Every finding on record at Village at Hillside

Based on interview and record review it was determined the facility failed to use the services of a registered nurse for at least eight consecutive hours a day for 19 of 46 days reviewed for staffing. This placed residents at risk for lack of RN oversight including comprehensive assessments. Findings include: A review of the Direct Care Staff Daily Reports for dates from 6/1/24 through 7/16/24 revealed no RN coverage during the 24-hour period on the following dates: - 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/10/24, 6/11/24, 6/12/24, 6/16/24, 6/18/24, 6/19/24, 6/22/24, 6/23/24, 6/25/24, 6/26/24, 7/2/24, 7/3/24, 7/6/24, 7/7/24, 7/10/24 In a follow up interview on 7/18/24 at 10:00 AM Staff 1 (Administrator) was informed of the identified dates when the staffing sheets indicated there was a lack of RN coverage. Staff 1 acknowledged there was no RN working as a charge nurse for at least 8 hours on the identified dates.

Based on observation and interview it was determined the facility failed to provide a sanitary kitchen environment, document food temperatures and ensure staff wore appropriate hair restraints during meal preparation for 1 of 2 kitchens reviewed for sanitation. This placed residents at risk for unsanitary food and cross contamination. Findings include: 1. On 7/15/24 at 9:23 AM and 7/17/24 at 7:21 AM, the inside of the refrigerator in the kitchen was observed to have three small fans circulating air, and each fan had approximately a quarter-inch buildup of dust particles. The ceiling of the refrigerator above the three fans had multiple visible dust particles. Adjacent to the three fans was a black insulated tubing which had visible dust particles on the exterior of the insulated tubing. On 7/17/24 at 10:18 AM Staff 6 (Certified Dietary Manager) and Staff 7 (Registered Dietician) both observed and acknowledged the three fans, the ceiling and the black insulated tubing were dirty and had a visible build-up of dust particles. 2. On 7/15/24 at 9:43 AM and 7/17/24 at 10:16 AM Staff 5 (Executive Chief) was observed in the kitchen prepping meals without a hair restraint or a beard restraint. On 7/17/24 at 10:18 AM Staff 6 (Certified Dietary Manager) and Staff 7 (Registered Dietician) observed Staff 5 without a hair or a beard restraint in the kitchen. Staff 7 stated she expected Staff 5 to have a hair and beard restraint whenever he was in the kitchen. 3. On 7/17/24 at 7:34 AM Staff 4 (Cook) was observed checking temperatures for hot breakfast items but she did not write down or log the food temperatures. Staff 4 stated they were out of the temperature log sheets and she was not able to record the temperatures. On 7/17/24 at 10:18 AM food temperature logs were requested. At 12:46 PM, Staff 7 provided one Dietary Food Temperature Log dated 7/16/24, which had nine breakfast items with temperatures listed on the form. Staff 7 stated she could not locate any other food temperature logs. Staff 7 stated staff were checking food temperatures but not recording them on the temperature log form. Staff 7 stated she expected staff to complete temperature checks for each meal and record the temperature on the temperature log form.

Based on interview and record review it was determined the facility failed to follow up on pharmacist recommendations for 1 of 5 sampled residents (#11) reviewed for unnecessary medications. This placed residents at risk for unnecessary medication administration. Findings include: Resident 11 admitted to the facility in 2023 with diagnoses including migraines and pain. Review of the 7/1/24 physician orders indicated Resident 11 received Depakote (anticonvulsant) BID for migraines and Miralax (laxative) as needed for constipation. Review of Resident 11's pharmacist reviews indicated the following recommendations: - 5/2024 recommended to clarify the order to administer Miralax with food/meals. There was no indication of follow up or a response by the physician. - 7/2024 recommended a gradual dose reduction (GDR) of the Depakote from BID to once a day at bedtime. The physician was noted to indicate yes and accepted the recommendation on 7/3/24. Review of the 7/2024 MAR from 7/4/24 through 7/16/24 indicated Resident 11 was still receiving Depakote BID. Review of the 5/2024, 6/2024 and 7/2024 MAR revealed no indication the use of Miralax was updated to include direction to be administered with food/meals. On 7/17/24 at 9:33 AM Staff 2 (LPN Resident Care Manager) stated she assisted with monthly pharmacist reviews. Staff 2 stated pharmacist recommendations were faxed to the physician and the facility typically received a response promptly. Staff 2 stated when a response was received, orders were either changed or updated. Staff 2 stated she misread the 7/2024 pharmacist recommendation for the Depakote and the recommendation to reduce Resident 11's Depakote was not implemented. Staff 2 also acknowledged there was no information to indicate the Miralax recommendation was followed up on.

Based on interview and record review it was determined the facility failed to include the resident's representative in care planning for 1 of 1 sampled resident (#8) reviewed for care planning. This placed residents at risk for lack of resident-centered care planning. Findings include: Resident 8 was admitted to the facility in 7/2023 with diagnoses including dementia and anxiety. Resident 8's 5/5/24 Quarterly MDS indicated Resident 8 had severe cognitive impairment. Resident 8's Profile Sheet, reviewed on 7/18/24, indicated she/he had a resident representative. A 1/14/24 Collaborative Care document indicated Resident 8 had a care conference on 1/14/24. In an interview on 7/15/24 at 3:01 PM Witness 1 (Family) stated they did not participate in a care conference in the past year. He said he did not get medical information unless he asked for it and Witness 1 said he was not notified of updates/changes to the resident's care plan or outcomes of healthcare provider visits. A review of Resident 8's clinical record revealed no indication that the resident representative was contacted regarding the resident's care plan. In an interview on 7/17/24 at10:40 AM Staff 3 (Social Service Coordinator) stated Resident 8's family was not offered a care conference since 1/2024.

Based on interview and record review, it was determined the facility failed to ensure residents did not receive unnecessart blood pressure medication for 1 of 5 sampled residents (#3) reviewed for medications. This placed the resident at risk for low blood pressure. Findings include: Resident 3 was admitted to the facility in 2/2022 with diagnoses including essential hypertension. A review of Resident 3's medication orders revealed an order dated 3/14/24 for verapamil HCI tablet 120 mg (an antihypertensive medication) to be given 1 time a day related to hypertension with instructions to hold for blood pressure less than 100 systolic or 60 diastolic. The order also indicated to hold the medication for pulse less than 60. A review of Resident 3's MARs dated 6/1/24 through 7/15/24 revealed six instances that the verapamil was administered when the resident's blood pressure or pulse were outside of ordered parameters: 6/8/24, 6/9/24, 6/21/24, 6/24/24, 6/26/24 and 7/6/24. During an interview with Staff 8 (RN) on 7/18/24 at 10:28 AM she stated stated she would expect the medication to be held when blood pressure or pulse was not within the ordered parameters. She confirmed that the medications were documented as administered on those dates.

Based on interview and record review it was determined the facility failed to inform the resident's representative of the risks and benefits of psychotropic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for not being informed of adverse side effects of medications. Findings include: Resident 8 was admitted to the facility in 7/2023 with diagnoses including dementia and anxiety. Resident 8's 5/5/24 Quarterly MDS indicated Resident 8 had severe cognitive impairment. Resident 8's Profile Sheet, reviewed on 7/18/24, listed a resident representative (Witness 1). Resident 8's record included a Physician Order dated 7/27/23 for citalopram hydrochloride (an antidepressant) 10 MG oral tablets daily. The 7/2023 MAR indicated Resident 8 began receiving the citalopram on 7/28/23. Resident 8's health record revealed a consent for citalopram signed by Witness 1 (Family) on 10/5/23 (more than two months after the resident began receiving citalopram). No evidence was found to indicate Resident 8 and Witness 1 were provided with risks and benefits of citalopram prior to the start of administration in 7/2023. In an interview on 7/17/24 at 2:30 PM Staff 2 (Resident Care Manager/MDS Coordinator) acknowledged the lack of timely notification of risks and benefits of citalopram.

Based on interview and record review it was determined the facility failed to ensure appropriate services and medical equipment were provided at time of discharge for 1 of 3 sampled residents (#11) reviewed for facility discharge. As a result, the unsafe discharge resulted with Resident 11 experiencing unnecessary hardship and pain. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses including essential tremors, left hip hemiarthroplasty (partial hip joint replacement). Resident 11's 2/17/23 Admission MDS indicated she/he was cognitively intact. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending was issued on 2/15/23 and indicated skilled services would end on 2/17/23. The physical therapy discharge summary, dated 2/16/23, indicated Resident 11 was a moderate fall risk, used a front wheel walker (FWW), and was making progress but limited due to only receiving three treatments. PT discharge recommendations included FWW, daily check-ins and home health PT. The occupational therapy discharge summary, dated 2/16/23, indicated Resident 11 required supervision or hands-on assistance with toilet transfers, showers, and lower body dressing using adaptive equipment. OT discharge recommendations included community support, home health OT, PT, bath aide, raised toilet seat, grab bars in shower, wheelchair and FWW. A nursing progress note on 2/17/23 indicated the resident requested to discharge that day at 11:30 AM. A Transition of Care and Discharge Summary, dated 2/17/23, indicated Resident 11 was independent with toilet transfers, showers, and lower body dressing and did not receive any therapy services during her/his stay. A walker was recommended, and no home health services were ordered. A 3/13/23 hospital discharge summary revealed Resident 11 was readmitted to the hospital on 3/8/23 for a revision surgery undergoing a left hip hemiarthroplasty and open reduction and internal fixation due to a femur fracture (surgical procedure in which broken pieces of thigh [femur] bone are held together by hardware such as metal rods, pins or screws) with partial weightbearing on left lower extremity. On 3/20/23 at 2:21 PM Resident 11 stated she/he was discharged home too soon, stated she/he trusted the facility when she/he was informed she/he was ready to go home and expected that the resources would be at her/his home already. No services, resources or equipment were set-up when Resident 11 arrived home. Resident 11 had to call a local community resource center to borrow a wheelchair and walker to get out of the car and into her/his home. Home health was never started. Resident 11 further stated she/he felt her/his left hip was refractured a week after being at home. Resident 11 was not able to get around her/his home without being in a wheelchair and the pain was unbearable. Resident 11 stated she/he did not take her/his medications for several days due to pain, not being able to move and not being able to reach her/his medications due to obstacles in the home. Resident 11 stated she/he requested x-rays from her/his surgeon due to the unbearable pain, inability to walk and weightbear on her/his left leg. Resident 11's surgeon admitted resident to the hospital for a revision surgery due to a left femur fracture on 3/8/23. On 3/21/23 at 11:11 AM Staff 3 (Operations Consultant RN) stated there was no additional documentation or paperwork regarding Resident 11's discharge regarding services provided or plan for Resident 11's discharge. On 3/22/23 at 11:07 AM Staff 2 (DNS) stated she completed the Transition of Care Discharge Summary on 2/17/23 however did not recall any information regarding the discharge.

Based on interview and record review it was determined the facility failed to staff an RN for 8 consecutive hours per day 7 days per week for 6 out of 113 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the facility's Pay Based Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 4 (7/2022, 8/2022 and 9/2022) revealed the facility reported the following dates the facility failed to provide staff an RN for eight consecutive hours a day for the following dates: 7/4/22, 7/23/22, 7/24/22, and 8/5/22. The Direct Care Staff Daily Reports from 3/1/23 through 3/20/23 revealed the facility did not have RN staffed on 3/11/23 and 3/18/23. On 3/24/23 at 10:05 AM Staff 1 (Administrator) acknowledged the PBJ Quarter 4 reported information and the 3/11/23 and 3/23/23 lack of RN coverage for 8 consecutive hours a day. No additional information was provided.

Based on interview and record review it was determined the facility failed to staff a licensed nurse on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and standards of nursing practice for 36 of 113 days reviewed for staffing: This placed residents at risk for lack of care. Findings include: Review of the facility's Pay Based Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 4 (7/2022, 8/2022 and 9/2022) revealed the facility reported the following dates the facility failed to have licensed nursing coverage, no RN or LPN, for 24 hours a day: 7/2/22, 7/16/22, 7/26/22, 7/27/22, 7/30/22, 7/31/22, 8/1/22, 8/2/22, 8/3/22, 8/4/22, 8/5/22, 8/6/22, 8/7/22, 8/8/22, 8/9/22, 8/10/22, 8/11/22, 8/15/22, 8/16/22, 8/17/22, 8/18/22, 8/22/22, 8/27/22, 8/29/22, 8/30/22, 8/31/22, 9/1/22, 9/12/22, 9/13/22, 9/18/22, 9/19/22, 9/20/22, 9/24/22, 9/25/22, and 9/26/22. On 12/28/22 a public complaint alledged on 12/24/22, in the afternoon, a resident did not receive medication due to no (licensed) nurse in the facility. On 3/23/23 at 12:03 PM Staff 5 (Human Resources Director) provided a list of staff hours worked on 12/24/22. On 12/24/22 between 4:02 PM and 5:56 PM the facility did not have a licensed nurse, no RN or LPN, available for resident care, needs or medications. On 3/24/23 at 10:05 AM Staff 1 (Administrator) acknowledged the PBJ Quarter 4 reported information. Staff 1 stated none of the current management staff were employed during the PBJ report time, he thought there should have been licensed staff in the facility but could not confirm or deny. Staff 1 was not able to provide additional documentation. Staff 1 acknowledged the 12/24/22 lack of licensed nurse coverage between 4:02 PM and 5:56 PM. No additional information was provided.

Based on observation, interview and record review it was determined the facility failed to ensure linens fit residents' beds for 2 of 2 sampled residents (#s 5 and 11) reviewed for linens. This placed residents at risk for uncomfortable sleeping conditions. Findings include: 1. Resident 5 was admitted to the facility in 2019 with diagnoses including diabetes. A 2/23/23 Quarterly MDS indicated the resident had some memory impairment but was able to communicate her/his needs. On 3/20/23 at 10:35 AM Resident 5 stated the fitted bottom sheets did not stay on the mattress. On 3/22/23 at 12:21 PM Resident 5 was observed in bed and the top half of the mattress was exposed. The fitted sheet was only visible to be on at the foot of the mattress. Resident 5 indicated the fitted sheets have been an issue for a long time. On 3/22/23 at 2:22 PM Staff 12 (Housekeeping) stated the facility had a hard time obtaining fitted sheets that fit all the beds. Staff 12 indicated she needed to go to the resident rooms to measure the mattresses and see which sheets fit the beds. On 3/22/23 at 12:24 PM Staff Staff 9 (CNA) stated for at least the last three months the facility did not have enough fitted sheets for all the beds. On 3/22/23 at 12:31 PM Staff 2 (DNS) and Staff 3 (Operational Consultant RN) stated the facility had a variety of beds, some were longer and wider than others, and acknowledged some of the fitted sheets did not fit all the mattresses. 2. Resident 11 was admitted to the facility on ,d+[DATE] with diagnoses including revised left hip surgery (partial hip joint replacement). A 3/16/23 Admission MDS indicated the resident was cognitively intact. On 3/22/23 at 11:10 AM two rough textured bath blankets were observed to be used as Resident 11's bottom sheet. On 3/23/23 at 9:19 AM Staff 19 (CNA) stated she used bath blankets as bed linens for at least a month or so on some beds due to a shortage of bed linens. On 3/23/23 at 4:17 PM was observed Resident 11 laying on two bath blankets used as a bottom sheet. Resident 11 stated the CNA just made her/his bed after her/his shower. Resident 11 stated she/he wished the bed linen was softer and smoother, but did not want to complain. On 3/22/23 at 12:31 PM Staff 2 (DNS) and Staff 3 (Operational Consultant RN) stated the facility had a variety of beds, some were longer and wider than others, and acknowledged some of the fitted sheets did not fit all the mattresses.

Based on interview and record review it was determined the facility failed to ensure a resident's advance directive was available for staff access in case of an emergency for 1 of 2 sampled residents (#1) reviewed for advance directives. This placed residents at risk for lack of end of life choices being honored. Findings include: Resident 1 was admitted to the facility in 5/2022 with diagnoses including back pain. The 2/26/23 Care Conference form indicated the resident had an advance directive. A 2/2023 Quarterly MDS indicated Resident 1 was cognitively intact. On 3/20/23 at 2:13 PM Resident 1 stated she/he filled out an advance directive. Resident 1's record did not contain a copy of her/his advance directive. On 3/20/23 at 2:20 PM and 3/21/23 at 9:51 AM Staff 2 (DNS) indicated upon admit staff were to ask residents if they had an advance directive. If the resident had one, the staff were to obtain a copy for the resident's record. Staff 2 stated Resident 1 had an advance directive but it was in the resident's previous living community and not in the facility where staff had immediate access.

Based on interview and record review it was determined the facility failed to ensure the ombudsman was notified of a resident's discharge for 1 of 1 sampled resident (#12) reviewed for hospitalization . This placed residents at risk for lack of advocacy assistance. Findings include: Resident 12 was admitted to the facility in 2022 with diagnoses including chronic lung disease. Progress Notes indicated on 1/23/23 Resident 12 reported she/he did not feel well. The resident's physician was notified and the resident was sent to the hospital for evaluation and treatment. The note indicated the family was notified but did not indicate the ombudsman was notified. On 3/24/23 at 8:48 AM Staff 4 (Social Services Director) stated she was new to the facility. Generally they notified the ombudsman and kept a log. The log only went back to 12/2022. Staff 4 stated there was no documentation which indicated the ombudsman was notified of Resident 12's discharge.

Based on interview and record review it was determined the facility failed to ensure laboratory services were obtained for 1 of 1 sampled resident (#2) reviewed for change of condition. This placed residents at risk for delayed treatment. Findings include: Resident 2 was admitted to the facility in 2022 with diagnoses including cognitive impairment. Progress Notes indicated on 12/8/22 Resident 2 had increased confusion, poor intake and a low grade fever. The resident's physician was notified and ordered a UA. On 12/10/22, Saturday, the facility staff called the laboratory to follow-up on the UA specimen pick-up. The note indicated the laboratory did not come to the facility on the weekends and a new UA would be collected on 12/11/22, Sunday, for an early 12/12/22, Monday, pick-up. On 3/21/23 at 3:25 PM Staff 2 (DNS) stated the facility used the local hospital laboratory and they only picked up samples Monday through Friday. Samples which were marked as urgent would be picked up on Saturday and Sunday. Staff 2 indicated on the weekend if a UA was not ordered as urgent the facility staff were to take to the sample to the hospital for processing to ensure treatment, if indicated, was not delayed. See F684 Example 1 (a) and (b) for additional information.

Based on observation and interview it was determined the facility failed to store treatment supplies in locked compartments for 1 of 1 treatment cart observed. This placed residents at risk for accidents. Findings include: On 3/20/23 from 10:03 AM through 10:16 AM an unlocked treatment cart was observed outside of the nurse's station. Staff were observed to walk by the cart but did not lock the cart. There were no residents in the area. On 3/20/23 at 10:22 AM Staff 3 (Operations Consulting RN) stated the treatment cart contained different items used for treatments and confirmed it was to be locked. On 3/20/23 at 2:16 PM this surveyor and Staff 2 (DNS) walked by a treatment cart at the nurse's station. The treatment cart was observed to be unlocked. There were no staff or residents near the treatment cart. The cart contained insulin, needles and creams. Staff 2 stated the cart was to be locked.

Based on interview and record review it determined the facility failed to obtain a UA per physician orders and monitor a resident for signs of a UTI for 1 of 1 sampled resident (#2) reviewed for change of condition, failed to follow physician parameters for medication administration for 1 of 5 sampled residents (#2) and failed to document a rationale for a decrease in a resident's antidepressant and monitor the residents after the medication change for 2 of 5 sampled residents (#s 2 and 5) reviewed for medications. This placed residents at risk for delayed treatment and adverse medication reactions. Findings include: 1. Resident 2 was admitted to the facility in 2022 with diagnoses including depression. a. Progress Notes indicated on 12/8/22 Resident 2 had increased confusion, poor intake and a low grade fever. Resident 2's physician was notified and ordered a UA. Resident 2's record did not reveal results of the UA. On 3/22/23 at 10:14 AM Staff 2 (DNS) stated a UA was not obtained per physician orders. b. A 12/8/22 Progress Notes revealed Resident 2 had increased confusion, had poor intake and a temperature of 100.7 degrees F. After Tylenol (reduces fever) was administered the resident's temperature decreased to 99.5 degrees F. The note also indicated the resident received the Covid-19 booster on 12/7/22. The physician was notified and ordered a UA and directed staff to monitor the resident closely. The progress notes did not have additional assessments of the resident related to her/his mentation or if the resident had signs of a UTI. On 3/22/23 at 10:14 AM Staff 2 (DNS) and Staff 3 (Operations Consultant RN) acknowledged the resident was not monitored for signs of a UTI after the physician was notified of the resident's change of condition on 12/8/22. On 3/24/23 at 10:02 AM Staff 2 (DNS) stated residents should be monitored for a change of condition every eight hours for at least 72 hours and longer if needed. c. An 11/14/22 pharmacy Consultation Report revealed Resident 2's physician declined to decrease the resident's Lexapro (antidepressant) because a reduction was contraindicated. The physician indicated a reduction would likely cause the resident to be psychologically unstable. Progress Notes dated 12/9/22 revealed Resident 2's Lexapro was decreased. The resident's record did not have a rationale for the decrease. There were also no progress notes after 12/9/22 to indicate staff monitored the resident to ensure there were no adverse reactions to the medication reduction. On 3/22/23 at 10:14 AM Staff 3 (Operations Consultant RN) acknowledged the resident was not monitored after the reduction of the resident's antidepressant. On 3/24/23 at 10:02 AM Staff 2 (DNS) stated a rationale, signed pharmacy recommendation or an assessment for the decrease in the resident's antidepressant was not located. d. Resident 2's 3/20/23 Active Orders Report revealed the resident was to be administered losartan (treats high blood pressure) and verapamil (treats high blood pressure). The medications were to be held if the top number of the blood pressure was less than 100. Review of the 2/22/23 through 3/23/23 MARs revealed on 3/4/23, 3/6/23, 3/12/23, 3/18/23 and 3/19/23 the medication was given prior to the blood pressure being taken. On 3/21/23 at 1:04 PM Staff 20 (CMA) stated if a resident had medications with vital sign parameters the vital signs were to be taken before the medications were administered. The vital signs were to be documented in the resident's record. On 3/22/23 at 10:18 AM Staff 2 (DNS) and Staff 3 (Operations Consultant RN) acknowledged there were five days when Resident 2's medications were administered prior to the blood pressure being taken. 2. Resident 5 was admitted to the facility in 2019 with diagnoses including depression. An 11/15/22 pharmacy Consultation Report revealed Resident 5's physician declined to decrease the resident's venlafaxine (antidepressant) because a reduction was contraindicated. The physician indicated a reduction would likely cause the resident to be psychologically unstable. Progress Notes by Staff 16 (LPN) dated 12/6/22 indicated, per pharmacy recommendation, the venlafaxine was decreased. The resident's record did not have a rationale for the decrease. There were also no progress notes after 12/6/22 to indicate staff monitored the resident to ensure there were no adverse reactions to the medication reduction. On 3/23/23 at 10:38 AM Staff 16 stated she did not recall the situation. On 3/22/23 at 10:14 AM Staff 3 (Operations Consultant RN) acknowledged Resident 5 was not monitored after the reduction of the resident's antidepressant. On 3/24/23 at 10:02 AM Staff 2 (DNS) stated a rationale, signed pharmacy recommendation or assessment for the decrease of Resident 5's decrease in antidepressant was not located.

Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being of 2 of 3 sampled residents (#s 4 and 5) reviewed for activities. Failure to provide meaningful and regular activities placed residents at risk for unmet psychosocial needs. Findings include: 1. Resident 5 was admitted to the facility in 2019 with diagnoses including depression. An 8/2022 Significant Change MDS and associated CAAs revealed the resident had memory issues but was able to make her/his needs known. A 2/23/23 Quarterly MDS indicated the resident was able to make her/his needs known. A 2/28/23 quarterly activity interest form revealed the resident liked activities including flowers. Group and individual activities from 2/22/23 through 3/22/23 revealed activities were not offered. On 3/20/23 at 10:32 AM Resident 5 stated she/he did not like to leave her/his room to participate in activities but would like to do more activities in her/his room like painting and flower arrangements. Observations revealed the following: -3/20/23 at 2:11 PM Resident 5 was in bed, her/his eyes were shut and the television was on. -3/21/23 at 11:54 AM Resident 5 was in bed with her/his eyes shut, the room lights were off and music played on the television. -3/22/23 at 9:09 AM Resident 5 was in bed with her/his eyes shut and music played on the television. On 3/22/23 at 9:24 AM Staff 13 (CNA) stated she was familiar with Resident 5. Resident 5 did not like to get out of bed to participate in activities. The resident usually watched television and was able to change the channels by her/himself. On 3/22/23 at 9:37 AM Staff 4 (Activities) stated she was new to the facility but was familiar with Resident 5 from another facility. The resident was very social and loved to talk. Staff 4 indicated the resident would benefit from more engaging 1:1 activities and not just being in her/his room watching television all day. Staff 4 indicated Resident 5 reported she/he liked nail care and going forward Staff 4 would include spa days and could also help the resident with floral arrangements. Staff 4 stated she would also see if the resident would like to set a goal to leave her/his room on occasion. Surveyor: [NAME], [NAME] R. 2. Resident 14 admitted to the facility in 7/2022 with diagnosis including Alzheimer's disease and a stroke. Resident 14's 8/2/22 Admission MDS indicated severe cognitive impairment. The preferences for activities were listed as the following: -Somewhat important: books/newspaper reading materials, music, keep up with news, groups of people, do favorite activity, and go outside in good weather; - Not very important: pets, and religion. The 7/20/22 care plan goal was to provide Resident 14 activities to maintain involvement in cognitive stimulation, social activities as she/he desired. The care plan directed staff to invite her/him to scheduled programs which might interest her/him, to provide 1:1 bed/side/in-room visits/activities if she/he was unable to attend out of room events and when not her/his choice to participate in a group activity, staff were to turn on the TV or music in room to provide sensory stimulation. The Optimum Life Program Admission Data (activity assessment) completed 7/27/22, indicated Resident 14 enjoyed to fish and hunt. It directed staff to provide a book for individual activities. Record review revealed activity Program notes were made for 1/28/23, 2/1/23 and 3/21/23. No other documentation of participation was found. Multiple observations were made of Resident 14 not engaged in group, meaningful or recreational activities between 3/20/23 through 3/22/23 between the hours of 8:53 AM to 3:09 PM. The activity calendar list groups activities offered which Resident 14 did not attend. Observation was made of Resident 14 on 3/21/23 between 10:12 AM to 11:12 AM to wander in her/his wheelchair the halls, push a mechanical lift down the hallway and moved some paper items on a table. Resident 14 stated she/he was looking for something do. On 3/23/23 at 2:44 PM Staff 4 stated she started to work with the activity program about a week prior. Staff 4 stated the facility did not have a staff person designated to the long term care unit and it was reported to her a person from another department would stop into the unit and provide activities to the residents every once in a while. She was unaware of any documentation of participation for which activities occurred for residents on the unit. Staff 4 acknowledged Resident 14 did not participate in the activities the week of 3/20/23 to 3/22/23 other than a brief one on one visit on 3/21/23. No further information was provided. On 3/24/23 at 10:05 AM Staff 1 (Administrator) acknowledged the lack of an on-going activity program for the unit in the past year. 38140

Based on interview and record review it was determined the facility failed to ensure Staff 6 (LPN) adhered to professional nursing standards related to leave the facility with no licensed nurse on duty and to count the medication with a non-licensed staff. This placed residents at risk for adverse health conditions and unmet needs. Findings include: On 12/28/22 a public alledged on 12/24/22, in the afternoon, a resident did not receive medication due to no (licensed) nurse in the facility. On 3/23/23 at 12:03 PM Staff 5 (Human Resources Director) provided a list of names, phone numbers and the hours worked on 12/24/22. The list included the following: -Staff 6 (LPN) worked from 9:49 AM to 4:02 PM. -Staff 8 (CNA) worked 1:54 PM to 10:40 PM. -Staff 10 (LPN) worked 5:56 PM to 6:23 AM (12/24/22). -Staff 21 (CNA) worked 1:20 PM to 10:00 PM. On 3/23/23 at 12:21 PM Staff 6 confirmed she worked on 12/24/22 from 9:49 AM to 4:02 PM. Staff 6 stated when she left at 4:02 PM there was no other licensed nurse in the facility. She stated she was aware the evening nurse could not arrive early for the 6:00 PM scheduled shift, so she left a note for the evening nurse. Staff 6 stated she counted the medications before she left the facility with Staff 5 because there was no licensed nursing staff available to count the medications. On 3/23/23 at 12:32 PM Staff 8 confirmed she worked on 12/24/22 from 1:54 PM to 10:40 PM. Staff 8 confirmed the facility did not have any licensed nurses available during the two hours (4:00 PM to 6:00 PM) prior to when Staff 10 arrived around 6:00 PM. Staff 8 did not recall any urgent events which required a licensed nurse and no negative resident outcomes during 4:00 PM to 6:00 PM on 12/24/22. On 3/23/23 at 12:43 PM Staff 10 confirmed when she arrived for her 12/24/22 evening shift there was not a licensed nurse in the facility. Staff 10 acknowledged Staff 6 left a note for her when Staff 6 left the facility earlier on 12/24/22. Staff 10 acknowledged she was told several residents missed medications and she checked in with all the residents. Staff 10 confirmed several residents missed medications opportunities. Staff 10 stated no negative outcomes for residents occurred in the two hours prior to the start of her shift on 12/24/22. On 3/24/23 at 10:05 AM Staff 1 (Administrator) stated he expected the facility to always have at least one licensed nurse in the facility and medications be counted with two licensed staff from the nursing department. _____________ Refer to F725

Based on interview and record review it was determined the facility failed to provide residents with the baseline care plan for 1 of 1 sampled resident (#114) reviewed for new admissions. This placed residents at risk for being uniformed of their plan of care. Findings include: Resident 114 was admitted to the facility on [DATE] with diagnoses including pelvic fracture. Review of the medical record indicated no evidence baseline care plan information was given to Resident 114. On 3/22/23 at 10:47 AM Staff 2 (DNS) and Staff 3 (Operations Consultant/RN) were not aware of baseline care plans which were to be given to the residents. Staff 3 stated Staff 17 (MDS Coordinator) was responsible for the initial resident care plans. On 3/22/23 at 10:49 AM Staff 17 stated the facility did not have a process to provide residents a baseline care plan and information was not given to residents' in the facility which included Resident 114.

Based on interview and record review it was determined the facility failed to provide a resident a bed hold policy at the time of hospital transfer for 1 of 1 sampled resident (#12) reviewed for hospitalization . This placed residents at risk for not being informed of her/his rights to return to the facility. Findings include: Resident 12 was admitted to the facility in 2022 with diagnoses including chronic lung disease. A 9/22/22 Bed Hold Agreement signed by Resident 12's spouse indicated they did not wish to hold the bed if Resident 12 was discharged to the hospital. Progress Notes revealed on 1/23/23 Resident 12 reported she/he did not feel well, the physician was notified and the resident was transferred to the hospital for evaluation and treatment. There were no notes to indicate the resident was provided a new bed hold form. On 3/23/23 at 2:51 PM and 3:42 PM Staff 3 (Operations Consultant RN) stated resident's signed a Bed Hold Agreement at the beginning of their facility stay. Staff 3 acknowledged residents were to get a bed hold policy when discharged to the hospital and stated Resident 12 did not receive a bed hold policy after she/he was discharged to the hospital.

Based on interview and record review it was determined the facility failed to provide a written notification to 3 of 5 sampled residents (#s 3, 4, and 7) reviewed for Beneficiary Protection Notices. This placed residents at risk for unknown financial liabilities. Finding include: 1. Resident 3 admitted to the facility 10/2014 with diagnoses including asthma and adult failure to thrive. Resident 3 started Medicare Part A services (skilled services including therapy) on 1/23/23. Resident 3's last covered day of Part A services was 2/2/23. A Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) which informed the resident of potential financial liability due to Resident 3 remaining in the facility was not issued. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal was not issued. On 3/22/23 at 10:23 AM Staff 3 (Operations Consultant RN) confirmed a SNF ABN and NOMNC was not issued to Residents 3 and the person who was assigned to issue the forms was not aware the forms were supposed to be issued when residents remained in the facility. 2. Resident 4 was admitted to the facility 7/2022 with diagnoses including Alzheimer's disease and high blood pressure. Resident 4 started Medicare Part A services (skilled services including therapy) on 1/27/23. Resident 4's last covered day of Part A services was 2/2/23. A Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) which informed the resident of potential financial liability due to Resident 4 remaining in the facility was not issued. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal was not issued. On 3/22/23 at 10:23 AM Staff 3 (Operations Consultant RN) confirmed a SNF ABN and NOMNC was not issued to Residents 4 and the person who was assigned to issue the forms was not aware the forms were supposed to be issued when residents remained in the facility. 3. Resident 7 was admitted ,d+[DATE] with diagnoses including a stroke with left sided weakness. Resident 7 started Medicare Part A services (skilled services including therapy) on 1/27/23. Resident 7's last covered day of Part A services was 2/2/23. A Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) which informed the resident of potential financial liability due to Resident 7 remaining in the facility was not issued. A Notice of Medicare Non-Coverage (NOMNC) which notified the resident of skilled services ending and their rights of appeal was not issued. On 3/22/23 at 10:23 AM Staff 3 (Operations Consultant RN) confirmed a SNF ABN and NOMNC was not issued to Resident 7 and the person who was assigned to issue the forms was not aware the forms were supposed to be issued when residents remained in the facility.

Based on interview and record review it was determined the facility failed to correctly administer medications for 1 out of 3 sampled residents (#6) reviewed for medication errors. The significant medication errors resulted in required medical treatment and monitoring by the hospital. Findings include: Resident 6 admitted to the facility in 2016 with [DIAGNOSES REDACTED]. The 12/11/16 progress notes revealed Resident 6 was administered incorrect medications which consisted of [MEDICATION NAME] 150 mg (antidepressant), [MEDICATION NAME] 5 mg (antihypertensive), [MEDICATION NAME] 100 mg (antidepressant), [MEDICATION NAME] 7.5 mg (antidepressant), losartan 100 mg (antihypertensive), Senna two tabs (bowel care), tamsulosin 0.4 mg (prostate) and [MEDICATION NAME] 360 mg (antihypertensive). The physician requested Resident 6 be sent to the emergency room (ER) for monitoring via the ambulance. The hospital called and indicated Resident 6 had orthostatic [MEDICAL CONDITION] (low blood pressure) and received intravenous (IV) fluids to raise her/his blood pressure. A 12/11/16 hospital ER History and Physical indicated Resident 6 had blood pressures in a range from 77/47 - 98/86. A 12/13/16 progress note revealed Resident 6 was readmitted to the facility and was reported to have continuing orthostatic [MEDICAL CONDITION]. A 12/13/16 incident report revealed Resident 6 was administered another resident's medication on 12/11/16. The medications given were [MEDICATION NAME], losartan,Senna, tamsulosin and [MEDICATION NAME]. The physician was notified and requested Resident 6 to be sent to the ER for monitoring due to receiving the blood pressure medication. The resident remained at the hospital and was reported to have episodes of orthostatic [MEDICAL CONDITION]. On 1/3/17 at 12:38 pm Staff 2 (Health Services Coordinator - HSC) verified Resident 6 was administered the medications listed above on 12/11/16 which were prepared for another resident. Staff 2 stated there was an RN and LPN (Staff 3) both preparing medications off of the medication cart at the same time. The RN prepared a residents medications and left the cart to administer the medication. Staff 3 was approached by Resident 6 who stated she/he was then ready for her/his medications. Staff 3 reached and grabbed another residents medications on the top of the cart and administered them to Resident 6. When Resident 6 questioned if she/he had other pills like the ones she/he saw in another pill cup on the cart Staff 3 realized Resident 6 had received the incorrect medications and notified the physician, administrator and the HSC. Staff 2 verified Resident 6 was sent to theER on [DATE] and returned to the facility on [DATE]. On 1/3/17 at 12:44 pm Staff 3 (LPN) stated she had prepared Resident 6's medications and attempted to administer them while the resident was eating breakfast. The resident requested the medications be administered after breakfast so Staff 3 took the medications back to the cart, labeled the cup and placed it in the drawer. Staff 3 stated she then prepared Resident 5's medications while another nurse was also working off of the same cart preparing medications for a third resident. Resident 6 approached the medication cart and requested her/his medications. Staff 3 pulled the medications out of the drawer and she grabbed Resident 5's medications and administered to Resident 6. Resident 6 then saw the fish oil capsule in the other cup and questioned if she/he would also receive those medications. Staff 3 stated this is when she realized a medication error had occurred and notified everyone. Staff 3 verified she incorrectly administered the [MEDICATION NAME], losartan, Senna, tamsolsin and [MEDICATION NAME] to Resident 6. Staff 3 verified Resident 6 was sent to the ER and remained in the hospital due to orthostatic [MEDICAL CONDITION].

Based on interview and record review it was determined the facility failed to follow care plan interventions for 1 of 3 sampled residents (#1) who were reviewed for accidents. As a result of not following the care plan, Resident 1 suffered a right tibia (shin bone) and ankle fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's 11/4/16 History and Physical indicated Resident 1 had general fatigue, weakness and had a fall on 10/31/16. The resident's temporary care plan dated 11/4/16, identified a [DIAGNOSES REDACTED]. A progress note dated 11/8/16, indicated the resident required a two person assist with a hoyer for transfers as resident tired easily. The Resident's 11/9/16 Admission MDS, Section G coded the resident as a two person extensive assist with transfers. On 11/9/16 at 1:46 pm, the resident's progress note documented the resident had a fall at 12:00 pm. The LPN was called by the CNA to the resident room. The resident was found to be sitting on the ground with her/his back propped up against recliner chair, a gait belt around her/his waist and shoes on her/his feet. The resident complained of pain in the right lower extremity. The resident was transported to the emergency room . The resident's hospital discharge summary dated 11/13/16, indicated Resident 1 suffered a right tibia and ankle fracture requiring surgical fixation as a result a ground level fall. The resident's undated Incident Investigation indicated Resident 1 activated the call light for assistance to use the bathroom. The CNA responded to the call light and upon entering the room, applied a gait belt around the resident and proceeded to raise the sit-stand recliner where resident was sitting. The resident started to slide in the chair as the chair was in an erect position. The resident was assisted to the floor. The investigation completed by Staff 1 (Administrator) concluded the CNA (Witness 1) used poor judgement when attempting to transfer and proceeded to raise the lift chair to an upright position without additional assistance. This action put the resident at unnecessary risk and the resident subsequently slid from the chair and sustained a right tibia fracture. There was current information the resident was a two person assist for transfers. In an interview on 1/3/17 at 10:27 am, Resident 1 stated she was getting up to go somewhere and knew Witness 1 came into to help her/him. Resident 1 stated she told Witness 1 she/he needed two people to transfer her/him and Witness 1 told her no, she could do it. The resident further stated both her/him and Witness 1 fell . In an interview on 1/3/17 at 1:56 pm, Staff 5 (Physical Therapist) stated when she walked by Resident 1's room, the resident was already on the floor. She stated staff were in the room. Staff 5 stated she saw the lift chair in the highest position. She stated she saw the resident had the gait belt on and the call light was on. Staff 5 stated she could see the resident's leg was broken and she/he was in pain. Staff 5 was asked if she had spoken to Witness 1 the day of the fall regarding the resident's transfer status? She stated that she does not recall speaking to Witness 1 earlier in the morning about Resident 1's transfer status but does remember informing Witness 1 she had transferred the resident on her own and believes Witness 1 also saw her transfer resident on her own during therapy. Staff 5 stated as far as she knew, Resident 1 was still a two person transfer. In an interview on 1/4/17 at 10:16 am, Staff 6 (LPN) stated she was finished passing medications when Witness 1 called her into the room and told her Resident 1 had fallen. She stated she saw the resident laying in front of the recliner with the walker to the side and gait belt on the resident. Staff 6 stated Witness 1 told her the resident slide out of the chair. Staff 6 stated Witness 1 told her she was waiting for someone to help transfer the resident, the resident was in the lift chair and the resident slipped out of the chair. She stated resident had to have been a two person assist with transfer. In an interview on 1/4/17 at 10:40 am, Witness 1 (former CNA) confirmed she was the CNA who was working with Resident 1 at the time of the fall. She stated the resident's call light was on and she went into the room to assist the resident back to the bed. She stated the resident had to be transferred in the wheelchair first before transferring the resident back into the bed. She stated she had lifted up the recliner to transfer the resident on her own when the resident told her she/he was too tired and wanted an additional person assist with the transfer. Witness 1 stated she had the walker in front of the resident and the gait belt on. She stated the resident then told her she/he was slipping. She stated she had a hold of the resident and the resident was slipping therefore she lowered the resident to the floor. Witness 1 was asked if she lifted up the chair. She stated she did lift up the chair which was the problem. Witness 1 was asked how she identified the resident's transfer status. She stated she saw the physical therapist (Staff 5) transfer the resident on her own earlier the same morning and Staff 5 had told her the resident was a one to two person assist with transfers. She acknowledged she did not refer to the care plan for the resident's transfer status.

1. Based on interview and record review it was determined the facility failed to accurately assess, monitor and prevent the development of an avoidable pressure ulcer for 1 of 3 sampled residents (# 42) reviewed for pressure ulcers. This resulted in the development of an avoidable pressure ulcer and associated increased pain. Findings include: Resident 42 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 5/13/16 Hospital History and Physical revealed Resident 42's skin was intact to the right lower extremity (RLE). The 5/16/16 hospital admission orders [REDACTED]. The 5/16/16 Nursing (facility) Readmission Data Collection revealed Resident 42 had a right ankle fracture with a boot in place. The record did not reveal the skin under the boot was checked for breakdown. The (MONTH) (YEAR) TARs revealed a 5/17/16 order to wear the total contact boot at all times unless checking for skin concern of breakdown. Resident 42 refused the boot on the evening/night shift of 5/24/16 only. The boot was worn the following day shift and then the order was put on hold for 5/25/15 evening/night shift through 5/26/16 day shift. On 5/17/16 at 10:00 pm turning and repositioning was initiated. Resident 42 refused 15 times out of 169 opportunities. The 5/23/16 Pressure Ulcer CAA indicated Resident 42 was at risk for developing pressure ulcers related to her/his non-weight bearing status from her/his right ankle fracture and use of a splint on the ankle for support. The (MONTH) (YEAR) CNA Task Documentation indicated Resident 42 had one behavior of yelling/screaming with no other behaviors noted, and to float/elevate the right heel beginning 5/26/16. The Daily Skilled Notes revealed the following: * 5/16/16 - 5/18/16 Resident 42 was not cooperative and refused position changes due to anxiety of rolling and falling out of bed. * 5/19/16 Resident 42 was more cooperative with position changes to her/his leg. * 5/24/16 No pressure ulcers noted. * 5/25/16 Right heel unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is completely covered) with black eschar (dead tissue) measured 1.8 cm x 3 cm. * 5/27/16 Resident 42 seen by the physician, new wound care orders. New air mattress to prevent further skin breakdown and to relieve pressure due to inability to turn body for offloading. * 6/3/16 Stage 4 pressure ulcer to right heel measured 2 cm x 1 cm x .1 cm. Outer edges with wound maceration (skin condition that occurs when fluid or moisture is in contact with the skin for extended periods of time) measuring .75 cm. Weekly Skin Integrity Review notes revealed the following: * 5/23/16 ankle fracture splinted. Skin under splint not checked. * 5/30/16 Right heel pressure ulcer 3 cm x 4 cm. Surrounding skin with early skin breakdown measuring 4.5 cm x 2.5 cm. * 6/6/16 Stage 4 pressure ulcer to right heel. A fax sent to both the primary care and the orthopedic (bone) physicians on 5/25/16 at 3:28 am indicated Resident 42 refused to wear the right ankle boot and demanded it be removed so her/his ankle was wrapped in ace wrap. Resident 42 indicated the boot was extremely uncomfortable/painful and put a lot of pressure on her/his heel. Staff continued to try and encourage Resident 42 to wear the boot. No documented skin check or pain evaluation was found. A 5/25/16 nursing progress note indicated therapy was working with Resident 42 and noted a black spot on the right foot when the boot was placed back on her/his right foot. The wound was described as a non-blanchable (normal skin color does not return after pressure applied) black spot measuring 1.8 cm x 3 cm with a 4 cm non-blanchable reddened area skin border. The 5/25/16 SBAR note (Situation, Background, Assessment, Recommendation Communication form)revealed a non-blanchable area on the right heel, black in color with surrounding skin red, measuring 1.8 cm x 3 cm. with a 4 cm non-blanchable skin border. The Resident requested the boot to be taken off. Staff applied a splint to relieve the pressure area. The 5/25/16 Evaluation Summary indicated Resident 42 had a pain level of eight out of 10 and [MEDICATION NAME] 10 mg (narcotic pain medication) was given for foot pain. The 5/25/16 Focus Charting-Skin Condition note indicated Resident 42 had developed an unstageable right heel pressure ulcer with eschar. The boot was removed and replaced with a splint and wrapped with ace wrap. Resident 42's leg was positioned parallel with the heel floated and front of the foot and the ankle supported. The 5/26/16 Focus Charting-Skin Condition note stated the heel was elevated with support of pillows under the ankle with repositioning every two hours to prevent further skin breakdown. A 5/26/16 fax sent to the wound clinic indicated Resident 42 developed a pressure ulcer on her/his right heel measuring 3.5 cm x 3 cm with eschar. It had a separate area underneath measuring 2.5 cm x 3.5 cm with eschar. A 5/27/16 physician office visit note indicated Resident 42 developed a pressure ulcer on her/his right heel from the cast (boot) she/he was placed in. The resident complained of increased right foot pain and her/his [MEDICATION NAME] was increased from 10 mg to 20 mg. Wound care orders for hydrogel (medical) wound dressing to right heel every three days were provided until resident was able to be seen at the wound care clinic. The 6/1/16 Weekly Wound Data Collection Flow Sheet note revealed an unstageable, in-house acquired right heel pressure ulcer. Resident 42 was seen by the wound clinic where the wound was debrided (the process of removing nonliving tissue from pressure ulcers) and staged as a Stage 4 pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Undermining and sinus tracts also may be associated with Stage IV pressure ulcers). The 6/1/16 physician orders [REDACTED]. The 6/1/16 Collaborative Care Review indicated Resident 42 had a Stage 4 pressure ulcer to the right heel with daily skin checks. The 6/3/16 physician orders [REDACTED]. Apply silver alginate to wound bed, mupirocin ointment and cover with foam dressing. Change dressing every other day. The current care plan indicated Resident 42 had potential impairment to skin integrity related to decreased mobility, toe-touch weight bearing status to the RLE and obesity. The care plan was updated on 5/25/16 with a right heel pressure ulcer and having a non-removable boot in place with the exception of skin checks. It was updated again on 6/1/16 when the wound was debrided and staged at a stage 4. On 11/3/16 at 1:48 pm Staff 2 (RAI Coordinator) stated Resident 42 was admitted with a boot on the RLE which was to stay on unless checking for skin breakdown. Staff 2 stated Resident 42's boot should have been removed for a skin check on 5/23/16 which did not occur. On 11/3/16 at 1:48 pm and 3:03 pm Staff 1 (Director of Clinical Services) stated all the facility beds were the same size and measured 42 inches by 80 inches. Staff 1 said she was unaware Resident 42 was not repositioned due to anxiety and fear of rolling and falling out of the bed. Staff 1 acknowledged Resident 42 was admitted with a boot on the RLE and developed a Stage 4 pressure ulcer. Staff 1 stated all facility beds measured 42 inches by 80 inches. On 11/3/16 at 3:25 pm Witness 2 (Physician's Medical Assistant) verified Resident 42 was seen by the physician in the office on 5/27/16 and verified the physician's documentation indicated Resident 42 developed a pressure sore on the right heel due to the cast (boot). Witness 2 verified no wound staging or description was included in the documentation. On 11/4/16 at 6:52 AM Staff 4 (LPN) stated she did not see the wound until after treatment was started. It had eschar on the majority of the wound and she was not able to stage it. On 11/4/16 at 8:06 am Witness 1 (Orthopedic Physician's Medical Assistant) verified the facility staff called on 5/26/16 with information regarding a pressure ulcer and a referral was made to the wound clinic. Witness 1 stated the facility then informed the clinic the resident refused to reposition. On 11/4/16 at 9:14 am Witness 3 (RN/former employee) stated there was blackening of the heel and it was unstageable when she faxed the wound clinic on 5/26/16. Witness 3 stated the facility was watching Resident 42's heel and the skin changed from a spot to unblanchable skin (Stage 1 pressure ulcer), to the darkening of the wound in a few days. Staff 3 stated the facility staff were watching the area of concern for awhile. Witness 3 verified the boot was usually on although Resident 42 often expressed it was uncomfortable. Witness 3 stated the skin checks should have been documented in the medical record and she was instructed to complete the weekly wound rounds and give the information to Staff 1 to input the information into the record. Witness 3 reiterated Staff 1 had all the information related to Resident 42's pressure ulcer and the wound reports should be completed. On 11/4/16 at 9:23 am and 10:11 am Staff 3 (LPN) stated she faxed the physician to make them aware the resident did not want to wear the boot. Staff 3 verified she sent the 5/25/16 fax which stated Resident 42 had refused to wear the RLE boot and complained it was extremely uncomfortable, painful and putting a lot of pressure on (the resident's) heel. A splint was applied but staff encouraged Resident 42 to wear the RLE boot. Staff 3 stated she did not assess the skin under the boot and acknowledged the resident was painful. On 11/4/16 at 11:12 am Staff 1 verified she had instructed Witness 3 to complete the Weekly Wound assessments and then give the measurements/assessments to her so she could enter the data. Staff 1 stated Witness 3 was responsible for the Weekly Wound Assessments. Staff 1 further stated she was the interim Director of Clinical Services at the time the wound developed and could not say if she was aware of the facility monitoring the area of skin. Staff 1 also stated she was unaware of Resident 42's 5/24/16 complaints of heel pain and request for the boot to be removed. On 11/4/16 at 12:51 pm Staff 1 stated she had no idea what the wound stage was on 5/30/16 and acknowledged only the wound measurements were documented on the Skin Integrity Sheet. The facility did not obtain a baseline skin assessment and did not monitor the skin prior to the development of the unstageable pressure ulcer. The facility did not assess the skin for skin breakdown or complete initial or ongoing assessments of the wound. The facility did not re-evaluate the resident's response to preventative treatments, did not accommodate the need for a larger bed to enable turning and repositioning without anxiety and fear, did not care plan or notify the physician of refusals of repositioning, and did not revise approaches until after the unstageable pressure ulcer developed. The facility did not provide a clinical justification for the development of the unstageable pressure ulcer. The resident experienced increased pain and discomfort from the pressure ulcer as evidenced by complaints of pain and the physician increasing the pain medication dosage on 5/27/16. There was no evidence the effectiveness of the boot use was assessed despite complaints of increased pain and not wanting to wear the boot. 2. Based on interview and record review it was determined the facility failed to assess and monitor skin for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at risk for unidentified skin breakdown. Findings include: Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. a. The 9/2/16 Nursing Admission Data Collection form revealed Resident 3 had a sacrum area possible r/t ((related to) pressur (sic). The form did not contain any further description of the sacral area such as measurements or if there was an open area. The form also indicated Resident 3 had a 7 cm x 2 cm discoloration to the inner left buttock. The (MONTH) (YEAR) TAR documented staff monitored redness to Resident 3's sacrum and discoloration to the left inner buttock starting on 9/2/16. Staff were directed to monitor those areas until they resolved. Resident 3's Progress Notes from 9/2/16 through 9/8/16 did not contain any entries with information regarding follow up assessment of the sacrum to determine if it was a pressure ulcer. The 9/9/16 Daily Skilled Progress Note described a Stage II pressure ulcer to the left inner buttock measuring 0.7 cm x 0.5 cm with no depth. It further indicated treatment orders were obtained from the physician. The documentation lacked any reference to Resident 3's sacral area. Stage II ulcers are characterized by partial-thickness loss of the dermis, presenting as a shallow, open ulcer with a red-pink wound bed without slough (dead tissue). Resident 3's 9/9/16 Admission MDS revealed the resident was at risk for pressure ulcers and currently had a Stage II pressure ulcer. The resident required extensive staff assistance with bed mobility and transfers. Resident 3 weighed 118 pounds and was not on a therapeutic diet. The resident had occasional pain which rated a 2 on a scale of 0 to 10, with 10 being the highest level of pain. The MDS triggered the areas of Nutritional Status and Pressure Ulcers for additional assessment. The Nutritional Status CAA, dated 9/12/16, indicated Resident 3's weight was 118 pounds, which was below the resident's IWR (ideal weight range). The resident reported her/his weight was usually around 140 pounds and she/he wanted to gain weight. Resident 3 was independent for dining and the resident's meal intake averaged 82%. Diseases and conditions that could affect appetite or nutritional needs were listed as [MEDICAL CONDITION], pain, pressure ulcers and [MEDICAL CONDITION] problems. The Nutritional Status CAA didn't assess the increased caloric or protein needs associated with healing the pressure ulcer. The Nutritional Status CAA lacked an evaluation of the impact to Resident 3's nutritional status from probable inadequate food intake, the [MEDICAL CONDITION] disorder, pain or history of [MEDICAL CONDITION]. The Pressure Ulcer CAA, dated 9/15/16, noted Resident 3 developed a pressure ulcer to the left buttock. The Pressure Ulcer CAA lacked an assessment of how the Stage II pressure ulcer developed after admission and didn't address the issue of the possible pressure area to the resident's sacrum identified on the 9/2/16 Nursing Admission Data Collection form. The Pressure Ulcer CAA lacked evaluation of how contributing factors and risk factors impacted the status of Resident 3's pressure ulcer such as Resident 3's need for extensive assistance for bed mobility and transfers, the onset of diarrhea following administration of new medications on 9/6/16, the effectiveness of the pressure ulcer treatment or Resident 3's weight loss and poor nutritional status,. On 11/3/16 at 12:51 pm, Staff 1 (Director of Clinical Services) agreed the Pressure Ulcer CAA was not comprehensive. The 9/9/16 Weekly Skin Integrity Review indicated the previously discolored area on the left inner buttock had developed into a pressure ulcer which was described as a small, shallow open area. The status of the skin to the sacral area was not addressed. Resident 3's clinical record lacked documentation the possible pressure area to the sacrum described in the 9/2/16 Nursing Admission Data Collection was ever assessed and if or when it resolved. The Progress Notes between 9/9/16 and 9/24/16 did not contain documentation the left buttock pressure ulcer or issue to the sacral area had resolved. The 9/16/16 and 9/25/16 Weekly Skin Integrity Review forms did not reference the sacrum or the left inner buttock. The 9/13/16 Collaborative Care Review form, signed by Staff 2 (RAI Coordinator) on 9/22/16, indicated the Stage II pressure injury to the left inner buttock resolved on 9/15/16. On 11/3/16 at 12:51 pm, Staff 1 (Director of Clinical Services/DCS) acknowledged there was no evidence the possible pressure area on Resident 3's sacrum was assessed. Staff 1 stated information related to improvement or deterioration of pressure ulcers should be in the Weekly Skin Integrity Reviews and verified the 9/16/16 and 9/25/16 Weekly Skin Integrity Review forms did not contain information the left buttock pressure ulcer had resolved. Staff 1 said she was uncertain exactly when the left buttock pressure ulcer resolved. Staff 1 agreed Resident 3's Pressure Ulcer CAA was not comprehensive. On 11/3/16 at 1:38 pm, Staff 10 (Dietary Manager) agreed Resident 3's Nutritional Status CAA was not comprehensive. Resident 3 was discharged with no return anticipated on 9/25/16. b. Resident 3 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Stage III ulcers are characterized by full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, and muscle aren't exposed. Slough may be present but doesn't obscure the depth of tissue loss. The resident was admitted with treatment orders for the Stage III pressure ulcer including cleaning the area and application of Allevyn dressing (used with exuding wounds to absorb excess fluid but maintain the wound surface in a moist condition conducive to healing) twice a week and as needed. The 10/19/16 Nursing Readmission Data Collection form noted Resident 3 had a history of [REDACTED]. The surrounding area was red but blanchable (when pressed the skin turned white but returned to normal color with the release of pressure). The description lacked information about the amount of slough, description of the edges of the wound bed or color of the wound bed. The 10/19/16 Weekly Skin Integrity Review form noted Resident 3's skin was intact. The (MONTH) (YEAR) TAR documented Resident 3's Stage III pressure ulcer dressing was changed on 10/21/16 and 10/24/16. The 10/21/16 Focus Charting Note revealed Resident 3's coccyx pressure wound measured 1.0 x 1.0 x 0.1 cm with redness around the pressure wound. A small amount of purulent (containing pus which formed at a site of inflammation) drainage was noted. The description did not include the wound bed edges, description of the slough or if the purulent drainage had odor. Resident 3's Progress Notes from 10/22/16 through 10/25/16 did not contain documentation the Stage III pressure ulcer was assessed following the 10/21/16 discovery of purulent drainage from the pressure ulcer or if it had resolved. The 10/24/16 Transition of Care and Discharge Summary Skin Review lacked any documentation of the presence or healing of Resident 3's Stage III pressure ulcer. Resident 3 discharged from the facility on 10/25/16. On 11/4/16 at 10:10 am, Staff 1 (Director of Clincal Services) stated if a pressure ulcer resolved between the weekly reviews, staff would have documented that information in a progress note. Staff 1 said the 10/19/16 Weekly Skin Review, which indicated Resident 3's skin was intact, was incorrect and verified Resident 3 admitted to the facility with a Stage III pressure ulcer. Staff 1 acknowledged Resident 3's Stage III pressure ulcer was not fully described or assessed during the 10/19/16-10/25/16 admission. Staff 1 acknowledged the 10/24/16 Transition of Care and Discharge Summary was inaccurate and the Stage III pressure ulcer was present.

Based on interview and record review it was determined the facility failed to transfer 1 of 4 sampled residents (#1) safely during a mechanical lift transfer. As a result the resident fell and was injured. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had physician's orders [REDACTED]. On [DATE] the resident's CNA care plan indicated she/he required a mechanical lift for transfers. On [DATE] an admission MDS assessment identified the resident had severely impaired cognitive skills for decision making, was totally dependent, and required two people for transfers. A CAA, dated [DATE], indicated the resident had difficulty maintaining sitting balance. In interview on [DATE] at 11:18 am Witness 1 (Complainant) reported Resident 1 slumped to the side and could not straighten her/himself or initiate any movement. Resident 1's [DATE] MAR indicated the resident was administered Coumadin as ordered by the physician. On [DATE] at 7:10 am a nursing progress note identified Resident 1 was transferred by two CNAs and a mechanical lift and the resident fell out of the sling and hit the left side of her/his body on the floor. The resident had a bloody nose, 911 was called, and the resident was transported to the hospital via ambulance. The facility's investigation indicated Resident 1 was dropped during a mechanical lift transfer by Staff 6 and 7 (CNAs) because the resident's usual sling was in the wash and the sling they used was too small. The investigation indicated Staff 6 and 7 reported they did not check in the laundry room for the usual sling prior to transferring the resident. On [DATE] a witness statement written by Staff 6 (CNA) indicated she placed the sling under Resident 1 and the resident was lifted up and away from the bed to move her/him into the chair. The resident flipped her/himself out of the sling and onto the floor, hitting the wall and then landing on the floor. The statement indicated the resident was at baseline prior to the fall. In an additional statement, dated [DATE], Staff 6 identified the resident tipped over face first due to the type of sling they had to use. She indicated there were no other slings available for the resident and she had used a sling that was too small. On [DATE] a witness statement written by Staff 7 (CNA) identified the resident was gotten up as was the usual routine and while attempting to place the resident in the chair, the resident fell on to her/his left side. On [DATE] a hospital Discharge Summary indicted Resident 1 was admitted to the hospital after a fall out of a lift. She/he fell forward into the wall, lost consciousness, and was brought to the emergency department. The final [DIAGNOSES REDACTED]. On [DATE] at 4:28 pm a nursing progress noted indicated the resident was readmitted to the facility after a fall. The resident was non-responsive and placed on hospice due to a brain bleed. On [DATE] and [DATE] the facility documented the following actions were taken as a response to Resident 1's fall: - All slings in the facility were located and matched up with the correct lifts and correct residents. All inappropriate slings were removed from the unit. - The mechanical lift representative brought in interim slings for the current lifts and the facility ordered new slings. - Lift training was initiated on [DATE] with the lift manufacturing representative. After training, CNAs were to demonstrate knowledge and then receive transfer certification upon completion. The facility had evidence of CNA certificates of completion for Transfer Specialist dated [DATE] and [DATE]. On [DATE] the facility identified there were four current residents using mechanical lifts and six slings were observed available. In interview on [DATE] at 12:08 pm and 12:40 pm Staff 8 and 9 (CNAs) reported they never transferred a resident without a proper fitting sling. They stated after the incident with Resident 1 they were in-serviced on mechanical lift transfers and reported they have new slings which were readily available. In interview on [DATE] at 1:35 pm Staff 1 (Administrator) reported on [DATE] the facility had two residents who used a mechanical lift and two slings appropriate to the lifts and ten generic slings. Staff 1 reported on [DATE] the sling that fit Resident 1 was in the laundry but clean. She stated the CNAs should have waited to get Resident 1 up until they retrieved the correct fitting sling. On [DATE] they used a sling that was too small for the resident and the resident fell out of it, sustained an injury, and died . After the incident the facility conducted mechanical lift transfer trainings and certification for staff, removed the generic slings that were not recommended by the lift manufacturer, ordered new slings, and conducted audits of mechanical lift transfers. Staff 1 reported the facility completed their corrective actions to the incident on [DATE] when the last few CNAs were transfer certified. She reported there were no additional resident falls during a mechanical lift transfer since [DATE]. In interview on [DATE] at 12:08 pm Staff 7 (CNA) reported she had training on mechanical lift transfers prior to working at the facility. She stated on [DATE] she helped Staff 6 get Resident 1 up for breakfast. They couldn't find the resident's sling, which was bigger and went below the resident's knees, and assumed it was in the laundry. Staff 7 reported they used a sling that was small for the resident because they didn't have a lot of choices. During the transfer while the resident was in the air and being drawn back to place above the chair, the resident fell forward and she couldn't catch her/him. The resident hit the wall and then slid to the floor. Staff 7 stayed with the resident while Staff 6 alerted the nurse. The resident was sent to the hospital. Staff 7 stated the aides had asked the facility for more and bigger slings for a long time. In interview on [DATE] at 12:25 pm Staff 6 (CNA) reported she had training on mechanical lift transfers at another facility prior to working at the facility. She stated on [DATE] she and Staff 7 went to get Resident 1 up as usual. They looked for slings and grabbed the only one they could find. Staff 6 reported Resident 1 was placed in the sling and it was fine. She stated the resident flung her/himself forward and fell on to the floor. Staff 6 reported the sling they used didn't fit Resident 1 correctly and if we would have had the better sling the resident wouldn't have fallen out. Staff 6 stated she had asked for new slings prior to the incident. In interview on [DATE] at 10:09 am Staff 5 (Medical Records) reported she was responsible for ordering supplies and stated she was not informed the facility needed new slings until after the incident on [DATE]. Staff 5 was hired in [DATE]. Staff 5 stated after Resident 1's fall the facility ordered six new slings and set up a system for supply requests. She stated a designated facility CNA provided her with a list of everyday supplies once a week. In addition, the facility placed a board in the supply room where staff could write supply or equipment requests, such as slings. Staff 5 reported she checked the request board daily. In interview on [DATE] at 11:18 am Witness 2, a mechanical lift representative, reported he was unclear as to how Resident 1 fell forward out of the sling but stated the resident could have been positioned asymmetrically in the sling, the (generic) sling that was used could have pivoted because of the long loop type, and/or the bottom loops could have not been placed all the way onto the lift correctly and they fell off. Witness 2 reported he was called out to the facility after the incident on [DATE] and he brought the facility slings that were designed to work with their mechanical lifts and trained and certified the staff on mechanical lift transfers. He stated he educated the staff on assessing residents for appropriate sling size and the physical transferring of residents via the mechanical lift. Witness 2 reported once staff demonstrated their transfer knowledge, they received a certification indicating they were proficient at transfers.