Every finding on record at Walworth County Care Center, Inc

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by:One of one certified nurse aide (CNA)/registered medication aide (RMA) (N) and one of one RMA (O) who did not wear gowns, gloves, or perform hand hygiene (handwashing or sanitizing hands) while providing care for one of one sampled resident (1) on enhanced barrier precautions (EBP) (glove and gown use when providing contact care).One of one observed CNA/RMA (N) who did not clean an EZ stand lift (a mechanical lift used to assist from a seated to a standing position) after it was used to provide care for one of one sampled resident (1) on EBP. One of one observed registered nurse (RN) (K) and one of one observed CNA (L) who did not wear a gown while providing care for one sampled resident (12) with open wounds on her buttocks and was not identified as needing to be on EBP. One of one observed housekeeper (Q) who did not use gloves or perform hand hygiene, and touched surfaces and resident's items with unclean hands while cleaning two of two sampled residents' (9 and 14) rooms. Findings include: 1. Observation on 4/28/26 at 2:20 p.m. in resident 1's room revealed there was a sign on the room door that indicated EBP was required. Without putting on gowns or gloves, CNA/RMA N and CNA/RMA O transferred resident 1 from his wheelchair to his recliner using an EZ stand lift. After ensuring the resident did not need any further assistance, CNA/RMA N and CNA/RMA O exited the room without performing hand hygiene. CNA/RMA N placed the EZ stand lift across the hall outside of the resident's room without cleaning it, then walked toward the nurses' station away from the resident's room. There was a canister of germicidal wipes in a holder near the base of the EZ stand lift. 2. Interview on 4/28/26 at 2:25 p.m. with CNA/RMA O regarding resident 1 revealed she was expected to wear a gown and a pair of gloves when she transferred that resident. After she completed that resident's care, she was to remove the gown and gloves, discard them into a trash can, and then perform hand hygiene. She felt she did not follow those expectations because she got distracted. 3. Interview on 4/29/26 at 12:30 p.m. with CNA/RMA N revealed she was to wear a gown and a pair of gloves when she assisted CNA/RMA O with transferring resident 1 on 4/28/26, but she did not. She did not clean the EZ stand lift that was used during that transfer after she removed it from the resident's room, but she should have. 4. Interview on 4/30/26 at 11:55 a.m. with assistant director of nursing (ADON)/infection preventionist (IP) C revealed resident 1 was on EBP because he had a Foley catheter (an indwelling tube inserted into the bladder to drain urine). Infection prevention and control practices were not implemented by CNA/RMA N and CNA/RMA O when they did not put on gowns and gloves before they transferred resident 1, did not perform hand hygiene after they transferred resident 1, and did not clean the EZ stand lift after it was used for that transfer. 5. Observation and interview on 4/28/26 at 2:39 p.m. with resident 12 in her room revealed she was sitting on a pressure-relieving cushion, and she stated she had an open sore on her bottom. 6. Interview on 4/29/26 at 1:22 p.m. with licensed practical nurse (LPN) H revealed that resident 12 had a stage II pressure ulcer (2; open wound or blister with partial-thickness skin loss) to her right and left buttock, and a new pressure ulcer was identified on her right heel yesterday (4/28/26). 7. Observation and interview on 4/30/26 at 9:37 a.m. of registered nurse (RN) K and CNA L assisting resident 12 use to the bathroom revealed that RN K and CNA L did not put on gowns, and they put on a pair of gloves. Resident 12 had an open stage II pressure ulcer to her inner right and left buttocks. CNA L applied a silicone barrier cream to her pressure ulcer and the rest of her buttocks. 8. Interview on 4/30/26 at 9:53 a.m. with RN K revealed that resident 12 did not have EBP interventions in place. She explained that resident 12 did not need to be on EBP since her pressure ulcer did not have any drainage. 9. Interview on 4/30/26 at 10:00 a.m. with ADON/IP C revealed a resident needed to be EBP if they had a chronic wound or an indwelling medical device. She felt resident 12 did not need to be on EBP because her pressure ulcer was not chronic. If her pressure ulcer was not healed within thirty days, then ADON/IP C would put resident 12 on EBP. 10. Review of resident 12's EMR revealed she was readmitted to the facility on [DATE]. Her 4/17/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Resident 12's wound assessments indicated her pressure ulcer to her right inner buttocks was identified on 4/6/26, and her left inner buttocks was identified on 4/27/26. Her 4/28/26 care plan indicated she had a pressure ulcer to her left and right inner buttocks. Her care plan did not indicate she was to be on EBP. 11. Interview and electronic medical record (EMR) review on 4/30/26 at 11:39 a.m. with director of nursing (DON)/wound nurse B revealed resident 12 had a pressure ulcer to her right and left inner buttocks, and she was not aware that resident 12 developed a pressure ulcer on her right heel on 4/28/26. She felt resident 12 did not need to be on EBP because she thought their policy indicated EBP was required if a resident had a chronic wound or an indwelling medical device. 12. Observation on 4/29/26 at 8:31 a.m. of housekeeper Q cleaning resident 9's room revealed she was mopping the floor. She finished mopping and removed the mop head with her ungloved hands. She did not wash her hands before she touched the resident's door handle to exit the resident's room and close the door. With unclean hands, she opened resident 14's door, put on a pair of gloves, cleaned the toilet bowl with a toilet brush, and used paper towels to dry the toilet brush container. With those same gloved hands, she moved the resident's water glass, denture cup, and soap bottle from the sink to the top of the toilet. With those same gloved hands, she cleaned the sink, put the denture cup, glass, and soap bottle back on the sink, and then wiped the grab bars attached to the wall by the toilet. She removed those gloves and discarded them in the trash can. Without washing her hands, she swept the floor, grabbed the door handle to move the door, and swept behind the door. She mopped the floor, removed the mop with her bare hands, and touched the door handle to pull the door closed when she exited the room. Housekeeper Q did not wash her hands before she put on a pair of gloves. She stated she was going to clean another room. 13. Interview on 4/30/26 at 11:00 a.m. with housekeeper Q revealed she was supposed to wash her hands after cleaning a bathroom, when she was done mopping, and between cleaning residents' rooms. She stated she was supposed to wash her hands to prevent the spread of germs and verified that she did not wash her hands during the observations on 4/29/26. 14. Interview on 4/30/26 at 3:37 p.m. with director of food and nutrition/housekeeping J and housekeeping/laundry supervisor R revealed that the housekeeping staff were to wash their hands before putting on gloves, after removing their gloves, after cleaning a bathroom, and before and after mopping. When they were done cleaning a resident's room, they were to wash their hands. Director of food and nutrition/housekeeping J indicated that not performing hand hygiene increased the risk for spreading infection and germs within the facility. 15. Review of the provider's revised December 2024 Enhanced Barrier Precautions policy revealed, EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs) during high contact resident care activities. EBP were to be used when A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained . and EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:. changing [resident's incontinence (involuntary urine or bowel leakage)] briefs or assisting [the residents] with toileting and transferring. 16. Review of the provider's revised September 2022 Cleaning and Disinfection of Resident-Care Items and Equipment policy revealed Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 17. Review of the provider's undated Proper Procedure to Clean a Room document revealed that the staff were to wash their hands after cleaning a bathroom, and before and after mopping a resident's room. 18. Review of the provider's undated Handwashing/Hand Hygiene policy revealed, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene was to be performed after contact with items in a resident's room and after removing gloves.

Based on observation, interview, record review, and policy review, the provider failed to ensure there was documentation to support if one of one sampled resident (3) was a candidate for a restraint (a device, material, or medication used to restrict a resident's movement or access to their body to ensure safety or prevent harmful behavior) reduction, a less restrictive restraint method, or for a restraint elimination.Findings include: 1.Observation on 4/29/26 at 8:00 a.m. in the dining room revealed resident 3 was seated in his wheelchair. The staff provided him with verbal and physical assistance to eat his breakfast. He repetitively moved his feet and gently rocked his trunk forward and back. Resident 3 moved his hand in and out of the waistband of his sweatpants several times. 2. Observation on 4/29/26 at 1:00 p.m. of resident 3 in his room revealed he was awake and seated in his recliner. He placed his hand in and out of the waistband of his sweatpants repeatedly. 3. Review of resident 3's electronic medical record (EMR) revealed his 3/19/26 Brief Interview of Mental Status assessment score was 0. That score indicated he had severe cognitive impairment. His diagnoses included a history of a traumatic brain injury (a disruption in normal brain function caused by a bump, blow, jolt, or injury to the head) and dementia (a group of symptoms affecting memory, thinking, and social behavior) with behavioral disturbances. The resident was administered medications by his physician to manage his behavioral symptoms. An Informed Consent For Use Of A One-Piece Garment (a one-piece jumpsuit) was signed by resident 3's spouse on 2/6/24. The garment was identified as a restraint intervention, and the potential benefits and risks associated with the use of that garment were discussed with the resident's spouse. A 7/29/25 faxed communication from nursing staff to resident 3's physician stated [Resident 3] continues to fondle himself and expose his genitals, as has been a continued concern. He has had multiple previous medication changes without resolution [of the behavior]. To enhance his dignity and to prevent exposure [of his genitals] to other residents and visitors, as this behavior is unable to be redirected or anticipated, may we have an order to use a onesie [a one-piece jumpsuit] as needed for the behavior of exposing himself? The physician approved that request. Resident 3's 4/7/26 quarterly Minimum Data Set (MDS) assessment, section P, indicated the resident used a trunk restraint on a less- than daily basis. MDS nurse D's 4/7/26 MDS Quarterly Assessment note indicated, [Resident 3's] spouse requested [the] use of adult adaptive clothing [a one-piece jumpsuit] in order to protect [resident 3's] dignity. When available [resident 3] will wear the one-piece [jumpsuit]. That Assessment did not include documentation that supported the continued use or discontinued use of that jumpsuit. There was no indication that other alternatives to the jumpsuit were tried. Resident 3's 3/30/26 through 4/29/26 behavioral tracking user-defined assessment (UDA) indicated that staff documented the daily frequency of the resident's targeted behaviors, which included kicking, pushing, scratching, grabbing, and abusing others sexually. Fondling and exposing his genitals were not identified as targeted behaviors on that UDA. Resident 3's revised 4/17/26 care plan focus area related to the use of the jumpsuit revealed, [Resident 3] will frequently remove [his] private parts [genitals] from [his] pants and urinate and/or dig in [his] pants at inappropriate times. Behavior does not appear to be correlated to toileting schedule, as it occurs immediately after toileting and/or intermittently throughout day. Resident 3's spouse requested the use of one-piece jumpsuit to protect his dignity. He [resident 3] has potential to smear bodily waste. 4. Interview on 4/29/26 at 2:50 p.m. with licensed practical nurse (LPN) H regarding resident 3's jumpsuit revealed the jumpsuit's zipper was on the backside of the garment, restricting the resident's access to his genitals. She stated resident 3 did not wear that jumpsuit in a long, long time. He had declined physically and cognitively over the past few years. 5. Interview on 4/29/26 at 2:55 p.m. with certified nurse aide (CNA) I regarding resident 3 revealed she had worked at the facility for about six months and did not see the resident wear a one-piece jumpsuit. 6. Observation and interview on 4/29/26 at 3:00 p.m. with MDS nurse D in resident 3's room revealed that a one-piece jumpsuit was hanging in his closet. MDS nurse D used her interview with day shift staff to support her 4/7/26 Quarterly MDS Assessment progress note that indicated, When available [resident 3] will wear the one-piece jumpsuit]. She did not know if the staff had completed any restraint-related documentation for resident. She had not known if the staff completed any restraint-related documentation for resident 3's jumpsuit use. She acknowledged that without that documentation, she did not know if the jumpsuit continued to be needed or it it could be discontinued. 7. Interview, EMR review, and review of the provider's revised April 2017 Use of Restraints policy on 4/30/26 at 10:00 a.m. with director of nursing (DON)/wound nurse B revealed she had not known if resident 3 was still wearing his one-piece jumpsuit. There was no restraint-specific form that staff were expected to use to document the dates and times when the jumpsuit was worn by resident 3, what precipitated his need to wear the jumpsuit, what less restrictive interventions (preventative approaches to mitigate the use of the jumpsuit), were tried before the jumpsuit was placed on the resident, or how long the jumpsuit was worn before it was able to be removed. She acknowledged that without that documentation, MDS nurse D was not able to comprehensively assess or make recommendations in her quarterly MDS progress note whether resident 3 continued need the jumpsuit or if the jumpsuit could be discontinued. Review of the provider's revised April 2017 Use of Restraints policy revealed, When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Restrained individuals [residents] shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination.

Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (11) who was observed not being transferred according to the resident's identified transfer assistance needs by one of one certified nurse aide (CNA) F and one of one CNA/registered medication aide (RMA) E which put the resident at risk for falling and sustaining an injury.Findings include:1.Observation on 4/28/26 at 5:20 p.m. in the dining room revealed resident 11 was heard calling out to the staff, Come here, come here. She had finished eating her evening meal. CNA F and CNA/RMA E approached the resident. They each placed one of their arms beneath the resident's underarms, lifted the resident from her dining room chair to a standing position, pivoted the resident, and lowered her onto her wheelchair seat. Continued observation and interview with CNA F revealed that she transported resident 11 to her room. CNA F placed her arms beneath the resident's underarms, lifted her from her wheelchair seat to a standing position, pivoted the resident, and lowered her onto a recliner. CNA F stated the resident was unable to bear her full weight on her feet to stand on her own. That was why she physically lifted resident 11 to a standing position. CNA F did not use a gait belt (a waist strap gripped as support for safe mobility and transfers) to transfer resident 11 because She's [resident 11] too tiny. CNA F only used a gait belt to transfer larger, male residents. 2. Observation and interview on 4/29/26 at 9:00 a.m. with CNA/RMA G in resident 11's room revealed CNA/RMA G used a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to transfer resident 11 from her wheelchair to the toilet. CNA/RMA G referred to the Kardex (a report of the resident's care needs and interventions) to know that resident 11 was to be transferred using a mechanical lift. 3. Review of resident 11's electronic medical record (EMR) revealed her Brief Interview for Mental Status assessment score was one, which indicated her cognition was severely impaired. Her 3/19/26 Morse Fall assessment score was 30, which indicated had a moderate risk for falling. Resident 11's revised 3/31/26 care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) related to her transfer needs indicated that resident 11 usually requires dependent staff assistance with sit-to-stand transfers and with chair/bed-to-chair transfers. [Resident 11] requires [a] Hoyer lift [a full body lifting device used to assist from a seated to a standing position] with staff assist x 2 [assistance by two staff persons] for transfers when she is not placing her feet on the ground for a pivot transfer with gait belt and staff assist x 1-2 [assistance by one to two staff persons] or in the sit-to-stand lift. 4. Interview on 4/30/26 at 10:00 a.m. with director of nursing (DON)/wound nurse B regarding revealed that the therapy department assessed each resident's mobility and transfer needs. Their recommendations were added to be added to the resident's care plan. That care plan information was then transferred to the resident's Kardex so staff members knew how to care for the resident.DON/wound care nurse B acknowledged that resident 11 was improperly and unsafely transferred by CNA/RMA E and CNA F when they failed to follow the transfer recommendations identified in the resident's care plan and on the resident's Kardex. That failure placed resident 11 at risk for falling and injuring herself. She expected staff to follow care-planned interventions for the safe transfer of all residents.

Based on observation, interview, record review, and policy review, the provider failed to assess, document, and notify the resident's physician of two facility-acquired pressure ulcers (skin and/or underlying tissue injury from prolonged pressure) for one of one sampled resident (12) who developed a pressure ulcer on her right heel and left buttock, and to complete wound assessment documentation weekly for her right inner buttock pressure ulcer by one of one director of nursing (DON)/wound nurse B and for nursing staff to monitor her right and left inner buttocks daily. Findings include:1. Observation and interview on 4/28/26 at 2:39 p.m. with resident 12 in her room revealed she was sitting on a Roho pressure-relief cushion in her wheelchair, and she stated she had an open sore on her bottom. 2. Interview on 4/29/26 at 1:10 p.m. with certified nursing aide (CNA) M revealed resident 12 had a pressure sore on her bottom, and CNA M found a pressure sore on the resident's right heel yesterday (4/28/26) that was boggy (texture that is soft or spongy), and dark red and purple in color. 3. Interview on 4/29/26 at 1:22 p.m. with licensed practical nurse (LPN) H revealed that resident 12 had a stage II pressure ulcer (2; open wound or blister with partial-thickness skin loss) to her right and left inner buttocks, and yesterday (4/28/26), a new pressure ulcer was found on her right heel. LPN H notified DON/wound nurse B, who would then notify resident 12's physician. 4. Interview on 4/30/26 at 8:05 a.m. with DON/wound nurse B revealed that nurses were to complete weekly skin assessments on all residents, and they did not monitor pressure ulcers daily. DON/wound nurse B would measure and assess the residents' pressure ulcers weekly. The CNAs applied the non-medicated barrier cream to resident 12's buttocks and pressure ulcer when they assisted her to use the bathroom. The residents' physician would assess the residents' pressure ulcers when he rounded (a visit where a doctor goes from room to room to check on every patient under their care) monthly at the facility. He had not rounded since she had been back from the hospital. 5. Observation and interview on 4/30/26 at 9:37 a.m. of registered nurse (RN) K and CNA L while assisting resident 12 to the bathroom revealed she had an open stage II pressure ulcer to her right and left inner buttocks. CNA L applied a silicone barrier cream to her pressure ulcer and the rest of her buttocks, which was to be applied by the CNA staff every time resident 12 was assisted in the bathroom. Resident 12 had an unstageable pressure ulcer on her right heel that was dry, intact, and purple. 6. Interview on 4/30/26 at 9:53 a.m. with RN K revealed that nurses did not monitor pressure ulcers daily, and they were to assess and document the resident's pressure ulcers weekly when they completed the weekly skin observation. 7. Interview on 4/30/26 at 10:00 a.m. with assistant director of nursing (ADON)/infection preventionist (IP) C revealed that nurses did not monitor pressure ulcers daily, CNAs were to notify the nurse if a resident's wound was worsening, and verified that CNAs could not assess a pressure ulcer. 8. Review of resident 12's electronic medical record (EMR) revealed she admitted back to the facility from the hospital on 3/30/26. Her 4/17/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included a fracture of her pelvis and weakness. She had a 4/6/26 physician's order to use a Roho pressure-relief cushion in her wheelchair. Resident 12's 4/6/26 wound assessment completed by DON/wound nurse B, indicated her pressure ulcer to her right inner buttocks was identified on 4/6/26, it was a stage II pressure ulcer and measured: length was 2.8 centimeters (cm), width was 1.5 cm, and depth was 0.1 cm. There was no drainage, and it was pink in color. The wound assessment directed daily documentation is required on pressure ulcers. On 4/9/26, her skin observation was documented as completed by LPN H and indicated she had a stage II pressure ulcer to her coccyx (tailbone) that measured 2 cm (length) by 2 cm (width). On 4/10/26, her wound assessment was completed by DON/wound nurse B, indicated her right inner buttocks pressure ulcer measured: length 2.8cm, width 1.5 cm, depth 0.1 cm. There was no drainage, and it was pink in color. On 4/16/26, her skin observation was documented as completed by LPN P and stated, Stage II right inner buttocks. Barrier cream applied. Lotion applied to extremities. On 4/23/26, her skin observation was documented as completed by LPN H and stated, pink under both breasts, pressure are[a] persists to buttock, barrier cream applied. On 4/27/26, her wound assessment was completed by DON/wound nurse B, indicated her right inner buttocks pressure ulcer measured: length 2.5 cm, width 1cm, depth 0.1 cm. There was no drainage, and it was pink in color. On 4/27/26, her wound assessment was completed by DON/wound nurse B, indicated she had a stage II pressure ulcer identified on her left inner buttocks that measured: length 3 cm, width 1 cm, depth 0.1 cm. There was no drainage, and it was pink in color. Her 4/28/26 care plan indicated she had a pressure ulcer to her left and right inner buttocks, and staff members were to administer treatments as ordered by the physician and observe for their effectiveness. 9. Interview and EMR review on 4/30/26 at 11:39 a.m. with DON/wound nurse B revealed resident 12 had a pressure ulcer to her right and left inner buttocks. DON/wound nurse B was not aware that resident 12 developed a pressure ulcer on her right heel. DON/wound nurse B reviewed resident 12's EMR and could not find any documentation of the pressure ulcer on her right heel or that the physician was notified. She stated that the staff typically notified her when a new pressure ulcer was found, and she followed up (to take further action, investigate, or check on a previous matter to ensure progress, or reinforce initial action) on it. The nurse was to notify the physician of any new pressure ulcers. The current treatment for resident 12's pressure ulcer on her right and left inner buttocks was applying a protective barrier cream and using a Roho pressure-relief cushion in her wheelchair. She felt she notified resident 12's physician when resident 12's stage II pressure ulcer was first identified on 4/6/26 to her right inner buttock by requesting a physician's order for the Roho pressure relief cushion and indicated it was for her pressure ulcer on her buttocks. She did not notify the physician when her stage II pressure ulcer on her left inner buttock was identified on 4/27/26. She stated she was going to notify him when he was at the facility on 5/12/2026. 10. Review of the provider's undated Pressure Ulcers/Skin Breakdown Clinical Protocol policy revealed that the nurse was to document and report the pressure ulcer, but it did not indicate how often it should be done or who it was to be reported to. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings., and applications of topical agents. The physician will help identify medical interventions related to wound management. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 11. Review of the provider's February 2021 Change in a Resident's Condition or Status policy revealed the nurse was to notify a resident's physician within twenty-four hours when a resident has a significant change of condition. The policy defined significant change of condition as a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not 'self-limiting'),. and it requires interdisciplinary [a group of experts from different fields] review and/or revision to the care plan [personalized plan that addresses a resident's care needs, goals, and interventions].

Based on observation, record review, interview, and job description review, the provider failed to adhere to nursing professional standards of practice for following a physician's order for one of one sampled resident (1) with physician's orders for a urology consultation for evaluation and care. Findings include:1.Observation on 4/28/26 at 2:20 p.m. in resident 1's room revealed he was transferred from his wheelchair to his recliner by certified nurse aide (CNA)/registered medication aide (RMA) N and CNA/RMA O. The resident's Foley catheter (an indwelling tube inserted into the bladder to drain urine) urine collection bag was stored inside a cloth bag for dignity. 2. Review of resident 1's electronic medical record (EMR) revealed he was hospitalized from [DATE] through 1/13/26 for treatment of a left femur (thigh bone) fracture. A 1/8/26 urology progress note indicated the resident's Foley catheter was removed, and he was able to urinate. A 1/10/26 Discharge Disposition note from the hospital stated that a Foley catheter was placed on 1/10/26. The 1/13/26 Discharge to SNF (skilled nursing facility) form included an area for instructions regarding the removal of the Foley catheter, catheter care instructions, and the indication for the catheter, but that area was not completed. A 1/23/26 faxed communication from the provider's nursing staff to resident 1's physician asked about discontinuing the resident's Foley catheter. The physician's response was Start Alfuzosin (a medication used to treat symptoms of enlarged prostate) 10 mg [milligrams] once daily for 4 days then attempt [a] trial without [the] catheter. On 1/30/26, the resident's physician was faxed a nursing communication indicating that a 1/29/26 trial removal of the resident's Foley catheter was not successful, and a catheter was re-inserted. The physician's response was Restart Foley [catheter] and f/u [follow-up] with urology. Resident 1's February 2026, March 2026, and April 2026 physician's progress notes regarding his assessment of the resident's urinary retention indicated, Referral to urology for further evaluation and care. Resident 1's 1/21/26 catheter care plan indicated the resident had a Foley catheter and included catheter care instructions. There was no mention of a plan for removing the Foley catheter. 3. Interview on 4/29/26 at 1:00 p.m. with licensed practical nurse (LPN) H regarding resident 1's urology consultation revealed she knew the resident was expected to be seen by a urologist, but did had not yet occur and she was not sure why. 4. Interview on 4/30/26 at 9:45 a.m. with director of nursing (DON)/wound nurse B and assistant director of nursing (ADON)/infection preventionist (IP) C regarding urology consultations revealed the resident's physician was expected to call a urologist to make that referral. The urology office would then call the facility to confirm the appointment time. ADON)/IP C was assigned to round (a process where healthcare staff, such as nurses and physicians, regularly visit residents to assess their needs, ensure safety, and improve care quality) with resident 1's physician during his monthly resident visits. The status of resident 1's urology consultation should have been discussed during those rounds. DON/wound nurse B and ADON/IP C revealed ADON/IP C recalled discussing the urology consultation with resident 1's physician during his January 2026 rounds. It was ADON/IP C's understanding that the physician would call the urologist to make the referral. ADON/IP C confirmed during the February 2026, March 2026, and April 2026 rounds that she did not discuss the status of resident 1's urology consultation with the physician. At no other time outside of the monthly rounds had she spoken with resident 1's physician about the urology consultation. DON/wound nurse B acknowledged the failure to follow the January 2026 physician-ordered urology consultation for resident 1 was 100% on us [the facility.] 5. Review of the undated Registered Nurse (RN) job description revealed duties and responsibilities include Assist in developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents' total regimen of care.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two residents had: *Received risks versus benefits education for side rail use. *Obtained signed informed consent forms for side rail use. *Quarterly assistive device assessments completed. *Routine inspections of side rails. Findings include: 1. Observation and interview on 3/22/22 at 9:04 a.m. with resident 38 revealed: *He had been in his room, sitting in a wheelchair and watching television. *He thought he was here to see patients. *His bed had a side rail attached on the right side. -This side rail was in the up position. *He stated he used the side rail to help him turn over in bed. Review of resident 38's medical record revealed: *He had been admitted on [DATE]. *His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *There was no documentation that a safety assessment had been completed for use of a side rail. *There was no documentation that education of risks versus benefits had been completed. *There was no documentation that informed consent had been given. Interview on 3/23/22 at 2:45 p.m. with director of nursing (DON) B revealed: *She thought a therapist completed safety assessments for side rails. *Resident 38 used the right side-rail as a grab bar. Interview on 3/23/22 at 2:48 p.m. with DON B and director of therapy-physical therapist (PT) K revealed: *The process for use of side rails was: *PT K would complete an informal assessment when a resident is admitted . -If she thought the resident would participate better in transferring with a side rail, she would recommend the use of it. *PT K stated resident 38 needed physical assistance of two people and a side rail for positioning while in bed. -The side rail should be used only for bed positioning. Observation and interview on 3/22/22 at 4:10 p.m. of resident 21 sitting on the edge of the bed with her daughter revealed: *The daughter had indicated that her mother's memory was not good and she could not remember things. *The bed had a side rail attached to the right side in the up position. *The daughter did not know why she had it, and had not been told why she needed it. Review of resident 21's 8/17/21, 11/8/21, and 1/31/22 Positioning Device/Restraint Assessments revealed they had not: *Included the side rail. *Included consent or education of the side rail. *Addressed the risk for entrapment. Review of resident 21's medical record did not include a signed consent for use of a side rail. Review of resident 21's 3/16/22 care plan revealed the side rail had not been part of the care plan. Interview on 3/23/22 at 5:03 p.m. with maintenance director D revealed: *He did not have documentation that the side rails are inspected regularly. *He had planned to start documenting when he inspected the rails. Interview on 3/24/22 at 1:20 p.m. with director of nursing B regarding use of side rails revealed: *Therapy did the assessment for use of the side rails. They did not document that assessment. *She had been aware of what was required for use of the side rails. *They had contacted families and had started to get consents signed for use of the side rails. Review of the provider's December 2016 Proper Use of Side Rails policy revealed: *3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -a. Bed Mobility; -b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet' -c. Risk of entrapment from the use of side rails; and -d. That the bed's dimensions are appropriate for the resident's size and weight. *4. The use of side rails as an assistive device will be addressed in the resident care plan. *5. Consent for using restrictive devises will be obtained from the resident or legal representative per facility protocol. *8. The risks and benefits of side rails will be considered for each resident. *There was a hand written statement on the bottom of the policy that stated The [name of facility] does not use bed rails. Grab bars are used to promote resident independence with rolling, scooting, and sit to/from lying transfers when needed.

Based on interview, record review, and policy review, the provider failed to ensure two of fifteen sampled residents (4 and 24) professional standards of practice were followed for insulin administration and response to low blood glucose levels. 1. Review of resident 24's medical record revealed: *She had been admitted on [DATE]. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her 2/7/22 admission assessment showed a brief interview for mental status (BIMS) score of 14, indicating her cognition was intact. Interview on 3/24/22 at 11:25 a.m. with resident 24 revealed she: *Had some low blood sugars since being admitted . *Had been able to feel when her blood sugar was getting low and alert the staff. *Felt the staff responded quickly when she had a low blood glucose level by giving her some juice and something to eat. *Did have changes in her insulin dose since she was admitted . Review of resident 24's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *Her insulin detemir dose had been decreased three times. She had received: -38 units from 2/1/22 through 2/6/22. -36 units from 2/7/22 through 2/14/22. -32 units from 2/15/22 through 2/24/22. -18 units from 2/25/22 through 2/28/22. *Her scheduled [MEDICATION(S)] insulin had been decreased two times. She had received: -7 units three times a day before meals from 2/1/22 through the morning dose on 2/3/22. -2 units three times a day from the evening dose on 2/3/22 through the noon dose on 2/7/22. *2 units daily prior to lunch from 2/8/22 through 2/26/22. *Another order for [MEDICATION(S)] to be given per sliding scale [varies the dose of insulin based on blood glucose level] parameters. -The resident was to have her blood glucose level checked three times a day before meals and insulin administered as indicated by the scale. -On 2/6/22 at 11:00 a.m. her blood glucose level was 153 and she should have received [MEDICATION(S)] 4 units per sliding scale. It was documented as Other/See Nurse Notes. -There was not a nurses note documented on 2/6/22. -On 2/18/22 at 4:00 p.m. her blood glucose level was 134 and she should have received [MEDICATION(S)] 2 units per sliding scale. There was no documentation indicating it was administered. *She also had her blood glucose level done at bedtime. *an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . -This was started on 2/9/22. -It had been administered on 2/23/22, 2/24/22, two times on 2/25/22, and on 2/28/22. *The scheduled [MEDICATION(S)] was not administered on 2/8/22 or 2/22/22. The documentation indicated her blood glucose was within normal limits. *The scheduled [MEDICATION(S)] was not administered on 2/5/22 at 11:00 a.m. and on 2/6/22 at 7:00 a.m. and at 11:00 a.m. The documentation indicated to see the nurses notes. -There were no nurses notes as to why these doses were not administered or notification of a physician. Review of resident 24's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *3/1/22 at 11:00 a.m. her blood glucose level was 291 and she should have received [MEDICATION(S)] 12 units per sliding scale. It was documented as Hold/See Nurse Notes. *3/2/22 at 11:00 a.m. her blood glucose level was 130 and she should have received [MEDICATION(S)] 2 units per sliding scale. It was documented as Other/See Nurse Notes. *3/4/22 at 4:00 p.m. there was no documentation of [MEDICATION(S)] 6 units per sliding scale was administered for a blood glucose level of 206. *There had been no documentation in the nurses notes as to why these doses were not administered. *3/8/22 a list of blood sugars was to be faxed to physician C. It was documented as Other/See Nurse Notes. *There was not a nurses note regarding a fax to physician C. Review of resident 24's blood glucose levels revealed on: *2/2/22 at 7:00 a.m. it was 49. *2/3/22 at 7:00 a.m. it was 60, at 11:00 a.m. it was 49, and at 4:00 p.m. it was 64. *2/4/22 at 5:20 a.m. it was 43, at 5:48 a.m. it was 58, and at 7:00 a.m. it was 46. *2/5/22 at 11:00 a.m. it was 68. *2/6/22 at 7:00 a.m. it was 50. *2/8/22 at 7:00 a.m. it was 52. *2/9/22 at 7:00 a.m. it was 35. *2/12/22 at 7:00 a.m. it was 64. *2/13/22 at 7:00 a.m. it was 48. *2/14/22 at 2:53 a.m. it was 50. *2/15/22 at 7:00 a.m. it was 53. *2/17/22 at 4:19 a.m. it was 47. *2/20/22 at 7:00 a.m. it was 66. *2/22/22 at 11:00 am. it was 50. *2/23/22 at 7:00 a.m. it was 59. *2/24/22 at 4:00 p.m. it was 63. *2/25/22 at 3:10 a.m. it was 47, at 3:25 a.m. it was 46, and at 11:00 a.m. it was 65. *2/27/22 at 7:00 a.m. it was 62. Review of resident 24's nurses progress notes from 2/1/22 through 3/24/22 revealed on: *2/2/22 at: -12:30 a.m. she had a blood glucose level of 54 and was given 8 ounces of a breeze nutritional supplement and a peanut butter sandwich. -1:04 a.m. her blood glucose level was 112. --No documentation of physician notification. *2/3/22 at 12:26 a.m. she had been woken up to check her blood glucose level because it had been low at bedtime. *2/4/22 at 12:39 p.m. resident had refused her lunch. The nurse had offered substitutes and educated her on [CONDITION(S)]. *2/8/22 at 4:43 p.m. physician C had made rounds and reviewed blood glucose levels with staff. *2/11/22 at 2:45 a.m. Her FSBS [fingerstick blood sugar] continue to run low especially in the mornings; discussed nutrition/blood sugar stabilization. She had an HS [hour of sleep] snack and is also agreeable to having a snack (prefers a PB&J [peanut butter and jelly] sandwich) after she uses the bathroom between 0200-0300 to see if this helps maintain her blood sugar until breakfast time. *2/12/22 at 9:14 a.m. her blood glucose had been 64 that morning and she did not eat well at breakfast. She was given an apple and a peanut butter and jelly sandwich. There was no physician notification or follow-up documentation. *2/13/22 at 7:36 a.m. her blood glucose had been 48 and was given an Ensure supplement. There was no physician notification or follow-up documentation. *2/14/22 3:14 a.m. her blood glucose level was 50 and was given a peanut butter sandwich and Breeze supplement. There was no physician notification or follow-up documentation. *2/14/22 at 7:33 a.m. indicated blood glucose levels had been faxed to physician C for review. There was not follow-up documentation. *2/15/22 at 12:18 a.m. indicated her FSBS remain unstable. Discussed nutrition, encouraged a heart healthy snack prior to bed; she voiced understanding. *2/15/22 at 9:18 a.m. her blood glucose level had been 53, she was given a cookie and Ensure supplement, then went to breakfast. There was no physician notification or follow-up documentation. *2/17/22 at 4:21 a.m. her blood glucose level was 47 and she was given a nutritional supplement and a peanut butter sandwich. There was no physician notification or follow-up documentation. *2/21/22 at 3:20 p.m. her blood glucose level was 65 and she was given a sandwich and milk. There was no physician notification or follow-up documentation. *2/22/22 at 12:21 p.m. her blood glucose levels for a week had been faxed to physician C. He reviewed the levels and made no changes to her medication. *2/25/22 at 7:38 a.m. her blood glucose levels from 2/11/22 through 2/25/22 had been faxed to physician C. There was no follow-up documentation. *2/28/22 at 1:57 p.m. her blood glucose level was 48 and she told the nurse she felt like it was low. She had been given a dose of glucose gel. *2/28/22 at 2:430 p.m. she was feeling better. Her blood glucose level was 92 and she had been given a snack. *3/1/22 at 10:59 a.m. education was provided to her about her blood glucose levels by director of nursing A. She had agreed to not throw her food away until nursing could look and see what she had eaten. *3/1/22 at 5:52 p.m. she had been refusing to eat supper and her insulin was held. There was no physician notification or follow-up documentation. Review of faxed communications for resident 49 between the provider and physician C revealed on: *2/3/22 a note was sent to notify him of low blood glucose levels that day along with a list of blood glucose levels. -He had returned the note with new orders to decrease her insulin and to fax her blood glucose levels again the following Monday. *2/9/22 to let him know of a blood glucose level of 35 and that they had administered glucose gel from their emergency kit. Had also asked for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -He returned the fax with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *2/15/22 a list of blood glucose levels had been faxed to him. He returned the fax with new order to decrease the [MEDICATION(S)] and fax blood sugars again, in one week. *2/25/22 a note indicated that her blood glucose levels continued to run low and a list of her blood glucose levels had been sent along with the note. -He faxed back with an order to decrease the [MEDICATION(S)] and stop the scheduled dose of [MEDICATION(S)]. *3/4/22 a list of blood glucose levels had been sent with no medication changes. Review of resident 49's Patient Visit Notes revealed: *Physician C had seen her on 2/8/22 and on 3/8/22. *He did discuss and review blood glucose levels and medications during each visit. Review of resident 49's 3/1/22 Care Conference Summary revealed: *She had been invited but chose not to attend. *Dietary, MDS (Minimum Data Set) nurse, activities, and social services had attended the conference. *Her blood glucose levels had not been addressed. *Her behavior to throwing food away before nursing could monitor what she had eaten had not been discussed. Review of resident 49's revised 3/16/22 care plan revealed: *[Resident's name] has potential to refuse to eat meals without reasoning given. She will indicate to nurse she is going to eat, insulin will be administered, and then refusal will occur. Education had been provided. *The goal was she would be free from complications related to refusing food . *Interventions included: -Explain importance of consuming prescribed diet and/or risks of taking insulin and then refusing to eat, to [resident's name]. Educate on need for adequate nutritional intake. -[Resident's name] triggers for refusing to eat are unclear at this time, will continue to monitor. [Resident's name] may indicate to staff she is upset, however does not provide reasoning/rationale. [Resident's name] behaviors are de-escalated by allowing time to self-calm, providing comfort and support. *It did not indicate what her blood glucose levels should be or what to do if they were low. 2. Review of resident 4's medical record revealed: *She was admitted on [DATE]. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her 1/24/22 quarterly assessment showed a BIMS of 4, indicating severe cognitive impairment. Review of resident 4's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *1/6/22 at 7:00 a.m. she was to have [MEDICATION(S)] 5 units and it had been documented Other/See Nurse Notes. *1/8/21 at 4:00 p.m. her blood glucose level was 59. *1/12/22 at 4:00 p.m. her blood glucose level was 62. *1/17/22 at 9:00 p.m. her blood glucose level was 62. *1/21/22 at 7:00 a.m. she was to have [MEDICATION(S)] 5 units and it had been documented that her blood glucose level was within normal limits, so she did not need the scheduled dose. *1/23/22 at 4:00 p.m. her blood glucose level was 49. *1/25/22 at 7:40 p.m. her blood glucose level was 60. *1/26/22 at 12:00 p.m. she was to have [MEDICATION(S)] 3 units and it had been documented Other/See Nurse Notes. Review of resident 4's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *2/2/22 at: -7:00 a.m. her schedule [MEDICATION(S)] 5 units was not given and it had been documented that her blood glucose level was within normal limits. -4:00 p.m. she had a blood sugar of 66. *2/16/21 at 8:17 p.m. she had a blood glucose level of 44. Review of resident 4's March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] *3/13/22 at 5:00 p.m. her blood glucose level was 54. *3/18/22 at 12:00 p.m. her blood glucose level was 61. Review of resident 4's nurses progress notes revealed on: *1/10/22 at 3:11 p.m. her blood glucose level was 66 and she was given a peanut butter sandwich. There was no physician notification or follow-up documentation. *2/17/22 at 9:34 p.m. resident had a blood glucose level of 44 so a list of blood glucose levels had been faxed to physician's office. *2/18/22 at 1:30 p.m. physician had reviewed the blood glucose levels and gave no new orders. *3/13/22 at 4:39 p.m. her blood glucose level was 54 and she had been given peanut butter toast. Her blood glucose level was 99 within 20 minutes. 7:00 a.m. There had been no documentation the physician had been notified. *There were no other notes indicating the physician had been notified of low blood glucose readings. *There were no notes indicating to hold scheduled [MEDICATION(S)] doses. Review of resident 4's revised 3/16/22 care plan revealed: *Her hospitalization prior to admission to the facility had been for severe [CONDITION(S)]. *The goals included: -[Resident's name] will have no complications related to diabetes . -[Resident's name] will be free from any s/sx [signs or symptoms] of [CONDITION(S)] or [CONDITION(S)] . *Interventions included: -Observe [resident's name] and document/report PRN [as needed] any s/sx of [CONDITION(S)]: Sweating, Tremor, Increased heart rate ([CONDITION(S)]), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. *It did not indicate what her blood glucose levels should be or what to do if they were low. 3. Interview on 3/24/22 at 1:26 p.m. with director of nursing B revealed: *She had considered a blood glucose level low if it was below 60. *If the resident had a blood glucose level below 60 and was alert she expected the nurse to give them juice or milk. *If the resident was not alert she would have expected the nurse to administer glucose gel or [MEDICATION(S)] injection. *She did not expect the nurses to call a physician for a low blood glucose, just would expect them to give them some milk or juice. *If a resident was on scheduled insulin and sliding scale insulin even if the sliding scale insulin was not indicated she would expect the nurse to still administer the scheduled dose. *A nurse needed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *She had not reviewed the provider's policy for management of [CONDITION(S)] and had not expected the nurses to follow it. *There was always a physician or nurse practitioner on-call. Interview on 3/24/22 at 4:00 p.m. with physician C revealed: *He does not have parameters set for blood glucose levels. *If a resident had a blood glucose level less than 80 he would expect a nurse to call and update him. *He expected nurses to treat a low blood glucose level with juice or crackers. *He was aware resident 24 had been refusing to eat at times. *He felt like the provider was good at keeping him updated when a resident had a low blood glucose level. On 3/24/22 at 4:10 p.m. surveyors had requested documentation of education provided to nurses on diabetes and blood glucose levels and a physician notification policy from the administrator and director of nursing. They did not have any documentation of education or the policy. Interview on 3/24/22 at 4:20 p.m. regarding residents 4 and 24 with administrator A and director of nursing B revealed: *They did not have a standard of practice for guiding policy development. *They used policies written for them by Med Pass. *They used nursing judgement and if they had questions they would call a nurse consultant. Review of the provider's November 2020 Management of [CONDITION(S)] policy revealed for a blood sugar less than: *70 the nurse should have: -Given oral glucose. -Notified the doctor immediately. -Stayed with the resident. -Rechecked the blood sugar in fifteen minutes. *54 the nurse should have: -Given [MEDICATION(S)]. -Notified the doctor immediately. -Stayed with the resident. -Make the resident comfortable. -Monitor vital signs. -Rechecked the blood sugar in fifteen minutes.

Based on observation, interview, and policy review, the provider failed to ensure: *One of one registered nurse (RN) F had completed appropriate hand hygiene (HH) during wound care for one of one sampled resident (32). *One of one certified nursing assistant (CNA) had completed appropriate HH when doffing an N95 and donning a face mask for one of one random observation. 1. Observation and interview on 03/23/22 at 11:35 a.m. of licensed practical nurse (LPN) E and registered nurse (RN) F completing resident 32's wound care revealed: *A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -Twice a day remove packing, rinse with half strength H2O2 [[MEDICATION(S)]]. Rinse with saline. Use 2 inch Kling roll and pack wound with dry dressing pack under all skin flaps and in abscess cavity. When Kling is in place, sprinkle with [MEDICATION(S)]. Cover with dry sterile dressings after that. Two times a day for wound care. *Nursing had followed the wound care procedure per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *RN F missed one of three opportunities' for handwashing during the wound care. -She had removed her gloves after she completed cleansing the wound and had not washed her hands or used hand sanitizer before she had applied clean gloves to place a new dressing. Interview on 3/23/22 at 2:20 p.m. with RN F regarding resident 32's wound care and infection control revealed; *Hand hygiene and glove changes should have occurred when moving from dirty to clean during wound care. *RN F agreed she had missed an opportunity for hand hygiene prior to putting on clean gloves to place a clean dressing. Review of the facility's August 2019 Handwashing/Hand Hygiene policy revealed; *2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before moving from a contaminated body site to a clean body site during resident care. *Procedure -Applying and Removing Gloves --1. Perform hand hygiene before applying non-sterile gloves. 2. Interview and observation on 3/23/22 at 8:40 a.m. with CNA L revealed she: *Had come from a resident room after performing personal cares. *Had an N95 mask on, which would have been contaminated. *Removed the contaminated N95 mask and discarded it in a trash can. *Obtained a new surgical mask from a personal protective equipment cart and put it on. *Did not complete HH when she removed the contaminated N95 and before obtaining the new surgical mask. *Agreed she had not completed HH and should have. -Had training in the last year regarding proper HH. Interview on 3/23/22 at 9:45 a.m. with administrator A and director of nursing B revealed: *Administrator A agreed HH should have been completed when removing an N95 as it would have been contaminated. *Administrator A and director of nursing B both would have expected to have HH completed each time gloves were removed. Interview on 3/23/22 at 2:58 p.m. with director of nursing B regarding HH revealed: *Her expectation was for staff to complete HH between: -Removing contaminated gloves and donning new gloves. -After removing gloves. -Removing a contaminated mask and a new mask. *Training had been for HH had been provided annually and upon hire. -Reminders of proper HH had been provided during stand-up meetings each day. *The infection control nurse and director of nursing completed random audits for HH on a continual basis. Review of provider's undated validation checklist for donning/removing personal protective equipment (PPE) revealed: *11. Goggles/face shield are removed from the sides or front . 12. Hand hygiene performed with alcohol-based hand sanitizer. 13. Mask/respirator is removed . 14. Hand hygiene performed with alcohol-based sanitizer paying attention to hands and forearms. Review of provider's April 2020 general procedure for donning and doffing masks revealed: *1. To put on a mask: a. When donning the face mask, do so immediately after hand hygiene. -d. After touching a facemask or before changing a face mask, perform hand hygiene. *2. To remove mask: a. Front of mask is contaminated-DO NOT TOUCH. If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer.

Based on observation, interview, record review, and policy review, the provider failed to ensure there was appropriate assessments, treatment, and documentation for one of one sampled resident (32) who had developed multiple facility-acquired pressure ulcers. Findings include: 1. Review of resident 32's medical record revealed: *Her original admission had been on 5/3/13. *She had been hospitalized from [DATE] to 4/17/19 for a fall with fractures and required more assistance upon return to the facility. *Her Brief Interview for Mental Status (BIMS) assessment score on 10/9/19 was eight indicating she had moderate cognitive impairment. *[DIAGNOSES REDACTED]. *On 4/17/19 her Braden Scale for predicting pressure sore risk score was seventeen indicating she was at mild risk for developing an acquired ulcer or injury. *She currently had an unstageable pressure ulcer on her buttock. -Throughout the documentation it was unclear if that pressure ulcer was on her coccyx, right buttock, left buttock, or sacrum. *She had a history of [REDACTED]. Review of resident 32's 4/24/19 annual Minimum Data Set (MDS) assessment revealed: *She was able to understand what others said and to make herself understood. *Her BIMS score was eleven indicating she had moderate cognitive impairment. *She required: -Extensive assistance of two staff for bed mobility and transfers. -Extensive assistance of one staff person for locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. *She had limited range of motion to one lower extremity. *She used a walker or a wheelchair (w/c). *She was at risk for developing pressure ulcers. *She had one stage two pressure ulcer. -No other pressure ulcers were coded on the MDS. *She was coded as having: -A pressure reducing device on her bed and chair. -Turning and repositioning program. -Nutrition or hydration intervention to manage skin problems. -Pressure ulcer care. -Application of non-surgical dressings. *The pressure ulcer care area note revealed: -A goal to maintain adequate skin integrity and lessen risk. -It had referred her to nursing, certified nursing assistants, physical therapy, and occupational therapy. Review of resident 32's 10/9/19 quarterly MDS assessment revealed: *She was able to understand what others said and to make herself understood. *Her BIMS score was eight indicating she had moderate cognitive impairment. *She required: -Extensive assistance of one staff person for bed mobility, dressing, and bathing. -Limited assist of one staff person for toilet use, personal hygiene, and transfers. -Supervision of one staff person for locomotion on and off the unit. -She had not walked in her room or the corridor. *She used a walker or a w/c. *She was at risk for developing pressure ulcers. *She had one unstageable pressure ulcer. -No other pressure ulcers were coded on the MDS. *She was coded as having: -A pressure reducing device on her bed and chair. -Turning and repositioning program. -Nutrition or hydration intervention to manage skin problems. -Pressure ulcer care. -Application of non-surgical dressings. -Application of ointments or medications other than to feet. Interview and observation on 11/18/19 at 4:11 p.m. and 5:02 p.m. and on 11/19/19 at 9:30 a.m. with resident 32 revealed: *She was sitting in her w/c in her room with a cushion in place underneath her. *She reported the nurses were very good about changing the dressing on her bottom twice a day. *She did not remember if she had pressure ulcers on her heels. *She said she spent the majority of her time in her w/c. *She was able to shift her weight from side-to-side in the w/c. *Due to her arthritis she did lean in the w/c and was not able to keep an upright posture. *She refused to let this surveyor observe the pressure ulcer she had on her bottom. -She denied pain to that wound. Interview on 11/20/19 at 10:22 a.m. with licensed practical nurse (LPN) B regarding resident 32 revealed: *LPN B had worked at the facility for less than one year and the resident had the pressure ulcer to her bottom when she started. *LPN B was told that she had an old wound to her coccyx in the past and the area would often heal and then reopen. *When she went to the hospital the wound to her coccyx was healed and there had been scar tissue present. *They had been treating the pressure ulcer to her coccyx with wet to dry dressings twice a day. -She had thought the pressure ulcer appeared to be healing. *The nursing staff had encouraged her to get off bottom, but she did not always comply. *She had been on a dietary supplement to promote wound healing. *She had a pressure reducing w/c cushion and a pressure reduction mattress in place. *She had electrical stimulation treatments per physical therapy, but she was not always compliant. *The director of nursing (DON) was the wound nurse in the facility. *If LPN B had found a red or open area to a resident's skin she would have: -Monitored the area of concern. -Told the DON what she had found. -Documented her observation. -Notified the physician. *The DON documented weekly on all wounds in the facility. *Prior to developing the pressure ulcers, she had: -The Roho cushion in her w/c. -Staff encouraged her to walk and lay down throughout the day. Interview on 11/20/19 at 1:29 p.m. with the MDS assessment coordinator regarding resident 32 revealed: *The provider did not stage pressure ulcers until they knew the area would not resolve. *The DON gave her an update on all wounds weekly. *She did not code the pressure ulcers from her heels on the 4/24/19 MDS assessment, because she thought they had determined they were not pressure ulcers. *She looked at past assessments and progress notes when doing MDS assessments. Interview on 11/20/19 at 3:57 p.m. with the DON regarding resident 32 revealed: *The pressure ulcers to the resident's buttock and bilateral heels were facility acquired. *The DON did not know when the pressure ulcers on her heels had healed. *The wound consultant saw the resident monthly, and then the DON used that documentation in her charting. -There was no record of a wound consultant seeing the resident for the pressure ulcers to her heels or coccyx. Interview and record review on 11/20/19 at 5:20 p.m. with the assistant director of nursing (ADON) regarding resident 32 revealed: *She expected a treatment order to be put on the TAR by the following day after discovering a pressure ulcer. *When a wound was discovered the nurse was to fax the physician with an update and ask for an order. -The provider did not get physician responses in a timely manner. *She expected the nurses to have contacted the physician again if there was no reply by the next day. *She expected pressure ulcers to be documented on daily. *She confirmed there was a lack of assessments and supporting documentation to support the appropriate treatment of [REDACTED]. Review of resident 32's 4/24/19 Wound Data Collection assessment revealed: *That was the initial data collected on the wounds to her left and right heel. *The right heel measured 2 centimeters (cm) by 0.4 cm by 0 cm. -It was documented as unstageable. *The left heel measured 2.4 cm by 1.2 cm by 0 cm. -It was documented as unstageable. *The documentation indicated the areas were scabbed with no drainage. *Heel protectors and a Roho cushion were being used. -It did not indicate if those were new interventions. *A body pillow would be tried as a new intervention. Review of resident 32's 4/24/19 Wound Registered Nurse (RN) Assessments revealed: *Pressure ulcers to bilateral heels and coccyx with partial thickness tissue loss. *Modifications to interventions were: -Repositioning/turning. -Support surfaces. -Friction/Shear management. -Wound treatment. *The physician had been notified on 4/24/19. Review of the provider's 4/24/19 faxed communication with the physician regarding resident 32 revealed: *The provider had sent the fax to update the physician on the status of the resident's wounds. -It indicated the area to the coccyx was a pressure ulcer. -It did not indicate what the areas on her heels were. -It did not indicate the wound stages. *The provider had asked the physician for the following orders: -[MEDICATION NAME] to be applied to the coccyx pressure ulcer two times a day. -Skin preparation to the heels, but it did not indicate how often or the duration. *The physician indicated on the form he was okay with the orders on 4/24/19. *The form was then noted on 4/24/19 by the staff as received. Review of resident 32's (MONTH) 2019 medication administration record (MAR) and treatment administration record (TAR) revealed no documentation of wound care or monitoring of pressure ulcers to the coccyx, buttocks, sacrum, or heels. Review of resident 32's (MONTH) 2019 MAR and TAR revealed: *A physician's orders [REDACTED]. Start date of 5/2/19. -Twenty-one administrations out of fifty-nine opportunities were not administered as the medication was not available. -Six administrations out of fifty-nine opportunities were left blank and not signed. -One administration was refused by the resident. -Two administrations out of fifty-nine opportunities were not administered, because the resident was sleeping. *There was no documentation of wound care or monitoring of the pressure ulcer to her right inner buttock. Review of resident 32's 5/1/19 skilled nurse's charting assessment revealed: *Resident has treatable wounds. *Area to buttocks has decreased in size and redness. Heels are dry and flaky. Review of resident 32's nursing progress notes from 4/24/19 to 6/6/19 revealed: *On 4/24/19: Pressure ulcer identified to coccyx. Appears as an opened blister with approx (approximately) half of the blister still covered and the rest open. Area measures 2.5cm (centimeters) x 2cm with 1.5cm x .8cm x .1cm open area. the Rt. (right) heel has a scabbed area measuring 2cm x .4cm x scabbed and the lt. (left) heel is soft and reddened. Area measures 2.4cm x 1.2cm. Area does blanch. Resident was placed on a Roho cushion while in w/c (wheelchair). Heel protectors and a body pillow for when she is in bed. She states she will try the body pillow. she is on a protective mattress. (Physician's name) was faxed update. -That was the first documentation of pressure ulcers since her return from the hospital. *On 4/29/19: -There was a correction note indicating the ulcer to the coccyx was on the right inner buttock not the coccyx. -There was another note from the contracted dietician addressing the pressure ulcers to the left heel, right heel, and coccyx. *On 5/1/19: there was an MDS Medicare fourteen day assessment note. It had not addressed the pressure ulcers to her bilateral heels. -It had addressed the pressure ulcer to her left buttock and daily dressing changes. *On 5/2/19 there was a note that stated: Treatment orders received for bilat. (bilateral) heels. *On 5/22/19 and 5/29/19: -Pressure area to the coccyx measures 2cm x .5cm x .05cm. Healing area is rough. Using skin protectant to area. Surrounding tissue is light red. No drainage noted. Denies pain to area. Bil. (bilateral) heels have firm light tan areas. Rt. measures .4cm x .4cm and Lt.4cm x .2cm. [MEDICATION NAME] Oint (ointment) applied to heels BID(twice a day). -Received order to continue with the [MEDICATION NAME] to bilateral heels. *On 6/6/19: Pressure area to heels continues with bilateral. Rt. heel measures .3cm x .6cm x firm tan callous. Lt. heel measures .4cm x .3cm x firm tan callous. The Rt. heel is lightly reddened and does blanch. Resident states it hurts at times. Encouraged to let staff know when she is having discomfort. *There was no documentation on the pressure ulcers to bilateral heels after 6/6/19 to support the status of them or when they had healed. Review of the provider's 6/27/19 faxed communication with the physician regarding resident 32 revealed no areas noted on heels. Review of resident 32's 10/9/19 care plan revealed: *Focus Area: (Resident name) has impairment to skin integrity R/T (related to) Fragile skin, easily bruised, and tends to bump her hands and wrists against wall or doorway when in her wheelchair. She has history of skin breakdown to buttocks (blister) 4/24/19 and skin tear to right posterior upper arm r/t fall 7/8/19. Skin tear has resolved. Pressure ulcer with surgical debridement to coccyx. *Focus Area: (Resident name) has a history of skin breakdown to coccyx and potential risk for other pressure ulcer development r/t limited mobility due to RA ([MEDICAL CONDITION] arthritis) and the time she spends in wheelchair r/t (related to) fall 7/8/19. Potential breakdown to both heels r/t laying in the same position. *Goal: (Resident name) pressure ulcer will show signs of healing and remain free from infection by/through review date. *Interventions included: -Administer treatments for wound care for (resident name) as ordered and monitor for effectiveness. Dressing as ordered per MD (medical doctor), change daily, and as needed. Continue to monitor size and if improving. -Assist or encourage (resident name) to reposition and avoid prolonged sitting in her wheelchair. -Apply [MEDICATION NAME] Ointment to both heels as directed for skin protection. -(Resident name) has a pressure reducing mattress and she has a Roho cushion in her wheelchair to protect the skin and pressure points. -Assess/record/monitor (resident name) healing to pressure sore on buttocks. Assess and document status of wound perimeter, wound bed and healing progress which is also noted by wound nurse and documented on progress notes. Report improvements and/or declines to the MD. -Avoid positioning (resident name) flat on her back for more than half an hour to avoid pressure on buttocks. She likes pillows for support on her side and lessen pressure to both heels when in bed. -(Resident name) requires extensive staff assist with cueing and reminders to reposition while in bed. Cue and assist her to turn and reposition before and after meals, at bedtime and during nights as she tolerates with hygiene check and skin care. -She receives a protein supplement for weight gain and wound healing. *There was no documentation of using heel protectors or other interventions related to her heels other than the [MEDICATION NAME] ointment. Review of the provider's (MONTH) (YEAR) Pressure Ulcer/Skin Breakdown - Clinical Protocol policy revealed: *The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). *In addition, the nurse shall describe and document/report the following: -Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; -Pain assessment; -Resident's mobility status; -Current treatments, including support surfaces; and -All active diagnoses. *The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. *The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. *The physician will help identify medical interventions related to wound management.

Based on record review, interview, and policy review, the provider failed to ensure a summary of stay was completed for one of one sampled discharged resident (45). Findings include: 1. Review of resident 45's medical record revealed she had been admitted on [DATE] for rehabilitation services. She had been discharged to an assisted living center on 11/6/19. Review of resident 45's discharge summary form revealed it did not include the following: *Health conditions that impacted the resident's functional status and quality of life. *Nutrition and hydration conditions. *Treatments, programs, or therapy received during her stay. *Laboratory results. Interview on 11/20/19 at 5:20 p.m. with the director of nursing revealed she was not sure what a summary of stay was. She agreed the discharge summary was not complete. Review of the provider's 1/22/19 Transfer or Discharge Documentation policy revealed: *When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge; -If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: --the specific resident needs that cannot be met; --this facility's attempt to meet those needs; and --the receiving facility's service(s) that are available to meet those needs. -That an appropriate notice was provided to the resident and/or legal representative; -The date and time of the transfer or discharge; -The new location of the resident; -The mode of transportation; -A summary of the resident's overall medical, physical, and mental condition. -Disposition of personal effects; -Disposition of medications; -Others as appropriate or as necessary; and -The signature of the person recording the data in the medical record.

Based on interview, record review, and policy review, the provider failed to accurately document the effectiveness of [MEDICAL CONDITION] medications for one of one sampled resident (14). Findings include: 1. Review of resident 14's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] with late onset. -Altered mental status, unspecified. -Cerebral cysts. -Dementia in other diseases classified elsewhere with behavioral disturbance. -Major [MEDICAL CONDITION], single episode, unspecified. -Anxiety disorder, unspecified. -[MEDICAL CONDITION], unspecified. -[MEDICAL CONDITION] with lower urinary tract symptoms. *He had been admitted to a behavioral health hospital on [DATE] and returned on 5/8/19. *He returned with new medications of [MEDICATION NAME] 10 milligrams (mg) every day, [MEDICATION NAME] 0.5 mg every evening, and [MEDICATION NAME] HCL 50 mg at bedtime. *[MEDICATION NAME] HCL 50 mg at bedtime had been discontinued on 6/14/19. Review of resident 14's 8/29/19 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status assessment score was thirteen indicating his cognition was intact. *He was not depressed. *He had no hallucinations, delusions, or behaviors. *He had no change in behavior compared to the prior assessment on 6/5/2019. *He rejected care one to three days during the assessment period. *He required limited assistance of one staff member for dressing, toileting, and bed mobility. -He required limited assistance of two staff members for transferring. *He was occasionally incontinent of bladder. *He was continent of bowel. Review of resident 14's current undated care plan revealed: *He took the anti-anxiety medication [MEDICATION NAME] related to anxiety disorder. *Administer [MEDICATION NAME] as ordered by physician. Monitor for side effects and effectiveness as needed per protocol. *Monitor (resident name) per shift and as needed for safety. (Resident name) is taking [MEDICATION NAME] which is associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Monitor (resident name) sleep pattern since [MEDICATION NAME] discontinued 6/14/19. *Monitor/document/report PRN (as necessary) any adverse reactions (resident name) may exhibit of ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Pharmacy review 8/25/19. *Monitor/record (resident name) with occurrence of for target behavior symptoms of inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. *He took an anti-depressant medication [MEDICATION NAME] related to depression and behavior. *Administer [MEDICATION NAME] as ordered by physician. Monitor/document side effects and effectiveness with clinical charting. Monitor sleep pattern since [MEDICATION NAME] discontinued 6/14/19. *Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition (resident name) may exhibit; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/[MEDICAL CONDITION]; fatigue, [MEDICAL CONDITION]; appetite loss, wt loss, n/v (nausea/vomiting), dry mouth, etc. Pharmacy review 8/25/19. Review of resident 14's nurses' notes from 5/7/19 through 6/18/19 revealed: *There was no documentation of mood and behaviors after he returned from the hospital on [DATE]. *There was no documentation on 5/9/19 regarding his mood and behavior. *On 5/10/19 they had documented no behaviors. *The next mood and behavior note was written on 5/17/19. *They had documented on mood and behaviors only fifteen out of forty-one opportunities. *There was no documentation of his sleep patterns. Interview on 11/19/19 at 11:32 a.m. with resident 14 revealed he was: *Angry, and stated he was being held captive at the facility. *Upset he no longer had a phone in his room. *Upset that his son, power of attorney, was selling all my stuff. Interview on 11/20/19 at 4:30 p.m. and again at 6:02 p.m. with the director of nurses (DON) and the assistant director of nurses (ADON) revealed: *Any documentation regarding monitoring for effectiveness of medications should have been documented in the nurses notes. *Asked for specific monitoring for the [MEDICATION NAME] and [MEDICATION NAME] started after he had returned from the hospital on [DATE]. *At 6:02 p.m. the ADON stated they were unable to locate any documentation on effectiveness or behavior monitoring regarding the above medications. Review of the provider's (MONTH) (YEAR) Medication Utilization and Prescribing - Clinical Protocol policy revealed: *The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications. *The staff and physician will monitor the progress of anyone with a probable adverse drug reaction and anyone for whom medications have been adjusted because of the possibility of an adverse drug reaction. *If the physician has stopped, tapered, or changed an existing medication, the staff will monitor for, document, and report any return of symptoms.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (22) had: *Appropriate assessments of pain. *Appropriate use of as needed (PRN) pain medication and non-pharmacological interventions for pain. *Followed the care plan interventions. *Obtained a physician's orders [REDACTED]. *Received hot pack therapy from restorative therapy as ordered. Findings Include: 1. Review of resident 22's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Pain. -Cervicalgia. -Spondylosis with radiculopathy, cervical region. -Primary generalized (osteo)arthritis. Review of resident 22's 9/23/19 quarterly Minimum Data Set (MDS) assessment revealed his Brief Interview for Mental Status (BIMS) score was nine indicating moderate cognitive impairment. Observation on 11/18/19 of resident 22 at 4:25 p.m. revealed he: *Was in his room seated in his wheelchair (w/c). He was facing the window. *Stated he could not turn his neck. *Stated he had pain in his neck. *Had a grimace on his face and furrowed eyebrows when he tried to turn his head. Observation on 11/18/19 at 5:09 p.m. revealed he was seated in his w/c in front of a dining table. His head was lowered onto the table with his hands folded in front of him supporting his head. Observation and interview on 11/19/19 at 9:01 a.m. with certified nursing assistant (CNA) (I) during personal care for resident 22 revealed: *He was transferred from his w/c to his bed using a full body lift. *He was turned from side-to-side when his personal care was performed and when removing the full body lift sling from underneath him. -He grimaced, tightened his jaw, and closed his eyes when he was being turned. *They positioned him on his left side with the pillow under his right side for support. *When CNA I was asked if the resident had pain she stated: He has a lot of pain, to my knowledge he has PRN [MEDICATION NAME]. *The resident was asked if he was in pain, and he said yes. He rated it a fifty on a number scale of one to ten with ten being the worst pain level. His eyes were closed and jaws clenched. Interview on 11/20/19 at 8:20 a.m. with CNA/unlicensed assistive personnel (UAP) G revealed: *Resident 22 received scheduled [MEDICATION NAME] gel 1 percent (%) to his neck two times a day for pain. *He also had physician's orders [REDACTED]. *The CNAs would tell her when he was having pain. *She would then notify the nurse to see what intervention was to have been used. Review of resident 22's physician's orders [REDACTED].>*A 10/29/19 order for [MEDICATION NAME] 50 milligrams (mg) give 50 mg by mouth every eight hours as needed for pain. *A 10/31/19 order for [MEDICATION NAME] liquid 160 mg per 5 milliliters (ml) give 26.5 ml by mouth every eight hours as needed. *A 7/22/19 order for [MEDICATION NAME] Gel 1% apply one application [MEDICATION NAME] two times a day for neck pain. *A 10/25/18 order for hot packs to back of neck in restorative every day for fifteen minutes. Review of resident 22's (MONTH) 2019 medication administration record (MAR) revealed: *[MEDICATION NAME] had been used once 11/13/19 at 11:13 a.m. for a pain rating of seven. *[MEDICATION NAME] had not been given so far in November. *Pain was assessed and recorded on the MAR with the [MEDICATION NAME] gel administration at 8:00 a.m. and 8:00 p.m. *A pain assessment on 11/19/19 by CNA/UAP G at 8:00 a.m. revealed he had stated his pain was a zero. *A pain assessment on 11/20/19 by CNA/UAP G at 8:00 a.m. had been recorded as a six. No other pain medications had been given other than the scheduled Volarten gel. *Review of his pain ratings for 11/1/19 through 11/20/19 at 8:00 a.m. revealed he had rated his pain at zero eighteen times out of twenty days. *Review of his pain ratings for 11/1/19 through 11/20/19 at 8:00 p.m. revealed he had rated his pain at zero, six times; at one, once; at two, twice; at three, five times; at four, three times; at five, one time out of twenty days. Review of resident 22's last revised 9/13/19 care plan revealed: *A focus area of: -(Resident name) has arthritis and history of Gout r/t (related to) immobility and pain. He is on scheduled pain medication. *Goals included: -(Resident name) will be/remain free of complications related to arthritis with less joint stiffness, swelling, or decline in mobility through review date. -(Resident name) will maintain acceptable level of comfort by describing level of pain at level 4 or less or mild pain through review date. He does not always admit to pain. *Interventions included: -Pain: Attempt non-pharmacological interventions with (resident name). Hot packs in Restorative give him comfort to his neck and upper shoulders. *A focus area of: -(Resident name) has a potential for communication problem R/T Hearing deficit and wears hearing aid only in left ear. *A goal of: -(Resident name) will be able to hear adequately with use of hearing aid in left ear in 1:1 (one-to-one) environment through the review date. *Intervention included: -Monitor and observe (resident name) for physical/nonverbal indicators of discomfort or distress, and follow up as needed. He has a history of stiffness to neck r/t cervical spondylosis. He has limited ROM (range of motion) to head and neck. *A Focus area included: -(Resident name) has a need for restorative intervention due to ADL (activities of daily living) self-care performance deficit/limited physical mobility and activity intolerance. He has [DIAGNOSES REDACTED]. * A goal included: -(Resident name) will maintain current level of function with eating/dining and maintain adequate caloric intake. *Interventions included: -NURSING REHAB (rehabilitation) WARM PACK: Apply warm packs to back of (resident name) neck to promote comfort and lessen stiffness for 15 minutes per day up to 7 days a week. Surveyor: Interview on 11/20/19 at 1:00 p.m. with the MDS assessment coordinator regarding resident 22 revealed: *The resident had not received the hot packs during his restorative therapy. *She had not added the restorative therapy aide for the hot pack intervention to his care plan. *If the discipline was not added it did not show up for restorative to complete. Surveyor: Review of resident 22's primary care provider's orders for pain medication revealed: *On 10/29/19: Change [MEDICATION NAME] to 50 mg every 8 hours PRN. Discontinue the scheduled [MEDICATION NAME]. *On 10/29/19: Tylenol 850 mg by mouth every eight hours PRN. *There was no nurse's signature to indicate those orders had been verified. *There was no order to have discontinued the scheduled Tylenol. Interview on 11/20/19 at 1:25 p.m. with the assistant director of nursing (ADON) revealed: *In (MONTH) 2019 he had received scheduled [MEDICATION NAME] and [MEDICATION NAME]. *He started to lose weight and complain of stomach pain, so his Tramodol was changed to PRN. *She was not aware he had stated his pain was a zero for eighteen of twenty times each morning. *She was not aware he had only received the PRN [MEDICATION NAME] one time in (MONTH) 2019. *She agreed he should have been offered PRN pain medication when he was grimacing or rated his pain at a four or higher. *He would rate his pain between fifty and one-hundred. *She had tried to get a physician's orders [REDACTED]. -There was no documentation to support that. *She could not find any physician's orders [REDACTED]. *She agreed that orders should have been double-checked by the night nurse and should have been noted by nurse. *She agreed it might have been assumed the scheduled Tylenol had been discontinued. *She could not find any order to discontinue the scheduled Tylenol. Review of the provider's revised (MONTH) (YEAR) Pain - Clinical Protocol policy revealed: *With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. *The physician will order appropriate non-pharmacologic and medication interventions to address the individual's (resident) pain. *The staff will reassess the individual's (resident) pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. *The staff will evaluate and report the resident/patient's use of standing and PRN [MEDICATION NAME]. Review of the provider's revised (MONTH) (YEAR) Medication and Treatment Orders policy revealed: *Drug and biological orders must be recorded on the physician's orders [REDACTED]. *Such orders are reviewed by the consultant pharmacist on a monthly basis.

Based on observation and interview, the provider failed to ensure homelike noise levels were maintained during observations in one of two resident units (100 hallway). Findings include: 1. Observation and interview on 11/19/19 from 9:05 a.m. through 9:20 a.m. with resident 195 in his room on the 100 unit revealed: *He had been admitted the week before and had lived in his own home prior to that. *He was working with therapy and hoping to get back home again soon. *During the interview the door to his room was nearly closed but was not shut all the way. *There was a significant amount of noise coming from the hallway at times including: -A cognitively impaired resident yelling out frequently. -Staff voices in the hallway including over the walkie-talkies they used to communicate to each other throughout the building. --The walkie-talkie volumes consistently seemed loud. *When the noise level outside the room increased the resident would stop talking for a bit. -When the noise level went back down he would start talking again. *He commented it was noisy in the building, and he was not used to that. *He wore hearing aides and stated sometimes he just took those out when he wanted quiet. Observation on 11/19/19 from 9:45 a.m. through 10:30 a.m. in the lounge area on the 100 unit revealed: *The lounge area was near the connecting point of the 100 hallway, main hallway, and a hallway to administrative offices including an exit door. *Also near that area was a small dining room, a staff break area, the beauty shop, and the therapy gym. *The lounge space had a couch and three recliners that residents, staff, and visitors used frequently. *There were two cognitively impaired residents sitting in the lounge area at the above time. -Resident 6 was resting in a recliner in front of the television, and resident 39 was sitting on the couch. *A few other residents stopped at the area to rest for a few minutes and then continued on to their destinations. *During the above time frame the noise level in that area was elevated, distracting, and included:-Several staff near or walking past the area talking to each other. -Call lights were dinging. -Door alarms were sounding when visitors went through them without de-activating them. -Staff voices were heard over the walkie-talkies frequently that were kept at a loud volume. -Housekeeping staff were vacuuming near the area. -The television was on with the volume at a moderate level. -Staff were frequently opening and closing the medication cart drawers near that area. -There were staff, visitors, and other residents in the beauty shop and therapy areas nearby that were adding to increased noise. *Resident 32 came to talk with resident 39 for a few minutes and held her hand. -She stated they were friends, and she liked to visit her at times. --During that visit she also talked to the surveyor and indicated she had a hard time hearing the surveyor's voice due to the noise level in the area. Random observations of the 100 unit lounge area throughout the rest of that day until 6:00 p.m. revealed: *The noise level had lessened some compared to the time frame above. *The staff walkie-talkies remained at a very loud volume. -Frequently it was clear what the speaker was saying even though the staff member carrying the walkie-talkie was halfway down the hallway or more. *Resident 39 spent a lot of time in that lounge area, and her mood fluctuated. Observation and interview on 11/20/19 at 11:19 a.m. with certified medication assistant/certified nursing assistant (CMA/CNA) C regarding the above observation revealed:*The lounge area again had a large amount of noise including the walkie-talkies, doors opening and closing, staff voices nearby including the beauty shop and therapy areas, call lights sounding, the television, and door alarms. *There were five residents sitting in the lounge area with a visitor trying to speak with one of them. *CMA/CNA C confirmed the noise in the area was distracting and loud. -That could have affected the residents who were sitting in that area. *She had not thought before about the impact the noise could have on the residents. *She stated the staff were just busy working and probably had not noticed the noise. *During our interview her walkie-talkie volume was at a loud level that interrupted the conversation a few times. *She confirmed most walkie-talkies staff carried were turned up loud, so they could hear them easily. -There was a way to adjust the volume, and they could have been adjusted down a little and still been heard. *She stated the loud noises could have been distracting and disruptive especially to the residents with cognitive impairment. Interview on 11/20/19 at 11:28 a.m. with the Minimum Data Set assessment nurse revealed: *Her office was close to the 100 unit lounge area and next to the therapy gym and beauty shop. *She confirmed that area of the building had increased activity, and the noise level was higher at times. *She agreed when the noise level was too loud it could have impacted the residents. -The noise level could have been lessened making it a more homelike atmosphere. *She indicated she had talked to staff in the past about lowering the volume of their voices including the volume of their walkie-talkies, because she felt they were too loud. Interview on 11/20/19 at 1:25 p.m. with the social services designee regarding the noise levels in the building revealed she: *Indicated she had a hearing impairment herself. *Stated most of the time she did not wear her hearing aides while she worked since it was loud enough for her to hear. *Confirmed the 100 unit lounge area and hallways were noisy at times. *Felt the lounge area should have been a calm and quiet environment for the residents to have a more homelike atmosphere. *Indicated resident 39 spent a lot of time in that lounge area, and her mood/behavior could have been affected by the surrounding environment. Interview on 11/20/19 at 1:43 p.m. with the director of nursing (DON) and administrator regarding the above revealed:*They had not heard any residents complaining of the noise level in the facility before. *They confirmed the lounge area and hallways had times throughout the day where the noise level might have been worse than others. *Increased noise levels could have been disruptive to the residents especially residents with cognitive impairment or mood and behavior concerns. -The atmosphere should have been less noisy and more homelike. *The walkie-talkie volumes had been discussed in the past, and they had confirmed they were too loud at times. -The volume should have been maintained at a reasonable level. A policy on homelike environment and sound levels had been requested from the DON on 11/20/19 at 1:50 p.m. and again at 5:25 p.m. and was not received by the end of the survey.

Based on observation, interview, record review, and guideline review, the provider failed to ensure the correct diet had been followed for one of one sampled resident (6) who was on a mechanically altered diet. Findings include: 1. Review of resident 6's medical record revealed: *An admission date of [DATE]. *He was unable to complete the Brief Interview for Mental Status assessment. *A physician diet order dated 4/13/18 for, Regular diet Level 1-Puree texture, Regular fluid consistency, special occasions permitted. *[DIAGNOSES REDACTED]. Observation on 11/19/19 of resident 6 revealed: *At 8:13 a.m.: -He was sitting at an assisted table in the dining room. -There was an unidentified staff member sitting next to him. -He was holding a whole peeled banana in his left hand eating it independently. *Between 9:04 a.m. to 9:30 a.m.: -He had been sitting in the 100 unit sitting area and was coughing. *At 11:03 a.m. he was coughing while being assisted to the bathroom. *At 12:16 p.m. he was given a pureed meal on a divided plate. Interview on 11/20/19 at 10:20 a.m. with certified nursing assistant A regarding resident 6 revealed: *He was to have food that had been blended. *She could not remember what the diet was called. Interview on 11/20/19 at 10:35 a.m. with licensed practical nurse B regarding resident 6 revealed: *He was on a pureed diet. *He had refused to let the staff mash up the banana in the past, so they gave him whole bananas. *His wife was aware they let him have whole bananas. *She was going to call a physician about an order. *She did not know if he had been evaluated by a speech therapist. Interview on 11/20/19 at 1:21 p.m. with the Minimum Data Set assessment coordinator regarding resident 6 revealed: *He had been put on a pureed diet, because he was pocketing food in his mouth. *They let him have bananas as they were soft enough, and he had not pocketed the banana in his mouth. *The only non-pureed food he was given was bananas. Interview on 11/20/19 at 1:58 p.m. with the director of rehabilitation revealed resident 6 had not been seen by a speech therapist. Interview on 11/20/19 at 2:11 p.m. with the director of dining services regarding resident 6 revealed: *He had been pocketing food, so they had asked the physician for an order for [REDACTED].>-She could not remember how long ago he had been changed to a pureed diet. *When they had a resident who was having problems with eating they discussed it with the interdisciplinary team. -Then the team decided what should be done to help the resident. *He had not been referred to speech therapy. *No attempt had been made to upgrade his diet. *It was his regular routine to have a banana while he was waiting for his meal. *Family was aware of the resident eating whole bananas. *He had no trouble swallowing the banana. Interview on 11/20/19 at 4:11 p.m. with the director of nursing regarding resident 6 revealed: *She had given him the banana. *She did not know he could not have a whole banana with a pureed diet. *She agreed he should not have had a whole banana. *She did not know why he was on a pureed diet. Review of resident 6's 10/1/18 care plan revealed: *He required supervision to extensive assistance with meals. *He was on a pureed diet. *Family was aware and agrees with the appropriate diet. *It had not addressed the resident eating a whole banana. Review of the provider's undated Dysphagia Level 1/Pureed Diet guideline revealed fresh bananas were to be well-mashed.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene, glove use, and disinfection of the glucometer had been used by: *Two of two certified nursing assistants (CNA) (H and I) during personal care for one of one sampled resident (22). *One of one CNA/unlicensed assistive personnel (UAP) (G) for two of two sampled residents (10 and 36) during checking their blood glucose levels. Findings include: 1. Observation on 11/19/19 at 9:01 a.m. of CNAs H and I during personal care for resident 22 revealed: *CNA H did not complete any hand hygiene prior to putting on gloves. *CNA I did not complete any hand hygiene prior to assisting with resident 22's transfer. *Both CNAs used the full body lift to transfer resident 22 from his wheelchair to his bed. *CNA I then put on gloves with no hand hygiene completed. *Both CNAs assisted to reposition resident 22 onto his side on the bed. *CNA H removed the resident's incontinent brief, provided perineal care, and placed a new incontinent brief on him without changing her gloves. She then put barrier cream on his perineal area. *CNA I had assisted with the repositioning him from side-to-side removing the soiled brief, placed a new brief on him, and rearranged his clothing. *No glove change was completed when they also placed a pillow behind his back to position him on his left side. *Both CNAs H and I disposed of their gloves. CNA I applied soap to her hands then she washed and rinsed her hands under the running water. *CNA I opened the drapes and placed a fall mat on the floor. She then washed her hands for six to ten seconds before leaving his room. Interview on 10/20/19 at 2:00 p.m. with CNA I confirmed she had not changed her gloves or washed her hands at the appropriate times when she had assisted resident 22. 2. Observation on 11/19/19 at 11:32 a.m. of CNA/UAP G during the blood glucose checks for residents 10 and 36 revealed: *For both residents she removed the glucometer from the top of the medication cart. *She set the glucometer and her finger stick supplies on the resident's dressers in their rooms without any barrier. *After she had completed the blood sugar checks she returned to the medication cart and wiped the glucometer with a Cavi-Wipe disinfectant cloth for approximately three to five seconds. *She then set the glucometer on the top of its case on top of the medication cart. Interview on 11/20/19 at 2:30 p.m. with the assistant director of nursing agreed proper hand hygiene and glove use had not been completed. 3. Review of the provider's revised (MONTH) (YEAR) Handwashing/Hand Hygiene policy revealed: *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Use an alcohol-based hand rub or soap and water: -Before and after direct contact with residents. -Before moving from a contaminated body site to a clean body site during resident care. -After removing gloves. *The procedure for washing hands included: -Vigorously lather hands with soap and rub them together creating friction to all surfaces. -That should have been done for a minimum of twenty seconds. Review of the provider's revised (MONTH) 2011 Obtaining a Fingerstick Glucose Level policy included to Clean and disinfect resusable equipment between uses according to manufacturer's instructions and current infection control standards of practice.

Based on observation, record review, interview, and policy review, the provider failed to ensure medication had been administered according to their policy and procedure by one of one licensed practical nurse (LPN) (B) causing a medication error rate of 7.41% for: *One of two observed residents (10) who had almost received insulin from another resident's (44) insulin pen. *One of one randomly observed residents (42) intravenous (IV) pump that had been set at the incorrect rate for administration. Findings include: 1. Observation and interview on 11/19/19 at 11:40 a.m. of LPN B regarding resident 10 revealed: *She removed a [MEDICATION NAME]flex-pen out of the medication cart. *She removed the cover from the pen that had the label attached to it. *She dialed two units of the insulin to prime the pen, and then dialed five units to give to the resident.*While she primed the insulin pen the cover dropped on the floor. *This surveyor picked the cover up and the label indicated it was resident 44's insulin pen. *LPN B went into resident 10's room and was about to inject the insulin. *This surveyor stopped her, asked her to come into the hall, and showed her the label of the insulin pen. *She stated the insulin pen for resident 44 had been put into resident 10's insulin supply container in the medication cart. *She agreed she had not read the label to ensure it was resident 10's insulin pen. 2. Observation and interview on 11/19/19 at 4:00 p.m. of LPN B during an intravenous medication administration for resident 42 revealed: *After she had attached and primed the IV tubing to the first bag of fluconazole 200 milligram in 100 milliliter (ml) of sodium chloride she: -Set the IV machine at a rate of 200 ml per hour and the volume to be infused of 100 ml. -Review of the medication label for the fluconazole revealed it should have been infused at 100 ml per hour. -The rate it was set at would have had it infused in one-half hour instead of one hour. *LPN B was questioned about the rate and stated it was correct. This surveyor explained it did not match the indicated rate of the medication label. *LPN B reset the rate to 100 ml per hour. 3. Interview on 11/20/19 at 2:30 p.m. with the assistant director of nursing agreed the above medication administration observations would have potentially caused harm to the residents. She agreed they should be considered medication errors. Review of the provider's revised (MONTH) (YEAR) Medication and Treatment Orders policy did not have any information about checking the medication labels for the resident's name, medication name, and dose of medication to have been given.

Based on observation, record review, interview, and policy review, the provider failed to follow, update, and revise care plans for 3 of 19 sampled residents (9, 19, and 22) to reflect their current needs. Findings include: 1. Review of resident 22's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Essential hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Vitamin D deficiency. -[MEDICAL CONDITION]. *He had been started on [MEDICATION NAME] on 8/22/18. Review of resident 22's 8/22/18 interdisciplinary notes revealed Resident to start [MEDICATION NAME] 25 mg (milligram) po (orally) daily for one week and then increase to 50 mg po daily for depression. This RN (registered nurse) will get with activities and social services in order to look at different interventions. He will follow-up with MD (medical doctor) in a month to see if his depression has improved. Review of resident 22's undated current care plan revealed: *A focus area of: The resident is adjusting to his new surroundings and activity involvement altered due to admission to (provider name). He is dependent on staff for activities, cognitive stimulation, and social interactions. *The interventions had been: -Discuss resident's feelings relative to admission and (provider name) surroundings, initiated on 8/2/18. -Assist resident to remind of activity schedule, provide 1:1s (one-to-ones) if he doesn't want to attend group activity. *There had been no other interventions documented regarding adjustment to the facility or feeling depressed. Interview on 9/19/18 at 4:21 p.m. with the interim director of nursing (DON) and the social services designee (SSD) regarding resident 22 revealed: *The physician had come to do rounds on 8/22/18 and had spoken with him. *He told the physician he was having a hard time being at the facility due to leaving his own home and lifestyle. *The physician was fairly new and wanted to assist the resident but had not understood attempting non-pharmacological interventions prior to starting a medication. *The interim DON had been doing rounds with her but had not felt like she could speak up about attempting non-pharmacological interventions. *The resident had not had a [DIAGNOSES REDACTED]. -The physician had added major [MEDICAL CONDITION] to his [DIAGNOSES REDACTED]. *There had been no other social service interventions listed on the care plan to assist the resident with adjusting to his new surroundings. 2. Review of resident 9's nurses notes revealed: *On 9/14/18: -She had a very dark purple area on her coccyx approximately 2.0 centimeters (cm) by 1.5 cm. -She had a 0.5 cm by 0.5 cm to her left and right buttock. -Breeze (nutritional) supplement had been refused. -Repositioning had been refused. *On 9/17/18 it was noted she was at risk for a pressure ulcer. *On 9/19/18 at 10:16 a.m.: -Noted a 2 x 3 stage 2 pressure ulcer residents coccyx. -Discussion with resident to lay on her side. *On 9/19/18 at 10:51 a.m. she was reassessed and it had been determined her wound was a stage 3. Interview and observation on 9/18/18 at 8:56 a.m. with the staff development coordinator revealed: *She was working as the charge nurse. *Resident 9 was sitting upright in her wheelchair. -She usually sat up most of the day. -She might have been developing a pressure ulcer on her bottom. Observation and interview with the staff development coordinator on 9/19/18 9:25 a.m. revealed: *She was providing pericare for resident 9. *She would consider her wound was a stage 3. Review on 9/19/18 of the wound data collection assessment for resident 9 revealed: *Increase of coccyx to purulent 2 x 3 wound. *No drainage. *She voiced complaints of pain. *Skin was red. Review of a 9/19/19 physician communication form revealed: *She had a 2.0 cm by 3.0 cm x 0.5 cm stage 3 ulcer in the crease of her buttocks. *That was the first communication to her physician about the above wound. Review of resident 9's care plan revealed: *It had been revised on 9/17/18 and 9/19/18. *It mentioned the potential for a pressure ulcer development. *It had not mentioned any wound area on her coccyx. 3. Review of resident 19's care plan initiated on 5/3/18 revealed: *Staff were to inspect her feet daily for open sores or [MEDICAL CONDITION] and report to the nurse. *She had a potential for skin break down. *She was to elevate her feet when sitting in her chair. Interview and observation of resident 19's right leg and foot on 9/18/18 at 11:50 a.m. revealed: *She had a support stocking on with a sock slipper. -The support stocking was loose and falling down. *Her toes were purple on that foot. *She had four plus [MEDICAL CONDITION] and her second toe had a black colored nail. *She stated she only kept her legs up at night while in bed. *Her foot was cold to the touch. *The swelling continued up towards her knee. *Her slipper sock had made large indentation around her mid-calf area. 4. Interview on 9/18/19 at 12:05 p.m. with the director of nursing revealed: *Staff had not updated the care plans as they should have. *The MDS coordinator did all of the care plan updating. -She had done this for at least a year. *All staff should have been involved with updating the care plans. *Care plans were not used much by the direct care staff. Interview on 9/19/18 at 12:45 p.m. with the MDS coordinator revealed: *She made all changes to the care plans. *She was trying to teach the nurses how to update the care plans. -She would let them know this individually and at care plan meetings. -Most of them did not know how to get to them in the computer. Review of the provider's (MONTH) (YEAR) Care Plan policy revealed: *An individualized, person-centered, comprehensive care plan should have been developed for each resident. *A qualified team of persons would review care plans at least quarterly. They would be reviewed, evaluated, and updated when there was a significant change in the resident's condition. *The care plan would be modified to reflect the care currently required that resident. Review of the provider's revised (MONTH) (YEAR) Care Plan procedure revealed the care plan was developed by the interdisciplinary team. -The interdisciplinary team would have consisted of the resident, resident representative, registered nurse, social services, activities. dietician or director of nutrition, rehabilitation coordinator, physician, and other healthcare professionals.

Based on record review, interview, and policy review, the provider failed to report to the South Dakota Department of Health (SD DOH) a fall with major injury for one of one sampled resident (10) who had a fractured arm. Findings include: 1. Review of resident 10's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Hypertension. -Asthma. -[MEDICAL CONDITION]. -[MEDICAL CONDITION] disorder. -Arthritis. -[MEDICAL CONDITION]. -Depression. *She had a fall on 6/3/18 where she had hit her head and Had a raised area on back Rt. (right) side of head. *On 6/6/18 she had fallen and was sent to the emergency room (ER) where it was determined she had fractured her arm. Review of resident 10's 6/27/18 Minimum Data Set (MDS) assessment revealed she had one major fall with injury since her prior MDS assessment completed on 4/4/18. Review of resident 10's 6/6/18 investigation report revealed: *She had fallen at 5:30 a.m. *Level of injury at time of investigation had been left blank. *There had been no witnesses. *The communication to the physician had been Res (resident) fell at 0530 (5:30 a.m.) this AM coming out of BR (bathroom). Hit head. Neuro's intact. Res c/o's (complains of) R (right) arm/shoulder pain. Sending to ER this AM. Review of resident 10's 6/6/18 interdisciplinary notes revealed Returned to facility from ER visit. X-rays indicated a R humerus fracture. Resident is to wear an immobilizer. New orders received: Tylenol 500 mg (milligrams) x's (times) 5 days. [MEDICATION NAME] 50 mg TID (three times a day) for pain. Resident is to have her call light at bedside and in the bathroom. Will continue to monitor. Interview on 9/19/18 at 3:05 p.m. with the administrator revealed they had not reported the incident from 6/6/18 to the SD DOH regarding resident 10's broken arm. Record review and interview on 9/19/18 at 3:43 p.m. with the administrator, the interim director of nursing (DON), and the social services designee (SSD) regarding the above fall revealed: *They had received the new algorithm from the SD DOH department in (MONTH) (YEAR). -Since the above mentioned incident occurred in (MONTH) (YEAR) they had been using the algorithm from (MONTH) (YEAR). *They felt from the (MONTH) (YEAR) algorithm they would not have had to report the fall with fracture. *Review of the SD DOH Reporting of Injuries of Unknown Source and Reasonable Suspicion of a Crime information sheet that came with both algorithms revealed Those falls that involve injury of a serious nature should be reported. *They agreed a fracture would be an injury of a serious nature. Review of the provider's (MONTH) (YEAR) Abuse/Neglect 7 Key Components policy revealed: *Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. *Take all necessary corrective actions depending on results of the investigation.

Based on observation, interview, and record review, the provider failed to modify and document interventions for one of one sampled resident (40) who had a major weight loss. Findings include: 1. Observation on 9/18/18 at 12:20 p.m. of resident 40 revealed her eyes were closed at the lunch table. The staff member at the table encouraged her to open her mouth and had to feed her. She was not observed feeding herself. The staff member supervised or assisted all five residents at that table. The staff member moved around the table on a wheeled stool from one resident to another. Observation on 9/18/18 from 3:45 p.m. through 4:30 p.m. of resident 40 revealed at the following times: *3:45 p.m. she was asleep in a chair in the 200 hallway. *4:15 p.m. she was awake and answered questions from this surveyor, her answerers were not appropriate for the questions asked. *4:30 p.m. she was asleep again in the same chair in the 200 hallway. Record review of the Medication Adminstration Record (MAR) and interview on 9/19/18 at 5:21 p.m. with the Certified Dietary Manager (CDM) regarding resident 40 revealed: *She was on the nutrition risk list. *She had been moved to another dining room table for residents who needed supervision with eating. *Her level of assistance fluctuated between supervision, encouragement, and physical assistance. *She received eight ounces (oz) twice a day of their house supplement which was Carnation Instant Breakfast (CIB). -She was taking the CIB better now than she had in the past. -Review of the Medication Administration Record [REDACTED]. --There was no documentation CIB was given twice daily as recommended. *The recommendation for ice cream was discontinued due to her not eating it. *She had fortified foods given at meal times. -There was no tracking system to ensure she ate the fortified foods. *There had been no other interventions attempted. *There had been no monitoring to verify benefit of moving her to the table for residents who needed assistance. Review of resident 40's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITIONS], unspecified. -Age-related [MEDICAL CONDITION] without current pathological fracture. -Other specified depressive episodes. -Nutritional deficiency, unspecified. -[MEDICAL CONDITION], unspecified. -Constipation, unspecified. -[MEDICAL CONDITION], unspecified. -Essential hypertension. -Muscle weakness. -Urinary tract infection. -Pain unspecified. *She had 5.17% weight loss in 30 days and 12.23% weight loss in 180 days. Review of resident 40's 8/23/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was five indicating her cognition was severely impaired. *She required supervision from one staff person for eating, bed mobility, walking in the corridor, and for locomotion on and off the unit. *She required limited assistance from one staff person for toileting, personal hygiene, and transferring from one location to another. *She required extensive assistance from one staff person for dressing. *She had not received occupational therapy since 01/05/16. *She had not received physical therapy since 10/11/17. *Weight loss of 5% in the last month and 10% or more in the last 6 months. *She had broken or loosely fitting full or partial dentures. Review of resident 40's care conference notes revealed: *On 3/20/18: She had a seven pound weight loss in the prior three months. *On 9/4/18: She was sleepy at meals and needed much encouragement to eat. -She had been moved to the assistance table. -Her son believed the pain medications were causing her to be sleepy during the day. Review of resident 40's nutrition notes, by the registered dietician (RD) and the CDM from 3/13/18 through 9/11/18 revealed: *On 3/13/18: -She had shown a 2.6% weight loss in 90 days and 6.9% weight loss in 180 days. -Continued on a regular fortified diet with ground meats. -Four ounces (oz) of CIB with her afternoon snack. *On 4/10/18: -7.3% weight loss for 180 days. -Recommendation to continue on a regular fortified diet with ground meats. -Four oz of CIB given daily. *On 5/8/18: -4.5% Weight loss for 180 days. -Continued on a regular fortified diet with ground meat. -CIB increased to eight oz daily. *On 6/8/18: -Continued on a regular fortified diet with ground meat. -Eight oz of CIB daily. *On 7/10/18 a 3.1% weight loss over 30 days. -Continued on a regular fortified diet with ground meats. -CIB was discontinued due to poor acceptance. *On 7/19/18: -The CDM noted on a 6 pound weight loss in 30 days. -Added ice cream cups twice daily for additional calories. *On 8/14/18: -5.4% weight loss in 30 days. -Continued on a regular fortified diet with ground meats. -Restarted on 8 oz of CIB daily. *9/11/18: -Weight continued to decline, 5.7% weight loss in 30 days and 15.5% in 90 days. -Regular fortified diet with ground meats. -She was moved to a dining table for residents who needed assistance. -Had eight oz of CIB given at breakfast. -Registered dietician recommended to increase the CIB to twice daily. Review of resident 40's 9/4/18 care plan regarding nutrition revealed the following interventions: *EATING-SWALLOWING: Resident requires ground meat and soft food diet since she does not were (wear) upper or lower partial and is missing teeth. *Provide supervision at meals. Needs to know food placement due to poor eye sight. CIB 8 oz qd (every day) for weight loss.

Based on observation, interview, and record review, the provider failed to implement interventions for treatments and services for mental and psychosocial concerns pre or post hospitalization for one of one sampled resident (41). Findings include: 1. Interview and observation on [DATE] at 5:15 p.m. with resident 41 revealed: *She had a flat affect, hair was tousled, her shirt and nails appeared clean, she had a blanket covering her lap, with a gap revealing her thigh indicating she had no pants on. *She ate the majority of her meals in her room. *She had not wanted to know anyone in the facility. *She stated she had no where else to go and would be at the NH until she died . Review of resident 41's medical records revealed: *She was admitted on [DATE]. *She was hospitalized on [DATE]. *She was transferred to the psychiatric unit at the hospital on [DATE]. *She was discharged from the hospital and readmitted to the nursing home on [DATE]. *Her [DIAGNOSES REDACTED].>-Dementia in other diseases classified elsewhere with behavioral disturbances. -[MEDICAL CONDITION] with late onset. -Anxiety disorder, unspecified. -Unspecified kidney failure. -Type 2 diabetes mellitus without complications. -Heart failure, unspecified. -Weakness, bilateral primary [MEDICAL CONDITION] of knee. -Other recurrent [MEDICAL CONDITION]. -[MEDICAL CONDITION], unspecified. Review of resident 41's [DATE] Minimum Data Set (MDS) assessment revealed: *Preadmission Screening and Resident Review (PASRR) indicated the patient had no serious mental illness and/or intellectual disability. *Her Brief Interview for Mental Status Score (BIMS) was thirteen indicating her cognition was intact. *Her Resident Mood Interview (PHQ-9) score was six indicating she was mildly depressed. *She was free of hallucinations and delusions. *She had behavioral symptoms not directed towards others. *She had rejected care one to three days in the assessment timeframe. *She had an active [DIAGNOSES REDACTED]. *She was on no antipsychotic, antianxiety, or antidepressant medications. Review of resident 41's [DATE] MDS assessment revealed: *BIMS score was thirteen indicating her cognition was intact. *PHQ-9 score was zero indicating minimal depression. *She had no hallucinations or delusions. *No behavioral symptoms indicated towards herself or others. *She had rejected care one to three days in the assessment timeframe. *She had an anxiety disorder identified. *Depression was no longer identified. *Antipsychotic medications and antidepressant medications were identified. *No psychological therapy administered. Review of resident 41's physician's orders [REDACTED].>*[MEDICATION NAME] tablet 50 milligrams (mg) by mouth at bedtime started on [DATE]. *[MEDICATION NAME] tablet 10 mg by mouth once per day started on [DATE]. Review of resident 41's [DATE] care plan revealed: *[DIAGNOSES REDACTED]. -Interventions included: --Assist resident in developing a program of activities that are of meaning and of interest to her. --Provide encouragement/assistance/support to maintain as much independence and control possible. --Monitor for changes in depression and contact health care provider if mood significantly interferes with activities of daily living. *Target date of the above was [DATE] with no additional interventions post hospitalization . Interview on [DATE] at 4:57 p.m. with the social services designee (SSD) regarding resident 41 revealed: *No referrals had been made for behavioral health services. *There was no documentation done for providing one-to-one activity with her to help her cope with moving to the NH outside of the MDS assessment timeframes. *There were no recommendations from the hospital at the time of discharge. *SSD indicated the resident had not had any additional behavioral health needs post-hospitalization . Review of resident 41's progress notes for (MONTH) (YEAR) revealed: *No notes from the activities director. *Registered nurse(RN) C noted on [DATE] the resident was tearful and confused as to why she was at the nursing home. Also indicated that was her baseline per family, and they had requested she see her primary care provider (PCP). *SSD on [DATE] had provided one-to-one activity to discuss transition to the nursing home (NH) and funding sources of being in a private room. *Licensed practical nurse (LPN) B noted on [DATE] her husband had requested to have the resident evaluated for antianxiety and antidepressant medications. *RN C noted on [DATE] a meeting with the husband and SSD where the husband reported her mood and behavior being different at the NH than at home and wanted her evaluated by her PCP. *On [DATE]: Care Plan Review note from SSD indicated resistive with care, tearful, upset with staff. Also stated She is adjusting to her new surroundings. *On [DATE]: SSD noted verbal behaviors of yelling, calling staff names, other behaviors along with ripped brief and rejection of care, refused medications and food. Overview of the following (MONTH) (YEAR) documentation for resident 41 included: *On [DATE]: SSD noted she had been refusing food and losing weight. Transferred to the emergency room (ER) and admitted for weight loss and weakness. *On [DATE]: SSD noted she was moved from the hospital to a psychiatric unit due to physical aggression, refusing to eat and drink, refusing medications, and verbal behaviors. *On [DATE]: SSD indicated she was being discharged from the psychiatric unit and would be readmitted to the NH. *On [DATE] Staff development coordinator noted dementia with agitation was addressed per psychiatry. *On [DATE] Interim director of nursing (DON) noted resident screaming out in her room and yelling the entire shift. Pushing call lights stating 'Just to annoy you,' ' I can do what I want.' CNA stated the resident behaved the same way the previous night. *On [DATE] LPN A noted Res. (resident) refused to go to bed earlier in the shift. This resident agreed to go to bed at this time. Res. has been yelling out and throwing items of off her tray table and accusing staff of taking her things away. Staff assisted to bed with 2 assist and Hoyer lift. Res. made the remark that she wishes that she could just die and that she hopes the staff have to suffer like this someday. Res. rude and calling staff names. Res. Now resting in bed with feet elevated, call light and belongings present at bedside. Res. Refused to use BR (bathroom). Res. was incontinent. Brief changed. Res. refused a snack or to drink water. Res. was also repositioned at this time and her feet elevated on pillows with foot end of the bed in highest position. Behaviors remain unchanged and res. continues to yell out. Will continue to monitor this shift. *On [DATE] SSD did one-to-one with resident to discuss stay at NH and MDS assessments. *On [DATE] LPN B noted she looked anxious/depressed in the morning. Noted she was tearful and stated I just want to sit in my recliner and die. *There had been no documentation of notification to her physician or additional interventions regarding the above notes.

Based on observation, interview, and record review, the provider failed to ensure a resident (1) that entered the facility without a pressure ulcer did not develop a pressure ulcer for one of two sampled residents with pressure ulcers. Findings include: 1. Observation on 9/21/11 at 7:50 a.m. revealed resident 1 had a black area on his right heel. Review of the Braden Scale for Predicting Pressure Sore Risk revealed: *On 6/24/11 (admission assessment) the score was 16. *On 7/1/11 the score was 17. *On 7/8/11 the score was 18. *On 7/15/11 the score was 18. Review of the Braden Scale Reference Tool revealed scores from 15 to 18 indicated the resident was at mild risk to develop a pressure ulcer. The suggested interventions were: *"Frequent turning (e.g. q (every) 2 hours. *Maximal Remobilization. *Pressure-Reduction Support Surfaces if Bed-or Chair-Bound. *Protect Heels. *Manage Moisture. *Manage Nutrition. *Manage Friction and Shear." Review of the care plan dated care 7/7/11 revealed: *The resident was admitted on [DATE]. *The resident needed extensive assistance of two or three staff for bed mobility and transferring. No further concerns, goals, or approaches were listed relating to the resident's skin condition. Review of the care plan dated 8/30/11 revealed the approach "Monitor skin weekly for breakdown" was added. Interview on 9/21/11 at 7:58 a.m. with the director of nursing (DON) revealed: *The update to the care plan was related to a medical procedure on resident 1's left foot. *She believed the weekly documentation dealt with the left foot and not a full body assessment. *The resident resisted care and was aggressive during care. Interview on 9/21/11 at 8:05 a.m. with the Minimum Data Set (MDS) coordinator confirmed the MDS dated [DATE] did not indicate resident 1 was at risk for pressure ulcers. She further stated any resident with a Braden score of 18 or higher she did not indicate on the MDS that resident was at risk. She confirmed it would have been addressed on the CAA or the care plan because they were not assessed as at risk on the MDS. Review of the focus audit for pressure ulcers revised September 2010 presented by the MDS/quality assurance coordinator revealed "The center has identified residents at risk for skin breakdown (Braden Scale of 18 or below is at risk)." Interview on 9/21/11 at 8:15 a.m. with the DON and the MDS coordinator revealed the certified nurse assistant (CNA) recorded the date, time, and type of bath a resident received on their hand-held documenting devices. There was no way to get the information regarding the resident's skin condition when accessing the resident's bath documentation. The MDS coordinator further stated if there was a concern a Nutritional Risk Notation was completed by the CNA and given to the nurse. Both agreed the Nutritional Risk Notation was not part of the medical record and was not retained. Interview on 9/21/11 at 8:30 a.m. with the DON after reviewing resident 1's chart confirmed there was no documentation in the nurses notes from 8/18/11 until 9/13/11 when the pressure ulcer was documented. She was not aware of any documentation relating to the pressure area on the right heel leading up to the documentation on 9/13/11. Review of the Interdisciplinary Progress Note dated 9/13/11 revealed "Res. (resident) has Rt. (right) heel suspected deep tissue injury 4.5 x 2. Intact pressure ulcer. Heel is suspended. Continue regular-level 4 diet. Good appetite." Review of the fax communication to the physician dated 9/14/11 revealed the resident "has a black area on his heel." Interview on 9/22/11 at 7:15 a.m. with staff F revealed if any abnormal skin condition was identified the CNAs reported it right away to the nurse and would note it in the CNA communication book for the next shift. The CNAs received resident care information from the CNA leaving work, the report sheets, the CNA report book. She confirmed the CNA communication book did not have any documentation for resident 1's skin condition prior to 9/12/11. She stated she could not enter comments on her hand-held device regarding skin condition. She further stated the bath aide would have different documentation available on her hand-held device. Interview on 9/22/11 at 7:40 a.m. with staff G revealed: *She was a new employee. *She had on her hand-held documentation device a diagram of the body, so she could identify where the problem was. *She reported to the nurse right away any abnormal skin conditions, so the nurse could see the resident before the resident was dressed following their bath. *She confirmed she could not write comments on the hand-held regarding a resident's skin condition. Review of the revised March 2008 Wound Flow Sheet for resident 1 revealed a pressure sore on his right heel identified on 9/12/11. It was 4.5 centimeters (cm) long and 2 cm wide. It was unstagable due to eschar. There was no drainage. The skin was intact. There was no odor. There was pain. The resident had his heel suspended. There was no further documentation. Review of the Pressure Ulcer policy revised March 2007 revealed "Based on the resident's comprehensive assessment, the center will utilize prevention and assessment interventions to ensure that a resident entering the center without pressure ulcers does not develop a pressure ulcer unless the individual's clinical condition demonstrates that this was unavoidable....Residents will receive appropriate assessments and services to promote and maintain skin integrity." Review of the Pressure Ulcer Guidelines revised September 2010 revealed: *"Prevention strategies should be developed and implemented at the time of admission based on the initial assessments of the causative factors that contribute to the resident's risk for skin breakdown. Prevention strategies are ongoing and will be individualized based on the areas or the level or risk determined. Include these preventions strategies on the resident's care plan." *"Residents at risk for pressure ulcer development and those with pressure ulcers/wounds should be monitored daily for changes in their skin condition. This may occur during the course of the resident's daily care and/or bathing where the CNA should perform a head to toe check of the resident's skin, paying particular attention to: -The surfaces of the skin that come in contact with the bed and chair. -Bony prominences (heels, tailbone/gluteal fold, shoulder blades, elbows, back of the head, etc.).... *Documentation of the primary care provider notification, orders received, family notification and resident response to any treatment should follow GSS (Good Samaritan Society) procedures as well. *Weekly skin checks are recommended to be performed on all residents but especially those identified as 'at risk'." *"It is recommended that the nursing progress notes reflect the nurse's observation an management of wounds from a shift to shift perspective and with each dressing change." Review of the Pressure Ulcer Management policy revised January 2011 revealed: *"Residents who are unable to reposition themselves independently should be repositioned as often as directed by the care plan approaches... *When a pressure ulcer is present, daily monitoring (with accompanying documentation when a complication or change is identified)should include the following: -An evaluation of the ulcer, if no dressing is present... -The status of the area surrounding the ulcer... -The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection... -Whether pain, if present is being adequately controlled."