Every finding on record at Village Health Care Center

Based on record review and interview, the facility failed to ensure an initial comprehensive care plan was completed within seven days of admission assessment for 1 (#1) of 7 sampled residents reviewed for comprehensive care plans. The administrator identified 52 residents resided in the facility. Findings:A facility policy titled Care Planning-Interdisciplinary Team, dated 09/2013, read in part, A comprehensive care plan for each resident is developed withing seven (7) days of completion of the resident assessment (MDS).An admission assessment for Resident #1, dated 02/10/26, showed the assessment was completed on 02/12/26.Resident #1's EMR was reviewed for a comprehensive care plan. There was not a care plan in the EMR.On 04/10/26 at 2:30 p.m., an undated Baseline Care plan was provided by the facility for Resident #1.On 04/10/26 at 2:35 p.m., the MDS coordinator stated they did not develop a comprehensive care plan for Resident #1.On 04/10/26 at 2:40 p.m., the administrator stated they could only find the baseline care plan for Resident #1. They stated they were aware a comprehensive care plan had not been done.

On 02/19/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision for a resident at high risk for elopement. Resident #1 eloped from the facility on five occasions. On 01/16/26, Resident #1 eloped and, while away from the facility, harmed themselves by intentionally burning the back of their hand with a cigarette lighter which resulted in multiple blisters to the back of their hand. On 02/08/26, Resident #1 eloped and was found by the local authorities at a residence the facility identified as a known drug house. For each elopement, the facility intervention was to initiate every 15-minute visual checks and no interventions were added to Resident #1's care plan. On 02/19/26 at 7:40 p.m., the OSDH was notified and verified the existence of the IJ related to elopement and self-harm.On 02/19/26 at 7:45 p.m., the administrator and DON were notified of the IJ situation. The IJ template was reviewed with the administrator and DON, and a copy was emailed to them at 7:50 p.m.On 02/20/26 at 5:05 p.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal, read in part,Upon identification of Immediate Jeopardy related to elopement risk, the facility immediately implemented the following corrective actions:1. The identified resident was placed on continuous 1:1 supervision (line-of-sight monitoring) effective immediately on 02/19/26 at 20:50 [8:50 p.m.].2. The assigned 1:1 staff member: .Visual contact at all times.Is relieved by a designated backup staff member during all breaks to ensure uninterrupted supervision.Charge nurse assigns a backup sitter at the beginning of each shift .Backup staff documented on assignment sheet.No break is permitted without confirmed face-to-face handoff.Person appointed to 1:1 care will document q 15mins [sic] that they have eyes on resident and the resident's location on the 15 min checks sheet.a. Upon completion of 15 min check sheet, it will be turned into DON for approval.The level of supervision is a clinical decision based on ongoing assessment of risk and may be increased or decreased at any time to ensure resident safety.3. A secondary staff member has been assigned each shift as designated break coverage to ensure there is no lapse in supervision at any time.4. Door alarm functionality was immediately verified by maintenance and nursing staff.5. The resident's care plan was updated to reflect: .1:1 supervision .High elopement risk status .Supervision requirements6. All wandering risk assessments for the facility will be complete by 02/20/2026 at 1700 [5:00 p.m.]Staff Education ConductedAll staff were educated on: .Risk of elopement .What to do in case of elopement .Stay with resident no matter what .Call 911 .Ensure the resident is safely returned to facility .Notify the charge nurse .Change [sic] nurse will notify physician, administrator, DON, and family.1:1 sitter responsibilitiesFacility implemented a procedure to educate all staff. This implementation started on 02/19/2026 at 2050 [8:50 p.m.] and was completed on 02/20/2026 1100 [11:00 a.m.] except for [CNA #1] and [CNA #2] who were called and unable to be reached. They will not be allowed to clock in/work a shift until education is provided and understood.Attendance sheets maintained in education file.Care Plan RevisionEffective 02/19/2026 at 2100 [9:00 p.m.], the resident's comprehensive care plan was reviewed and updated by the interdisciplinary Team to reflect: .Identification of high elopement risk .Continuous 1:1 supervision (line-of-sight) .Designated break relief protocol (face-to-face handoff required) .Redirection techniques to be utilized .Monitoring frequency and documentation requirements .Following any additional exit-seeking behavior an investigation will be conducted and the findings from the investigation along with the findings a root cause analysis preformed [sic] by the interdisciplinary team will be used to update the residents care plan. The IJ was lifted, effective 02/21/26 at 3:00 p.m., when it was determined the facility completed all components of their plan of removal. This was determined through observations of 1:1 supervision and staff/resident interactions; record review of the 1:1 supervision, in-services, wandering risk assessments, and interventions; and interviews regarding in-service training, residents at risk for wandering/elopement, and interventions.The deficiency remained at an isolated level with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide supervision to prevent elopement and self-harm for 1 (#1) of 4 sampled residents reviewed for supervision. The DON identified two residents who were high risk for wandering and/or elopement. Findings:On 02/17/26 at 11:55 a.m., Resident #1 was observed ambulating/pacing the hall and talking to themselves. Resident #1 slurred their words, making what they said intelligible. The resident paced slightly faster with each pass in front of the activity room door and their voice sounded higher in pitch with each pass.An admission assessment for Resident #1, dated 09/28/25, showed the resident was cognitively intact with a brief interview for mental status score of 14; felt down/depressed/hopeless several days of the last two weeks; exhibited delusions; wandered one to three days of the week; and their wandering placed the resident at significant risk of getting to a potentially dangerous place. The assessment showed Resident #1 felt it was important to be able to go outside to get fresh air, was independent with most activities of daily living, was continent of bowel and bladder, and had an active diagnosis of a progressive neurological condition. The assessment showed Resident #1 was diagnosed with Huntington's Disease, anxiety, and depression. The assessment showed the resident had a history of falls in the last two to six months prior to admission to the facility. The assessment showed Resident #1 received an antianxiety medication, antidepressant medication, an opioid, and anticonvulsant in the seven days leading up to the assessment. The assessment showed Resident #1 did not receive an antipsychotic medication since admission to the facility. A care plan, dated 09/28/25, showed Resident #1 was at risk of elopement and wandering related to their diagnosis of hallucinations. The interventions included:a. assess for fall risk,b. distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book,c. identify patterns of wandering: was the wandering purposeful, aimless, or escapist; was the resident looking for something; did it indicate the need for more exercise; and intervene as appropriate,d. monitor for fatigue and weight loss, ande. provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. A wandering risk evaluation for Resident #1, dated 10/03/25, showed a risk score of 15 for the resident which indicated a high risk for wandering. A state reportable incident report for Resident #1, dated 10/15/25, showed the resident left the facility without notice, crossed the parking lot, and fell while ambulating through an adjacent field. The report showed the local authorities were contacted and assisted in the resident returning to the facility. The report showed the facility initiated visual checks every 15 minutes on the resident. The report, read in part, The facility will be implementing Q15 minute checks on [Resident #1]. Please lay eyes on [them] every 15 minutes every shift until stated otherwise. An incident note for Resident #1, dated 11/06/25, showed the nurse observed Resident #1 pacing the facility while talking to themselves. The incident note showed the nurse could hear Resident #1 speaking as though to someone named (name withheld) but no one was there. The incident note showed Resident #1's behavior continued to escalate. The incident note showed Resident #1 approached the nurse and asked that they talk in the resident's room. The incident note showed once in the room, Resident #1 stated they had video of 9name withheld) threatening them. The incident note showed when the video was played for the nurse, the nurse observed Resident #1 on the screen, acting as though they were (name withheld). The incident note showed Resident #1 confirmed the video looked like themselves but was really (name withheld). Resident #1 requested the nurse contact the FBI on their behalf. A short time later, Resident #1 asked the nurse what the FBI had said and the nurse responded the FBI said they would get back with the nurse. The incident note showed Resident #1 then stated that was because (name withheld) blocked the nurse's call to the FBI as well. The incident note showed Resident #1's behavior continued to escalate throughout the day, and Resident #1 made threats toward others. The incident note showed Resident #1 was quoted as saying, I'm going to kick these workers [explicit language] and I might not be able to control myself by hurting these elderly people. The incident note showed the nurse contacted 911 from a landline business phone and Resident #1 yelled they were trying to have the resident committed. The incident note showed Resident #1 grabbed the base of the phone and jerked hard, pulling the phone line from the wall. The incident note showed the nurse walked to the back door and again contacted 911. While on the phone with the 911 dispatcher, the nurse overheard that Resident #1 had run out the front door of the facility. The incident note showed the nurse requested police be dispatched to assist in finding the resident. An incident note for Resident #1, dated 11/06/25 at 7:54 a.m., showed the local authorities reported they had found Resident #1 but determined Resident #1 was of sound mind and so they could not force Resident #1 to return to the facility. The local authorities were reported to have left Resident #1 at a local hotel. The incident note showed the nurse argued Resident #1 exhibited delusion and hallucination daily and threatened harm to the other residents and staff, but the officers maintained they could not bring the resident back as Resident #1 was of sound mind during their interactions with the resident. The incident note showed the administrator was at the hotel attempting to get Resident #1 to return to the facility and work with them on discharge plans, but Resident #1 was adamant they did not have to return because the local authorities had informed them, they did not have to do so. The incident note showed the facility was in communication with family who attempted to contact the resident by phone. A court order for Resident #1, dated 11/10/25, showed two family members were appointed special guardianship of the person and estate for Resident #1.A state reportable incident report for Resident #1, dated 11/11/25, showed the resident ran from the facility on 11/06/25 and was involuntarily admitted to the hospital for psychiatric evaluation and treatment. A nurse's progress note for Resident #1, dated 11/19/25, showed the resident returned to the facility from an inpatient psychiatric hospital. A behavior note for Resident #1, dated 01/16/26 at 6:00 p.m., showed the nurse was making rounds but was not able to locate Resident #1 in the facility. The behavior note showed the nurse contacted the resident's family who reported they were able to locate the resident. The behavior note showed family went to the location of Resident #1 and transported the resident back to the facility. The behavior note showed the facility checked on Resident #1 every 15 minutes as an intervention for elopement.A behavior note for Resident #1, dated 01/16/26 at 7:24 p.m., showed the resident returned to the facility with blisters to the back of their hand. The behavior note showed Resident #1 reported they had burned their hand with a cigarette lighter because they did not want to come back to the facility. A state reportable incident report for Resident #1, dated 01/16/26, showed nursing staff was unable to locate Resident #1 in the facility. The report showed family was able to locate the resident on their phone, picked up the resident, and returned Resident #1 to the facility. The report showed the facility checked on Resident #1 every 15 minutes as an intervention for elopement. The report did not show Resident #1 had blisters to the back of their hand from the resident burning themselves with a cigarette lighter. The weekly skin observation for Resident #1, dated 01/26/26, showed the resident had a wound to the back of the left hand. The weekly skin observation, read in part, Multiple blister sites from resident stating she burned self. A behavior note for Resident #1, dated 02/08/26 at 6:45 a.m., showed staff would not administer the resident's medication early and Resident #1 followed the medication aide down the hall and cursed at them. Resident #1 then came to the nurses' station, demanded their medication, and threatened to call the police. The behavior note showed the nurse informed the resident they were not able to administer the medications early. The behavior note showed Resident #1 returned to their room and donned a hoodie before walking out the door. The behavior note showed the nurse and other staff drove up and down the street looking for the resident. The behavior note showed local authorities found the resident at a local residence. The behavior note showed the local authorities identified the residence as a known drug house. The behavior note showed Resident #1 returned to the facility and received their morning medications. A state reportable incident report for Resident #1, dated 02/08/26, showed the resident requested medication ordered as needed but was informed it was too early to administer the medication. The report showed Resident #1 announced they would leave the facility before walking out the front door. The report showed staff contacted the local authorities and followed the resident in a vehicle until police were able to locate Resident #1 and return them to the facility. The report showed Resident #1 was already on every 15 minute checks for an indefinite period of time. An incident note for Resident #1, dated 02/09/26 at 5:45 p.m., showed the resident eloped. The incident note showed at 4:30 p.m., Resident #1 asked for medication that was unavailable and to go for a walk. The incident note showed the CMA informed Resident #1 the medication was not due yet and they were busy and unable to go with the resident on a supervised walk. The incident note showed Resident #1 informed the CMA they would go for a walk by themselves. The incident note showed the facility realized Resident #1 was not in the building at 5:00 p.m.A state reportable incident report for Resident #1, dated 02/09/26, showed the resident requested medications that were not scheduled to give and was informed they would have to wait for the medication. Resident #1 requested a supervised walk outside and was denied by staff due to the staff member's responsibilities during resident mealtime. Resident #1 stated they would walk alone. The report showed the facility was unaware of Resident #1's elopement for 30 minutes. The family found the resident approximately one mile away at a local business and escorted the resident back to the facility. The report showed the facility initiated every 15 minute observation of Resident #1 for an indefinite period of time as an intervention.A nurse's progress note for Resident #1, dated 02/11/26, showed the burn wounds Resident #1 inflicted on themselves were healed.On 02/19/26 at 5:38 p.m., LPN #1 stated Resident #1 was pretty independent but needed supervision. LPN #1 stated Resident #1 liked to leave the facility without telling anyone which was ok when the resident was their own POA but now the resident was not their own POA and could not leave the facility. LPN #1 stated as one of the interventions, they performed every 15 minute checks on the resident, which started when the resident returned from their second elopement in two days. LPN #1 stated Resident #1 had a history of illicit drug use, and the resident exhibited drug seeking behaviors in the facility. LPN #1 stated what often triggered the resident's behavior was not getting medications when they wanted them. LPN #1 stated the resident would get angry and demand medications they could not have yet. LPN #1 stated having a staff member walk outside with the resident often helped. LPN #1 stated other things that helped included listening to music in the common area. LPN #1 stated if Resident #1 was too upset, the resident would call for an ambulance or just get up and walk away from the facility. On 02/19/26 at 5:55 p.m., the DON stated they did not investigate the elopements to determine the root cause of each elopement. The DON stated they did look at the cameras to see when and how the resident eloped. The DON stated the resident did not always exit through the front door and on 01/16/26, was observed on camera to watch the activity around a back door for a time before exiting through the back door. The DON stated when they asked the staff when the resident was last seen, the staff reported it had been 10-20 minutes earlier during the administration of a medication, but when they reviewed the camera footage, the medication was administered an hour earlier. The DON stated that was the date the resident purposely burned themselves with a lighter. The DON stated the police report for the elopement on 02/08/26 identified the residence Resident #1 was found in was a known drug house. The DON reviewed documentation for observation of the resident every 15 minutes. The DON stated the intervention to observe the resident every 15 minutes did not seem to be an effective intervention.

Based on record review and interview, the facility failed to complete a quarterly assessment for 1 (#1) of 4 sampled residents reviewed for quarterly assessments. The DON identified 49 residents resided in the facility. Findings:A review of the clinical record showed an annual assessment dated [DATE] for Resident #1, a discharge with return anticipated dated 11/06/25 for Resident #1, and an entry dated 11/19/25 for Resident #1. There were no documented assessments since the admission assessment on 09/28/25. On 02/23/26 at 1:55 p.m., LPN #2 stated they were the second and most recently hired nurse to perform MDS assessments and care plans while the MDS coordinator was on leave. LPN #2 stated they were not aware Resident #1's quarterly MDS was due.On 02/23/26 at 2:15 p.m., the DON stated the quarterly assessment for Resident #1 was late due to the interim MDS nurse not performing their duties.

Based on record review and interview, the facility failed to update the plan of care for 1 (#1) of 4 sampled residents reviewed for their plan of care for elopement. The DON identified 49 residents resided in the facility. Findings:A care plan for Resident #1, dated 09/28/25, showed a concern for elopement. The care plan for elopement did not show it was reviewed or updated after elopements on 10/15/25, 11/06/25, 01/16/26, 02/08/26, or 02/09/26.On 02/19/26 at 5:38 p.m., LPN #1 reviewed the care plan for elopement and stated the interventions were not updated since the care plan for elopement was developed. On 02/23/26 at 1:55 p.m., LPN #2 stated they thought the DON had recently updated the care plan for elopement. On 02/23/26 at 2:15 p.m., the DON stated the care plan for Resident #1 was not updated due to the interim MDS nurse not performing their duties.

Based on observation, record review, and interview, the facility failed to ensure routine safety inspections of resident bed frames and bed rails were conducted for 3 (#3, 4, and #28) of 4 sampled residents reviewed for accident hazards.Maintenance #1 identified 48 residents who used facility-maintained bedframes.Findings:On 08/26/25 at 10:13 a.m., Res #4 was observed laying in their bed. The bed was observed to have a 1/8 sized side rail attached to the bed frame.On 08/26/25 at 11:02 a.m., Res #28 was observed laying in their bed. The bed was observed to have a 1/8 sized side rail attached to the bed frame.On 08/27/25 at 12:30 p.m., Res #3 was observed laying in their bed. The bed was observed to have two 1/8 sized side rails attached to the bed frame.On 08/28/25 at 1:38 p.m., Maintenance #1 was asked if the facility had conducted bed frame and bed rail inspections. They stated they had not performed inspections of the bed frames or side rails. They stated when they started, they were told a bed rail would at least cover half of the bed and they did not consider the smaller ones they used as bed rails. When asked if there were any records of bed frame and bed rail inspections, they stated they did not find any such records. They stated 46 beds had side rails attached to them

Based on record review and interview, the facility failed to ensure residents were not prescribed antipsychotic medication for the medical diagnosis of dementia for 2 (#40 and #45) of 5 sampled residents reviewed for unnecessary medications.The ADON stated seven residents in the facility were prescribed antipsychotic medications. Findings:A facility policy titled Antipsychotic Medication Use, dated July 2022, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.1.A medication order for Res #40, dated 06/19/25, showed the resident was to be administered Seroquel (a medication approved to treat psychotic disorders) 25 mg, 2 tablets to equal 50 mg by mouth every day and evening for vascular dementia, mild, with other behavioral disturbance.A medication administration record for Res #40, dated 08/01/25 through 08/31/25, showed the resident had received 47 doses of Seroquel 50 mg on and between the dates of 08/01/25 and 08/26/25.2.A medication order for Res #45, dated 06/23/25, showed the resident was to be administered Seroquel (a medication approved to treat psychotic disorders) 12.5 mg by mouth every day for unspecified dementia, unspecified severity, with psychotic disturbance.A medication administration record for Res #45, dated 08/01/25 through 08/31/25, showed the resident had received 26 doses of Seroquel 12.5 mg on and between the dates of 08/01/25 and 08/26/25.On 08/27/25 at 11:37 a.m., LPN #1 was asked regarding Res #40 and #45's prescribed use of Seroquel, what reason the medication was being used. They stated it was being used for behaviors such as hitting or refusing care. They were asked what diagnosis was documented as being treated by the Seroquel. They stated it was dementia. They were asked if Seroquel had been approved for the treatment of dementia. They stated they did not know.On 08/28/25 at 11:55 a.m., DON was asked to explain the use of antipsychotic medications for the treatment of dementia at the facility. The DON stated they had worked at geriatric psychiatric facility previously. The DON stated they preferred antipsychotic medication not be used and their goal for this facility was to get the residents off those medications. The DON stated antipsychotic medications were not approved for the treatment of dementia and should be used for specific problems such as delusions.

Based on record review and interview, the facility failed to provide a written notice of transfer for residents who transferred to a hospital for 3 (#28, 40, and #47) of 3 sampled residents reviewed for hospitalizations. The ADON stated 54 residents had been transferred to a hospital between 02/27/25 and 08/27/25.Findings:An undated facility policy titled Transfer or Discharge, Emergency, did not show the requirement to send a written notice of transfer to the resident and resident representative prior to transfer.1.A progress note for Res #40, dated 07/21/25 at 10:45 p.m., showed the resident was transferred to a hospital on that date for tremors and unresponsiveness.On 08/27/25 at 11:44 a.m., the ADON was asked about the paperwork that was sent with Res #40 when they were sent to a hospital on [DATE]. The ADON described the various forms but did not state the resident had received a written notice of transfer. They were asked if Res #40 had received a written notice of transfer prior to being sent to the hospital. The ADON stated they had not as they had never heard of the requirement to do so.2.A progress note for Res #47, dated 07/29/25 at 9:18 a.m., showed the resident was transferred to a hospital on that date for an abnormal heart rate and report of difficulty breathing.On 08/27/25 at 2:58 p.m., the interim DON was asked if Res #47 had been given a written notice of transfer when they were transferred to a hospital on [DATE]. They stated they had not been giving any residents a written notice of transfer when they were sent out to a hospital.3.A progress note for Res #28, dated 08/11/25 at 1:31 p.m., showed the resident was transferred to a hospital on that date for abnormal Co2 levels.On 08/27/25 at 1:50 p.m., LPN #1 was asked if Res #28 had been given a written notice of transfer when they were sent to a hospital on [DATE]. The LPN stated they had never heard of a written notice of transfer and was not aware they were supposed to give the resident the letter.On 08/27/25 at 3:06 p.m., the interim DON stated they had looked through the EMR's of Res #28, 40, and #47 and had not found any letters of transfer for any of them. They stated they had not been aware of the regulation to present those letters to residents so that had not been done.

Based on record review and interview, the facility failed to ensure routine catheter care was documented in the clinical record for 1 (#5) of 1 sampled resident reviewed for catheter care.The ADON reported 5 residents had an indwelling urinary catheter.Findings:An undated Catheter Care, Urinary policy, read in part, The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care.A quarterly assessment, dated 07/24/25, showed Res #5 had a BIMS (a test for cognition) score of 12, which was indicative of moderate cognitive impairment. The assessment showed the resident had an indwelling urinary catheter, and diagnoses which included acute kidney failure and diabetes mellitus.A review of Res 5's medical record for 06/2025, 07/2025, and 08/2025 did not document catheter care had been performed.On 08/27/25 at 11:05 a.m., Res #5 stated the staff provided frequent catheter care.On 08/27/25 at 3:38 p.m., the ADON stated catheter care should be documented on the TAR, and if it was not documented, they could not say if it had been completed or not.On 08/28/25 at 11:56 a.m., the DON stated if catheter care was not documented, then it was not done.

Based on record review and interview, the facility failed to ensure residents were offered pneumonia immunizations as required for 2 (#3 and 45) of 5 sampled residents reviewed for immunizations.The administrator reported 48 residents resided in the facility.Findings:1. A physician's order, dated 08/02/25, showed Res #3 was to be offered a pneumonia immunization if indicated.A review of Res #3's medical record did not show they had received or been offered a pneumonia immunization.2. A physician's order, dated 02/25/22, showed Res #45 was to be offered a pneumonia immunization if indicated.A review of Res #45's medical record did not show they had received or been offered a pneumonia immunization.On 08/28/25 at 10:37 a.m., the infection preventionist stated the facility did not have a policy regarding pneumonia immunizations and had not been offering pneumonia immunizations to residents consistently.On 08/28/25 at 11:56 a.m., the DON stated that the facility should have a policy related to pneumonia immunizations and residents should be offered to the residents according to that policy.

Based on record review and interview, the facility failed to ensure laboratory tests were completed as ordered by the physician for 1 (#45) of 5 sampled residents whose labs were reviewed.The administrator reported 48 residents resided in the facility.Findings:An undated facility policy titled Lab and Diagnostic Test Results - Clinical Protocol, read in part, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test request and arrange for tests.An admission record, dated 02/25/22, showed Res #45 had diagnoses which included dementia and osteoarthritis.A quarterly assessment, dated 07/25/25, showed Res #45 had a BIMS score (a test for cognition) of 6 which was indicative of severe cognitive impairment.A physician's order, dated 01/07/24, showed Res #45 was to receive the following lab tests every six months in January and July: Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Stimulating Hormone, Lipid Panel, Vitamin B-12, and Vitamin D.A review of Res #45's health record did not show any lab results since 01/10/24.On 08/26/25 at 2:12 p.m., LPN #1 stated the most recent lab results for Res #45 were from 01/10/24. They stated the labs for July 2024, January 2025, and July of 2025 had not been completed.On 08/28/25 at 11:56 a.m., the DON stated if there was an order for lab work from the physician, the lab work should have been completed.

Based on record review and interview the facility failed to ensure advanced benefit notification forms were provided to three (#9, 11, and #21) of three residents reviewed for Advanced Beneficiary Notifications. The MDS coordinator identified four residents who had received skilled services in the past six months. Findings: Resident #9 admitted to Part A Skilled Services on 08/29/23. The facility initiated a discharge from Medicare Part A Services on 10/06/23 with 18 days remaining. Resident #9 remained at the facility. An Advanced Beneficiary Notice was not provided to Resident #9 throughout their stay at the facility. Resident #11 admitted to Part A Skilled Services on 10/09/23. The facility initiated a discharge from Medicare Part A Services on 11/27/23 with 52 days remaining. Resident #11 remained at the facility. An Advanced Beneficiary Notice was not provided to Resident #11 throughout their stay at the facility. Resident #21 admitted to Part A Skilled Services on 09/27/23. The facility initiated a discharge from medicare Part A Services on 10/26/23 with 70 days remaining. Resident #21 remained at the facility. An Advanced Beneficiary Notice was not provided to Resident #21 throughout their stay at the facility. On 04/10/24 at 1:44 p.m., the MDS coordinator stated they were not aware an Advanced Benficiary Notice was to be provided when residents discharged from Medicare Part A Services and remained in the facility.

Based on observation, record review and interview, the facility failed to ensure residents were free from physical restraints which were not required to treat a resident's medical symptom for four (#7, 13, 14, and #24) of four residents reviewed for restraints. The administrator identified 44 residents who resided at the facility. Findings: A Physical Restraints & Hazards Policy, undated, read in part, .Physical restraints are defined as any manual method or physical device, material, or equipment attached so that the individual cannot remove easily, which restricts freedom of movement to one's body .No resident will be restrained for convenience . 1. Resident #7 had diagnosis which included dementia. A quarterly assessment, dated 02/29/24, documented the resident was moderately impaired in daily decision making and required moderate assistance with ADLs. 2. Resident #13 had a diagnosis which included dementia. A quarterly assessment, dated 02/27/24, documented the resident was severly impaired in daily decision making and required moderate to maximum assistance with ADLs. 3. Resident #14 had diagnosis which included major depressive disorder. A quarterly assessment, dated 03/08/24, documented the resident was severly impaired in daily decision making and required moderate to maximum assistance with ADLs. On 04/08/24 at 8:34 a.m., CNA #1 was observed to reach down and lock Resident #13's wheelchair. Resident #7 and #14's wheelchairs were also observed to be locked. On 04/08/24 at 8:38 a.m., CNA #1 stated the wheelchairs were locked. We have to do for them so they don't push away. They stated the residents were unable to unlock the wheelchairs themselves. On 04/10/24 at 08:51 a.m., the DON stated a restraint was the restriction of bodily movement. On 04/10/24 at 08:52 a.m, the DON stated locking the wheelchairs was a restraint.

Based on record review and interview the facility failed to ensure the accuracy of assessments for one (#17) of twelve residents reviewed for accuracy of assessments. The administrator identified 44 residents who resided at the facility. Findings: Resident #17 admitted with diagnoses which included cerebral infarction (stroke), reduced mobility, and hypertension. Review of the quarterly assessment, dated 02/25/24 for Resident #17, revealed a diagnosis of pneumonia. Review of physician orders, for Resident #17, revealed no antibiotics ordered currently or in the recent past for pneumonia. Review of diagnoses for Resident #17 revealed a history of pneumonia in 2017. On 04/10/24 at 10:52 a.m., the MDS coordinator stated they reviewed the diagnoses, progress notes and physician orders to complete the MDS assessment. The coordinator stated they would review the clinical record and return with where they found the pneumonia information for the quarterly assessment. On 04/10/24 at 1:48 p.m., the MDS coordinator stated they were not able to locate where they had found the information regarding pneumonia. They stated it was an inaccurate MDS.

Based on record review and interview the facility failed to ensure care plans were updated for one (#38) of twelve reviewed for updated care plans. The administrator identified 44 residents who resided at the facility. Findings: Resident #38 was admitted with diagnoses which included congestive heart failure, hypertension, and atrial fibrillation. The care plan, revised 01/23/24, documented a stage two pressure ulcer to the coccyx. The care plan did not document the stage two pressure ulcer had healed. The care plan did not document the resident was admitted to hospice, and was not updated to included hospice. A Physician's Order, dated 01/26/24, documented to admit Resident #38 to hospice. On 04/11/24 at 8:22 a.m., the MDS coordinator stated they updated the care plan with wounds or infections and during reviews. The MDS coordinator stated Resident #38 did have a stage two wound in January but it had resolved earlier this week. They stated they had forgot to update the care plan for the healed wound and for hospice.

Based on record review, observation, and interview, the facility failed to ensure the ice machine was clean. The administrator identified 44 residents who resided at the facility. Findings: An untitled and undated policy, read in part, .Ice will be produced, stored, and dispensed in a manner to avoid contamination .The ice dispenser will be cleaned and sanitized at least monthly, and/or as needed. Inside and outside of machine and the area around the machine will be cleaned . An invoice dated 03/08/24, documented the bin sensor was cleaned. No other cleaning of the machine was documented. On 04/09/24 at 11:25 a.m., the ice machine was observed to have black and pink substances on the deflector plate in the bin of the ice machine. On 04/09/24 at 11:28 a.m., Dietary Aide #1 stated the ice machine had last be cleaned four weeks ago. They stated the substance was mold and should not be there. They stated the ice company was responsible for cleaning of the ice machine. On 04/09/24 at 11:30 a.m., Dietary Aide #1 stated the ice machine should be shut down and cleaned.

Based on interview and record review the facility failed to provide written notice of room change for one (#38) of three residents reviewed for room change. Findings: Resident #38 had diagnoses which included paraplegia. On 04/26/23 at 3:10 p.m. the resident stated they had been moved to another room on 04/18/23. Review of the clinical record confirmed the room change on 04/18/23. The clinical record did not include information that the resident received written notification of room change. On 04/18/23 at 2:36 p.m. the administrator was asked if the resident was given a written notification of room change. The administrator stated I guess we forgot.

Based on record review, observations, and interview, the facility failed to ensure two (#1 and #38) of 16 residents sampled for ADLs received baths as scheduled. The Resident Census and Conditions of Residents form identified 43 residents who resided in the facility. Findings: 1. Resident #1's active diagnoses included down syndrome and dementia. Resident #1 admitted to the facility on [DATE]. The admission assessment, dated 01/09/23, documented the resident's cognition was severely impaired and required extensive assistance with dressing, personal hygiene, and bathing. According to the residents bath schedule he was to receive a shower on Monday, Wednesday, and Friday on day shift. The facility produced seven bath sheets for this resident which documented he had a shower five times and refused two times during the time frame from 12/28/22 through 02/24/23 with an opportunity to receive 26 showers/baths according to the bath schedule. On 2/22/23 during the survey, the resident was observed in his wheel chair in the foyer and in the dining room. His shirt was dirty with food on it. He was not interviewable. 2. Res #38 admitted to the facility on [DATE]. The admission assessment, dated 12/19/22, documented her cognition was intact; required extensive assistance with ambulation, transfers, and dressing; ROM was impaired on both sides of lower extremities; the resident required a one person physical assist for bathing. On 02/22/23 at 2:11 p.m., The resident was observed in her bed in her room her hair appeared to not be combed. The resident reported that she did not get her showers/baths like she should. She said she has refused a couple of times but she should be getting more showers. She reported, I have only had two showers since admitting to the facility. According to the residents bath schedule she was to receive a shower on Tuesday, Thursday, and Saturday on day shift. The facility produced four bath sheets which documented she had two showers and had refused two times during the time frame between 12/06/22 and 02/24/23 with an opportunity for 34 showers/baths according to the bath schedule. On 02/24/23 at 11:00 a.m., the ADON reported the resident had refused her showers sometimes but the 4 baths sheets they had were all they could find for this resident. On 02/24/23 at 11:15 a.m., the ADON reported, We are working on a new bath schedule to ensure the residents are receiving their baths.

Based on record review and interview, the facility failed to: a. ensure accurate coding of MDS assessments for anticoagulant use for six (#1, 16, 18, 21, 27, and #34) of 14 residents whose MDS assessments were reviewed. b. ensure accurate coding of MDS assessment for diagnoses for one (#20) of 14 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: 1. Res #1 had diagnoses which included dementia, chronic ischemic heart disease, and hypertension. An admission assessment, dated 01/09/23, documented Res #1 received an anticoagulant seven out of seven days during the review period. On 02/23/23 at 10:55 a.m., Res #1's records were reviewed and did not document an order for anticoagulants during the review period. 2. Res #16 had diagnoses which included hypertension, and history of aneurysm. A quarterly MDS, dated [DATE], documented Res #16 received an anticoagulant seven out of seven days during the review period. On 02/23/23 at 8:29 a.m., Res #16's records were reviewed and did not document an order for anticoagulants during the review period. 3. Res #18 had diagnoses which included atherosclerotic heard disease, angina pectoris, and hypertension. A quarterly MDS, dated [DATE], documented the resident received an anticoagulant seven out of seven days during the review period. On 02/23/23 at 11:35 a.m., Res #18's records were reviewed and did not document an order for anticoagulants during the review period. 4. Res #21 had diagnoses which included coronary artery disease and hypertension. A quarterly MDS, dated [DATE], documented Res #21 received an anticoagulant seven out of seven days during the review period. On 02/23/23 at 1:23 p.m., Res #21's records were reviewed and did not document an order for anticoagulants during the review period. 5. Res #27 had diagnoses which included cardiomyopathy, and hypertensive heart disease. A quarterly MDS, dated [DATE], documented the resident received an anticoagulant seven out of seven days during the review period. On 02/22/23 at 3:45 p.m., Res #27's records were reviewed and did not document an order for anticoagulants during the review period. 6. Res #34 had diagnoses which included hypertension and hyperlipidemia. A quarterly MDS, dated [DATE], documented the resident received an anticoagulant seven out of seven days during the review period. Res #27's records were reviewed and did not document an order for anticoagulants during the review period. On 02/23/23 at 11:11 a.m., the ADON/MDS coordinator stated the MDS was coded incorrectly. She stated she coded them based on the indication of an order for aspirin instead of the drug classification. 7. Res #20 had diagnoses which included COPD, CHF, and hypertension. The Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual Version 1.17.1, dated October 2019, read in part .ACTIVE DIAGNOSES Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period . A diagnosis, dated 05/05/21, documented sepsis due to streptococcus pneumoniae. An annual MDS, dated [DATE], documented Res #20 had septicemia during the review period. On 02/23/23 at 11:47 a.m., the ADON/MDS coordinator stated she was instructed not to change the diagnoses that populated on the MDS. She stated she was not aware the diagnoses are only to be coded if they are active at the time of the assessment.

Based on record review and interview, the facility failed to: a. offer residents the choice to formulate advance directives for four (#16, 26, 27, and #32) of 16 residents reviewed for advance directives. b. ensure a resident's code status was documented in the medical record for three (#16, 26, and #32) of 16 residents reviewed for advance directives. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. It documented there were 40 residents who had advance directives. Findings: 1. Res #27 was admitted [DATE] and had diagnoses which included vascular dementia, acute kidney failure, cerebral infarction, and cardiomyopathy. A physician order, dated 04/15/22, documented the resident was a full code. A quarterly assessment, dated 10/26/22, documented the resident had moderate cognitive impairment. There was no documentation the resident and/or their representative was offered a choice to formulate an advance directive. On 02/23/23 at 9:12 a.m., RN #1 stated the advance directive documentation should be located within the advanced directive tab in the front of the chart but Res #27's was not there. She stated she did know where the documentation could be found. On 02/23/23 at 11:22 a.m., the ADON stated there is no documentation that this resident and/or their representative was offered a choice to formulate an advance directive. 2. Res # 32 was admitted [DATE] and had diagnoses which included chronic pain syndrome, inflammatory polyneuropathy, and malignant neoplasm of breast. A quarterly assessment, dated 01/19/23, documented the resident was cognitively intact. The medical record did not document a code status for the resident. There was no documentation the resident and/or their representative was offered a choice to formulate an advance directive. On 02/23/23 at 9:10 a.m., RN #1 stated she was unable to locate this resident's code status or documentation the resident and/or their representative was offered a choice to formulate an advance directive in the medical record. On 02/23/23 at 9:19 a.m., LPN #1 stated the resident did not have a code status documented in the medical record and the physician would be contacted to obtain a code status order. On 02/23/23 at 11:22 a.m., the ADON stated there is no documentation the resident and/or their representative was offered a choice to formulate an advance directive in the medical record. 46387 3. Res #16 admitted to the facility on [DATE] with diagnoses which included paralytic syndrome following cerebral infarction, Parkinson's disease, and seizures. A quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired. On 02/23/23 at 8:38 a.m., Res #16's chart was reviewed. There was no documentation that the resident had an advance directive or was offered one at admission. The chart did not document Res #16's code status. On 02/23/23 at 10:36 a.m., LPN #1 stated Res #16 had no code status order. She stated Res #16 was a full code and the physician had been contacted for an order. She stated the order had not been put in the EHR yet. 4. Res #26 admitted [DATE] with diagnoses which included Parkinson's disease, cognitive communication deficit, aphasia, and seizures. A quarterly MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance with ADLs. On 02/23/23 at 10:10 a.m., Res #26's chart was reviewed. There was no documentation that the resident had an advance directive or was offered one at admission. The chart did not document Res #26's code status. On 02/23/23 at 10:36 a.m., LPN #1 stated Res #26 had no code status order. She stated Res #26 was a full code. She stated the physician had been contacted for an order but the order had not been put in the EHR yet.

Based on record review, observation, and interview, the facility failed to ensure a comprehensive care plan was completed for one (#190) of one residents reviewed for new admission. The Resident Census and Conditions of Residents form documented 43 residents resided in the facility. Findings: Resident #190 admitted to the facility on [DATE] with diagnoses which include chronic heart failure, major depressive disorder, hemiplegia, bipolar disorder, atrial fibrillation, chronic respiratory failure, anxiety, and hypertension. On 02/22/23 at 12:05 p.m., Res #190 was observed in bed with eyes closed with oxygen supplied by nasal cannula. On 02/23/22 at 08:13 a.m., Res #190's record was reviewed and documented a care plan initiated 02/06/23. The care plan was blank. On 02/23/23 at 11:50 a.m., the ADON/MDS coordinator stated Res #190's care plan was not started. She stated there was not a comprehensive care plan completed.

Based on observation, staff and resident interviews, and record review, it was determined the facility failed to ensure residents received adequate interventions to prevent unavoidable weight loss for two (#2 and #11) of six sampled residents who were reviewed for weight loss. This resulted in actual harm for resident #2 who had a severe weight loss of 34 pounds (20.7%) in six months. This had the potential to affect 13 residents identified by the facility as having experienced weight loss in the last six months. Findings: An undated facility policy titled, Weight Loss Protocol, documented, .Procedure .Monitor monthly weights for significant or severe loss using significant weight change guidelines .Implement nutritional interventions based on the individual case .Notify nutrition services, nursing and physician of interventions by using the established notification procedure in the facility . An undated facility policy titled, Procedures: Weight Prevention and Nutritional Risk, documented, .Quality Assurance: Weight Loss-Consideration for intervention may use all or some of list per recommendations of: Physician . Staff . Consultant . Labs: [MEDICATION NAME] .[MEDICATION NAME] .Med: Mutli-Vit (sic) .Supplement: [MEDICATION NAME] .House Supplement .Yogurt . 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 06/08/15, and revised on 01/01/16, documented, .Focus: I have had a 6 lb weight loss June 2015 r/t Poor food intake resident continues significant weight loss. Currently is on hospice. Continues weight loss [DATE] .Goal .The resident will consume (75%) two of three meals/day .Interventions/Tasks .Monitor and evaluate any weight loss .Determine percentage lost and follow facility protocol for weight loss .yogurt @ HS .yogurt at breakfast and lunch .Assist with feedings at the assisted diners table . A laboratory result, dated 09/10/15, documented, .[MEDICATION NAME] .9L .(20-40) . A quarterly assessment, dated 10/20/15, documented she was severely impaired cognitively for daily decision making skills. She required extensive assistance of one person for eating. She was 67 inches tall, weighed 138 pounds, was on a therapeutic diet, and had experienced a loss of 5% or more in the last month or 10% or more in the last six months. A Medication Administration Record, [REDACTED].give 1 carton at HS .Start Date: 11/18/2015 at bedtime .weight loss .Yogurt .give 1 carton at bkfst and lunch .Start Date: 12/29/2015 .weight loss . A physician order, dated 01/06/15, documented, Start date 10/05/15 .4 oz house supplement TID with meals . A facility monthly weight report, documented the following weights for resident #2, June 164.0 .July 153.5 .August 153.5 .September 149.0 .October 138.0 .November 135.0 .December 130.0 . On 01/04/16 at 12:30 p.m., the noon meal was observed. She was observed seated in a geri-chair at the assisted dining table. NA #1 was observed to encourage the resident to eat and had occasionally offered her a bite from the plate. The house supplement was available beside the resident's plate, but no yogurt was observed to be at the table. During the 35 minutes of observation, the resident received minimal assistance with eating. On 01/05/25 at 8:33 a.m., the breakfast meal was observed in the dining room. Resident #2 was observed seated in a geri-chair at the assisted dining table, with her eyes closed. She was served breakfast which included hot cereal, scrambled eggs, and pureed biscuits and gravy. There was no house supplement or yogurt observed on the table where the resident was eating. At 8:35 a.m., the restorative aide brought a pillow and placed it behind her back to prop her forward. CNA #1 was observed to have placed a bite of food on a spoon and attempted to feed the resident. Her eyes remained closed. CNA #1 then attempted to offer the resident orange juice using a straw. The resident remained unresponsive. Staff attempted to wake the resident by calling her name multiple times and wash her face with a wash cloth. She was not observed to have responded. At 8:50 a.m., the ADON moved her chair to the resident's side at the assisted dining table. She was observed to call her name multiple times and wash her face with a wash cloth. The ADON placed hot cereal on the spoon and placed it into the resident's mouth. The resident closed her mouth slightly and began to swallow. She was then offered orange juice through a straw and drank the entire contents. The ADON continued to sit with the resident and feed her throughout the rest of the meal. The resident was able to eat all of her hot cereal and a small amount of the pureed biscuits and gravy with extensive staff assistance. She also drank all of the fluids that were offered to her including milk and orange juice. A review of the resident's dietary card, obtained from the kitchen, documented, she was on a regular puree diet with diabetic desserts. She was to receive 4 ounces of regular house supplement three times daily and yogurt with lunch, dinner, and bedtime. A facility dietary accommodations chart, documented, she was to have yogurt at breakfast, lunch, and dinner. On 01/05/16 at 9:15 a.m., the ADON requested the house supplement from the kitchen. The resident drank all four ounces of the supplement once it was provided. She required extensive assistance. At 9:30 a.m., the ADON was asked if she normally assisted the resident with eating at meals. She stated, No. At 12:00 p.m., the resident was observed during the noon meal. The resident's tray did not include yogurt or the house supplement. At 1:05 p.m., the dietary manager was asked if the resident received any special foods from the kitchen due to her weight loss. She stated she gets what she asks for which has lately been ice cream. She was asked when does she receive the ice cream. She stated, Only when she asked for it but, if she doesn't ask for it, staff will ask her if she wants it. She was asked when does the resident receive the house supplement and yogurt. She stated it depended on how she ate and if she asked for it. She stated, Everyone knows she is losing weight. Some days are better than others. The dietary manager was asked if the resident had any dietary orders from the physician. She stated, None that I know of. On 01/05/16 at 1:15 p.m., the registered dietician was asked what interventions had been put in place to address the resident's weight loss. After reviewing her notes, she stated, she had recommended a diabetic house supplement in September 2015. In November she had recommended yogurt at bedtime, but increased it to breakfast and lunch in December 2015 due to continued weight loss. She was asked if she was aware the kitchen only provided the house supplement and yogurt when the resident or staff asked for it She stated, No. She was asked if the kitchen should have sent the supplements out automatically without the resident requesting them. She stated, Yes. She further stated, She should have been receiving them as ordered. She was asked if she felt her weight loss could have been avoided. She stated, Possibly, if she had been receiving supplements as ordered. On 01/05/16 at 3:05 p.m., the DON was asked how dietary supplements are monitored for residents who are experiencing weight loss. She stated, Currently there is no way for me to know how much supplement is taken or offered because all liquids at the table are counted as one intake percentage. A review of the clinical record contained documentation of a new laboratory result, dated 01/06/2016, which documented an [MEDICATION NAME] level of 2.5L (3.4 - 5.0). 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 08/12/14, documented, Focus .The resident refuses to eat at times and becomes agitated. I have a hx of refusing meals in nursing home stating, 'I don't like the food.' I had a 4lb weight loss in October. I do not like breakfast .Goal .The resident will eat at least one bite of each food offered daily through the review period .Interventions .Administer medications as ordered. Monitor/document for side effects and effectiveness .Empower the resident by allowing choices in meal time, menu selection, dining location .Encourage the resident's family members to bring in favorite food items from home or favorite restaurant items . A care plan, dated 09/24/14, documented, .Focus .The resident has potential nutritional problem r/t being below IBW .Interventions .multivitamin daily .Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated .Provide, serve diet as ordered. Monitor intake and record q meal . A quarterly assessment, dated 07/17/15, documented she was cognitively intact for daily decision making skills. She was independent with eating, was not on a therapeutic diet, was 66 inches tall, weighed 117 pounds, and had no weight loss. A dietician note, dated 09/30/15, documented, .Wt. 107.5#, down 6.5#. Intake inconsistent. Is on Regular diet. Labs 9/4: Glu 68L, BUN 23H, Creat 2.37H, Alb 3.0L, H/H 9.3L/30.6L. Is on multivitamin daily. Rec checking Vit B12, Folate and Iron Panel. Also rec giving ice cream bid with lunch and supper . An annual assessment, dated 10/15/15, documented she was cognitively intact for daily decision making skills. She was independent with eating, was not on a therapeutic diet, was 66 inches tall, weighed 106 pounds and had no weight loss. A dietician note, dated 10/29/15, documented, .Wt. 106#, down 1.5#. Intake inconsistent. Was started on ice cream bid per previous rec. Also started on yogurt 1 carton @ HS. Labs 10/7 Iron 22L, Vit B12 366, Folate > 20.0. Continues on multivit/min. Rec re-check CBC at this time . A physician progress notes [REDACTED]. She was diagnosed with [REDACTED]. No interventions related to the decreased appetite were documented. A dietician note, dated 11/30/15, documented, .Wt 103#, down 3#. Intake very inconsistent. Labs 11/3 H/H 10.1L/31.6L but improving; 1/9 BUN 31H and Creat 2.5H. Rec 90cc Med Pass 2.0 tid with med pass . The clinical record did not contain documentation 90cc Med Pass 2.0 tid was started by the facility. A dietician note, dated 12/21/15, documented, .Wt 99.5#, down 3.5# Intake inconsistent. No recent labs or skin breakdown reported. No response noted to previous rec to give 90cc 2.0cal tid with med pass. Will re-rec . On 01/06/16 at 8:10 a.m., the resident was observed seated in a wheelchair in the front lobby waiting in line for breakfast. She stated, I usually am not hungry. I eat only toast and jelly. They give me eggs and cereal, but I do not eat it. A review of her dietary card from the kitchen documented she was on a regular diet, ice cream offered 2x daily with meals, and had yogurt at bedtime. On 01/07/16 at 8:00 a.m., CMA #1 was asked if the resident was given 90cc Med Pass 2.0 when her medications were given. She stated, No, she is not on it. She further stated, Her appetite is not very good. Someday's she refuses meals for up to two days. On 01/07/16 at 8:15 a.m., the resident was asked if she received yogurt and ice cream. She stated, I don't like yogurt so I don't eat it. I get ice cream at bedtime but often it's melted and I don't eat it. On 01/07/16 at 9:00 a.m., the DON was asked what the interventions were and how she monitored the resident's weight loss. She stated she was weighed monthly and the dietician makes recommendations. She further stated the CNAs write down the percentage of food eaten in the computer. She was asked if a resident has consistent weight loss, should the monthly weights be increased to weekly. She stated, No, I would have to get a physician order [REDACTED].>She was asked how nutritional supplements were monitored for those residents with weight loss. She stated all liquids are combined and documented as one percentage. She further stated since it was not separated, then there was no way for the supplements to be monitored. She was asked if she had spoken to the resident regarding food preferences such as yogurt and ice cream before starting them as a supplement. She stated food preferences were obtained upon admission however; she had not spoken with the resident. She was asked if the recommendation from the dietician to start Med Pass had been ordered. After reviewing the physician's orders [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to provide care to prevent the development of pressure ulcers for one (#2) of one resident reviewed for pressure ulcers. The facility failed to: a) implement interventions for the prevention of pressure ulcers for the resident, and b) provide care and treatment in a manner to promote healing of pressure ulcers for the resident. On 07/27/14 documentation noted the resident had developed an open stage three pressure ulcer. The facility's census and condition report documented three residents had pressure ulcers which were in-house acquired. Findings: The facility's pressure ulcer prevention policy documented the staff were to complete a skin evaluation for the residents on admission to the facility. The policy documented the staff were to implement interventions to prevent the development of pressure ulcers which included a speciality mattress for the bed, positioning devices, and repositioning for the resident. The policy documented the staff were to check the resident's skin during baths and document the findings on the bath sheets. The bath sheets were to be given to the charge nurse for review. The policy documented abnormal findings on the bath sheets were to be reported to the director of nurses (DON) and the physician. The facility's policy for wound care procedure documented the nurse was to remove and inspect the soiled dressing noting drainage, color, odor, and necrotic debris. The policy documented the nurse was to clean the wound with a wound cleaning solution and remove debris with gauze in a circular manner. The policy documented the wound was to be dried using the same procedure for cleaning. The policy documented the nurse was to reassess the condition of the wound after cleansing then redress the wound as ordered. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 06/02/14, documented the resident weighed 114 pounds (lbs), required extensive assistance for bed mobility, had no skin abnormality, and received a regular diet. A physician's orders [REDACTED]. The comprehensive assessment, dated 06/15/14, documented the resident was severely impaired for daily decision-making, had delusions, required extensive assistance with the activities of daily living, required extensive assistance with bathing, and was incontinent of bowel and bladder. The assessment documented the resident had no pressure ulcers. The comprehensive care plan, dated 06/24/14, documented the resident had a a history of pressure ulcers. The care plan documented interventions to prevent pressure ulcers were for the staff to administer treatments as ordered and monitor the effectiveness, follow the facility's policy and procedures for the prevention of pressure ulcers, inform the family of new areas of skin breakdown, monitor nutritional status/record intake, notify the nurse immediately of skin redness, blisters, bruises, or discoloration noted during baths/daily care, and report any changes in skin status to the physician. The Braden Scale skin assessment, dated 06/24/14, documented the resident was at low risk for pressure ulcers. The nurses' notes, dated 06/02/14 through 07/27/14, were reviewed. The nurse's notes documented no details regarding the development of the resident's pressure ulcer. The nurses' notes had no documentation regarding the size, depth, location, drainage, or stage of the ulcer. The notes did not document the physician had been notified or the treatment orders which were received. A physician's orders [REDACTED]. The skin assessments/wound care sheets documented the resident's pressure ulcer was first observed on 08/01/14. The record documented the pressure ulcer was a stage three ulcer. The report documented no measurements or assessment of the ulcer on 08/01/14. The nurse's notes, dated 08/06/14, documented the resident was out of the facility for evaluation of rectal bleeding and returned to the facility on [DATE]. The skin assessment/wound record for 08/11/14 documented the wound was located on the coccyx, was a stage three ulcer, measured 2.5 centimeters (cm) by 1.0 cm and was 0.3 cm deep, was 40 percent granulation tissue, had no odor, and had light serous drainage. A physician's orders [REDACTED]. The order documented for the staff to cleanse wound to coccyx with wound cleaner, pat the wound dry with 4 by 4 gauze, apply Santyl to wound, and cover with an adhesive border dressing daily. The skin assessments documented the first skin assessment was completed on 09/05/14. The assessment documented the skin was normal and no wounds were documented. The assessment documented the treatment was continued to healing coccyx. The skin assessments from 09/05/14 through 10/17/14 document the same findings. A physician's orders [REDACTED]. The skin assessment/wound record, dated 09/12/14, documented the wound was a stage three ulcer, measured 2.3 cm by 0.9 cm and was 0.2 cm deep, had 50 percent granulation tissue, had no odor, and had light yell drainage. A laboratory report, dated 09/16/17, documented the resident's pre-[MEDICATION NAME] (an indicator of nutritional status) level was low. A physician's orders [REDACTED]. The skin assessment/wound record, dated 09/26/14, documented the wound was a stage two ulcer, measured 2.9 cm by 1.2 cm and was 0.1 cm deep, had 90 percent granulation tissue, had no odor, and had light yell drainage. The physician's orders [REDACTED]. The order documented the staff was to cleanse wound to coccyx with wound cleaner, pat the wound dry with a 4 by 4 gauze, apply GRX Hydrogel Gauze two inches by 2 inches, and cover with an adhesive border dressing daily until resolved. The skin assessment/wound record, dated 10/10/14, documented the wound was a stage two ulcer, measured 3.0 cm by 1.2 cm and was 0.2 cm deep, was 90 percent granulation tissue, had no odor, and had light yellow drainage. The Braden Scale skin assessment, dated 11/04/14, documented the resident was at moderate risk for pressure ulcers. The skin assessment/wound record, dated 11/07/14, documented the wound was a stage two ulcer, measured 2.8 cm by 0.8 cm and was 0.1 cm deep, was 100 percent granulation tissue, had no odor, and had light yellow drainage. On 11/13/14 at 3:00 p.m., licensed practical nurse (LPN) #3 and certified nurse aide (CNA) #3 were observed providing wound care to the resident's coccyx. The CNA rolled the resident over on her left side and exposed the resident's buttocks. The resident right buttocks was soiled with stool. The LPN assisted the CNA with peri-care by holding the resident over to her side. Without changing her gloves or sanitizing her hands, the LPN removed the resident's dressing and discarded the dressing in the trash. The LPN changed her gloves. The LPN squirted the wound with wound cleaner and without drying the wound and removing wound debris, the LPN packed the wound with Hydrogel gauze, and covered the wound with the border dressing. The LPN was asked to read the wound care orders. The LPN stated the order instructed for the wound to be dried after cleansing. The LPN stated she did not dry the wound. On 11/13/14 at 6:00 p.m., the director of nurses (DON) was interviewed regarding the resident's weekly skin assessment sheets. The DON stated no weekly skin assessment sheets were completed for the resident prior to 09/05/14. The DON stated they were unable to locate bath sheets for the resident for the months of June 2014 and July 2014. On 11/14/14 from 7:40 a.m. to 10:55 a.m., the resident was continuously observed. At 7:40 a.m., the resident reclined in a geri-chair in the common area. The resident was positioned on her back, her legs were elevated, and supported with pillows. A long thin blue cushion lined the geri-chair. No pillows were placed to the resident's back for positioning. The resident had soft booties on her feet. The staff provided no repositioning for the resident to relieve pressure on the resident's coccyx. At 7:50 a.m., the resident was moved to a room to watch television. The staff provided no change in position for the resident. At 8:44 a.m., the resident was taken to the dining room. The staff repositioned the geri-chair from a reclining position to a sitting position. The staff did not reposition the resident off her buttocks. At 9:10 a.m., the resident was taken to her room. The staff repositioned the geri-chair to a reclining position. The staff did not reposition the resident off her coccyx with support of pillows. At 9:30 a.m., the resident was given a drink of water but no repositioning was provided. At 9:40 a.m., a CNA repositioned a pillow beneath the resident's head but no repositioning to relieve pressure on the coccyx was provided. At 10:55 a.m., the staff took the resident to the dining room. The staff positioned the geri-chair in sitting position. The staff provided no repositioning to relieve pressure on the resident's coccyx. On 11/14/14 at 12:15 p.m., CNA #4 was asked at what time the resident was placed in the the geri-chair. The CNA stated night shift got the resident up before day shift arrived at 7:00 a.m. The CNA stated she was probably up about 6:00 a.m. The CNA stated pressure ulcer prevention included turning the resident while in the geri-chair and placing a cushion in the geri-chair. On 11/14/14 at 12:30 p.m., CNA #1 was interviewed regarding pressure ulcer prevention. The CNA stated pressure ulcer prevention included incontinent care and repositioning the resident every two hours. The CNA stated every two hours the resident was repositioned off her back and was supported with pillows while in the geri-chair. On 11/14/14 at 3:10 p.m., LPN #1 was interviewed regarding pressure ulcer prevention. The LPN stated the policy consisted of turning the resident every two hours, placing a pressure relieving mattresses on the resident's bed, incontinent care every two hours and as needed, completing weekly skin assessments, completing the Braden Scale assessments, following dietary recommendations, and monitoring the resident's weight. The LPN was asked how the staff was monitored to ensure the staff carried out their responsibilities regarding pressure ulcer prevention. The LPN stated she asked the staff if repositioning for the residents was completed. The LPN stated the nurses took turns checking the residents. The LPN stated in June 2014 and July 2014 it was the responsibility of the wound care nurse to complete skin assessments. The LPN stated the weekly bath sheets and skin assessments were not monitored when the DON position was vacant. The LPN stated it was the responsibility of the registered nurses (RN) to complete the DON's responsibilities when the DON's position was vacant. The LPN stated resident #2 had no skin issues upon admission and the pressure ulcer developed on 07/27/14. The LPN was asked to review the nurses' notes. The LPN stated the notes did not document the pressure ulcer or notifications. The LPN stated the notes and treatment records did not document baseline measurements or the condition of the ulcer. The LPN stated she could not state the reason there were no documented details regarding the ulcer. The LPN was asked how the resident suddenly had a stage three pressure ulcer. The LPN stated she could not state the reason the resident had a stage three ulcer. The LPN was asked to review the Braden Scale skin assessments. The LPN stated the assessments were incorrect and the resident was at high risk for pressure ulcers.

Based on observation, record review, and interview, it was determined the facility failed to provide care to maintain the highest practicable well-being for two (#1 and #2) of 13 sampled residents reviewed for highest well-being. The facility failed to: a) thoroughly assess pain and implement measures to manage pain for resident #1. Resident #1 verbalized pain that was constant and really bad. The facility census and condition report documented 23 residents were on a pain management program. b) ensure the catheter tubing was positioned below the bladder for gravity drainage for resident #2. The facility census and condition report documented one resident required the use of an indwelling urinary catheter. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change assessment, dated 03/24/14, documented the resident's cognition was moderately impaired with memory problems. The assessment documented the resident reported severe horrible pain almost constantly. A quarterly pain evaluation, dated 04/21/14, documented the resident reported signs and symptoms of severe pain daily. The report was completed and signed by a registered nurse (RN). The facility could not provide documentation for monthly pain screenings completed by a licensed nurse. A quarterly pain evaluation, dated 08/17/14, documented the resident reported mild pain 3-4 days during the assessment period. The report documented the resident received routine [MEDICATION NAME] ([MEDICATION NAME]) patch for pain with effective results. The report was blank related to the use of PRN pain medications. The report was completed and signed by a licensed practical nurse (LPN). The facility could not provide documentation for monthly pain screenings completed by a licensed nurse. The care plan, updated 09/17/14, documented the resident had acute/chronic pain related to arthritis and [MEDICAL CONDITION]. The care plan documented the resident received a [MEDICATION NAME] ([MEDICATION NAME]) patch routinely for pain and had as needed (PRN) pain medication. The care plan documented the staff should anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of the pain interventions. The care plan documented the resident should be medicated for pain one hour before wound treatment. A quarterly assessment, dated 09/24/14, documented the resident had no cognitive impairment. The assessment documented the resident reported severe horrible pain almost constantly. A quarterly pain evaluation, dated 10/31/14, documented the resident reported "almost constant" moderate pain at an 8/10. The report documented the resident received routine [MEDICATION NAME] ([MEDICATION NAME]) patch for pain. The report was blank related to the use of PRN pain medications. The report was completed and signed by an RN. The physician's orders [REDACTED]. On 11/13/14 at 3:15 p.m., the resident was observed during treatment to the vascular wounds on the lower extremities. LPN #3 removed the dressings and cleaned the wounds. The resident moaned and winced during the treatment. The LPN proceeded with the treatment and the resident stated, "Ouch that hurts." The resident flinched with movement of the leg. The LPN proceeded with the treatment. The resident cried out, "Oh that foot really hurts." LPN #3 was asked if the resident had been medicated prior to treatment to which she replied the resident had a routine pain patch. LPN #3 stated she did not know when the resident had received PRN pain medication and the surveyor would have to ask the med aide (certified medication aide). LPN #3 stated the resident hollered every time the dressings were changed. LPN #3 stated the resident always complained of pain when the left leg was moved. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 11/14/14 at 9:35 a.m., the resident was observed in the Geri-chair in her room. The resident was awake and alert. The surveyor asked the resident how she was feeling to which the resident replied, "Not too good." The surveyor stated to the resident, "I noticed when the nurse was changing your dressing yesterday you said it hurt pretty bad. Do you hurt a lot?" The resident stated, "Yes it hurt really bad. I hurt really bad most of the time." The surveyor asked the resident if the staff gave her pain medication to which she replied sometimes. The surveyor asked the resident if she had told the nurse, to which the resident replied no. The surveyor asked the resident if would like the nurse to be notified, to which she replied yes. The surveyor reported the resident's complaint to the charge nurse. On 11/14/14 at 11:30 a.m., CMA #1 was asked when the resident had received PRN pain medication. The CMA stated she had not given the resident anything for pain. The CMA stated usually the certified nurse aide (CNA) would tell her if the resident was in pain but no one had said anything about the resident hurting. The CMA asked if the resident had said something to the surveyor. The surveyor stated the resident had complained of pain around 9:30 a.m. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment, dated 06/15/14, documented the resident was severely impaired for daily decision-making and was incontinent of bowel and bladder. The nurse's notes, dated 08/06/14, documented the resident was out of the facility for evaluation of rectal bleeding and returned to the facility on [DATE]. The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive care plan, updated on 08/11/14, documented the resident had a indwelling urinary catheter due to [MEDICAL CONDITION]. The care plan documented the catheter bag and tubing was to be placed below the level of the bladder. A laboratory report, dated 09/26/14, documented the resident had a bladder infection and was to be treated with [MEDICATION NAME] 100 milligrams twice daily for seven days. On 11/13/14 at 9:00 a.m., the resident was reclined in a geri-chair in the common room. The catheter drainage bag was attached to the arm of the chair. The drainage bag was at or above bladder level. On 11/13/14 at 3:00 p.m., the certified nurse aide (CNA) repositioned the resident onto her left side in her bed. The catheter tubing was draped up and over the large bed bolster. The tubing went above bladder level. The CNA was asked about the positioning of the catheter bag and tubing. The CNA stated the urine flows to gravity. The CNA stated the urine flowed over the bolster into the bag. The CNA stated she was not aware the catheter tubing and bag were to be positioned below the bladder. On 11/14/14 at 7:40 a.m. the resident reclined in a geri-chair in the common area. The resident was positioned on her back, her legs were elevated, and supported with pillows. The catheter bag was positioned on the arm of the geri-chair. The drainage bag was at or above bladder level.