R104 documented diagnoses of dementia without behavior disturbance (progressive mental disorder characterized by failing memory, confusion), difficulty walking, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE] documented R104 had severely impaired cognition and required extensive assistance of two staff for transfers, toileting, and extensive assistance of one staff for bed mobility, ambulation, and personal hygiene. The MDS further documented R104 was frequently incontinent of bladder and had no toileting program. The Bowel and Bladder Care Plan, dated 04/25/23, initiated on 11/04/21, documented R104 had a history of incontinence and, due to dementia, was unable to voice her need to void. The care plan directed staff to use absorbent briefs for incontinence management to keep moisture away from the skin and for dignity, assist with peri-care after each incontinent episode, and to change brief when needed, R104's care plan directed staff to offer assistance with toileting/check and change upon rising, before and after meals, at bed time, 01:00 AM, 03:00 AM, at 05:00 AM rounds and as needed. On 05/18/23 at 11:15 AM, observation revealed Certified Nurse Aide (CNA) P and CNA Q assisted R104 to the bathroom. Further observation revealed CNA P placed a gait belt around R104's waist, took off the foot pedals on the wheelchair, and pushed the resident into the bathroom. Continued observation revealed, the room did not have a trash can and CNA Q had to leave to go find one. Upon her return CNA Q stood behind R104 and both CNA P and CNA Q assisted R104 to stand, and as CNA Q pulled down R104's pants, the incontinence brief was extremely soiled with urine and bowel was noted to be seeping out of the brief up to R104's back. Continued observation revealed when CNA Q removed the incontinence brief, R104's buttocks and the back of her legs were red. CMA P provided personal care, applied barrier cream and a new incontinence brief was placed on the resident. CNA P told CNA Q that R104's shirt was soiled and she would need a clean shirt. R104 was transferred into her wheelchair. On 05/18/23 at 11:20 AM, CNA Q stated R104 should be toileted every two hours and as needed and stated most of the time R104 was dry and she would fight the nurse aides when they tried to toilet her. CNA Q verified R104 had not been toileted since 08:00 AM, when she was taken to the dining table for breakfast. When CNA Q was asked about the room not having a trash can and where they had thrown away the incontinence brief when they had gotten the resident up, she stated, R104 was dry when they got her up. On 05/22/23 at 12:04 PM, Licensed Nurse (LN) J stated staff offered toileting every two hours. LN J said staff should make sure R104 was toileted as care planned. On 05/22/23 at 01:30 PM LN GG stated a bladder assessment was completed at admission and was resolved so there was not one in the system for review On 05/23/23 at 10:34 AM, Administrative Nurse D stated R104 should be toileted on a timely basis and as care planned. The facility's Bowel and Bladder policy, dated 02/01/23, documented the facility would ensure a quality assessment and treatment for Bowel and Bladder incontinence and to establish appropriate toileting program for the resident's elimination. An assessment for incontinence was performed as part of the admission process and as clinical judgement determines, Staff will use clinical judgement to determine when it is appropriate to reevaluate a resident's ability to participate in a toileting trials. The resident's incontinence would be reviewed and the plan of care updated if there is a change in their baseline. The facility failed to provide R104, who had incontinence, with toileting opportunities in an effort to avoid incontinence and related complications. This placed the resident at risk for skin breakdown and infections.

The facility had a census of 118 residents. The sample included 25 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 106, who had behaviors of urinating in inappropriate places, grabbing items out of other resident's hands, and wandering. This placed the resident at risk for injury, unmet needs, and imapired quality of life. Findings included: - The Electronic Medical Record (EMR) for R106 documented diagnoses of dementia without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set (MDS), dated [DATE], documented R106 had severely impaired cognition and required extensive assistance of one staff for bed mobility, toileting, dressing, personal hygiene, and required supervision and one staff for ambulation. The assessment further documented R106 had inattention, disorganized thinking and wandered daily. R106's Quarterly MDS, dated [DATE], documented R106 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and limited assistance of one staff for ambulation. The assessment further documented R106 had inattention, disorganized thinking, rejection of care one to three days, and other behavioral symptoms one to three days. R106 wandered daily, and his wandering significantly intruded on the privacy or activities of others. R106 received an antidepressant (medication used to treat depression) medication daily. The Admission Assessment, dated 12/22/21, documented R106 had a history of wandering and was anxious and restless. The Mood and Behavior Care Plan, dated 03/03/23, initiated on 12/22/21, documented R106 wandered around the special care unit and would go into other resident rooms at times. R106 would mimic the staff and follow them around. The update, dated 01/07/22, directed staff to give R106 time and space to ambulate and self sooth. R106 liked music and to sing. The update, dated 11/14/22, directed staff to give R106 items to fidget with, redirect as possible when wandered, and refer to the physician for review as needed. The update, dated 05/15/23, documented, when R106 declined cares, staff were to ensure he was safe and reapproach later or try other staff to approach. The Bowel and Bladder Care Plan, dated 03/03/23, initiated on 12/22/21, documented R106 often pulled at his brief as a warning he needed to void or that he felt wet from already voiding. When he was wandering and staff were unable to redirect to the bathroom, staff were to give R106 time and space, redirect back as able, and when R106 paced, it was a warning for the need to be toileted. The care plan directed staff to offer assistance with toileting/check and change upon rising, before and after meals, bedtime, at 01:00 AM, 03:00 AM, at 05:00 AM rounds and as needed. The Physician's Order, dated 02/03/22, directed staff to administer Depakote (medication used to treat manic-depressive illnesses), 125 milligrams (mg), by mouth, daily. This order was discontinued on 08/25/22. The Physician's Order, dated 8/26/22, directed staff to administer Depakote Sprinkles, 125 mg, by mouth, daily. This order was discontinued on 08/29/22. The Physician's Order, dated 08/30/22, directed staff to administer Depakote Sprinkles, 125 mg, by mouth, in the morning, This order was discontinued on 09/09/22. The Physician's Order, dated 09/10/22, directed staff to administer Depakote Sprinkles, 125 mg, by mouth at bedtime. The Physician's Order, dated 10/23/22, directed staff to monitor R106 for agitation with cares and document the number of behavior episodes, interventions, and effectiveness of the interventions. The Nurse's Note, dated 01/31/22 at 12:49 AM, documented R106 wandered into other residents' rooms and touched their belongings. The note documented staff found R106 urinating on his roommates bed. Staff were unable to redirect R106. He yelled and pushed staff's hand away when staff attempted to assist R106 to the bathroom. The note further documented toileting was frequently offered but the resident had started to refuse and became angry during cares. The Nurse's Note, dated 07/28/22 at 01:04 PM, documented R106 wandered, and was disruptive. R106 grabbed food and items from other residents, upsetting residents, and redirection only escalated the behavior. The Nurse's Note, dated 11/10/22 at 11:41 AM, documented R106 had increased behaviors with going into other resident rooms, including lying on their beds, and taking food from other resident's plates. When staff redirected R106 out of another residents room, he became agitated and did not want to leave. The note further documented R106 would also go over to the other hall on the Special Care Unit and do the same things. The note documented staff continued to redirect and tried to keep R106 occupied with other things but at times staff had to allow R106 to calm down for a few minutes before they tried to redirect him. The Nurse's Note, dated 11/19/22 at 12:53 PM, documented R106 grabbed food items from other residents, tried to hold other resident's hands and tried to push wheelchairs. The Nurse's Note, dated 12/15/22 at 01:50 PM, documented staff tried to help R106 with cares but he would refuse, so staff would leave and try again at a later time to prevent R106 from becoming upset. The Nurse's Note, dated 12/30/22 at 01:16 PM, documented R106 was restless, wandered, and was difficult to redirect. He grabbed other residents' food. The Nurse's Note, dated 01/24/23 at 03:34 PM, documented R106 wandered into other resident rooms, grabbed items from other residents, and redirection was not effective most times. The Nurse's Note, dated 02/02/23 at 02:18 PM, documented R106 required redirection throughout the shift with cares to prevent him from becoming agitated or from getting into other residents' faces. The Nurse's Note, dated 02/25/23 at 01:45 PM, documented R106 did not want to use the bathroom and staff would continually take him until they were able to get him to go to the bathroom. The Nurse's Note, dated 02/26/23 at 07:00 AM, documented R106 urinated on a fell ow resident in the dining room area. The note further documented R106 was seen walking around the dining room prior to him urinating on the resident. The note documented staff took the resident to the bathroom and talked to him about boundaries. The Nurse's Note, dated 05/08/23 at 08:04 PM, documented R106 was intrusive, grabbed other residents' food and items, and staff redirected. On 05/18/23 at 08:30 AM, observation revealed R106 independently wandered in the dining room, singing. R106 approached the surveyor, and tapped the outside of the computer. On 05/18/23 at 01:00 PM, Certified Nurse Aide (CNA) O stated R106 had urinated on another resident when the other was in bed but CNA O did not know about the incident in the dining room. on 02/26/23. CNA O stated it had happened more than once. On 05/18/23 at 01:30 PM, Administrative Nurse E stated she had not been made aware of the incident in the dining room on 02/26/23 but she would investigate and talk with staff. At 03:00 PM, Administrative Nurse E stated the incident would be thoroughly investigated, reported, and R106 would be placed 1:1 with staff. Administrative Nurse E further stated the physician and family were made aware and staff would be educated on reporting after any incidents. On 05/22/23 at 10:09 AM, Licensed Nurse (LN) K stated, since R106 urinated on the other resident there had not been any further incidents between the two residents. LN K stated R106 had urinated on his roommates bed and on the floor of another resident's room. LN K further stated staff tried to redirect R106 and he can get agitated, but staff kept trying. On 05/22/23 at 03:16 PM, Social Service X stated she had contacted the families involved and the physicians. Social Services X further stated she had also contacted the psychologist and he did visit with R106 and gave recommendations. On 05/23/23 at 09:51 AM, LN L stated staff were educated on reporting events and the staff in the Special Care Unit are provided with extra education on behaviors and dementia by outside sources and through computer training. On 05/23/23 at 10:11 AM, Administrative Nurse D further stated, the facility was taking precautions so this would not happen again. On 05/23/23 at 11:11 AM, Administrative Staff A stated the facility reeducated staff on reporting incidents and are utilizing a report from the computer that would be generated daily to see if there were any incidents or behaviors so they can make sure nothing like the incident with R106 would happen again. The Behavior Assessment, Intervention and Monitoring policy, dated January 2023, documented the facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The behavior symptoms would be identified using facility approved behavioral screening tools and the comprehensive assessment. The team would evaluate behavioral symptoms in residents to determine the degree of severity, distress ad potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies would be implemented immediately if necessary to protect the resident and others from harm. The facility failed to provide the necessary dementia care and services for R106. This placed the resident at risk for injury, unmet needs and impaired quality of life.

The facility identified a census of 150 residents. The sample included 26 residents. Based on observations, record review and interviews the facility failed to ensure that facility staff properly utilized accepted standard universal precautions (infection prevention practices which include, but are not limited to hand hygiene and use of gloves) while performing percutaneous endoscopic gastrostomy (PEG- a tube placed in the stomach that allows a person to receive nutrition through the tube) care for resident (R)68; failed to ensure staff did proper hand hygiene during wound care for R128; failed to ensure that staff used a protective barrier and disinfect a glucometer (a machine used to obtain blood glucose levels) while obtaining R56 blood glucose level; and failed to ensure that a container used to distribute ice to residents glasses was covered and the scoop properly stored. Findings included: - On 09/23/21 at 08:37 AM Licensed Nurse (LN) J entered resident R68's room to do PEG tube care. She donned (put on) clean gloves without washing/sanitizing hands prior to putting on gloves. Certified Nurses Aide (CNA) N also donned clean gloves without washing/sanitizing hand prior to putting them on. When procedure was completed both staff LN J and CNA N doffed their dirty gloves without hand hygiene after, placed a gait belt around R68 and assisted her back to the dining room, hand hygiene was performed after they left the resident. On 09/27/23 at 10:00 AM LN I entered R128's room and performed hand hygiene. She gathered supplies for wound care and placed the clean items on a clean barrier on the bedside table, performed hand hygiene again and donned clean gloves. LN I removed the soiled dressing from one wound and cleansed the area. Without performing hand hygiene or changing gloves, she removed a soiled dressing from a different wound and cleansed it with cleaner (she failed to doff dirty gloves and do hand hygiene in between each wound). She doffed gloves and did hand hygiene and donned clean gloves. She obtained a clean dressing and applied the dressing as ordered to wound areas. LN I then doffed gloves and performed hand hygiene. On 09/23/21 at 08:01 AM LN H entered R56's room, she placed the glucometer, insulin pen, and medication cup on the tray table. No barrier was placed under the glucometer. LN H donned gloves and placed testing strip into the machine, and held the machine in his hand, cleansed the resident's finger, lanced resident's finger with the lancet (an device that has a small needle/scalpel to obtain small blood specimens) LN H disposed of lancet in sharps container, doffed gloves, did hand hygiene, then donned clean gloves. He then cleansed residents right lower belly area, and injected ordered insulin (a hormone made in your body that allows your body to use glucose for energy). LN H then carried the glucometer, insulin pen, and lancet container back to the medication cart and placed it in the top drawer. He did not disinfect glucometer before placing it in the drawer. On 09/21/21 at 08:10 AM observation revealed a cart that had a tray of uncovered ice on it that was outside of the serving area in the main dining area. A green handled slotted spoon laid in the ice with the handle touching the ice. On 09/22/21 at 01:10 PM a cart sitting outside of the serving area was observed to have a tray/container of uncovered ice with a slotted scoop spoon laying in the ice. In an interview on 09/27/21 at 4:38 PM Certified Medication Aide (CMA) R stated that hand hygiene should be done when they first enter the facility, in between care of each resident, after taking a resident to the bathroom, in between glove changes, and in between each resident when passing medications. In an interview on 09/27/21 at 02:20 PM LN I stated that hand hygiene and gloves changed should be done in between each wound, but R128 wound not have allowed her to complete the treatment had she done that. In an interview on 09/27/21 at 04:48 PM with LN G stated that hand hygiene should be performed before and after providing care; before and after donning and doffing of gloves; and, should be done before, during, and after each wound during wound care. In an interview on 09/27/21 at 05:09 PM Administrative Nurse and Infection Preventionist E stated that hand hygiene should be done before and after each resident's care, hands can be sanitized up to five times before being washed again. Hands should be sanitized after taking gloves off, and gloves should be changed in between each dirty to clean wound dressing change and in between each wound site. A barrier should be placed underneath of the glucometer before it is placed on a resident's bedside table, and the glucometer should be sanitized after each use. In an interview on 09/27/21 at 03:50PM with Certified Dietary Manager (CDM) BB stated that he was not aware that his staff was using a clear container and a scoop for ice. He stated that was not normal practice and there was an ice machine at the drink center that should be used to fill resident's cups with ice. If they did use and ice chest and/or other type of container for ice, there should be a lid on it when not in use and the scoop should never be left in the ice container. The facility policy Infection Control Policy dated 7/30/21 documented: The facility will facilitate safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The facility will follow Standard Precautions for Infection Control and Prevention including but not limited to: Hand hygiene-refers to both washing with plain or anti-microbial (a substance used to reduce the number of bacteria) soap and water and use of alcohol gel; when hands are not visibly soiled, alcohol gel is preferred method of hand hygiene. Perform hand hygiene: before and after contact with a resident; immediately after touching blood, bloody fluids, non-intact skin, mucous membranes or contaminated items; immediately after removing gloves; when moving from contaminated body sites to clean body sites during resident care area; after touching objects and medical equipment in immediate resident care area; before eating; after using restroom; and after coughing or sneezing in to a tissue. The facility policy Finger Stick Blood Sugars/[CONDITION(S)] (a low blood sugar reading)/[CONDITION(S)] (an elevated blood sugar reading) dated 09/01/21 documented: It is the policy of this facility that the management of finger stick blood sugars involves the use of Point Click Care and the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy for Ice Machine/Chest Safety dated 04/01/21 documented: All employees will use sanitary methods to obtain ice for themselves and for elders and visitors from any ice machine or portable ice chest and elders will use sanitary methods to obtain ice for themselves from self-dispensing ice makers. Only employees may obtain ice if the use of an ice scoop is needed; scoop must be clean; when and ice scoop is reused, it must be stored in an upright position in a clean container, ensuring that all moisture has been drained off the scoop before placing in a clean container; Keep ice container closed except when removing ice. The facility failed to ensure staff used standard precautions and proper use of hand hygiene when providing PEG tube care for R68, failed to ensure staff used standard precautions and proper use of gloves and hand hygiene during wound dressing change and care for R128, failed to ensure staff used standard precautions during routine testing of blood glucose for R56, and failed to ensure staff stored ice in a covered container and stored the scoop in a container that ensured moisture drained off the scoop after being used. These practices had the potential for the development and spread of infectious disease to residents and staff.

The facility identified a census of 150 residents. The sample included 26 residents; one resident sampled for discharge review. Based on observations, record reviews, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 49 or to her family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to). This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services. Findings included: - R49 was admitted on [DATE], discharged to hospital on 06/13/21, and readmitted to facility 06/15/21. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE], documented R49 had a Brief Interview for Mental Status of zero which indicated severe cognitive impairment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/06/21, documented R49 had severe impairment and staff and family anticipated her needs. The Care Plan dated 06/15/21 documented R49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Assessments tab of R49's EMR documented a Transfer to Hospital assessment that documented R49 was transferred to the hospital for left hip pain and her representative was notified of transfer. R49's medical record lacked documentation of a written notification of transfer to resident or family for the transfer on 06/13/21. Facility unable to provide written notification of transfer for transfer to hospital on 06/13/21. On 09/22/21 at 02:52 PM, R49 laid in bed on her left side, eyes closed. She rested comfortably without signs of distress. On 09/27/21 at 03:13 PM, Social Services X stated social services did not do any written notifications of transfer. On 09/27/21 at 04:48 PM, Licensed Nurse (LN) G stated when a resident transferred to the hospital, the family was notified by phone call and the transfer form was sent with the resident to the hospital. LN G did not know about a written notification of transfer. On 09/27/21 at 05:24 PM, Administrative Nurse D stated when a resident transferred to the hospital, the family was notified by phone call and the resident/family was notified about their right to appeal their transfer. He stated the resident or family were not provided a written notification of transfer. The facility's Transfer or Discharge Notice policy, last revised 04/01/21, directed the resident and/or representative was provided the following information: reason for transfer; effective date of the transfer; location to which resident was transferred; name, address, and telephone number of the state long-term care ombudsman; and the name, address, and telephone number of the state health department agency that was designated to handle appeals of transfers. The policy lacked direction that the notification was to be written. The facility failed to provide a written notification of transfer to R49 or her family/DPOA. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare services.

The facility reported a census of 161 residents. The sample included 3 of the 46 residents residing on the Secured Care Unit. Based on observation, interview, and record review the facility failed to provide protection from resident #1's inapropiate sexual behaviors when he/she inappropriately touched five residents (same and opposite gender) (#2, #3, #4, #5 and #6). This deficient practice placed the 46 residents residing on the secured unit of this facility in immediate jeopardy. Findings included: - The physician's orders [REDACTED]. The Admission Minimum (MDS) data set [DATE] recorded a Brief Interview for Mental Status score of 12 which indicated moderately impaired cognition. The assessment documented the resident's mood of feeling down, depressed, and bad about self. He/she exhibited no behavioral symptoms, wandering occurred for 4 to 6 days of the look back period and had a significant impact on the privacy and activity of other residents. He/she required supervision with walking and locomotion on the unit. The Care Area Assessment (CAA) for behaviors dated 10/25/2016 documented that the resident had behaviors of refusing cares and wandering around the facility and in and out of other's rooms uninvited. Staff should provide redirection and continue to check on him/her throughout the day. The CAA lacked documentation regarding sexually inappropriate behaviors directed toward other residents. The Care Plan dated 10/18/2016 revealed the resident was alert and oriented to person, place, and general situation with confusion. He/she was at risk for alterations in behaviors that interrupt his/her activities of daily living related to dementia and depression and directed staff to report any changes in mental health status to the physician. The revised care plan dated 11/22/2016 documented he/she had a history of [REDACTED]. Staff were to re-direct the resident as needed and provide 15 minute checks on the resident until staff initiated further interventions. Staff were to obtain a psychologist consult as indicated. The resident rejected cares and wandered since moving into the facility. The Psychologist Consult note dated 10/27/2016 at 9:20 A.M. documented resident #1 was seen for stabilization of depressed, anxious, irritable mood, reduction of confusion, and disorganized thinking. The note documented a conclusion that the resident's mood persistence was not easily altered. The nurse's note dated 10/18/2016 at 11:19 P.M. documented the resident was alert with significant confusion and when his/her spouse was not present he/she constantly paced and needed supervision to not wander through the facility. He/she was hostile towards the spouse for placement in the facility. The nurse's note dated 10/29/2016 at 6:29 P.M. documented the resident wandered into resident #2, opposite gender room, sat down, and the other resident used his/her call light to alert the nurse to remove resident #1 from the room; resident #1 refused at first and did not want to leave. The facility failed to implement interventions following this incident. The nurse's note dated 11/03/2016 at 12:05 P.M. documented resident #1 followed opposite gender resident #3; sat by him/her and kissed on resident #3. Resident #3 put his/her head down as if asleep, however, resident #1's behavior continued from breakfast through lunch. The facility failed to implement interventions following this incident. The social service note dated 11/03/2016 at 3:45 P.M. documented that resident #1's family member reported in the care plan meeting resident #1 thought a resident of the opposite gender was his/her spouse. The family member explained to resident #1 that the person was not his/her spouse. The social service note failed to address interventions regarding this report. The nurse's note dated 11/14/2016 at 2:00 P.M. documented the resident came out of his/her room with pants off and only a bed pad wrapped around the lower body, the resident refused to let staff help him/her, tried to hit staff, yelling at staff. The nurse's note dated 11/21/2016 at 2:15 P.M. documented staff left a message on voice mail for the doctor and started resident #1 on 15 minute checks. The nurse's note dated 11/21/2016 at 3:38 P.M. titled late entry for 11/20/2016 day shift documented staff found resident #1 in resident #2's wheelchair 12 times, and each time staff redirected resident #1 and assisted him/her back to his/her walker and assisted resident #2 back to his/her wheelchair. Staff found resident #1 in resident #2's bed 4 times and assisted him/her out of the room and redirected to the activity room. At approximately 6:30 P.M. direct care staff O reported to licensed staff J he/she walked into resident #1's room (the door was closed) and resident #1 was standing by the sink with his/her pants below the knees and shirt pulled up, while resident #2 was sitting in his/her wheel chair and touching resident #1's genital area. Licensed staff J removed resident #2 from the room and placed him/her at the nurse's station for monitoring. Licensed staff J asked resident #1 what happened and he/she stated How do I go to the bathroom in these trash cans? License staff J increased monitoring to keep the two residents in eye view. The nurse's note dated 11/22/2016 at 1:15 P.M. documented resident #1 walked around in the dining room trying to get to resident #2, who voiced his/her wish to be left alone while eating. Resident #1 stood at the table by resident #2. When the behaviors started, staff redirected resident#1 without success, and completed 15 minute checks, and one on one at the table, this intervention was not effective. The doctor ordered [MEDICATION NAME] (Mood Stabilizer) 500 mg (milligrams) 1 capsule given by mouth. A General note dated 11/23/2016 at 1:30 P.M. documented staff placed resident #1 on one on one monitoring until the 3:00 P.M. to 11:00 P.M. shift with direct care staff P assigned to the resident. The Nurse's note dated 11/25/2016 at 12:51 P.M. documented resident #1 cried about his/her spouse wanting the spouse here all the time, and remained one on one with 15 minutes checks. On 11/23/2016 at 8:43 A.M. observation revealed resident #1 in his/her room with a visitor. Further observation revealed resident #1 came out into the hallway the resident wore his/her spouse's underwear on his/her head. During an interview on 11/23/2016 at 9:41 A.M. direct care staff O reported he/she was doing the last round on Sunday 11/20/2016 and asked the licensed nursing staff J if he/she had seen resident #1 and resident #2. Staff had already been watching the residents because they had wandered off together. Direct care staff O entered resident #1's room and saw that resident #1 had his/her pants down, and resident #2 sat in front of resident #1 with his/her hand close to the genital area between resident #1's legs. Direct care staff O called licensed nursing staff J to the room. Licensed nursing staff J escorted resident #2 out of the room and to the nurse's station where he/she could be observed. Staff O furthered stated that resident #1 pulls his/her clothes off when he/she gets to the resident of opposite gender's room. An interview on 11/29/2016 at 2:05 P.M. licensed staff H reported when resident #1 admitted to the Secured Unit he/she demonstrated some bizarre behavior at that time; he/she walked out with a bed pad around him/her and no underwear, pulled his/her walker, he/she touched resident #3 on the shoulder and whispered something in his/her ear. On 11/29/2016 at 9:15 A.M. consultant physician KK stated staff first notified him/her about the inappropriate touching incident that occurred on 11/20/2016, on 11/21/2016 via voice mail and that the staff started 15 minute checks for resident #1. On 11/30/2016 at 4:00 P.M. administrative staff D stated resident #1 kissed resident #4 and he/she attempted to kiss resident #5 by grabbing his/her face but staff intervened and redirected resident #1. Review of resident #1's clinical record lacked documentation of incidents with resident #4 and resident #5. On 11/30/16 at 5:22 P.M. direct care staff R stated on a Tuesday (unsure of the date) he/she received a phone call from the 200 hall that resident #1 was bothering resident #5 and wanted staff to come and get him/her. Direct care staff R stated when he/she approached, resident #1's hands were grasping resident #5's face (attempting to kiss resident #5), but he/she did not kiss resident #1. Staff R further stated the following day resident #1 was coaxing resident #2 to follow into his/her room. Resident #2 did not follow and resident #1 came out of his/her room and hollered for resident #2 stating I want you to help take these pants off. Resident #1 walked out of his/her room and grabbed resident #4 by the face and kissed his/her cheek. Direct care staff R stated that resident #1 approached resident #6 and touched his/arm in an affectionate way and thought it was his/her spouse. Review of resident #1's clinical record lacked documentation of incidents with resident #6. The facility provided Abuse Prevention Policy and Procedure, undated and unsigned, documented each resident had the right to be free from abuse defined as the willful infliction of sexual contact, including fondling, with a resident caused by an employee, agent, or other resident of a long-term care facility by force, threat, duress or coercion, or sexual contact where the resident has no ability to consent. The facility failed to protect residents on the secured unit from sexually inappropriate behaviors, after incidents of sexually inappropriate touching, kissing and grabbing residents of opposite and same gender by resident #1. This deficient practice placed the 46 opposite and same gender residents of the secured unit in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 12/3/16 at 4:00 P.M. by initiating the following: 1) Resident #1 was placed on 1 on 1 staff supervision 24 hours a day. 2) The facility revised their Abuse, Neglect, and Exploitation policy with instructions for staff to follow in the event of sexually inappropriate behaviors. 3) All staff received a face-to-face in-service on identification of potential sexually inappropriate behavior and the revised Abuse, Neglect, and Exploitation policy. This deficient practice remained at a scope and severity of an H.

The facility reported a census of 161 residents. The sample included 3 of the 46 residents residing on the Secured Care Unit. Based on observation, interview, and record review the facility failed to provide an environment free of sexual abuse from resident #1 when he/she inappropriately touched five residents (same and opposite gender) (#2, #3, #4, #5 and #6). This deficient practice placed these 5 residents residing on the secured unit of this facility in immediate jeopardy. Findings included: - The physician's orders [REDACTED]. The Admission Minimum (MDS) data set [DATE] recorded a Brief Interview for Mental Status score of 12 which indicated moderately impaired cognition. The assessment documented the resident's mood of feeling down, depressed, and bad about self. He/she exhibited no behavioral symptoms, wandering occurred for 4 to 6 days of the look back period and had a significant impact on the privacy and activity of other residents. He/she required supervision with walking and locomotion on the unit. The Care Area Assessment (CAA) for behaviors dated 10/25/2016 documented that the resident had behaviors of refusing cares and wandering around the facility and in and out of other's rooms uninvited. Staff should provide redirection and continue to check on him/her throughout the day. The CAA lacked documentation regarding sexually inappropriate behaviors directed toward other residents. The Care Plan dated 10/18/2016 revealed the resident was alert and oriented to person, place, and general situation with confusion. He/she was at risk for alterations in behaviors that interrupt his/her activities of daily living related to dementia and depression and directed staff to report any changes in mental health status to the physician. The revised care plan dated 11/22/2016 documented he/she had a history of [REDACTED]. Staff were to re-direct the resident as needed and provide 15 minute checks on the resident until staff initiated further interventions. Staff were to obtain a psychologist consult as indicated. The resident rejected cares and wandered since moving into the facility. The Psychologist Consult note dated 10/27/2016 at 9:20 A.M. documented resident #1 was seen for stabilization of depressed, anxious, irritable mood, reduction of confusion, and disorganized thinking. The note documented a conclusion that the resident's mood persistence was not easily altered. The nurse's note dated 10/18/2016 at 11:19 P.M. documented the resident was alert with significant confusion and when his/her spouse was not present he/she constantly paced and needed supervision to not wander through the facility. He/she was hostile towards the spouse for placement in the facility. The nurse's note dated 10/29/2016 at 6:29 P.M. documented the resident wandered into resident #2, opposite gender room, sat down, and the other resident used his/her call light to alert the nurse to remove resident #1 from the room; resident #1 refused at first and did not want to leave. The facility failed to implement interventions following this incident. The nurse's note dated 11/03/2016 at 12:05 P.M. documented resident #1 followed opposite gender resident #3; sat by him/her and kissed on resident #3. Resident #3 put his/her head down as if asleep, however, resident #1's behavior continued from breakfast through lunch. The facility failed to implement interventions following this incident. The social service note dated 11/03/2016 at 3:45 P.M. documented that resident #1's family member reported in the care plan meeting resident #1 thought a resident of the opposite gender was his/her spouse. The family member explained to resident #1 that the person was not his/her spouse. The social service note failed to address interventions regarding this report. The nurse's note dated 11/14/2016 at 2:00 P.M. documented the resident came out of his/her room with pants off and only a bed pad wrapped around the lower body, the resident refused to let staff help him/her, tried to hit staff, yelling at staff. The nurse's note dated 11/21/2016 at 2:15 P.M. documented staff left a message on voice mail for the doctor and started resident #1 on 15 minute checks. The nurse's note dated 11/21/2016 at 3:38 P.M. titled late entry for 11/20/2016 day shift documented staff found resident #1 in resident #2's wheelchair 12 times, and each time staff redirected resident #1 and assisted him/her back to his/her walker and assisted resident #2 back to his/her wheelchair. Staff found resident #1 in resident #2's bed 4 times and assisted him/her out of the room and redirected to the activity room. At approximately 6:30 P.M. direct care staff O reported to licensed staff J he/she walked into resident #1's room (the door was closed) and resident #1 was standing by the sink with his/her pants below the knees and shirt pulled up, while resident #2 was sitting in his/her wheel chair and touching resident #1's genital area. Licensed staff J removed resident #2 from the room and placed him/her at the nurse's station for monitoring. Licensed staff J asked resident #1 what happened and he/she stated How do I go to the bathroom in these trash cans? License staff J increased monitoring to keep the two residents in eye view. The nurse's note dated 11/22/2016 at 1:15 P.M. documented resident #1 walked around in the dining room trying to get to resident #2, who voiced his/her wish to be left alone while eating. Resident #1 stood at the table by resident #2. When the behaviors started, staff redirected resident#1 without success, and completed 15 minute checks, and one on one at the table, this intervention was not effective. The doctor ordered [MEDICATION NAME] (Mood Stabilizer) 500 mg (milligrams) 1 capsule given by mouth. A General note dated 11/23/2016 at 1:30 P.M. documented staff placed resident #1 on one on one monitoring until the 3:00 P.M. to 11:00 P.M. shift with direct care staff P assigned to the resident. The Nurse's note dated 11/25/2016 at 12:51 P.M. documented resident #1 cried about his/her spouse wanting the spouse here all the time, and remained one on one with 15 minutes checks. On 11/23/2016 at 8:43 A.M. observation revealed resident #1 in his/her room with a visitor. Further observation revealed resident #1 came out into the hallway the resident wore his/her spouse's underwear on his/her head. During an interview on 11/23/2016 at 9:41 A.M. direct care staff O reported he/she was doing the last round on Sunday 11/20/2016 and asked the licensed nursing staff J if he/she had seen resident #1 and resident #2. Staff had already been watching the residents because they had wandered off together. Direct care staff O entered resident #1's room and saw that resident #1 had his/her pants down, and resident #2 sat in front of resident #1 with his/her hand close to the genital area between resident #1's legs. Direct care staff O called licensed nursing staff J to the room. Licensed nursing staff J escorted resident #2 out of the room and to the nurse's station where he/she could be observed. Staff O furthered stated that resident #1 pulls his/her clothes off when he/she gets to the resident of opposite gender's room. An interview on 11/29/2016 at 2:05 P.M. licensed staff H reported when resident #1 admitted to the Secured Unit he/she demonstrated some bizarre behavior at that time; he/she walked out with a bed pad around him/her and no underwear, pulled his/her walker, he/she touched resident #3 on the shoulder and whispered something in his/her ear. On 11/29/2016 at 9:15 A.M. consultant physician KK stated staff first notified him/her about the inappropriate touching incident that occurred on 11/20/2016, on 11/21/2016 via voice mail and that the staff started 15 minute checks for resident #1. On 11/30/2016 at 4:00 P.M. administrative staff D stated resident #1 kissed resident #4 and he/she attempted to kiss resident #5 by grabbing his/her face but staff intervened and redirected resident #1. Review of resident #1's clinical record lacked documentation of incidents with resident #4 and resident #5. On 11/30/16 at 5:22 P.M. direct care staff R stated on a Tuesday (unsure of the date) he/she received a phone call from the 200 hall that resident #1 was bothering resident #5 and wanted staff to come and get him/her. Direct care staff R stated when he/she approached, resident #1's hands were grasping resident #5's face (attempting to kiss resident #5), but he/she did not kiss resident #1. Staff R further stated the following day resident #1 was coaxing resident #2 to follow into his/her room. Resident #2 did not follow and resident #1 came out of his/her room and hollered for resident #2 stating I want you to help take these pants off. Resident #1 walked out of his/her room and grabbed resident #4 by the face and kissed his/her cheek. Direct care staff R stated that resident #1 approached resident #6 and touched his/arm in an affectionate way and thought it was his/her spouse. Review of resident #1's clinical record lacked documentation of incidents with resident #6. The facility provided Abuse Prevention Policy and Procedure, undated and unsigned, documented each resident had the right to be free from abuse defined as the willful infliction of sexual contact, including fondling, with a resident caused by an employee, agent, or other resident of a long-term care facility by force, threat, duress or coercion, or sexual contact where the resident has no ability to consent. The facility failed to provide an environment free of sexually inappropriate behaviors, after incidents of sexually inappropriate touching, kissing and grabbing residents of opposite and same gender. This deficient practice placed the 5 opposite and same gender residents of the secured unit in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 12/3/16 at 4:00 P.M. by initiating the following: 1) Resident #1 was placed on 1 on 1 staff supervision 24 hours a day. 2) The facility revised their Abuse, Neglect, and Exploitation policy with instructions for staff to follow in the event of sexually inappropriate behaviors. 3) All staff received a face-to-face in-service on identification of potential sexually inappropriate behavior and the revised Abuse, Neglect, and Exploitation policy. This deficient practice remained at a scope and severity of an H.

The facility identified a census of 146 residents. Based on observation, record review and interview, the facility failed to timely assess and implement timely and effective interventions to prevent further falls for 1 of 3 residents (#1) sampled for falls who experienced 17 falls in a 9 month time period resulting in fractures. Findings included: - Resident #1's September physician's orders [REDACTED]. The POS recorded please wear aspen collar (neck brace for fractures) at all times. The quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The resident required limited assistance with bed mobility, transfers, walking, toileting and total assistance with locomotion on and off the unit. The resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet and surface to surface transfers. The resident had falls since the prior assessment with 2 or more falls with injury. The significant change MDS dated [DATE] recorded the resident with a BIMS score of 12, which indicated moderate cognitive impairment. The resident rejected care daily. The resident was independent with bed mobility; required limited assistance with transfers; extensive assistance with dressing, eating, toilet use, personal hygiene and bathing; and total dependence with locomotion on and off the unit. The resident was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, moving on and off the toilet and surface to surface transfers. The resident was frequently incontinent of bladder and always continent of bowel. The resident fell in the last month; last 2-6 months, and obtained a fracture related to a fall in the last 6 months. The Activities of Daily Living (ADL)/functional rehabilitation potential Care Area Assessment (CAA) dated 9-19-12 recorded the resident had a [DIAGNOSES REDACTED]. The resident had shown a general decline in both physical and mental ability to do ADLs, he/she needed assistance to accomplish his/her ADLs, and he/she was capable of getting out of bed on his/her own but was extremely unsteady and had a history of [REDACTED]. The fall Care Area Assessment (CAA) dated 9-19-12 recorded the resident had increased falls from June to September with incurring 6 falls with 2 or more resulting in major injuries. In July, the resident had a laceration (cut) and fracture. The resident had a hi-low bed (a bed that lowered down close to the floor), a mat on the side of the bed, wore a helmet when out of bed, 15 minute checks, and a lap tray when up at times in wheelchair. The 2-2-12 Morse fall risk assessment score was 75; 55 or higher indicated a fall risk. The 7/3/12 Morse fall risk assessment total score was 105 and score of 55 or higher revealed the resident was at risk for falls. The facility's fall investigations and care plan recorded the following: 1-24-12 the resident fell in his/her room, intervention was to ensure adequate lighting at all times, resident went to the emergency room and received steri-strips. 2-4-12 the resident fell in his/her bathroom, intervention was to obtain a urinalysis for increased confusion, remind to use call light, replace alarm on chair, on 2-6-12 the results of the urinalysis were negative. 2-17-12 the resident fell in his/her bathroom, with the intervention to continue previous interventions, advised to ask for help. 4-15-12 the resident fell in his/her room, interventions were to stay with the resident in the bathroom, check every 30 minutes at night, and remind to use call light. 4-16-12 the resident fell in his/her room, interventions were a hi-low bed and safety mat. 4-26-12 the resident fell in his/her room, intervention was to continue previous interventions. 5-4-12 the resident fell in his/her room, interventions were to continue previous interventions and encourage the resident to use the call light. 5-10-12 the resident fell in the bathroom, intervention was to continue the previous interventions, the resident was non-compliant and to encourage the resident to use the call light. 6-6-12 the resident fell in his/her room, and the interventions were to encourage the use of the call light, monitor in chair closely at all times, alarmed floor mat, and keep the bed in low position and locked. 7-1-12 the resident fell in his/her room, the intervention was to continue other interventions and encourage to call for assist. The nurse's note dated 7-1-12 at 11:00 A.M. recorded staff found the resident sitting just inside his/her room in a wheelchair with bright red drainage dripping down his/her face from a skin tear above the left eyebrow. The care plan and nurse's notes revealed 7-2-12 the resident fell in his/her room, interventions included floor mat replaced (with a thicker one) and remove personal chair from room. The nurse's note dated 7-2-12 at 1:55 P.M. recorded staff heard the resident moaning from the doorway and found the resident sitting on his/her bottom on the floor with his/her back against the door to the room. Staff noted bright red blood on the left side of the resident's forehead. At 2:10 P.M., staff obtained a physician order [REDACTED]. The facility's Nursing fall investigation information dated 7-2-12 recorded the resident was sent out to the emergency room due to head injury. The care plan interventions were staff placed a floor mat and would remove the personal chair to make a clearer pathway for him/her. The progress note dated 7-3-12 recorded the resident admitted to a local hospital on 7-2-12 after a fall in which he/she obtained an approximately 10 centimeter (cm) stellate-shaped laceration to his/her forehead requiring sutures. On 7/2/12 the initial computed tomography (CT) scan suggested a very small intraparenchymal bleed (bleeding into the tissue of the brain caused by trauma to the head). The CT of head/neck suggested a non-displaced fracture over the left zygomaticofrontal suture (part of the skull), but was not definite. Psychiatric positive for: compulsive behaviors, depressed affect, poor insight and poor judgment. The resident was at risk for falls due to gait disturbance, resident had no motor safety awareness which continued to increase his/her risk for falls. The nurses' note and care plan revealed: 7-9-12 the resident fell in his/her room, looking for a urinal, intervention to keep personal items close by. 7-11-12 the resident fell in his/her room, intervention was frequent checks. 7-14-12 the resident fell in his/her room, interventions were to continue 15 minute checks, added alarmed bedside mat; and on 7-15-12 intervention not to be left unattended in the bathroom. 7-21-12 the resident fell in his/her room, intervention was to stay in room while resident was in restroom and do not leave unattended. 8-28-12 resident fell in room, intervention was to wear a helmet when up. Nurse's notes dated 8-28-12 at 1:00 P.M. recorded at 9:45 A.M., staff found the resident on the floor lying face down with the wheelchair on top of him/her, resident unable to clearly state what happened. The resident obtained a bruise on top of his/her head. Patient teaching continued on safety and use of call light when help was needed. The resident was still non-compliant and requested that staff did not assist him/her to the bathroom. The resident denied pain or discomfort. Nurse's notes dated 8-31-12, with no time recorded, listed the facility admitted the resident to a local hospital. Documentation from a local hospital recorded the resident admitted to the hospital on 8-31-12 after a fall and his/her [DIAGNOSES REDACTED]. The care plan listed the intervention dated 9-7-12 for a lap tray when in the wheelchair. The nurse's note and care plan revealed on 9-19-12 the resident fell in his/her room with the intervention for a personal chair alarm. The clinical record lacked documentation the facility completed a thorough bowel and bladder assessment/voiding diary to determine when best to toilet the resident. On 10-2-12 at 10:02 A.M., observation revealed the resident sat in his/her high back wheelchair during church services. The resident was wearing a cervical collar with chair alarms in place and without a lap tray in place. Observation on 10-2-12 at 10:37 A.M., the resident laid in bed with the cervical collar on, the wheelchair was in the hallway by his/her room, bed was in the low position, alarms were on and urinal was within his/her reach. Observation on 10-2-12 at 11:22 A.M. revealed the resident laid in bed with a cervical collar on. The fall mat was next to the bed and alarms were in place and functioning. Observation revealed a scar on the resident's left upper forehead. Observation on 10-2-12 at 12:56 P.M., direct care staff J wheeled the resident into his/her room from the dining room. Once in his/her room, the resident immediately tried to stand without staff assist. Staff transferred the resident to the bed using a gait belt after they offered the urinal. The bed was in a low position with the alarms on and functioning. During an interview on 10-2-12 at 4:51 P.M., licensed nursing staff C stated the resident was very non-compliant. During an interview on 10-3-12 at 2:46 P.M., administrative nursing staff A acknowledged the resident had several falls in the bathroom and stated he/she doubted if the facility completed a voiding trial to determine when staff should toilet the resident. He/she stated staff toileted the resident before and after meals and offered the urinal at bedside. Administrative nursing staff A stated he/she did not feel it was appropriate when a resident fell and staff reviewed the care plan and the intervention was to continue with current interventions. Administrative nursing staff A stated there should be a new intervention added. During an interview on 10-3-12 at 3:27 P.M., administrative nursing staff A acknowledged the resident fell on [DATE] and the intervention was to re-educate this cognitively impaired resident about using the call light, and the resident fell again on 7-2-12, and went to the hospital with a hematoma and a fracture. Administrative nursing staff A stated for the resident, education was not an appropriate intervention, as he/she had dementia. The clinical record lacked evidence the facility assessed the causative factors for each fall. The facility failed to timely assess and failed to implement timely and effective interventions for this cognitively impaired, dependent resident with a history of multiple falls which resulted in injury.

The facility identified a census of 146 residents. The sample included 3 residents reviewed for falls or injury of unknown origin. Based on observation, record review, and interviews, the facility failed to ensure that the residents environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance to prevent accidents for 2 of 3 sampled residents (# 1, and #3). Findings included: - The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) with an assessment reference date of 7/12/11 reported the resident with a Brief Interview for Mental Status (BIMS) score of 4 which indicated severe cognitive impairment. The resident required limited assistance for bed mobility, locomotion on/off the unit, and extensive assistance to transfer, walk in room, walk in corridor, dressing, toilet use and personal hygiene. The resident was totally dependent for bathing. The resident was independent of staff for eating. The resident was frequently incontinent of urine, and always continent of bowel. The annual MDS with an assessment reference date of 1/9/12 reported a BIMS score of 3 which indicated severe cognitive impairment, delusions, and otherwise no behaviors. The resident required extensive assistance for bed mobility, transfer, walk in room, toilet use, personal hygiene, and limited assistance with locomotion on/off the unit. The resident required total assist with dressing and bathing. The resident also received antipsychotic medications. The quarterly nursing assessment dated [DATE] listed no history of falling. The quarterly nursing assessment dated [DATE] listed no history of falling. The Interdisciplinary monthly behavior and psychotropic monitoring sheet dated 2/15-3/14/11 listed behaviors on 3/23/11 of yelling, exit seeking, and urgency to leave. The Interdisciplinary monthly behavior and psychotropic monitoring sheet dated 11/15/11-12/14/11 listed behaviors on 11/25/11 of yelling, on 11/26/11 yelling and crying, and on 12/14/11 increased restlessness and yelling. The Interdisciplinary monthly behavior and psychotropic monitoring sheet dated 2/15-3/14/12 listed no behaviors. The Interdisciplinary care plan meeting form dated 7/12/11 listed therapy worked on transfers with the resident as he/she was difficult to transfer due to weight and filling with fluid, walking only with therapy, required extensive assistance with activities of daily living (ADLs), ambulation and transfers. The Interdisciplinary care plan meeting form dated 10/10/11 listed extensive assistance with most ADLs and total assistance for dressing, toileting, and bathing. Restorative nursing for active range of motion, transfers and walking. The care plan dated 7/26/11 reported the resident at risk for isolation or injury due to behavioral needs due to insomnia and restlessness. Document behaviors as they occur and the outcome of interventions used, keep resident safe in low stimulus environment. Identify behaviors that affect residents or others quality of life. Develop individual behavior interventions of successful redirection and actions that successfully manage the behaviors. The care plan dated 7/26/11 reported the resident at risk for injury from falls related to history of falls at home, debility, and use of psychotropic medications, to assess risk for falls with MDS, assist with ADLs, mobility and transfers. An Untoward event investigation dated 10/19/11 reported swelling to left outer hand. The resident was sitting in a chair after getting a shower, certified nursing assistant reported the resident complained pain to the left hand during care and also swelling, no bruising is noted. The investigation recorded decreased range of motion to left hand; increased pain upon flexion of 3rd and 4th fingers. Staff obtained an x-ray which revealed an oblique non-displaced fracture to the 5th finger. The Facility complaint investigation report dated 10/19/11 reported the resident was quiet and calm, does not strike out at anyone or anything, could assist with ADLs such as feeding self, required assist with two person transfers with a gait belt, and he/she pushed up with his/her hands out of the wheelchair to transfer which is how "we believe the fracture happened". The care plan dated 2/4/12 reported the resident was at risk for injury and loss of self care abilities due to cognitive impairment due to dementia Alzheimer's type. At risk for injury due to behavioral needs due to depression, anxiety, psychosis, insomnia, and restlessness. Document behaviors as they occur and the outcome of interventions. Identify behaviors that affect residents or others quality of life. Develop individual behavior interventions of successful redirection and actions that successfully manage the behaviors. Monitor medication for desired effects and report any adverse side effects. At risk for injury from falls related to history of falls at home, debility, and use of psychotropic medications. Assist with ADLs, mobility and transfers as indicated. Consult therapy to assure resident's functional ability is optimized. Evaluate interventions and progress interventions as indicated to prevent injury. Check on resident frequently. Reinforce use of call light for transfers. Utilize bed and wheelchair alarms. At risk for complications due to being frequently incontinent of bladder. Check frequently throughout day for bladder incontinence. Assist to toilet in the morning, before and after meals, as needed. Check on resident frequently. Reinforce use of call light for transfers. Utilize bed and wheelchair alarms. At risk for complications due to being frequently incontinent of bladder. Check frequently throughout day for bladder incontinence. Assist to toilet in the morning, before and after meals, and as needed. Nurses notes on 2/15/12 at 3:30 P.M. noted the resident was found to have swelling on the lateral right hand 5th finger area and unable to verbalize how the injury occurred. The facility investigation report noted that the resident had been observed on may occasions banging the side of his/her hands on the side of the table. A staff questionnaire completed as part of this investigation reported that the resident bangs his/her hands on the table and has hand fracture on opposite hand in the past which was similar to this. An interview of staff completed as part of the facility investigation reported that the resident pounded his/her hand on the table, striking mid palm on the edge of the table, and that he/she had the same type of fracture on his/her other hand on 10/19/11. The radiology report dated 2/15/112 reported a comminuted angulated boxers type fracture, distal and fifth metacarpal of the right hand. No prior film for comparison therefore this was probably an acute fracture as there was soft tissue swelling also present. Observation on 3/21/12 at 8:40 A.M. revealed resident sat in wheelchair in dining room with staff assisting resident to eat, a splint on the resident's right hand (which had been placed pursuant to a physician's orders [REDACTED]. The resident was sitting quietly. Interview of direct care staff B on 3/21/12 at 11:10 A.M. indicated that the resident had a behavior of striking his/her hands on the table, and had this behavior since prior to his/her first hand fracture on 10/19/11. He/she said that the resident could not or would not tell them what he/she needed and did not complain of pain. He/she stated that after the resident's second hand fracture, staff padded the edge of the table. He/she said that the resident continued to exhibit this behavior of hitting. He/she said that they notified the nurses about the behavior and that they were supposed to document it. Interview of licensed nursing staff E on 3/21/12 at 11:20 A.M. indicated the resident had this behavior of hitting his/her hands on the table off and on since before the first fracture occurred. He/she stated that the resident occasionally still displayed this behavior. He/she said that the resident would hit the edge of the table with a flat hand, but usually strikes it with the medial (top, palm) side of the hand at which time staff pull him/her away from the table. He/she said the behavior was sometimes displayed when the resident was seeking attention of if another resident was being loud. He/she said that the behavior should be documented by the nursing staff but could not locate in the record any place where the staff recorded the behavior. Interview of licensed nursing staff F on 3/21/12 at 10:40 A.M. indicated that it was not known for sure how the resident sustained [REDACTED]. An interview of administrative nursing staff A on 3/21/12 at 11:30 A.M. indicated that it was the responsibility of the unit managers to complete care plan updates. He/she stated that if there was not an intervention documented in the care plan following the first fracture on 10/19/11, then there was no new intervention. He/she said that they believed at the time the first fracture was an isolated incident. He/she said that the behavior of striking hands on the table should have been documented either on the Behavior Monitoring sheets or in the care plan. The facility policy for Fall Prevention updated 12/12/11 included an Untoward Event/Assessment/Investigation Report which was required to be completed following any untoward event such as falls, injuries, and elopements etc. as stated by administrative nursing staff G. The facility policy for Psychotropic and Behavior Monitoring (undated) stated that behavior flow sheets would be initiated for all residents on the Special Care Unit; all residents on psychotropics and any resident with significant behavior problems. Behaviors would be documented by slash marks in the appropriate spaces and would be summarized weekly for anti-psychotic, otherwise monthly. This was a minimum requirement and more documentation may be required if the circumstances warrant. The facility failed to develop and implement interventions for this cognitively impaired resident with a known behavior of striking his/her hands on the dining room table following a left hand fracture on 10/19/11, which resulted in a fracture of the right hand on 2/15/12. - Resident #3 [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) of 12/6/11 documented the resident had short and long term memory problems. The resident was not able to recall current season, location of room, staff names and faces, or that she/he was in a nursing home. The resident had moderately impaired cognitive skills and made poor decisions with supervision and cueing required at all times. The MDS further documented the resident required extensive assistance of one staff with bed mobility and transfers, and total dependence of two staff with toileting. The MDS documented the resident had no falls since the prior assessment. The Care Area Assessment (CAA) dated 3/15/11 for Falls recorded the resident had an issue with positioning while in her/his wheelchair. Occupational Therapy (OT) had been involved and addressed the problem that placed her/him at risk for falls. The care plan revised 7/26/11 recorded beginning 4/20/10 the resident needed assistance of two staff persons for transfers and bathing, assistance of one staff for all other ADLs. The Certified Nursing Assistant (C.N.A.) 24 Hour Report Sheet updated on 2/9/12 documented the resident required moderate assistance of one staff and a gait belt with transfers. The facility provided an Untoward Event/Assessment/Investigation dated 2/15/12, noted the resident had a witnessed non-injury fall on 2/15/12 at 11:00 A.M. The nurse assessed the resident in the shower room where she/he was lying down on the floor with her/his head against the wall. Direct care nursing staff C (the only staff assisting the resident per interview) witnessed the fall and reported the resident had been given a shower and dressed. The resident stood at the bar in the shower room, the resident's leg "gave out" before the resident transferred to the other wheelchair. The care plan intervention dated 2/16/12 recorded to encourage staff to always have resident transferred by two staff persons when in the shower room. An observation on 3/21/12 at 11:18 A.M. revealed direct care staff C and D transported the resident to the shower room via wheelchair, secured a gait belt around the resident's waist, and assisted resident to a standing position. The resident was weight bearing on lower extremities, grabbed the transfer bar upon verbal cuing from staff, pivoted, direct care staff C removed incontinent product and resident sat on toilet. An interview on 3/20/12 at 2:29 P.M. with administrative nursing staff A verified after review of 2/15/12 Untoward Event/Assessment/Investigation that at this time of the fall only one nursing staff was present in the shower room with the resident. An interview on 3/21/12 at 9:27 A.M. with direct nursing staff C stated a Certified Nursing Assistant (C.N.A.) Hour Report Sheet was available at the nursing station which documented the level and amount of assistance required by the residents who resided on the unit. An interview on 3/21/12 at 9:41 A.M. with licensed nursing staff F stated staff utilized the C.N.A. 24 Hour Report Sheets on every shift, the charge nurse was responsible for making recent changes on the sheets, at the end of the shift and staff gave the sheet to administrative nursing staff H and she/he completed permanent updates on the report sheets as needed. An interview on 3/21/12 at 11: 49 A.M. with administrative nursing staff A stated administrative nursing staff H was responsible for updating care plans and C.N.A. assignment sheets. She/he further confirmed the intervention of two person assist with transfers was already care planned for this resident prior to resident's fall in shower room. The facility failed to implement interventions as planned to prevent falls for this cognitively impaired, dependent resident.

The facility identified a census of 159 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to have a system in place to meet residents needs promptly for 1 resident. (#48) This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #48's Physician order [REDACTED]. The annual Minimum Data Set (MDS) 3.0 with an Assessment Reference Dated (ARD) date of [DATE] recorded the resident had no cognitive impairment. The MDS further recorded the resident required total assistance for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. The MDS further recorded the resident did not walk and was independent for locomotion in his/her electric wheelchair. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] recorded the resident was a quadriplegic, had the [DIAGNOSES REDACTED]. The CAA further recorded the resident was alert and oriented, and had "very limited movement of (his/her) right hand and arm and required assistance for all ADLs." The ADL care plan dated [DATE] directed staff: Day shift: 2 staff assistance to place the resident in his/her wheelchair, assure the scrotum was repositioned so skin is not pinched or lodged between or under thighs, place his/her shirt on. Evening shift: Bowel Program, lay the resident on the left side with right leg bent with blanket between the thighs, put booties on both feet, pillow behind back, sheet over the resident, trash bag over the hip, nurse may need to do digital stimulation to initiate stool. Evening shift, bedtime ritual: rinse the resident's mouth with mouthwash, brush dentures, put into soak, blow his/her nose, wash his/her face, ears, and neck with a wet cloth, empty leg bag, clean and put bag in Ziploc bag and hang to dry, put catheter bag on and hang onto bed frame in dignity bag, hook the resident in the lift and with 2 staff present place the resident in bed, after in bed assure his/her scrotum was repositioned so skin is not pinched or lodged between or under thighs, position for comfort with pillows, put sheet over him/her, put his/her glasses up. Night shift care staff: get resident up, empty catheter of night urine, clean and put bag in Ziploc bag and hang to dry, no briefs, put leg bag over left ankle, rinse his/her mouth with mouthwash, brush dentures and place in mouth, blow the resident's nose, wash his/her face, ears, neck with wet cloth, put the resident's pants on, reposition his/her scrotum so skin is well aligned and skin not under or behind any pressure from thighs, put socks on. During an interview on [DATE] at 3:30 P.M. the resident stated on [DATE] he/she turned his/her call light on and staff did not answer the light for over an hour. The resident further stated he/she had an allergic reaction and had symptoms including burning in the chest, trouble breathing, jaw pain and a swollen tongue. The resident further stated he/she asked their roommate to call 911 which they did, and paramedics came to the facility and took the resident to the hospital. Observation of the resident on [DATE] at 3:30 P.M. revealed the resident in his/her room, and sat in his/her electric wheelchair. The resident appeared clean and well groomed. Review of the resident's hospital record dated [DATE] recorded the emergency medical responders took the resident from the facility to the hospital's emergency room with the [DIAGNOSES REDACTED]. It further recorded the resident had difficulty breathing and had a blood pressure reading at 9:33 P.M. of ,[DATE] millimeters (mm) of mercury (Hg), and hospital staff gave the resident immediate intravenous doses of medication including [MEDICATION NAME][MEDICATION NAME][MEDICATION NAME] and [MEDICATION NAME] in addition to 4 liters of oxygen and 1 unit of plasma and admitted the resident to the hospital's Intensive Care Unit (ICU). During interview on [DATE] at 4:32 P.M., administrative nursing staff C stated the facility neglected the resident by not answering his/her call light in a timely manner. During interview on [DATE] at 7:01 A.M., administrative staff A acknowledged the resident could have died if the paramedics had not arrived in time to help the resident. Review of the facility's hallway and nurse's station videotapes dated [DATE] revealed the resident turned his/her call light on at 7:18 P.M., and the light remained on until 8:44 P.M. when the paramedics entered the resident's room. During the 1 hour and 26 minutes the call light was on, direct care staff P was in the resident's hall 29 times and did not answer the resident's call light; direct care staff S was in the resident's hall 10 times and did not answer the resident's call light; licensed nursing staff U was in the resident's hall at the medication cart for 15 minutes (7:18 P.M.-7:33 P.M.) and did not answer the resident's call light, and licensed nursing staff T was in the resident's hall 2 times and did not answer the resident's call light. The videotape revealed several other staff in the resident's hall, but no one answered the resident's light. Review of direct care staff P's personnel file revealed the Employee Verbal Progressive Disciplinary Action form dated [DATE] (date of incident:[DATE]) for direct care staff P, and included the following information. "(Resident #47) had (his/her) light on at 5:45 A.M., call light not answered until 6:15 A.M. when (he/she) heard you in the hall and called you to help (him/her). Verbal exchanges made and your comments were inappropriate. The disciplinary form further stated the expectations for the future included, "You will treat the resident (with) respect fully and in a timely fashion. Call lights should be answered in 15 minutes or less. This is our resident's home and we are the intruder. If you feel ill at ease dealing with a resident, always take someone with you." Direct care staff P commented, " I did not have the argument as indicated though the resident has the right to express (his/her) feelings. I'm sorry for anything caused". During an interview on [DATE] at 2:11 P.M., administrative nursing staff C stated he/she expected staff to answer call lights promptly, and not longer than 15 minutes for all residents. During an interview on [DATE] at 3:13 P.M., administrative staff A stated his/her expectation was for staff to answer call lights as soon as possible, and no longer than 15 minutes, and that expectation was the same for all residents. The facility-provided policy entitled Abuse Reporting and Investigation dated [DATE] directed, "Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness" The facility-provided policy entitled Answering the Call Light dated [DATE] directed the purpose of the policy was to respond to the resident's requests and needs, and to provide a sense of security for the resident, and directed, "Answer the resident's call as soon as practical, in ,[DATE] minutes in a timely manner". On [DATE] at 3:15 P.M., administrative staff A acknowledged the immediate jeopardy this neglect posed to residents and stated the facility corrected the situation. The facility failed to answer the call light in a timely manner. The immediate jeopardy was abated on [DATE] based on the facility's written plan of correction that included: "1. Follow-up on resident's possible allergy to strawberries. Added to his/her care plan, kardex, front of chart and dietary notes. Lab testing had been done for allergies [REDACTED]. This information will be discussed with Registered Dietician, dietary manager, resident and family, and nursing staff. 2. Follow-up with employee suspensions (6 employees were suspended immediately and according to the employee disciplinary guide this suspension was for 5 days.) After this time two (direct care staff) continued their suspension indefinitely pending final investigation of the event which was sent to the state. Social workers interviewed other residents on 800 hallway to determine any other possible complaints/concerns regarding response time to call lights. Two nurses and two Certified Medication Assistants were brought back to work. 3. Camera tape from this hallway was reviewed showing that the nurse had also been on the hallway at the time (the resident's) call light was on. 4. Two employee's jobs were terminated, (named). 5. Inserviced all nursing personnel Monday-Friday shifts and weekend shifts call light response time. 6. Attached please see report of all employees at (facility) who have completed the Silverchair course of Preventing, Recognizing, and Reporting Abuse and Neglect. 7. Nursing completed follow-up charting to monitor for any further signs and symptoms of allergic reactions for seven days. Monitored for seven days for urinary tract infection and antibiotic side effects. Nurses are also charting any and all inappropriate behavior per behavior monitoring guide. 8. Monitoring by all nursing staff that all call lights are answered per facility policy. 9. Continue to work with social worker to address resident complaints and concerns. Social workers interview all alert and oriented residents to look for any possible trends in complaints. 10. Review of security tapes as necessary." 11. Security Officers will be employed to monitor facility call lights through the video surveillance system on the evening and night shifts until a new nurse call system can be installed. The new call system will alert the CNA then the charge nurse then the house supervisor/unit manager/Assistant Director of Nursing, and Director of Nursing. The administrator will get a report as necessary of any variances. 12. All department heads and nursing leadership team are making grounds at varied times to monitor call lights and other quality of care requirements. This deficient practice remained at a scope and severity of a G.

The facility identified a census of 154 residents with 15 residents sampled. Based on observation, interview and record review, the facility failed to ensure that one of one sampled residents (#11), a cognitively impaired dependent resident at high risk for and with a history of pressure ulcers did not develop a recurrent avoidable mucosal pressure ulcer. Findings included: - The facility admitted resident #11 on 10/8/09, with [DIAGNOSES REDACTED]. Review of the significant change Medicare 5-day Minimum Data Set (MDS) 2.0 assessment dated [DATE], recorded the resident with short- and long-term memory impairment, severely impaired decision-making skills, and required total staff assistance for transfers, dressing, toileting, personal hygiene and bathing. This same MDS assessment recorded the resident with an indwelling Foley catheter, a stage 1 and stage 2 pressure ulcer, abrasion or bruises, and skin desensitized to pain/pressure. Review of the Resident Assessment Protocol summary (RAPs) dated 12/14/09, recorded the resident needed assistance for most activities of daily living, general decline in ability to perform activities of daily living, and required assistance from two staff for transfers. Review of the Admission Nursing assessment dated [DATE] and timed 1:40 P.M., recorded the resident with open [MEDICAL CONDITION], pressure ulcers present (open area to the buttock and a red blanchable area). Review of the resident ' s plan of care dated 8/19/10 identified the resident at risk for impaired skin integrity and pressure ulcers. This plan of care directed staff to: -if a pressure ulcer developed, administer treatment as ordered, monitor for healing process and document specific measurements weekly -mandatory assessment risk for pressure ulcer due to current pressure ulcer, history of pressure ulcer, impaired bed mobility, bedfast, incontinent of bowel/and/or bladder, altered skin sensitivity to pain, impaired hydration or impaired nutrition on admission and with reassessment -mandatory: assure care team members monitor skin during treatment (licensed weekly skin check), routine care and bathing (checks by Certified Nursing Assistant report to charge nurse) -gentle moving and application of clothes and equipment -anchor indwelling catheter tubing to prevent tension Review of care plan addendums recorded the following: 3/4/10 Cleanse top of penis with normal saline, apply [MEDICATION NAME] and OpSite, change daily and monitor effectiveness of treatment. 3/11/10 [MEDICATION NAME] (protein supplement) one packet orally at bedtime, monitor wound healing. 5/21/10 Discontinue treatment to penis, apply triple antibiotic ointment (TAO) to penis around catheter. 5/26/10 Apply TAO on excoriated area on top of penis and around catheter each shift and monitor excoriations 6/15/10 Cleanse wound on top of penis with normal saline, apply [MEDICATION NAME] and OpSite each day, monitor the wound healing and notify the physician if wound worsens. Review of the resident ' s Treatment Administration Record dated 8/15/10 recorded a physician order [REDACTED]. Review of physician progress notes [REDACTED]. -1/8/10 - penis denuded (sic), 2 centimeters (cm) by 0.5 cm - stage 2 lesion with red characteristics(sic)., -1/29/10 - Staff wants us to assess his/her penis area, torn meatus 2 cm long, cleanse with triple antibiotic ointment twice daily to penis to heal. -2/12/10 - follow up for urethral bleeding, direct care staff present for exam. Report - short tubing was putting tension on urethra causing irritation. The resident needs a Foley catheter indefinitely; small tubing was back on catheter today and not anchored to the resident ' s leg. The staff to anchor catheter tubing to prevent tension on urethral meatus. -3/12/10 - penile wound- urethral area with excoriated area to shaft/glans, scant sanguineous drainage. -6/18/10 - area on glans reopened, staff began dressing area again. Review of the resident ' s skin assessment lacked documentation of any wound measurements. Review of nurse ' s notes recorded the following: 1/18/10 Noon, readmitted the resident with a Foley catheter present to dependent drainage. 2/14/10 (untimed) penis healing well, continued to be open area. OpSite not sticking and staying intact to penis. New physician order [REDACTED]. 3/3/10 10:10 P.M., Upon performing skin assessment, noted resident treatment for [REDACTED]. Notified wound nurse. Will continue to monitor. 3/10/10 7:30 A.M., Dressing changed top of penis, open area 2 cm by 2 cm approximately, without drainage. Excoriated area next to it approximately 1.0 cm by 0.5 cm without drainage. 3/13/10 11:50 P.M., Resident has open wound on his penis. Well dressed with [MEDICATION NAME] AG and covered with tape. 5/7/10 Noon, Open area on penis 0.5 cm by 0.5 cm no drainage. 5/19/10 2:15 P.M., Foley patent, area on top of penis being treated with [MEDICATION NAME] and OpSite is healed. 5/21/10 2:20 P.M., Order to discontinue treatment to penis and apply TAO to penis around Foley catheter. 5/25/10 7:30 A.M., Foley catheter changed ...Applied TAO on excoriated area on top of penis as orders. Notified physician ' s office. 5/26/10 2:10 P.M., Order to put TAO over excoriated area on top of penis and around catheter each shift. 6/15/10 3:30 P.M. Notified physician regarding area on penis being reopened and approximately 2 by 2 cms, measured. Wound bed looks (sic) without any drainage. Got order for dressing change daily. 7/17/10 2:15 P.M., Foley catheter patent ...open area of penis approximately 0.4 cm by 0.4 cm without drainage. Dressing changed as ordered. 8/12/10 7:45 A.M., Dressing to top of penis applied as ordered, several superficial open area without drainage. 9/7/10 11:30 P.M. Dressing intact to penis. 9/10/10 4:00 P.M., Physician practioner recommended staff pad the catheter at the penis with [MEDICATION NAME] and tape to prevent further damage to the resident ' s penis. Review of the resident ' s active clinical record revealed that from 1/8/10 to 9/13/10 the mucosal pressure sore healed and reopened three times and remained open on 9/13/10. During an interview on 9/9/10 at 1:30 P.M., licensed nursing staff D, reported staff measurement of the resident ' s pressure ulcer today approximately 0.5 cm by 0.5 cm, staff assess the wound, measure and document in the resident ' s record weekly. Licensed nursing staff D reported the ulcer on the resident ' s penis healed up and then appeared again periodically, where the Foley catheter tubing rubbed. Licensed nursing staff D confirmed the resident ' s clinical record lacked weekly documentation and measurements of the pressure ulcer. During an interview on 9/9/10 at 7:40 A.M., direct care staff C denied knowledge of how the resident acquired the open area on his/her penis. Observation of the resident ' s shower on 9/9/10 at 2:21 P.M., revealed direct care staff C dried the resident ' s right leg, catheter leg strap, and catheter leg bag, turned and twisted the catheter leg strap, which pulled the resident ' s Foley catheter and tugged against the upper edge of the resident ' s penile foreskin. The resident suddenly jerked up in the shower chair. Observation of a dressing change on 9/9/10 at 2:22 P.M., revealed licensed nursing staff D, gloved, removed the current dressing on the resident ' s penis, pulled the foreskin back to reveal a red-open mucosal area that measured approximately 0.5 cm by 0.5 cm. Licensed nursing staff D cleansed the area with normal saline, dried the area with sterile gauze and placed a 2 cm by 2 cm [MEDICATION NAME] square pad over the red-open area and then placed OpSite over [MEDICATION NAME] on the resident ' s retracted foreskin. On 9/9/10 at 2:20 P.M., direct care staff C reported, licensed nursing staff does skin assessments with resident showers. During an interview on 9/13/10 at 8:32 A.M., licensed nursing staff I reported the resident had a skin issue off and on with his/her penis related to the Foley catheter. Licensed nursing staff I reported facility monitor wound care with weekly review audits that included checking skin assessments, treatment plans, and physician orders [REDACTED]. On 9/13/10 at 9:59 A.M. licensed nursing staff J reported licensed nursing staff perform weekly skin assessment with resident showers or if not showered, during a bed bath after which staff document any changes in condition or skin issues. The facility provided policy for Skin Management and Pressure Ulcer Care dated 5/27/09 recorded: -Avoidable Pressure Ulcers are when the resident develops a pressure ulcer, or an existing pressure ulcer fails to heal adequately, because the steps of recognition, problem and cause identification, prevention and management, or monitoring were not done. -Admission documentation identified resident with an " at risk " status. The prevention interventions must be documented in the Plan of Care. -Any pressure ulcer identified in the first 24 hours of admission will not be classified as nosocomial. Those identified after 24 hours will be classified as nosocomial. -Progress of wound healing will be evaluated and recorded weekly. -Reassessment and re-evaluation of interventions will occur when progress is not noted (may include surface, nutritional support or treatment modality). -The Licensed Nurse Weekly skin Assessment report will be completed weekly on all residents at risk for skin breakdown and follow up action will occur as indicated. The skin assessment sheets are part of the resident ' s medical record. -A resident is " at risk " for skin breakdown - if the assessment indicates impaired bed mobility. -Physician orders [REDACTED]. According to the National Pressure Ulcer Advisory Panel (NPUAP) (<http://www.npuap.org>) 1/7/2010, recorded on Mucosal Pressure Ulcers an NPUAP Position Statement documented: Mucous membrane is the moist lining of the body cavities that communicate with the exterior. These tissues line passages such as nasal and urinary tract. Pressure applied to this lining can render it ischemic and lead to ulceration. Mucosal tissues are especially vulnerable to pressure from medical devices, such as urinary catheters and fecal containment devices. The clinical record lacked evidence to show staff appropriately notified the physician of the resident ' s lack of progress with wound healing and changes in treatments. The facility failed to perform and document weekly skin assessments with wound measurements by a licensed nurse. The facility further failed to provide appropriate care and prevention of a mucosal pressure ulcer for this cognitively impaired dependent resident with an indwelling Foley catheter at high risk for developing pressure ulcers that developed a facility acquired avoidable recurrent mucosal pressure ulcer.

The facility identified a census of 154 residents with 15 residents sampled. Based on observation, interview and record review, the facility failed to ensure that one of one sampled residents (#11), a cognitively impaired dependent resident with an indwelling Foley catheter received the necessary care and treatment to prevent injury, hospitalization , and recurrent urinary tract infections. Findings included: - The facility admitted resident #11 on 10/8/09, with [DIAGNOSES REDACTED]. Review of the initial admission Minimum Data Set (MDS) 2.0 assessment dated [DATE], recorded the resident with bladder incontinence and on any scheduled toileting plan. Review of the Admission Nursing assessment dated [DATE] and timed 1:40 P.M., recorded the resident continent of bladder, difficulty starting urine stream, needs a scheduled toileting plan, and pads/briefs used. Review of the incomplete admission 3-day bowel and bladder assessment dated [DATE] - 10/10/09 recorded the resident as independent and continent of bladder. Review of the resident ' s initial admission plan of care dated 10/21/09, identified the resident at risk for [MEDICAL CONDITION] complications for bladder and directed staff to: -assess for signs and symptom of urinary tract infection (fever 2 degrees above normal - burning/pain with urination, flank pain, chills, change in character of urine, worsening mental function, notify physician if present -encourage optimal hydration -implement check and change procedures - per resident voiding pattern - resident refuses to use briefs and will wet on himself several times during the day. He needs to be checked every 2 hours or more often and as needed. -resident has total incontinence of bladder, no sensation of urinating, no communication of need to urinate, has persistent and continuous loss of urine. Use skin care products as indicated -provide pericare per standards. -assess ability to reach and drink fluids at bedside and offered assist as needed and if impaired assure offered with care and treatments, is on [MEDICATION NAME] daily. Review of the resident ' s active clinical record lacked evidence of accurate assessments, monitoring and documentation of the resident ' s bladder function. Review of a hospital history and physical dated 11/30/09, recorded the following: A chief complaint of distention, the resident has had abdominal distension over the last couple of days, increasing lethargy. He/she began becoming tremulous and having decreased oral intake. He/she was placed in a nursing home about a month ago; this steadily declined with the most obvious decline just the past couple of days. Significant abdominal distension and was being treated with laxatives. He/she came to the emergency department. A Foley catheter was placed and he/she immediately [MEDICATION NAME] over 3 liters (of urine). His/her blood pressure dropped, after he/she [MEDICATION NAME], into the 70s. A CAT scan of the abdomen and pelvis showed very distended urinary bladder, stool throughout the colon of moderate amount (no evidence of bowel obstruction), and compression fractures (old). Review of a hospital physician consultation report dated 12/2/09, recorded the resident with [MEDICAL CONDITION], a Foley catheter placement with 3 liters of residual urine and that the Foley will need to remain in place unless the patient could become ambulatory. Review of the residents ' active clinical record revealed an admission back to the facility from the hospital on [DATE]. Review of the significant change Medicare 5-day (MDS) 2.0 assessment dated [DATE], recorded the resident with short- and long-term memory impairment, severely impaired decision-making skills, and required total staff assistance for transfers, dressing, toileting, personal hygiene and bathing. This same MDS assessment recorded the resident with an indwelling Foley catheter. Review of the Resident Assessment Protocol summary (RAPs) dated 12/14/09, recorded the resident needed assistance for most activities of daily living, general decline in ability to perform activities of daily living, and required assistance from two staff for transfers. This same RAPs recorded the resident with a recent hospitalization , [MEDICAL CONDITION], and urinary outlet obstruction and returned with an indwelling Foley catheter. Review of the residents ' plan of care dated 8/19/10, for urinary care directed staff to: -assess for signs and symptoms of urinary tract infection (fever 2 degrees above normal, burning/pain with urination - flank pain, chills, change in character of urine, worsening of mental function). Notify physician if present. -encourage optimal hydration. -implement check and change procedures (on 10/19/09) -Resident now has indwelling Foley catheter. -monitor bowel movement pattern to prevent stool in fecal vault from triggering incontinence. -provide pericare per standards -administer medications (antimuscarinics) as ordered -anchor indwelling catheter tubing to prevent tension -assure Foley care per procedure and assure Foley is medically justified. -catheterize per orders and standards -please anchor urethral to resident ' s leg to prevent tension on urethral meatus -Foley bag at night, leg bag throughout the day -empty Foley every shift -Foley catheter care every shift and as needed (prn). Review of nursing notes dated 1/16/10 recorded the following: Late entry for 6:00 A.M., " Foley changed as ordered. No blood or discharge noted. No resistance or any signs or symptoms of bleeding. Resident tolerated procedure without any signs or symptoms of pain or discomfort. No return was noted after first insertion of the catheter. Catheter was pulled back and re-inserted, another nurse present during this procedure. Will monitor for urine output. Checked on, no urine output in Foley catheter. On-coming nurse informed to monitor for urine output. " Timed 11:30 A.M., " at 11:00 A.M., no urine output noted in Foley. Attempted to change Foley and when Foley taken out, blood noted from penis. An 18 French, 30 cubic centimeter (retention-bulb) Foley attempted to be inserted and unable to insert due to resistance and blood continued to come out of penis. Physician notified and new order to send resident to acute care hospital emergency room for treatment and evaluation. Resident transferred by ambulance at 11:30 A.M. " Review of a nursing home to acute care hospital transfer form dated 1/16/10 timed 12:15 P.M. recorded the " resident having bleeding through penis, unable to place Foley due to resistance. Foley placed at 6:00 A.M. and at 11:00 A.M., no urine. Attempted to replaced, when Foley was taken out, blood was coming from penis and unable to place Foley. " Review of an acute care hospital Operative Report dated 1/16/10, documented: " Cystoscopy - urethra had a marked amount of clot within the entire urethra. I was able to remove some of this clot and finally negotiate the cystoscopy into the bladder. There was almost a cup full of old dark red blood clot within the bladder. This was irrigated with an Ellik evacuator. Inspection of the urethra revealed too much clot to assess any area of injury to the urethra, although clearly this is the site of the injury. A urethral catheter was placed into the bladder. " Review of nurse ' s notes recorded the following: 1/18/10 Noon, readmitted the resident with a Foley catheter present to dependent drainage. Review of care plan addendums recorded the following: 2/3/[MEDICATION NAME](antibiotic) 500 milligrams on day one, 250 milligrams daily days 2-5 for urinary tract infection, start antibiotic protocol. Monitor color, odor, amount urine, encourage fluids, monitor temperature. 3/5/10 Recollect urinalysis from collection port on Foley catheter. Monitor urine for sediment, foul odor, and dark coloration 3/10/10 Bactrim DS (antibiotic) twice daily for 5 days for urine positive [MEDICAL CONDITION] (MRSA). Monitor signs and symptoms of adverse reaction, monitor effectiveness. 4/5/10 [MEDICATION NAME] (antibiotic) 500 milligrams day one. [MEDICATION NAME] 250 day 2 and day 3. Monitor for adverse reactions, effectiveness. 4/5/10 [MEDICATION NAME] (antibiotic) four times daily - monitor adverse reactions, effectiveness 5/17/10 Bactrim DS (antibiotic) twice daily for 5 days. Monitor for signs and symptoms of adverse reactions 6/14/10 [MEDICATION NAME] (antibiotic) 250 milligrams daily for 7 days for urinary tract infection. Monitor signs and symptoms of infection, behaviors, and adverse reactions. 6/16/10 -MRSA of urine (Bactrim (antibiotic)/urinary tract infection) Monitor adverse reactions, educate staff of hand-washing, wearing gloves - Review of a lab report dated 6/23/10 recorded greater than 100,000 colonies of staphylococcus aureus and greater than 100,000 colonies of pseudomonas aeruginosa. Review of physician progress notes [REDACTED]. -11/30/09 - follow up on residents toe wounds, resident not feeling well, okay this A.M., just tired, per staff now lethargic and patient not responding appropriately verbally. Cardiovascular: irregular 98 apical pulse, abdomen: distended firm centrally, hypoactive bowel sounds. No [MEDICAL CONDITION]. Labs: Bun 70 (normal 5.0-25.0 millimoles/liter), creatinine 3.1 (normal 0.5-1.5 milligram/deciliter) and sodium 128 (normal 138-153 millimoles/liter)... -1/29/10 - Staff wants us to assess his/her penis area, torn meatus 2 cm long, cleanse with triple antibiotic ointment twice daily to penis to heal, might end up and have to have a suprapubic catheter. -2/12/10 - follow up for urethral bleeding, direct care staff present for exam. Report - short tubing was putting tension on urethra causing irritation. The resident needs a Foley catheter indefinitely; small tubing was back on catheter today and not anchored to the resident ' s leg. The staff to anchor catheter tubing to prevent tension on urethral meatus. Review of nurse ' s notes recorded the following: 9/12/10 (time unreadable) " This nurse changed resident Foley under the supervision and direction of the house supervisor 7A - 7P. Urine dipstick was supposed to be performed but urine never returned. Resident continue to denied pain after change when ask after 30 minutes. Resident showed no s/s of discomfort. Report given to oncoming nurse, assess Foley and the need for dipstick urine sample for urinalysis and culture/sensitivity, too. " 9/12/10 timed 9:30 P.M., " A Foley, 18 French-10 cubic centimeter (cc) (sic-bulb) inserted with a return of yellow urine, about 350 cc collected at this time. UA specimen collected. " 9/12/10 timed 10:00 P.M., dipstick done on urine, positive for leucocytes ...positive for [MEDICATION NAME], blood positive +1 ...Urinalysis directed per standing physician order [REDACTED]. During observation on 9/9/10 at 7:28 A.M., direct care staff C provided privacy, washed his/her hands and put on gloves, then unclamped the dependent drainage Foley bag at the end and empties it into a urinal (approximately 100 cubic centimeters of urine). Direct care staff C emptied the urinal in the toilet, then partially filled the urinal with water from the sink, rinsed the urinal out in the sink, and placed the urinal in a trash bag. Direct care staff C rewashed his/her hands applied gloves and opened a new wrapped bag with a sterile Foley catheter leg bag and new bag with a Foley catheter extension tubing (approximately 15-18 inches long). Direct care staff C removed the protective ends, cleaned the sterile end of the extension tubing and cleaned the sterile end of the leg bag with alcohol then attached one end of the tubing into the leg bag and laid the leg bag with extension tubing attached on the resident ' s bed spread (without a sterile barrier). Direct care staff C then opened the resident ' s incontinence brief, detached the dependent drainage tubing from the indwelling Foley catheter, laid the tubing on the bedspread, cleaned the outside edge of the catheter tubing with an alcohol swab, picked up the leg bag and extension tubing from the bedspread and attached it to the extension tubing in leg bag. Direct care staff C then picked up the dependent drainage tubing and bag, flipped the tubing toward the surveyor on the way to the trashcan. Direct care staff reported staff replaced the dependent drainage bag and leg bag with extension tubing every day with a new bag. During observation of catheter care on 9/9/10 at 7:40 A.M., direct care staff, washed his/her hands, put on gloves, opened the resident ' s incontinence brief, pulled the resident ' s foreskin back from the end of the penis, (which revealed a small intact pad with OpSite dressing cover dated 9/9/10. Direct care staff C, cleaned the area around the Foley catheter insertion into the resident ' s penis with an alcohol swab. Staff failed to cleanse the perineal area or any of the resident ' s penis. During an interview on 9/9/07 at 7:40 A.M., direct care staff C reported licensed nursing staff performs catheter care for the resident. When asked how the resident obtained a wound on the penile foreskin, the direct care staff C reported, he/she " did not know " . During an interview on 9/9/10 at 1:30 P.M., licensed nursing staff D, reported direct care staff perform catheter shift for the resident at least each shift. Licensed nursing staff D reported that measurement of the resident ' s penile ulcer today was approximately 0.5 centimeters (cm) by 0.5 cm and staff assesses the wound, measures and documents in the resident ' s record weekly. Licensed nursing staff D reported the ulcer on the resident ' s penis had healed up and then appeared again periodically, where the Foley catheter tubing rubbed. During an interview on 9/13/10 at 8:32 A.M., licensed nursing staff I reported the resident had a skin issue off and on with his/her penis related to the Foley catheter. On 9/13/10 at 9:59 A.M. licensed nursing staff J reported that any nursing or direct care staff can staff perform Foley catheter care just like total incontinence care after each incontinent episode, with bathing and hygiene when the Foley catheter is changed. Licensed nursing staff J stated nursing changed the Foley catheter each month and change from dependent drainage bag at night to a leg bag during the day. The facility provided undated policy for Giving Daily Urinary Catheter Care directed staff to - " check to see that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Catheter tubing should be strapped to the resident ' s inner thigh). -Steps in the procedure for urinary catheter insertion: -insert the catheter gently into the meatus (approximately 2-3 inches) or until urine begins to flow. -Insert the Foley and inflate the balloon to its capacity with sterile water per physician's order [REDACTED]. Test it by sliding the Foley freely until the balloon reaches the bladder neck.). The resident ' s assessment should include - any problems or limitations as a result of the Foley Catheter. The resident ' s plan of care should address - when catheter care is to be given and by whom. The residents ' medical record should reflect that: 1. The resident is assessed for urinary tract infection. 2. The resident has no abdominal distension. 3. The resident has been assessed for a bladder and bowel-retraining program. 4. Goals have been modified as necessary. 5. Appropriate catheter care is being provided. The facility provided policy Catheter Drainage Bags dated 7/23/02, directed that staff clamp the catheter before disconnecting cleanse connecting site with an alcohol wipe, remove protective cap form catheter adapter and connect to the catheter. Review of the Catheter Care Competency Test review sheet recorded: -For females, separate labia---for males; push back foreskin -Wash perineum well with soap and water or wipes, taking care to wash from front to back; using one area of washcloth per stroke; rinse well (if using soap) using the same procedure. If using wipe use new wipe per each wipe. -Cleanse area of catheter insertion well, being careful not to pull on catheter or advance further into urethra. -Wash catheter itself by holding onto catheter at insertion site, wash with one stroke downward from meatus. -Towel dry perineal area on the male return the foreskin to normal position. -Secure catheter The clinical record lacked evidence to show staff performed a comprehensive bladder assessment and adequately monitored the resident ' s incontinence for a pattern of [MEDICAL CONDITION]. The facility failed to provide urinary catheter care in accordance with their established policy and appropriate necessary care and treatment in a manner to prevented urethral injury that required emergent hospitalization and acute medical treatment for [REDACTED].