Every finding on record at Wathena Healthcare & Rehabilitation Center

The facility identified a census of 39 residents. The facility had one main kitchen and one dining area. Based on record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed the residents at risk for unmet dietary and nutritional needs. Findings included: - On 09/23/24 at 04:27 PM, Dietary BB stated the registered dietitian visited every two weeks. Dietary BB stated she still needed to pass the test to become a CDM because she took it once and did not pass but had to wait 90 days to try again. On 09/24/24 at 11:05 AM, Dietary BB stated she had been the dietary manager for four years and it had taken a couple of years to get the CDM education completed because of the pandemic. On 09/25/24 at 01:36 PM, Administrative Staff A stated Dietary BB had taken the state test to become a CDM but did not pass. He stated the current plan included her taking the test again but they might have to see if another dietary member wanted to become certified or find a CDM if it did not work out. The facility policy Organizational Plan and Roles of Key Staff documented that in states without an established minimum standard, the following qualifications of the Dining Services Manager should be considered: Certified Dietary Manager {CDM, CFPP) credential; or Certified food service manager; or National certification for food service management and safety from a national certifying body; or Associate's or higher degree in food service management or hospitality from an accredited institution of higher learning. The facility failed to ensure the director of food and nutrition services had the required qualifications of a CDM. This placed the residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 39 residents. Based on record review and interviews, the facility failed to ensure agency direct care staff had received the required infection control training. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 07/10/24 at 10:40 AM a review of the training for agency Certified Nurses Aid (CNA) M, and CNA N and CNA O revealed the following: CNA M's facility-provided credentialling file lacked evidence training was completed for infection control training. CNA N's facility-provided credentialling file lacked evidence training was completed for infection control training. CNA O's facility-provided credentialling file lacked evidence training was completed for infection control training. On 09/25/24 at 01:48 PM Administrative Nurse D stated the facility did go over resident rights and Abuse, Neglect, and Exploitation training with the agency staff. Administrative Nurse D stated she would begin doing the communication, infection control, and the other required nurse aide training upon hire and orientation. On 09/25/24 at 01:5 PM Administrative Staff A stated that he just assumed that agency staff had completed the required training, but none of that information was sent by the Agency company. Administrative Staff A stated that staff would ensure that the training was completed upon their first shift of working from this time forward. The facility did not provide a policy regarding required training for nurse aide staff as requested. The facility failed to ensure agency direct care staff had received infection control training. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 39 residents. Based on observations, record review, and interviews, the facility failed to ensure staff followed Enhanced barrier precautions (EBP), and failed to ensure staff performed appropriate hand hygiene during medication pass. The facility further failed to assess, identify risks, and create a plan to address the risk for Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 09/24/24 at 08:58 AM, Resident (R)8 had an isolation basket with isolation supplies on the back of her room door without a sign denoting the type of isolation or PPE required. Licensed Nurse (LN) G performed wound care on R8 without wearing an isolation gown. On 09/24/24 at 09:20 AM, R16 had an isolation basket with isolation supplies on the back of his room door without a sign denoting the type of isolation or PPE required. Certified Nurse Aide (CNA) P performed catheter care without wearing an isolation gown. On 09/25/24 at 08:03 AM, Certified Medication Aide (CMA) R obtained R26's blood pressure in his room. She exited his room then donned (put on) gloves and disinfected the blood pressure machine and cuff with disinfecting wipes. CMA R doffed (removed) gloves but did not perform hand hygiene before preparing R26's medications. On 09/25/24 at 08:22 AM, CMA R prepared R29's medications. She donned gloves and placed a tablet of Seroquel (antipsychotic medication- a class of medications used to treat major mental conditions that cause a break from reality) in a pill cutter, placed half a tablet in a medication cup, then wasted the other half in the sharps container. CMA R disinfected the tablet cutter with a disinfectant wipe and then doffed gloves. She did not perform hand hygiene before continuing with R29's medication pass. Upon request, the facility was unable to provide a Legionella water management plan. On 09/25/24 at 12:05 PM, Maintenance U stated he had not done anything with the Legionella water management plan yet but it would be his responsibility. On 09/25/24 at 01:28 PM, CMA R stated staff performed hand hygiene after touching residents and before leaving the resident's room. She stated she performed hand hygiene after taking off her gloves. CMA R stated staff knew what residents required EBP from the signs on the doors and sometimes from the report. On 09/25/24 at 01:31 PM, LN G stated staff performed hand hygiene before and after care, after touching residents, and before and after using gloves. He stated staff knew what residents required EBP by their name being in blue outside their door. LN G stated the facility held an in-service about EBP and they no longer had isolation signs. He stated staff wore gloves and isolation gowns with any direct care with residents on EBP. On 09/25/24 at 01:36 PM, Administrative Staff A stated in December 2023, the facility completed the Legionella assessment and planned to get the testing in place but the maintenance man at the time passed away and it was not put into place. On 09/25/24 at 01:47 PM, Administrative Nurse D stated staff performed hand hygiene any time they went into a resident's room and when coming out of their room, before and after putting gloves on, and when going from a dirty to clean procedure with glove changes. She stated staff knew what residents required EBP by their name being in blue outside their room. Administrative Nurse D stated residents on EBP had isolation baskets hanging on the back of their door that had gloves and isolation gowns to be worn. She stated staff discussed EBP at length. Administrative Nurse D stated the facility did have isolation signs on the door but they were told to take them down and find a new way to mark what residents required EBP. She stated she expected staff to wear isolation gowns and gloves any time they performed direct contact with residents on EBP. The facility's Legionella Surveillance policy, last revised 05/31/22, directed the facility to establish primary and secondary strategies for the prevention and control of Legionella infections. The facility's Enhanced Barrier Precautions policy, dated 04/01/24, directed EBP referred to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employed targeted gown and glove use during high-contact resident care activities. The policy directed the facility to have discretion on how to communicate to staff which residents required the use of EBP, as long as staff were aware of which residents required the use of EBP before providing high-contact care activities. The facility's Hand Hygiene policy, dated 2024, directed all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy directed if a task required gloves, staff performed hand hygiene before donning gloves and immediately after removing gloves. The facility failed to ensure staff followed EBP, and failed to ensure staff performed appropriate hand hygiene during medication pass. The facility further failed to assess, identify risks, and create a plan to address the risk for Legionella disease or other opportunistic waterborne pathogens. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 39 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 39 residents residing in the facility. Findings Included: - An inspection of the Facility assessment dated [DATE] provided by the facility revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each shift. The assessment lacked an informed contingency plan for events that do not require activation of the facility's emergency plan but have the potential to impact resident care. The assessment lacked a contingency plan to maximize recruitment and retention of direct care staff. The assessment failed to identify the means of input gathered from the residents and their representatives when formulating the assessment data. On 09/25/24 at 01:54 PM Administrative Staff A stated the facility had just revised the facility assessment on 08/01/24 and thought all areas had been covered for the new requirements. Administrative Staff A stated he would be going over the new requirements again and adding in the areas that were lacking. The facility was unable to provide a policy related to its facility assessment as requested on 09/25/24. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 39 residents residing in the facility.

The facility identified a census of 39 residents. The facility had one main kitchen. Based on observations, record review, and interviews, the facility failed to ensure the big cooler maintained an appropriate temperature range, failed to ensure staff consistently monitored cooler and freezer temperatures, and failed to ensure staff consistently monitored the dishwasher temperatures and chemical sanitation levels. The facility further failed to ensure adequate hand hygiene during meal service. This deficient practice placed residents at risk for food-borne illnesses. Findings included: - On the initial tour of the kitchen on 09/23/24 at 08:11 AM, the big cooler had a temperature of 46 degrees Fahrenheit. The big cooler contained produce, cheese, condiment containers, eggs, sour cream, cottage cheese, and other food items. On 09/24/24 at 07:48 AM, Administrative Nurse D delivered a bowl to a resident in the dining room and then helped a male resident with a clothing protector. She then asked Resident (R) 3 if he wanted a clothing protector and helped him put it on. The kitchen staff brought out a cart of food and without performing hand hygiene, Administrative Nurse D grabbed a plate, sat it back down, and then touched another plate on another cart. She then grabbed an empty tray and moved the breakfast plate/bowl/cups to the tray. Administrative Nurse D moved another covered plate on the cart and then pushed the cart towards the kitchen door. R4's clothing protector fell off and she attempted to refasten it then walked over to the stack of clean clothing protectors to grab a different one for R4. Administrative Nurse D placed the previous clothing protector on the table after placing the new clothing protector on R4. She then walked away from the table moved her hair out of her face then pushed a food cart towards a female resident. She gave the female resident cups of fluids, and her breakfast tray then pushed the cart towards the kitchen. Administrative Nurse D then performed hand hygiene. On 09/24/24 at 11:19 AM, the big cooler had a temperature of 46 degrees Fahrenheit. Dietary BB verified the big cooler's temperature and reported the temperature at 48 degrees Fahrenheit. Review of the Temp Log- Big Cooler from 09/01/24 to 09/22/24 revealed missing temperature monitoring documentation on 09/01/24 evening (PM), 09/06/24 morning (AM) and PM, 09/08/24 PM, 09/09/24 PM, 09/11/24 PM, 09/14/24 PM, 09/15/24 PM, 09/18/24 PM, 09/20/24 PM, and 09/21/24 PM. The Temp Log instructions directed staff recorded temperatures for each cooler in the department; record time, temperature, and initials twice per day (AM and PM); and notify the supervisor immediately if the cooler temperature was not within the acceptable range of 41 degrees Fahrenheit to 33 degrees Fahrenheit. Review of the Temp Log- Milk and Juice Cooler from 09/01/24 to 09/22/24 revealed missing temperature monitoring documentation on 09/01/24 PM, 09/06/24 AM and PM, 09/08/24 PM, 09/09/24 PM, 09/11/24 PM, 09/14/24 PM, 09/15/24 PM, 09/18/24 PM, 09/20/24 PM, and 09/21/24 PM. The Temp Log instructions directed staff recorded temperatures for each cooler in the department; record time, temperature, and initials twice per day (AM and PM); and notify the supervisor immediately if the cooler temperature was not within the acceptable range of 41 degrees Fahrenheit to 33 degrees Fahrenheit. Review of the Temp Log- Kitchen Big Freezer from 09/01/24 to 09/22/24 revealed missing temperature monitoring documentation on 09/01/24 PM, 09/06/24 AM and PM, 09/08/24 PM, 09/09/24 PM, 09/11/24 PM, 09/14/24 PM, 09/15/24 PM, 09/18/24 PM, 09/20/24 PM, and 09/21/24 PM. The Temp Log instructions directed staff recorded temperatures for each cooler in the department; record time, temperature, and initials twice per day (AM and PM); and notify the supervisor immediately if the freezer temperature was not within the acceptable range of two degrees Fahrenheit or below. Review of the Temp Log- Kitchen Small Freezer from 09/01/24 to 09/22/24 revealed missing temperature monitoring documentation on 09/01/24 PM, 09/06/24 AM and PM, 09/08/24 PM, 09/09/24 PM, 09/11/24 PM, 09/14/24 PM, 09/15/24 PM, 09/18/24 PM, 09/20/24 PM, and 09/21/24 PM. The Temp Log instructions directed staff recorded temperatures for each cooler in the department; record time, temperature, and initials twice per day (AM and PM); and notify the supervisor immediately if the freezer temperature was not within the acceptable range of two degrees Fahrenheit or below. A review of the Dish Machine Log- Low Temp from 09/01/24 to 09/22/24 revealed missing temperature and sanitizer level monitoring documentation for 16 out of 66 possible scheduled times. The Dish Machine Log instructions directed staff to record wash temperature, sanitizer parts per million (ppm), and initials three times per day; and notify the supervisor immediately if sanitizer ppm was not within the acceptable range of 50 to 100 ppm. A review of the Pots and Pans Sanitization Log from 09/01/24 to 09/22/24 revealed missing sanitizer level monitoring documentation for 12 out of 66 possible scheduled times. The Pots and Pans Sanitization Log did not include instructions. On 09/24/24 at 11:12 AM, Dietary CC stated she checked refrigerator and freezer temperatures every morning. She stated the cook's responsibility included checking the refrigerator and freezer temperatures in both morning and evening and the dietary aide checked the dishwasher temperature and sanitizer levels. Dietary CC stated the refrigerator temperature had to stay below 41 degrees Fahrenheit and if the temperature reached above 41 degrees Fahrenheit, she let Dietary BB know about it. On 09/24/24 at 11:13 AM, Dietary BB stated the cook's responsibility included checking refrigerator and freezer temperatures and the dietary aide monitored the dishwasher temperature and sanitizer levels. She stated she reviewed the monitoring logs every morning and if they were not completed, she called the staff to do them. Dietary BB stated if staff discovered refrigerator or freezer temperatures out of range, they notified her and she notified maintenance. On 09/25/24 at 01:28 PM, Certified Medication Aide (CMA) R stated staff performed hand hygiene after each tray during meal pass. On 09/25/24 at 01:31 PM, Licensed Nurse (LN) G stated staff performed hand hygiene between trays during meal service. On 09/25/24 at 01:47 PM, Administrative Nurse D stated if staff passed trays without touching anything in the resident's room, they performed hand hygiene every three to four residents. She stated if staff passed trays in the dining room, they performed hand hygiene in between residents because they usually touched the residents to set them up for the meal. The facility's Food Storage policy, dated 2020, directed the facility to set refrigerators to the proper temperature and the setting must ensure the internal temperature of food was 41 degrees Fahrenheit or lower and staff conducted random temperature checks of food items. The facility's Dishwashing: Machine Operation policy, dated 2020, directed twice daily, staff recorded either the final rinse temperature for high-temperature dishwashing machines or sanitizer concentration for low-temperature dishwashing machines with chemical sanitizer. The facility's Hand Hygiene policy, dated 2024, directed all staff to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The facility failed to ensure the big cooler maintained an appropriate temperature range, failed to ensure staff consistently monitored cooler and freezer temperatures, and failed to ensure staff consistently monitored the dishwasher temperatures and chemical sanitation levels. The facility further failed to ensure adequate hand hygiene during meal service. This deficient practice placed residents at risk for food-borne illnesses.

The facility identified a census of 39 residents. The sample included 12 residents with three residents reviewed for hospitalization . Based on observation, record review, and interviews, the facility failed to provide a bed hold policy notice to Resident (R) 4 and R20 or their representatives when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R4 and R20. Findings included: - R4 admitted to the facility on [DATE], discharged to the hospital on 03/31/24, readmitted to the facility on [DATE], discharged to the hospital on 05/20/24, and readmitted to the facility on [DATE]. R4's Electronic Medical Record (EMR) documented diagnoses of nausea, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and cough. The Annual Minimum Data Set (MDS) dated [DATE], documented that R4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Quarterly MDS dated [DATE], documented R4 had a BIMS score of 15 which indicated intact cognition. The Functional Abilities Care Area Assessment (CAA) dated 01/25/24, documented that staff assisted R4 with activities of daily living (ADL) care as needed and anticipated her care. R4's Care Plan dated 07/15/22, documented R4 had an ADL self-care performance deficit and required assistance with her care needs. Staff encouraged R4 to participate to the fullest extent possible with each interaction. R4's EMR revealed a General Note on 05/20/24 at 05:17 PM that R4 had nausea and vomiting after lunch and experienced pain in her abdomen. The facility sent R4 to the emergency room (ER) and notified R4's representative. Upon request, the facility did not provide documentation that R4 or her representative received a written notice of the bed hold policy for R4's transfer to the hospital on 03/31/24 and 05/20/24. On 09/23/24 at 02:16 PM, R4 lay in bed and watched television. On 09/25/24 at 01:26 PM, Social Services X stated when a resident transferred to the hospital, she sent a written notification of transfer to their representative. She stated the nurse filled out a bed hold in the EMR but did not send the notice out to the representative. On 09/25/24 at 01:31 PM, Licensed Nurse (LN) G stated when a resident transferred to the hospital, the nurse completed a transfer form in the EMR and then notified the family and doctor. He stated the nurse filled out a bed hold assessment that documented if the resident was their own person but he did not give out the bed hold to the resident or their representative. On 09/25/24 at 01:47 PM, Administrative Nurse D stated when a resident transferred to the hospital, the nurse notified the on-call nurse and the resident's representative. She stated the nurse completed a bed hold assessment in the EMR, but she was unsure if the staff sent out the bed hold policy to the representative. The facility's Bed Hold Notice Upon Transfer policy, dated 2023, directed at the time of transfer for hospitalization or therapeutic leave, the facility provided the resident and/or their representative a written notice which specified the duration of the bed-hold policy and addressed information explaining the return of the resident to the next available bed. The facility failed to provide a bed hold policy notice to R4 or their representatives when she transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R4. 41713 - R20's Electronic Medical Record (EMR) documented diagnoses of chronic respiratory failure a long-term condition where there is not enough oxygen), hypertension (HTN-elevated blood pressure), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and a pressure ulcer (localized injury to the skin and underlying tissue usually over a bony) of sacral (large triangular bone/area between the two hip bones) area. R20's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R20 had impairment of both lower extremities. R20 was dependent on staff for all functional abilities. R20 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag). R20 had an unhealed Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R20 had impairment of both lower extremities. R20 was dependent on staff for all functional abilities. R20 had an indwelling catheter. R20 had an unhealed stage 4 pressure ulcer. R20 04/25/24's Discharge MDS dated [DATE] documented he had an unplanned discharge to a short-term acute hospital with a return anticipated. R20's Pressure Ulcer Care Area Assessment (CAA) dated 10/18/23 documented that staff was to assist with repositioning per the protocol and as needed to help maintain skin integrity. The licensed nursing staff was to monitor skin integrity every week to help monitor for any skin issues. Incontinence creams were to be used as needed to help maintain skin integrity. A pressure redistributing surface was in place on the resident's bed and on his wheelchair to help maintain skin integrity. R20's Care Plan last revised on 07/22/24 directed staff to monitor and document any signs or symptoms of infection in any open area. The facility was unable to provide evidence the bed hold policy was provided to R20 on 12/10/23, 02/23/24, 03/07/24, 04/05/24, 04/25/24, 05/18/24, 06/26/24, and 07/31/24. On 09/25/24 at 01:26 PM, Social Services X stated when a resident transferred to the hospital, she sent a written notification of transfer to their representative. Social Services X stated the nurse filled out a bed hold in the EMR but did not send the notice out to the representative. On 09/25/24 at 01:31 PM, Licensed Nurse (LN) G stated when a resident was transferred to the hospital, the nurse completed a transfer form in the EMR, then they would notify the family and doctor. He stated the nurse filled out a bed hold assessment that documented if the resident was their own person, but he did not give out the bed hold to the resident or their representative. On 09/25/24 at 01:47 PM, Administrative Nurse D stated when a resident transferred to the hospital, the nurse notified the on-call nurse and the resident's representative. She stated the nurse completed a bed hold assessment in the EMR, but she was unsure if the staff sent out the bed hold policy to the representative. The facility's Bed Hold Notice Upon Transfer policy, not dated, directed at the time of transfer for hospitalization or therapeutic leave, the facility provided the resident and/or their representative a written notice that specified the duration of the bed-hold policy and addressed information explaining the return of the resident to the next available bed. The facility failed to provide a bed hold notice to R20 or their representative when R20 transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility or the same room for R20.

The facility reported a census of 41 resident. Based on observations, record review, and interviews, the facility failed to ensure safe/secure storage for one of the two medication carts in the facility. This deficient practice placed the residents at risk for accidental medication ingestion or diversion. Findings Included: - On 04/25/2023 at 08:53AM the medication storage (treatment) cart was left unsecured in the 100's hallway. An inspection of the cart revealed Resident (R)12's Novolog (short-acting hormone which regulates blood sugar) Kwik pen injector medication and Lantus (long-acting hormone which regulates blood sugar) kwikpen injector medication, R24's prochlorperazine medication (used to treat migraines and nausea), R22's cyanocobalamin (vitamin b12 supplements) medication, and R6's Tylenol medication. The cart was secured by Licensed Nurse (LN) G at 09:00AM. LN G reported the nurses should ensure the carts are locked when not in use or unattended. On 04/26/23 at 03:35PM Administrative Nurse D stated staff should be locking the cart any time they are not using them. She reported that the nurse thought she secured the cart before leaving it but the lock was not fully pushed in to secure it. A review of the facility's Medication Storage policy revised 01/2020 that all medications will stored in a manner that is sanitary, temperature/moisture controlled, and secured. The facility failed to ensure safe/secure storage for one of the two medication carts in the facility. This deficient practice placed the residents at risk for accidental medication ingestion or diversion.

The facility identified a census of 41 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide activities for the residents during weekends. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing. Findings Included: - A review of the Activity Calendar for April 2023 indicated Saturday activities listed were Resident Choice and Movies with a resident shopping trip on the 04/15/23. A review of Sunday activities revealed only Church and Leisure for the month. A review of January 2023, February 2023, and March 2023 calendars revealed the same activities pattern with little facility led groups. On 04/24/23 at 10:33AM, Resident Council members reported the facility used to have a volunteer come in on weekends to provide games and activities, but the volunteer stopped coming. The council reported the Activities Coordinator tried to come in some weekends but many weekends, the residents do not have activities other than television. On 04/26/23 at 02:45PM Activities Coordinator (AC) Z reported that she came in some weekend to provide some activities. She stated the volunteer the facility had to provide weekend activities stopped coming. She stated snacks and games were left out for the residents on the weekends. A review of the facility's Activities policy revised 08/2019 indicated that facility will provide ongoing programs to support resident's choice of activities and preferences. The policy indicated the provided activities will promote emotional health, social wellbeing, pleasure, comfort, and interest. The facility failed provide consistent activities for the residents during weekends. This deficient practice placed the residents at risk for decreased psychosocial wellbeing.

The facility identified a census of 41 residents. The sample included 13 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to store Resident (R)12 and R26's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed both residents at risk for complications related to respiratory care and infections. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of urinary incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), muscle spasms, history of hip fracture (broken bone), major depressive disorder (major mood disorder), morbid obesity (severely overweight), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A review of R12's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required supervision with all her activities of daily living (ADLs). The MDS indicated she received oxygen treatments. A review of R12's Activities of Daily Living Care Area Assessment (CAA) completed 04/12/22 indicated she required assistance from staff as needed but staff should encourage resident participation in ADLs to promote independence. A review of R12's Care Plan initiated 11/26/23 indicated she received oxygen therapy related to her medical diagnoses. The plan instructed staff to provided supplemental oxygen (two liters) via nasal cannula at night. The plan instructed staff to clean the filter and change the tubing weekly. The plan lacked documentation indicating how the oxygen equipment would be stored when not in use. On 04/24/23 at 08:52AM R12's oxygen tubing was on the floor with her nasal cannula hanging off the trash can next to her bed. At 10:12AM her tubing and cannula were both on the floor next to her bed. On 04/24/23 at 03:05PM Certified Nurse's Aide (CNA) M stated oxygen therapy equipment should be changed out every Sunday and stored in a plastic bag when not in use. She stated that if the tubing or cannula becomes contaminated the nurse will change it out. On 04/24/23 at 03:20PM Licensed Nurse (LN) G stated all staff should be checking the oxygen equipment each time cares are provided in the rooms. He stated that tubing and oxygen equipment should be stored in plastic barrier bag when not in use. On 4/24/23 at 03:35PM Administrative Nurse D stated staff are expected to store all oxygen tubing and equipment when not in use. She stated that R12 does take her oxygen cannula off, but staff should be ensuring its stored in a sanitary manner. A review of the facility's Oxygen Administration policy revised 11/2017 indicated oxygen equipment and tubing would be handled in a sanitary manner. The policy indicated all delivery devices (tubing, nasal cannulas, masked) be stored in plastic bags when not in use. The facility failed to ensure R12's supplemental oxygen equipment and nasal cannula was stored in a sanitary manner when not in use. This deficient practice placed both residents at risk for complications related to respiratory care and infections.

The facility identified a census of 41 residents. The sample included 13 residents with five reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to monitor weekly weights and ensure supplements for Resident (R) 96 who had a history of weight loss and failed to monitor the effectiveness of interventions for R35, who continued to lose weight. This deficient practice placed the residents at risk for continued unintended weight loss and malnutrition. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96 required extensive assistance of two staff members for activities of daily living (ADLs). The MDS documented no weight loss for R96 during the look back period. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99 and a staff documented R96 had moderately impaired cognition. The MDS documented that R96 required limited assistance of one staff member for ADLs. The MDS documented R96 was on a physician-prescribed weight-loss regimen. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. R96's Nutritional Status Care Area Assessment (CAA) dated 03/03/23 documented R96 was to maintain current level of functioning and have no significant weight loss or weight gain through next review. R96's Care Plan dated 04/11/23 documented diet order for a regular/general diet with regular consistency and texture. The Care Plan documented staff was to encourage R96 to eat meals in the dining area. The Care Plan documented R96 ate meals in his room. The Care Plan documented R96 understood the importance of maintaining his diet as ordered. R96 understood the consequences of refusal, obesity/malnutrition risk factors. By compliance, R96 could reach his goals. The Care Plan documented health shake two times a day. The Care Plan lacked direction for a physician-prescribed weight-loss regimen. Review of the EMR under Orders tab revealed physician orders: Weigh daily for three days, then weekly for four weeks, and then monthly in the morning every Friday for routine monitoring dated 04/11/23. Review of the EMR under Vitals tab documented a weight on 02/20/23 of 121 pounds (lbs.) and a weight on 03/02/23 of 114 lbs., which revealed a seven-pound loss in nine days. Review of R96's Medication Administration Record (MAR) for April 2023 revealed a health shake two times a day for weight loss was discontinued on 04/03/23. Offer a HS snack was discontinued on 04/03/23. Review of R96's Treatment Administration Record (TAR) for April 2023 revealed documentation of a weight of 114 lbs. on 04/12/23, 04/13/23, and 04/14/23. The TAR documented R96 refused weekly weight on 04/21/23. The clinical record lacked documentation of physician notification of R96's refusal of compliance for weight monitoring. The clinical record lacked any documentation, order or direction of a physician ordered weight loss regimen. On 04/25/23 at 12:18 PM R96 sat on the edge of the bed, lunch tray on bedside table. The tray lacked fluids. R96 ate lunch unassisted. On 04/26/23 at 02:45 PM Certified Nurses Aide (CNA) M stated the CNAs obtain the weights and report the results to the nurse. CNA M stated if a resident refused, she would attempt a few more times and if continued to refuse, she would report the refusal to the nurse. CNA M stated snacks are documented by the evening shift, if a resident had received a snack during the dayshift, it was not documented any where because there was no place to document. CNA M stated she would offer R96 a snack at times to redirect him. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated the Registered Dietician (RD) comes to the facility monthly to review weights and make recommendations for weight loss. LN G stated the RD reviewed all new admission and possibly the readmission for dietary needs to prevent weight loss. LN G stated staff review resident's weights weekly and review interventions related to weight loss. LN G stated the kitchen passed the health shakes out to the resident's mealtime and the amount consumed was documented in the meal's intake. LN G stated the CNA's documented the snack intake. LN G stated R96 refused to be weighed frequently. LN G stated the physician should be notified of R96's refusals. On 04/26/23 at 03:40 PM Administrative Nurse D stated R96 should have been reviewed upon return from the hospital visit related to prior weight loss. Administrative Nurse D stated the interventions for health shakes was not carried over from previous orders when R96 returned from the hospital. Administrative Nurse D stated she had no RD recommendations for R96. The facility's Weight Monitoring undated policy documented monitoring the interventions and revising as necessary. The care plan should identify the resident's personal goals and preferences. Reflect the resident-specific interventions. Resident with weight loss would be monitored weekly. The physician should be informed of a significant change in weight. The physician should be encouraged to document the diagnosis or clinical condition that may have contributed to the weight loss. The facility failed to monitor weekly weights and ensure supplements for R96 who had a history of significant weight loss. This deficient practice placed R96 at risk of continued unintended weight loss and malnutrition. 47834 - R35 admitted to the facility on [DATE]. The Diagnoses tab of R35's Electronic Medical Record (EMR) documented a diagnosis of vascular dementia (progressive mental disorder characterized by failing memory, confusion) and abnormal weight loss. The Admission Minimum Data Set (MDS), dated [DATE], documented R35 had a Brief Interview for Mental Status (BIMS) score of six which indicated severe cognitive impairment. The MDS documented that R35 required limited assistance of one staff member during transfers, walking and toileting. R35 had no significant weight loss or weight gain. The Quarterly MDS, dated [DATE], documented R35 had a BIMS score of 99 and staff indicated that R35 was unable to complete the interview. Staff assessment indicated R35 had moderate cognitive impairment, had poor decision making and required cues/supervision. R35 required limited assistance of one staff member during walking and transfers, and extensive assistance of one staff member for toileting. R35 had no significant weight loss or weight gain. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/27/22, documented that R35's cognition will be addressed in resident's care plan and staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. The Activities of Daily Living (ADL) Functional/ Rehabilitation Potential CAA, dated 09/27/22, documented that R35's functional mobility will be addressed in resident's care plan and that staff were to assist with ADL cares as needed, anticipating cares, so that care needs are effectively met. The Nutritional CAA dated 09/27/22, documented that R35 had potential for altered nutrition and that she was to maintain current level of functioning and have no significant weight loss or gain through next review. The ADL Assistance Care Plan, dated 09/23/22, documented R35 needed ADL assistance for weakness from recent hospitalization . The Care Plan documented R35 required setup assistance with eating. The Care Plan, dated 09/23/22 and revised on 10/26/22, documented R35 had a potential for diet/nutrition changes due to new environment and recent admission to the center. R35 was at risk for weight loss due to recent acute hospital stay. The Care Plan revealed an intervention, initiated 01/13/23, that documented R35 received a health shake two times a day for weight loss. The Weights/Vitals tab of R35's EMR documented a weight on 10/13/22 of 134.0 pounds (lbs), a weight on 11/01/22 of 133.0 lbs, a weight on 12/01/22 of 128.0 lbs, a weight on 01/02/23 for 126.0 lbs, a weight on 02/01/23 of 127.0 lbs, a weight on 03/01/23 of 127.0 lbs, and a weight on 04/07/23 of 124.0 lbs. The Assessments tab of R35's EMR revealed a Nutritional Assessment on 12/28/22 that documented R35 lost two pounds in one month and eight pounds in three months. The registered dietitian recommended health shakes twice a day. The Orders tab of R35's EMR documented an order with a start date of 01/11/23 for health shake two times a day for weight loss. Review of R35's clinical record lacked evidence the facility monitored R35's intake of the twice daily health shakes. On 04/25/23 at 07:54 AM, R35 sat on her bed and ate breakfast. On 04/26/23 at 02:44 PM, Certified Nurse Aide (CNA) M stated the CNAs were responsible for documenting what percentage of meals residents consumed and the health shakes were included into the drink intake during meals, not documented separately. On 04/26/23 at 03:03 PM, Licensed Nurse (LN) G stated the dietitian came to the facility on ce a month and made recommendations to Administrative Nurse D or Administrative Nurse F then they were reported to the physician. LN G stated snacks were documented by CNAs and some supplements were charted by kitchen staff and were mixed with meal percentages. The facility's Weight Monitoring policy, not dated, documented the facility monitored the interventions and revised as necessary. The care plan identified the resident's personal goals and preferences and reflected the resident-specific interventions. The facility failed to monitor health shake intakes to evaluate effectiveness of weight loss prevention interventions for R35. This deficient practice had the risk for increased weight loss for R35.

The facility identified a census of 41 residents. The sample included 13 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized toileting interventions related to bowel and bladder incontinence for Residents (R)12, and R35. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of urinary incontinence (involuntary passage of urine occurring soon after a strong sense of urgency to void), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), muscle spasms, history of hip fracture (broken bone), major depressive disorder (major mood disorder), morbid obesity (severely overweight), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A review of R12's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required supervision with all her activities of daily living (ADLs). The MDS indicated she was not on a toileting program for bowel or bladder incontinence but had frequent urinary incontinence. A review of R12's Activities of Daily Living Care Area Assessment (CAA) completed 04/12/22 indicated she required assistance from staff as needed but staff should encourage resident participation in ADLs to promote independence. The MDS indicated she was taking diuretic medication (medication to promote the formation and excretion of urine). R12's Urinary Incontinence CAA completed 04/12/22 instructed staff to provide incontinence cares and assistance as needed to help minimize the risks associated with incontinence. A review of R12's Care Plan created 04/04/22 indicated she was independent with transfers, bed mobility, toileting, and locomotion with her wheelchair. The plan instructed staff to provide good peri-care after incontinent episodes and provide barrier cream to protect her skin. The plan lacked intervention related to frequency of toileting, prompted assistance, and interventions related to her recent decline in bowel continence. A review of R12's Bowel and Bladder Assessment completed 01/10/23 noted she was continent of bowel and frequently incontinent of bladder. The assessment noted she was a good candidate for an individualized/self-toileting. The assessment indicated she had the ability to communicate and had no surgical or medically conditions related to the onset of incontinence. The assessment noted she was on a diuretic and could not always make it to the restroom. A review of R12's Bowel and Bladder Assessment complete 04/04/23 noted she was a good candidate for an individualized/self-toileting. The assessment indicated she had a decline in bowel incontinence and required assisted to from staff while toileting. The assessment indicated she had no medical conditions associated with her urinary incontinence. The assessment indicated she was occasionally incontinent of urine but taking diuretics. R12's clinical record lacked evidence of an indivdualized plan which addressed R12's bladder incontinence and increased bowel incontinence. On 04/24/23 at 10:03AM R12 reported she has had an increase in bowel and bladder incontinence due to needing more assistance from staff for toileting. She stated she was able to toilet herself but broke her hip during a fall while toileting. She stated that she believed increased toileting opportunities from staff would help eliminate some of her incontinence. She was not sure if she was ever on a toileting program. On 04/26/23 at 02:50PM Certified Nurses Aid (CNA) M stated that she was not aware of any of the residents having individualized toileting plan. She stated staff do complete check and changes on residents and attempting two-hour toileting. She stated that R12 was independent but would receive assistance if needed. She stated that all staff have access to the care plans to review each resident's assistance requirements. On 04/26/23 at 03:05PM Licensed Nurse (LN) G stated all residents are on a two-hour toileting but if someone is able to retrain for toileting they should be put on an individualized plan. He was not sure if R12 was on a plan. On 04/26/23 at 03:35PM Administrative Nurse D stated that all residents are assessed upon admission for bowel and bladder. She stated the interdisciplinary team reviews each resident's care needs and will implement interventions specific to their needs. She stated no residents were currently on an individualized plan, but staff should be checking in on each resident and offer assistance with cares. The facility did not provide a policy related to Bowel and Bladder Management as requested on 04/26/2023. The facility failed to implement individualized toileting interventions to assist R12 with bowel and bladder incontinence. This deficient practice placed the residents at risk for complications related to incontinence. 47834 - R35 admitted to the facility on [DATE]. The Diagnoses tab of R35's Electronic Medical Record (EMR) documented a diagnosis of vascular dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented R35 had a Brief Interview for Mental Status (BIMS) score of six which indicated severe cognitive impairment. The MDS documented that R35 required limited assistance of one staff member during transfers, walking and toileting. R35 was frequently incontinent of urine, always continent of bowel movements, and that a toileting program had not been attempted. The Quarterly MDS, dated [DATE], documented R35 had a BIMS score of 99 and staff indicated that R35 was unable to complete the interview. Staff assessment indicated R35 had moderate cognitive impairment, had poor decision making and required cues/supervision. R35 required limited assistance of one staff member during walking and transfers, and extensive assistance of one staff member for toileting. R35 was frequently incontinent of urine and bowel movements, and a toileting program had not been attempted. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 09/27/22, documented that R35's cognition will be addressed in resident's care plan and staff were to monitor for signs and symptoms of acute mental status changes to help treat the underlying condition. The Activities of Daily Living (ADL) Functional/ Rehabilitation Potential CAA, dated 09/27/22, documented that R35's functional mobility will be addressed in resident's care plan and that staff were to assist with ADL cares as needed, anticipating cares, so that care needs are effectively met. The Falls CAA, dated 09/27/22, documented that R35's falls will be addressed in resident's care plan and that staff to anticipate and meet resident's care needs so that resident does not attempt to unsafely perform ADL cares without staff assistance. The Urinary Incontinence CAA dated 09/27/22, documented that R35's urinary incontinence will be addressed in resident's care plan and that staff to provide incontinence cares as needed to help minimize risks of incontinence. The ADL Assistance Care Plan, dated 09/23/22, documented R35 needed ADL assistance for weakness from recent hospitalization . The Care Plan documented R35 required assistance with one staff for toileting. The Bowel and Bladder Care Plan, dated 09/23/22, documented R35 was frequently incontinent and was at risk for incontinence due to impaired mobility. The Care Plan documented the following interventions: staff check and changed R35 to maintain dignity, initiated 09/23/22; R35 took any medication ordered related to incontinence and constipation, initiated 09/23/22; staff provided good peri-care (involves washing the genital and rectal areas of the body or peri-area) after incontinent episodes and used barrier cream as needed to keep R35's skin healthy, initiated 09/23/22; and staff assisted R35 with toileting when she was awake in the morning, before each meal, at bedtime, and as needed, initiated 02/07/23. The Falls Care Plan, dated 11/12/22, documented R35 had a fall related to impaired mobility, gait/balance problems, and impaired thought processes. The Care Plan revealed an intervention, dated 11/14/22, that documented R35 had a fall on 11/13/22 and was found on the floor in her room and stated she was coming back from the bathroom and staff were to round on R35 frequently. The Care Plan revealed an intervention, dated 11/29/22, that documented R35 had a fall on 11/29/22 and was noted to be on the floor in her restroom. The Care Plan revealed an intervention, dated 02/23/22, that documented R35 had a fall on 02/22/23 and was noted to be in on the floor in her room, sitting in bowel movement and staff had to coax R35 to let them clean her up. The Care Plan revealed an intervention, dated 03/13/23, that documented R35 had a fall on 03/13/23 and staff frequently asked her if she wanted assistance with bathroom mobility. The Assessments tab of R35's EMR revealed a Bowel and Bladder Assessment on 09/28/22 that documented R35 had a score of 15 which indicated she was a good candidate for individualized toileting/self-toileting. The Assessment documented R35 had the ability to participate in a bowel and bladder training program and a toileting program was appropriate for R35. R35 needed assistance from one side and was always mentally aware of toileting needs. R35's medical record lacked evidence of further bowel and bladder assessments after the initial assessment on 09/28/22 and lacked evidence the facility implemented a bowel and bladder training program or a toileting program. On 04/25/23 at 07:54 AM, R35 sat on her bed and ate breakfast. On 04/26/23 at 02:44 PM, Certified Nurse Aide (CNA) M stated there were no bowel and bladder programs at that time and staff knew if a resident was incontinent by checking them every two hours. On 04/26/23 at 03:03 PM, Licensed Nurse (LN) G stated R35 was pretty independent and went to the bathroom alone. He stated the CNAs go in R35's room if they hear her up and check to see if she needed to use the restroom. LN G stated he was not sure if it was care planned. He stated if the resident was able to bladder train, they were checked every two hours to try and retrain. LN G stated all incontinent residents were checked every two hours. On 04/26/23 at 03:44 PM, Administrative Nurse D stated R35 was independent with using the bathroom and sometimes refused to let staff check on her. She stated R35 was not on a toileting program. Administrative Nurse D stated a bowel and bladder assessment triggered in EMR system and once it was done, Administrative Nurse F reviewed it and met with Administrative Staff B to implement a bowel and bladder program if needed but she was unaware of any resident on a bowel and bladder program at that time. The facility did not provide a policy related to Bowel and Bladder Management as requested on 04/26/2023. The facility failed to identify increased incontinence for R35 or implement an individualized toileting program per the last assessment. This deficient practice placed R35 at risk for complications related to incontinence.

The facility identified a census of 41 residents. The sample included 13 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to notify the medical provider of Resident (R)11's repeated refusals for his lab draws related to his valproic acid levels (also known as Depakote- medication used to treat seizure disorders). This deficient practice placed R11 at risk for unnecessary medicals and adverse medication effects (unintended harmful reaction to a drug administered at normal dosage). Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), seizures (violent involuntary series of contractions of a group of muscles), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A review of R11's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated R11 required total assistance from two staff for all activities of daily living (ADLs). A review of R11's Cognitive Loss Care Area Assessment (CAA) completed 07/14/22 instructed staff to monitor him for acute mental status changes related to his medical condition. R11's Psychotropic Medication CAA completed 07/14/22 indicated staff should monitor him for adverse side effects (unintended effect of a medication, diagnostic test or therapeutic intervention) related to his medications and complications. A review of R11's Care Plan initiated 07/01/22 indicated he took Depakote medication related to his history of seizures. A review of R11's Physician Orders revealed an order started 07/16/22 for staff to administer 250 milligrams (mg) of Depakote (delayed release) every morning related to his seizures. On 07/27/22 a second Depakote order was added for R11 to receive an additional 500mg of Depakote (delayed released) totaling 750mg every morning. On 08/12/22 a lab order was added to obtain his valproic acid levels. A review of R11's Consulting Pharmacist Review dated 08/05/22 recommended an annual or bi-annual valproic acid level test be completed based on R11's medication review. The medical provider /agreed with the need for the lab test. A review of the contracted laboratory communication form for R11 on 08/16/22 revealed his valproic acid level test was not performed and the order was cancelled by the lab services. A review of R11's Consulting Pharmacist Review dated 01/12/23 recommended monitoring guidelines for Depakote include annual valproic acid levels be reviewed. The facility acknowledged the recommendation and ordered. A review of the contracted laboratory communication form for R11 on 02/10/23 revealed R11 refused to his blood drawn for his ordered labs. The communication indicated labs services would attempt to perform the blood draw on two further attempts and then discontinue the order per resident's request. The communication instructed the facility staff to notify R11's medical provider of his refusal and to reschedule his blood draw. A review of R11's EMR revealed no notification to R11's medical providers related to his lab refusals or ordered valproic acid levels. A review of R11's EMR revealed no valproic acid levels available for review. The facility was unable to provide R11's valproic acid levels as requested on 04/27/23. A review of R11's Lab Results in his EMR revealed he had successful lab results drawn on 12/29/22 and 01/27/23 but neither included his valproic acid levels. On 04/24/22 at 08:20AM R11 sat in the television day room area. R11's feet were off his foot pedals and resting on the floor. R11's arms and upper body had visible shakes and rigid movements as he attempted to use his body to move his wheelchair back towards his room. At 08:25AM an unidentified staff member asked R11 if he wanted to go back to his room. The staff member pushed R11 forward without checking his feet placement. R11's wheelchair abruptly stopped as his feet went under the wheelchairs leg rest. On 04/27/23 at 03:05PM Licensed Nurse (LN) G stated that R11 can be difficult to get labs on, but staff should reschedule his draw the next if he refused. He stated the contracted lab company does not always notify staff of missing or needed labs and the nurses should be checking the orders and results. He stated that medical provider should be notified of the refusal. On 04/27/23 at 03:35PM Administrative Nurse D stated that lab orders were printed out by medical records and given to the nurses to assist with the lab draws. She stated if a resident refused labs a fax or notification would be sent to the medical provider. She stated that labs would be rescheduled for the resident. She stated that R11 had refused several times to complete the lab draws and a notification was sent to his medical provider. A review of the facility's Notification of Change policy revised 11/2017 indicated that facility would promptly notify the medical provider of any changes in the resident's care including clinical complications, decision making/choices for cognitively impaired residents, or changes of care. The facility failed to notify the medical provider of R11's repeated refusals for his lab draws related to his valproic acid levels. This deficient practice placed R11 at risk for unnecessary medications and adverse medication effects.

The facility had a census of 39 residents. The sample included 13 residents with five residents reviewed for accidents. Based on observation, record review and interview the facility failed to secure rooms containing hazardous materials out of reach of the residents and ensure the proper usage of wheelchair foot pedals during transport for Residents (R)10 and R11. The facility additionally failed to implement individualized toileting interventions in response to repeated falls for R35. This deficient practice placed the residents at risk for preventable injuries and accidents. Findings Included: - On 04/24/23 at 07:40AM an inspection of the facility's Supplemental Oxygen storage room revealed the door securing the room was unlocked and accessible to the residents. The room contained 48 oxygen cannister stored in racks and three small cylinder cannister left unsecured on a shelf above the larger tank rack. At 07:45AM Licensed Nurse (LN) G secured the room and reported it should always be locked. On 04/24/23 at 07:47AM an inspection of the facility 100's hallway Shower Room revealed the entry door unlocked and accessible to the residents. An inspection of the shower room revealed, and unsecured cabinet contained a bottle of drain cleaner and foul odor enzymatic spray bottle. A Virex-Plus disinfectant spray bottle sat on a shelf in the room. All the cleaning agents contained the Caution- Keep Out of Reach for Children label indicating a poison ingestion risk. A red Sharp (bin to place used needles and lancets) container box sat on the floor with used disposable shaving razors inside. On 04/24/23 at 07:52AM an inspection of the facility's Beauty Salon revealed the entry door unlocked and accessible to the residents. An inspection of the room revealed a bottle of Virex-Plus left out on top of a cabinet and a disposable razor left by the sink. An inspection of the room's hair washing sink revealed the water temperature reached 118 degrees Fahrenheit. On 04/24/23 at 08:12AM an inspection of the facility's 200's hallway Shower Room revealed the entry door unlocked and accessible to the residents. An inspection of the room revealed an unmounted Sharps box filled with used disposable containers left on the bathtub area. On 04/26/23 at 10:23AM the beauty salon and both shower rooms were again found unlocked and accessible to the residents. On 04/26/23 at 03:05PM Certified Nurses Aid (CNA) M stated resident should never have access to chemicals or the rooms that store them. On 04/26/23 at 03:30PM Administrative Nurse D stated that all the room with potential hazards should be locked and keep out of reach from residents. She stated staff should have ensured the chemicals were left secured after use. A review of the facility's Accidents and Supervision policy revised 11/2017 indicated that facility will identify, implement, and monitor environmental hazards to prevent accident. The policy indicated staff will continue to monitor and report potential hazards that place the resident at risk for injury or illness. A review of the facility's Oxygen Therapy policy 01/2020 indicated oxygen shall be stored in a secured and safe manner. The facility failed to secure oxygen tanks and hazardous materials out of reach of the residents. This deficient practice placed the residents at risk for preventable injuries and accidents. - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), morbid obesity (severely overweight), neuropathy (pain associated with nerve damage), muscle weakness, cerebrovascular accident (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), cognitive communication deficit, and schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). A review of R10's Quarterly Minimum Data Set (MDS) completed 03/04/23 noted he had a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated he required extensive assistance from two staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated he required extensive assistance from one staff for locomotion in his wheelchair. A review of R10's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 08/07/22 indicated still will assist him with ADLs as needed and encourage resident participation to promote independence. R10 was not triggered for Falls CAA. A review of R10's Care Plan initiated 04/04/22 indicated he required assistance from one staff for bed mobility, transfers, toileting, personal hygiene, dressing, and locomotion. The plan noted he used a wheelchair for mobility. The plan instructed staff to ensure he had well fitting socks and or shoes for ambulation. The plan indicated he had a history falls. On 04/25/23 at 12:33PM staff transported R10 from the dining room through television area and to his room. R10 had no foot pedals on his wheelchair. R10's feet slid on the floor as she pushed him towards the 200 hallways. R10 was asked by staff to pick up his feet while staff continued to push him to his room with both feet dragging on the floor. On 04/26/23 at 02:50PM Certified Nurses Aid (CNA) M stated staff should never allow a resident's feet to drag and should ensure the foot pedals were properly being used. She stated that some residents push themselves around in their wheelchairs, but staff should be using the foot pedals when pushing them. On 04/26/23 at 02:50PM Certified Nurses Aid (CNA) M stated staff should never allow a resident's feet to drag and should ensure the foot pedals were properly being used. She stated that some residents push themselves around in their wheelchairs, but staff should be using the foot pedals when pushing them. On 04/26/23 at 03:40PM Administrative Nurse D stated staff are expected use the foot pedals when transporting residents to prevent falls and injury. A review of the facility's Fall Prevention Program revised 01/2017 indicated staff will ensure all residents are wearing appropriate footwear while ambulating or being transported. The policy indicated All assistive devices must be in good repair and used appropriately to ensure resident safety and prevent falls and injuries. The facility failed to utilize R10's wheelchair foot pedals resulting in his feet dragging during transport to his room. This deficient practice placed the residents at risk for preventable injuries and accidents. - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), dementia (progressive mental disorder characterized by failing memory, confusion), seizures (violent involuntary series of contractions of a group of muscles), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A review of R11's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated R11 required total assistance from two staff for all activities of daily living (ADLs). A review of R11's ADLs Care Area Assessment (CAA) completed 07/14/22 instructed staff to monitor him for acute mental status changes related to his medical condition. R11 was not triggered for Falls CAA. A review of R11's Care Plan initiated 07/01/22 indicated he was at risk for impaired skin integrity related to impaired mobility. The plan instructed for staff education related to the causes of skin break down during repositioning, ambulation, and transferring. The plan indicted he was dependent on staff for bed mobility, transfers, grooming, toileting, locomotion, and bathing. On 04/24/22 at 08:20AM R11 sat in the television day room area. R11's feet were off his foot pedals and resting on the floor. R11's arms and upper body had visible shakes and rigid movements as he attempted to use his body to move his wheelchair back towards his room. At 08:25AM an unidentified staff member asked R11 if he wanted to go back to his room. The staff member pushed R11 forward without checking his feet placement. R11's wheelchair abruptly stopped as his feet went under the wheelchairs leg rest. R11's feet were then placed on the foot pedals by staff and was taken to his room. On 04/26/23 at 02:50PM Certified Nurses Aid (CNA) M stated staff should never allow a resident's feet to drag and should ensure the foot pedals were properly being used. She stated that some residents push themselves around in their wheelchairs, but staff should be using the foot pedals when pushing them. She stated R11 likes to move his feet around during transport and staff should always check his positioning before moving him. On 04/26/23 at 03:40PM Administrative Nurse D stated staff are expected use the foot pedals when transporting residents to prevent falls and injury. A review of the facility's Fall Prevention Program revised 01/2017 indicated staff will ensure all residents are wearing appropriate footwear while ambulating or being transported. The policy indicated All assistive devices must be in good repair and used appropriately to ensure resident safety and prevent falls and injuries. The facility failed to ensure R11's was on his wheelchair's foot pedals before pushing him resulting his feet being ran over by the wheelchair. This deficient practice placed the residents at risk for preventable injuries and accidents. 47834 - The Diagnoses tab of R35's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and abnormal weight loss. The Admission Minimum Data Set (MDS), dated [DATE], documented R35 had a Brief Interview for Mental Status (BIMS) score of six which indicated severe cognitive impairment. The MDS documented that R35 required limited assistance of one staff member during transfers, walking and toileting. The MDS documented that R35 was frequently incontinent of urine, always continent of bowel and that a toileting program had not been attempted. The Quarterly MDS, dated [DATE], documented R35 had a BIMS score of 99 and staff indicated that R35 was unable to complete the interview. Staff assessment indicated R35 had moderate cognitive impairment, had poor decision making and required cues/supervision. The MDS documented that R35 required limited assistance of one staff member during walking and transfers, and extensive assistance of one staff member for toileting. The MDS documented that R35 was frequently incontinent of urine, and bowel and that a toileting program had not been attempted. The Urinary Incontinence CAA dated 09/27/22, documented that R35's urinary incontinence will be addressed in resident's care plan and that staff to provide incontinence cares as needed to help minimize risks of incontinence. The Falls CAA dated 09/27/22, documented that R35's falls will be addressed in resident's care plan and that staff to anticipate and meet resident's care needs so that resident does not attempt to unsafely perform ADL cares without staff assistance. Review of R35's Care Plan, dated 09/23/22, documented that R35 was at risk for incontinence due to impaired mobility and directed staff to check and change to maintain dignity. An update dated 02/07/23 directed staff to assist with toileting when R35 woke up in the mornings, before each meal, at bedtime and as needed. Review of R35's Care Plan, 11/12/22, documented that R35 had a fall/s related to impaired mobility, gait/balance problems and impaired thought process. The Care Plan updated 12/01/22 directed staff to encourage R35 to wear nonskid socks when not wearing shoes, use walker while ambulating to bathroom and while in in her room and hallway, and use call light for assistance as needed. The Care Plan updated on 03/13/23 directed staff to frequently ask R35 if she would like assistance with bathroom mobility. The Nurses Note dated 11/13/22 documented that staff found R35 sitting on the floor and that R35 had stated that she had crawled from her bathroom to her recliner. The Facility Investigation #889, dated 11/14/22, concluded R35 was found on the floor in her room crawling from the bathroom to her recliner. No injury was noted at the time. The investigation also documented that she had a fall earlier in the day. It documented the facility would request a urinalysis related to falls. The investigation documented that staff educated R35 to use the call light before ambulating. The Incident Note, dated 11/29/22 documented that an aide found R35 on the floor in the bathroom with no socks on and skin tears on her right elbow. The Facility Investigation #907, dated 11/30/22, concluded that R35 was noted to be on the floor in her restroom and that she had several skin tears. The investigation documented that R35 ambulates with a walker independently. It further documented that nonskid strip would be applied in her restroom to prevent future falling. The investigation recorded incontinence as a predisposing physiological factor. The Incident Note dated 12/09/22 documented that staff found R35 sitting near the bathroom on the floor wearing nonslip socks. The Facility Investigation #915, dated 12/13/22, documented that R35 was noted to be sitting on the ground near the bathroom door. The investigation further documented that R35 had on nonskid socks at the time. It recorded that no injuries were noted. It directed staff to encourage R35 to use her walker when ambulating to the restroom. The Nurses Note, dated 02/22/23, documented that R35 was noted to be on the floor sitting in her bowel movement and leaning back on her bed. The facility could not provide an investigation. The General Note, dated 03/13/23, documented that R35 had used her call light and informed staff that she had fallen. R35 was found sitting on the floor, facing her bed. The note further documented that R35 stated that she was returning from the restroom and missed the bed. Her bathroom light was noted to still be on with the door open. The note documented that R35 reported hitting her head on the floor and a small bump was noted to be on the back right, top of her head. The facility could not provide an investigation. On 04/25/23 at 07:54 AM an observation revealed R35 sat on the side of her bed and ate breakfast. On 04/26/23 at approximately 05:40 PM an observation revealed that R35 used her walker while ambulating in the hallway without any staff assistance. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated that R35 often overestimates her limits and falls. LN G stated that R35 gets up to walk, walks to the bathroom alone and forgets to use her walker. He further stated that R35 was fairly independent; however, he reported that staff check her every two hours or if staff hear her up in her room. On 04/26/23 at 03:44 PM Administrative Nurse D stated that R35 has dementia and that at times she does not sue her walker when getting out of bed to go to the restroom. She stated that she is reminded to use her walker when ambulating, use her call light and keep nonskid socks on. Administrative Nurse D was asked if R35 does well with reminders when considering her diagnosis of dementia, and she stated that it depends on the day as to whether reminders work. Administrative Nurse D stated that she did not believe a toileting program was started for the resident and that she believed the resident was independent while using the bathroom. The facility's undated policy Accidents and Supervision documented that the facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. The policy further documents in the section titled Monitoring and Modification that monitoring is the process of evaluating the effectiveness of care plan interventions. Modifications is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. The facility failed to identify and implement resident centered interventions and evaluate toileting needs and patterns in order to prevent falls for R35, who was at risk for falls. R35 had multiple falls, with five specifically related to toileting or bathroom needs, which resulted in skin tears.

The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure staff implemented appropriate infection control practices during wound care for Resident (R) 246, who had a history of cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling). This deficient practice placed R246 at risk of wound worsening and complications related to infections. Findings included: - R246's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and obesity (a condition of being grossly overweight). The Admission Minimum Data Set (MDS) was in progress and not completed. R246's Care Area Assessment (CAA) was in progress. R246's Care Plan dated 04/11/23 documented for staff to apply peri-guard (petrolatum-based barrier ointment) to buttocks every shift related to moisture-associated skin damage (MASD-inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva or mucous) and directed staff to provide the treatment as ordered. The Care Plan dated 04/12/23 documented staff to cleanse R246's left buttocks with normal saline or wound cleaner and apply foam dressing. Review of the EMR under Orders tab revealed the following physician orders: Cleanse buttocks with normal saline or wound cleanser, apply peri guard and antifungal cream to buttocks every shift for MASD dated 04/11/23. Left buttock: cleanse with normal saline or wound cleanser, apply hydrogel (water-based gel which donates moisture and aides' autolytic debridement) and cover with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) as needed when soiled. No tape to skin dated 04/19/23. Left buttock: cleanse with normal saline or wound cleanser, apply hydrogel (water-based gel which donates moisture and aides' autolytic debridement) and cover with ABD pad daily. No tape to skin dated 04/19/23. On 04/25/23 at 01:00 PM R246 laid on the bed, Administrative Nurse F entered the room and explained the procedure to R246. She placed an electronic tablet directly onto the bedside table. Administrative Nurse F exited the room and returned with wound care supplies in a plastic basket; she placed the plastic basket directly onto the bedside table next to the electronic tablet without a clean barrier. Administrative Nurse F washed hands in the bathroom, Licensed Nurse (LN) G entered the room and hand sanitized, both staff donned gloves. LN G removed the incontinence brief from R246, LN G doffed gloves, no hand hygiene preformed. Administrative Nurse F cleansed the open area on R246's lower back on his left side, then cleansed the buttocks and rectal area with wound cleanser. Administrative Nurse F then doffed gloves and donned a new pair of gloves without performing hand hygiene. LN G obtained wound pictures of R246's buttocks and coccyx area. LN G donned gloves and applied a foam dressing to R246's open area on his lower left back. Administrative Nurse F and LN G washed hands in the bathroom and exited the room with wound care basket and electronic tablet. Administrative Nurse F placed items on the treatment cart without a clean barrier. On 04/26/23 at 02:45 PM Certified Nurses Aide (CNA) M stated hand hygiene should be performed between every patient, before and after providing care, and after every third item you touch. CNA M stated shared equipment should be disinfected between each resident and the facility policy was to use disincentive wipes that are locked in the medication cart, treatment cart and in the locked medication room. CNA M stated staff had to ask for the disincentive wipes from the nurse. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated hand hygiene would be performed between donning and doffing only if hands were visibly soiled, hand hygiene should be performed between every resident's care. LN G stated a clean barrier should be placed between medical supplies/equipment if placed on resident's personal items in their room to prevent spread of infection. LN G stated shared equipment should be cleaned and disinfected between each use. On 04/26/23 at 3:40 PM Administrative Nurse D stated hand hygiene should be performed when a person's hands are visibly soiled between donning and doffing of gloves, between every third interactions, and shared equipment should be disinfected between each use. Administrative Nurse D stated shared equipment was disinfected with disinfect wipes that were locked up in the medication cart and treatment cart; the facility placed some in the locked utility room starting that week. Administrative Nurse D stated her expectation would be to place a clean barrier down when nursing staff place shared equipment onto resident personal belongings to prevent spread of infection. The facility's Wound Treatment management policy dated 01/01/20 documented it is the policy of this facility to provide evidence-based treatment in accordance with current standards of practice and physician orders. The Facility's Hand Hygiene policy last revised 05/31/22 documented hand hygiene should be performed either with soap and water or alcohol-based hand rub after handling contaminated objects, before applying and after removing personal protective equipment (PPE) including gloves, and after handling items potentially contaminated with blood, body fluids, secretions, or excretions. The facility failed to ensure staff implemented appropriate infection control practices during wound care for R246, who had a history of cellulitis. This deficient practice placed R246 at risk of wound worsening and complications related to infections.

The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to update the comprehensive care plan with current interventions related to a significant weight loss for Resident (R) 96. This deficient practice placed R96 at increased risk for continued weight loss due to uncommunicated care needs/goals. Findings included: - R96's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96 required extensive assistance of two staff members for activities of daily living (ADLs). The MDS documented no weight loss for R96 during the look back period. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99 and a staff documented R96 had moderately impaired cognition. The MDS documented that R96 required limited assistance of one staff member for ADLs. The MDS documented R96 was on a physician-prescribed weight-loss regimen. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. R96's Nutritional Status Care Area Assessment (CAA) dated 03/03/23 documented R96 was to maintain current level of functioning and have no significant weight loss or weight gain through next review. R96's Care Plan dated 04/11/23 documented diet order for a regular/general diet with regular consistency and texture. The Care Plan documented staff was to encourage R96 to eat meals in the dining area. The Care Plan documented R96 ate meals in his room. The Care Plan documented R96 understood the importance of maintaining his diet as ordered. R96 understood the consequences of refusal, obesity/malnutrition risk factors. By compliance, R96 could reach his goals. The Care Plan documented health shake two times a day. The Care Plan lacked direction for a physician-prescribed weight-loss regimen. Review of the EMR under Orders tab revealed physician orders: Weigh daily for three days, then weekly for four weeks, and then monthly in the morning every Friday for routine monitoring dated 04/11/23. Review of the EMR under Vitals tab documented a weight on 02/20/23 of 121 pounds (lbs.) and a weight on 03/02/23 of 114 lbs., which revealed a seven-pound loss in nine days. Review of R96's Medication Administration Record (MAR) for April 2023 revealed a health shake two times a day for weight loss was discontinued on 04/03/23. Offer a HS snack was discontinued on 04/03/23. Review of R96's Treatment Administration Record (TAR) for April 2023 revealed documentation of a weight of 114 lbs. on 04/12/23, 04/13/23, and 04/14/23. The TAR documented R96 refused weekly weight on 04/21/23. The clinical record lacked documentation of physician notification of R96's refusal of compliance for weight monitoring. The clinical record lacked any documentation, order or direction of a physician ordered weight loss regimen. On 04/25/23 at 12:18 PM R96 sat on the edge of the bed, lunch tray on bedside table. The tray lacked fluids. R96 ate lunch unassisted. On 04/26/23 at 02:45 PM Certified Nurses Aide (CNA) M stated the CNAs had access to the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change) which provided the information for the care for each of the residents. CNA M stated the CNAs obtain the weights and report the results to the nurse. CNA M stated if a resident refused, she would attempt a few more times and if continued to refuse, she would report the refusal to the nurse. CNA M stated snacks are documented by the evening shift, if a resident had received a snack during the dayshift, it was not documented anywhere because there was no place to document. CNA M stated she would offer R96 a snack at times to redirect him. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated the Administrative Nurse D and Administrative Staff B update the care plans with any new interventions or changes for each resident. LN G stated, Registered Dietician (RD) comes to the facility monthly to review weights and make recommendations for weight loss. LN G stated the Rd reviewed all new admission and possibly the readmission for dietary needs to prevent weight loss. LN G stated staff review resident's weights weekly and review interventions related to weight loss. LN G stated the kitchen passed the health shakes out to the resident's mealtime and the amount consumed was documented in the meal's intake. LN G stated the CNA's documented the snack intake. LN G stated R96 refused to be weighed frequently. LN G stated the physician should be notified of R96's refusals. On 04/26/23 at 03:40 PM Administrative Nurse D stated all the staff had access to the care plan or Kardex for all the residents. Administrative Nurse D stated R96 should have been reviewed upon return from the hospital visit related to prior weight loss. Administrative Nurse D stated the interventions for health shakes was not carried over from previous orders whenR96 returned from the hospital. Administrative Nurse D stated she had no RD recommendations for R96. The facility's Weight Monitoring undated policy documented monitoring the interventions and revising as necessary. The care plan should identify the president's personal goals and preferences and reflect the resident-specific interventions. The facility failed to update current comprehensive person-centered care plan with current interventions related to a significant weight loss for R96. This deficient practice placed R96 at increased risk for continued weight loss due to uncommunicated care needs/goals.

The facility identified a census of 41 residents with 13 residents included in the sample. The facility identified two residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 34 and R247. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R34's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 09/14/22 and ended on 12/16/22. R34 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. Review of R247's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 08/29/22 and ended on 11/11/22. R247 remained in the facility for custodial care. The facility-issued SNF ABN 10055 lacked an estimated cost for continued services. On 04/26/23 at 02:39 PM Social Services X stated that she received training through the facility's management company; however, she reported that she was unsure if she was trained specifically on whether the ABNs required an estimated cost for continued services to be listed on the forms. The facility's Advance Beneficiary Notices policy, dated 11/01/19, documented that the current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary and the contents of the form shall comply with related instructions and regulations regarding the use of the form. The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired right to appeal.

The facility identified a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to notify the physician of Resident (R) 96's refusal to be weighed for weight loss monitoring. This deficient practice placed R96 at risk of miscommunication between facility and physician and a possible missed opportunity for healthcare services related to continued weight loss. Findings included: - R96's Eelectronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia with behaviors (progressive mental disorder characterized by failing memory, confusion), mild cognitive impairment, and psychosis (any major mental disorder characterized by a gross impairment testing). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99 and a staff interview documented R96 had severely impaired cognition. The MDS documented that R96 required extensive assistance of two staff members for activities of daily living (ADLs). The MDS documented no weight loss for R96 during the look back period. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99 and a staff documented R96 had moderately impaired cognition. The MDS documented that R96 required limited assistance of one staff member for ADLs. The MDS documented R96 was on a physician-prescribed weight-loss regimen. The MDS documented R96 did not exhibit behavior of refusal of care during look back period. R96's Nutritional Status Care Area Assessment (CAA) dated 03/03/23 documented R96 was to maintain current level of functioning and have no significant weight loss or weight gain through next review. R96's Care Plan dated 04/11/23 documented diet order for a regular/general diet with regular consistency and texture. The Care Plan documented staff was to encourage R96 to eat meals in the dining area. The Care Plan documented R96 ate meals in his room. The Care Plan documented R96 understood the importance of maintaining his diet as ordered. R96 understood the consequences of refusal, obesity/malnutrition risk factors. By compliance, R96 could reach his goals. The Care Plan documented health shake two times a day. The Care Plan lacked direction for a physician-prescribed weight-loss regimen. Review of the EMR under Orders tab revealed physician orders: Weigh daily for three days, then weekly for four weeks, and then monthly in the morning every Friday for routine monitoring dated 04/11/23. Review of the EMR under Vitals tab documented a weight on 02/20/23 of 121 pounds (lbs.) and a weight on 03/02/23 of 114 lbs., which revealed a seven-pound loss in nine days. Review of R96's Medication Administration Record (MAR) for April 2023 revealed a health shake two times a day for weight loss was discontinued on 04/03/23. Offer a HS snack was discontinued on 04/03/23. Review of R96's Treatment Administration Record (TAR) for April 2023 revealed documentation of a weight of 114 lbs. on 04/12/23, 04/13/23, and 04/14/23. The TAR documented R96 refused weekly weight on 04/21/23. The clinical record lacked documentation of physician notification of R96's refusal of compliance for weight monitoring. On 04/25/23 at 12:18 PM R96 sat on the edge of the bed, lunch tray on bedside table. The tray lacked fluids. R96 ate lunch unassisted. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated the physician assistant came to the facility weekly to review for any changes related to the residents and the physician came to the facility monthly. LN G stated R96 refused to be weighed frequently. LN G stated the physician should be notified of R96's refusals. On 04/26/23 at 03:40 PM Administrative Nurse D stated R96 should have been reviewed upon return from the hospital visit related to prior weight loss. Administrative Nurse D stated the interventions for health shakes was not carried over from previous orders when R96 returned from the hospital. Administrative Nurse D stated she had no RD recommendations for R96. Administrative Nurse D stated the physician came monthly and the physician came weekly to the facility to make rounds. The facility's Notification of changes undated policy documented the facility would promptly notify the medical provider of any changes in the resident's care including clinical complications, decision making/choices for cognitively impaired residents, or changes of care. The facility failed to notify the physician of R96's refusal to be weighed for weight loss monitoring. This deficient practice placed R96 at risk of miscommunication between facility and physician and a possible missed opportunity for healthcare services related to continued weight loss.

The facility identified a census of 41 residents. The sample included 13 residents with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19 was treated with dignity. This deficient practice placed R19 at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia without behaviors (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), and posttraumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R19 required extensive assistance of two staff members for activities of daily living (ADLs). R19's Cognitive Loss Care Area Assessment (CAA) dated 03/31/23 documented staff would monitor for signs and symptoms of acute mental status changes. Staff would communicate using short and simple sentences to allow adequate time for R19 to understand and for him to communicate his needs. Staff would approach R19 in a calm and non-threatening manner as to help R19 feel calm and unhurried. R19's Care Plan dated 02/10/22 documented caregivers would provide opportunities for positive interaction and attention. The Care Plan dated 03/04/22 documented staff had been educated not slam doors or cause loud noises around R19 because it could upset him and could make R19 have an anxiety attack (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and his PSTD would kick in. The Care Plan dated 11/09/22 documented staff would provide a quiet, non-threatening environment with decreased stimulation. On 04/24/23 at 09:27 AM R19 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) slightly reclined in the common area in front of the TV. R19's shirt was pulled upend R19' abdomen area was exposed, and no behaviors noted. R19 cheerfully engaged visitors and staff as they passed him. On 04/24/23 at 11:28 AM R19 remained in common area slightly reclined in the Broda chair, his shirt remained pulled up and R19's abdomen was exposed. R19 remained cheerful as he engaged staff and visitors as they passed by him, no behaviors noted. On 04/24/23 at 12:09 PM R19 sat reclined in Broda chair in the dining, his abdomen was exposed. Certified Nurse Aide (CNA) N commanded R19 several times in a loud tone to pull his shirt down over his exposed abdomen. CNA N then attempted to pull R19's shirt down over his exposed abdomen at the dining room table. R19 became agitated and began to yell out. On 04/26/23 at 03:03 PM Licensed Nurse (LN) G stated R19 did not have behaviors very often. LN G stated CNA N should have removed R19 from the dining room to a more private area to provide personal care. On 04/26/23 at 03:40 PM Administrative Nurse D stated the expectation would be to provide personal care in a private area. Administrative Nurse D stated R19 had a history of removing his shirt at times but was not sure if that was on his care plan. The facility's Attachment J: Statement of Resident Rights undated policy documented each resident would have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the adult care home. The facility failed to ensure R19 was treated with dignity. This deficient practice placed R19 at risk for negative psychosocial outcomes and decreased autonomy and dignity.

The facility identified a census of 41 residents. The sample include 13 residents. Based on observation, record review, and interviews, the facility failed to provide mail services on Saturdays. Findings Included: - On 04/24/23 at 10:31AM, Resident Council members reported that facility does not provide mail services for the residents on Saturdays. The council reported that most of the mail they received was on Monday due to no one passing it over the weekend. On 04/26/23 at 02:15PM Activities Coordinator (AC) Z reported that she was responsible for delivering the mail to the residents but does not work every weekend. She stated staff should have been providing the mail to the residents on weekend. She stated that the direct care staff should have pulled out greeting cards and presents for the residents and delivered it to them. She stated if staff was unable to pass the mail, she would deliver it on the following Monday. She stated the facility had volunteers to come in on weekends to assist but haven't the last few Saturdays. On 04/26/23 at 03:40PM Administrative Nurse D stated that staff should be assisting will mail delivery on Saturdays. The facility did not provide a policy related to mail delivery as requested on 04/26/23. The facility failed to provide mail services on Saturdays. This deficient practice placed 41 residents at risk for decreased psychosocial wellbeing.

The facility identified a census of 34 residents. The facility had one main kitchen. Based on observations, record reviews, and interviews, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened, and the food item was not placed in a sealed container/storage bag with the proper labeling and date. This deficient practice had the risk to spread food-borne illness to residents and staff. Findings included: - The initial tour of the facility kitchen on 10/18/21 at 07:19 AM revealed the following: in dry storage area there was an opened bag of dried mashed potato chips that was not in a sealed bag, was not labeled or dated when opened. There was a sealed plastic storage bag with flour tortillas inside, the bag was not dated or labeled; there was a sealed plastic storage bag in the refrigerator that contained half of a tomato, no label or date on the bag; the freezer had an opened box of grilled chicken breast fillets, original bag in box was opened to air, remaining chicken breasts had not been placed in a sealed bag, and not labeled with open date. In an interview with Dietary Staff CC on 10/18/21 at 07:30 AM, she stated she noticed the box of chicken breast had been opened, and she said the remainder of the chicken breasts should have been placed in a sealed bag with a label and date (she disposed of those items). In an interview with Dietary Staff BB on 10/20/21 at 01:57 PM, she stated that kitchen staff are trained about proper food storage. Those items should have all been put in the proper storage container or bag, then labeled and dated. She stated her staff usually do a good job of bagging, labeling and dating food items after original container is opened. The undated facility policy Food Safety Requirement documented the following: Food safety practices shall be followed throughout the facility's entire food handling process; Elements of the process include the following- Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of micro-organisms; Refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer; Practices to maintain safe refrigerated storage include: labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded, and keeping foods covered or in tight containers. The facility failed to ensure kitchen/dietary staff properly stored, labeled, and dated food items after their original storage container/package was opened. This deficient practice had the risk to spread food-borne illness to residents and staff.

The facility identified a census of 38 residents. The sample included 5 residents reviewed for abuse and neglect. Based on record review and interview the facility failed to provide an environment free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 of 2 residents sampled for bedpan use (a receptacle used for the toileting of a bedridden patient), when resident #1 sat unattended on a bedpan for an estimated 12-13 hours. Resident #1 developed an avoidable suspected deep tissue injury (an intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes). The residents right buttock wound opened and he/she required hospitalization , wound debridement (removal of damaged tissue), and suturing to treat. This deficient practice placed resident (#1) in Immediate Jeopardy on 2/19/19 at approximately 8:30 P.M. Findings included: - The Electronic Medical Record (EMR) documented resident #1 admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED].) and [MEDICAL CONDITION] (a disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness). The annual Minimum Data Set (MDS) assessment dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. He/she had no mood indicators of depression and no adverse behaviors such as rejection of cares documented during the assessment period. The resident required extensive assistance of 2 staff members with bed mobility, transfers, and toilet use. The MDS recorded the resident used a urinary catheter (a tubular medical device used to drain urine from the bladder) for urination and was continent of bowel movements. The assessment recorded the resident was at risk for pressure ulcers (a wound that occurs as a result of prolonged pressure on a specific area of the body), but he/she had no unhealed pressure ulcers. The quarterly MDS assessment dated [DATE] recorded no cognitive and/or functional change with the resident. The 1/19/19 Braden assessment (a numerical tool used to assess risk for developing a pressure ulcer) documented a score of 16 (high risk status). The resident's care plan last revised 1/19/19, for activities of daily living (ADLs) recorded the resident required extensive assistance of two staff members with toilet use on a bed side commode. The care plan recorded the resident was continent of bowel and could transfer (with assist) to the toilet or a bedside commode. The care plan advised the resident required frequent skin inspections and directed staff to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The resident' care plan lacked documentation the resident used a bedpan for bowel movements. Review of the facility-initiated investigation timeline revealed: on 2/19/19 (no time noted) A change of condition was recorded in the EMR which indicated the resident had reddened, bruised buttocks from sitting on a bedpan and falling asleep. The change of condition and/or skin assessment lacked documentation of measurements to the reddened areas. A weekly wound observation tool dated 2/20/19 recorded the resident had a facility acquired pressure area of intact pink skin that measured 20 millimeters (mm long) by 20 mm wide around his/her left upper left leg and buttocks. Based on observation of a photograph in the resident medical record and comment per administrative licensed nurse D, the area was approximately 20 centimeters (cm) (not millimeters) long and approximately 1 cm wide of intact skin (confirmed by administrative licensed nurse D). Witness accounts indicated the wound was semi-circular purplish skin running horizontally (across top of buttocks at level of tailbone and extending downward around the left buttock, in the shape of a bedpan). The observation tool noted a stage 2 pressure area. According to the National Pressure Sore Advisory Panel, a stage 2 pressure sore is: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue, usually cream or yellow in color); may also present as an intact or open/ruptured serum-filled blister. The weekly skin assessments dated 2/25/19 revealed no change in the resident wound measurements. The weekly wound observation tool dated 3/5/19 documented the wound was 200 mm long and per interview administrative nurse D revealed this was incorrect, (should be 20 cm) by 10 mm (should be cm) wide and not open. Review of a wound photograph in the resident's medical record and comment per administrative licensed nurse D, the wound was more accurately, 13 centimeters (cm) horizontally (9 to 3 on a clock face) by 7 centimeters vertically (12 to 6 on a clock face). Review of the daily nurses' progress notes lacked documentation the resident had a wound from 2/18/19 thru 2/25/19. On 2/25/19 at 4:45 P.M. the nurses progress notes documented a physician's orders [REDACTED]. Review of the clinical record from 3/1/19 through 3/22/19 revealed staff did not administer the Prostat supplement due to unavailability. The nurses progress notes lacked evidence of documentation related to any wound from 2/25/19 through 3/12/13. The nurses note dated 3/13/19 at 2:44 P.M. documented direct care staff O called this nurse to the resident's room and noted the resident had a long sloughy (dead tissue, usually cream or yellow in color) wound to his/her left buttock. There was not an odor and/or drainage (signs of possible infection) and therapy provided a ROHO cushion (a specialized pressure relief cushion) for the resident's wheelchair and staff educated the resident on the risk/benefit related to the wound and benefit of laying down. Resident stated understanding but refused to lay down. Review of the physician progress notes [REDACTED]. Resident has very limited mobility, very poor cooperation with physical therapy and staff. Resident did not want to get up to use bathroom or commode and used a bedpan. Apparently, he/she was on that for quite some time and had a buttocks area wound. Staff treating wound with A&D ointment with some concern for resident to see a wound clinic. Observation during a limited physical exam today showed the buttocks with a linear area that would correspond approximately to the outline of a bedpan. One area was a little bit wider area with some dried adherent exudate (fluid that leaks out of body vessels and tissues). The resident would probably be better served by [MEDICATION NAME] (medical removal of dead, damages, or infected tissue to improve the healing potential for the remaining healthy tissue) from the wound clinic. The nurses progress note dated 3/26/19 at 9:00 P.M. recorded upon assessment the resident had large amounts of red drainage on the back of his/her night clothes and disposable pad in wheelchair. Resident assisted to stand with a mechanical lift and revealed an open wound (no other description). Staff attempted to place resident in bed, but he/she could not stand and slid to floor with assist. Placed on buttocks on the floor and wound assessed and revealed 11.0 cm long by 2.3 cm width by 5.0 cm deep area (does not define location). Physician notified and ordered emergency room evaluation and treatment. Resident transported via emergency medical services (EMS) at 10:32 P.M. Review of the clinical summary from an acute hospital admitted d 3/27/19 at 12:01 A.M. documented [DIAGNOSES REDACTED]. trauma) of buttock. The resident presented when a buttocks wound started bleeding. He/she stated, over a month ago, he/she fell asleep on a bedpan and developed ulcerations around his/her buttocks. These had been healing until today when staff were moving the resident and the area to the left buttock opened and started bleeding. Surgery was consulted in the emergency department and sutured the area, but it continued to bleed. A hospital wound care progress note on 3/28/19, recorded likely a decubitus ulcer from sitting on a bedpan overnight, the resident went to the operating room the evening of 3/27/19. The left gluteal (buttocks) wound had extensive infected hematoma. The pressure injury extended all the way down to fascia. There was no bone exposed, but he/she had an extensive necrotic tissue (dead tissue) and hematoma. A wound vac (a vacuum-assisted device with an airtight dressing which drains seeping liquid and promotes closure of a wound) was placed for wound healing. Interviewed on 4/1/19 at 10:00 A.M licensed nurse H stated he/she first noticed a reddened area in the shape of a bedpan on the resident buttocks, cannot remember the date, approximately (MONTH) 2019 the resident's right buttocks noted to be pink/red on a shower day. Approximately 1 month ago, when he/she was called to the shower room and observed the red area was sloughy. A physician visit was scheduled, and he/she said he/she would see resident's wound when visiting. The resident was provided a new wheel chair cushion by therapy and educated on the need to offload, but he/she refused. The witness statement documented the resident did not go to the wound care center appointment. He/she was very upset and tearful when gotten up to go. On 4/1/19 at 10:10 A.M. administrative licensed nurse F stated he/she first found out about this wound when administrative licensed nurse D asked him/her to look at it on 3/26/19. Nurse F had no knowledge whether this was reported to the state agency or not. Interview with direct care staff O on 4/1/19 at 10:43 A.M. stated, Someone on night shift left (the) resident on (the) bedpan all night; the only reason I know because I saw it and there was a bruise on (his/her) bottom in the shape of a bedpan. I did see the bruise and was not here when happened but saw afterwards. Direct care staff was unsure of when the incident actually occurred but stated somewhere between (MONTH) and (MONTH) 2019. Interview with direct care staff R on 4/1/19 at 1:17 P.M. stated he/she did not remember when staff left the resident on the bedpan. Night shift did not tell me anything about it and the resident did not even remember being on bedpan. The resident gets up at 9:30 every morning, and that was when he/she would allow us to get him/her up to sit on the commode. When we got the resident up in the morning, he/she was on the bedpan. We reported this to the charge nurse and director of nursing, at that time, there was a purple ring on his/her buttocks like someone had traced the bedpan that day. Interviewed on 4/1/19 at 1:22 P.M. direct care staff S stated he/she got the resident up that day (does not remember date sometime in February) and saw the bedpan under him/her. Direct care staff S stated he/she called the former DON and charge nurse (does not remember what nurse was on duty) and they looked at the resident. Former administrative nurse (DON) had us put A&D ointment on the area. Direct care staff S stated he/she immediately noted a ring around the area and he/she was upset about finding it. Interview with licensed administrative staff F on 4/1/19 at 1:30 P.M. revealed the first time he/she saw the resident's wound was with the physician on the 21st last month (March 21, 2019). The area presented as a dark pink area around his/her left buttock with open area, slough, and the physician gave an order for [REDACTED].>Direct care staff Q notarized witness statement dated 4/1/2019, documented he/she was giving resident a shower (unsure of date) and noticed bruising on his/her bottom and reported it to the charge nurse and DON. The resident's bottom wound was oozing and had a foul odor. Direct care staff U notarized witness statement dated 4/1/2019 documented he/she worked at the facility (MONTH) 19, 2019 and put the resident on the bedpan with assistance from direct care staff T around 8:00 P.M. I filled his/her ice mugs and asked resident if he/she was done with the bedpan around 8:45 P.M. Resident told me, No. I said okay since the resident always hits the light to be taken off. Direct care staff T then told night shift that resident was on the bedpan. Direct care staff V notarized witness statement dated 4/1/2019 documented he/she was aware of the wound on buttocks area through report or handoff from night nurse through report. I was informed resident was left on the bedpan. Direct care staff X notarized witness statement dated 4/1/2019 documented he/she knew about the resident's wound but never saw it. The resident would rather use the bedpan at night, so he/she does not have to get out of bed. When the resident asked to be put on the bedpan, he/she says when he/she is finished and will use the call light. Licensed Therapy staff X notarized witness statement dated 4/1/2019 documented he/she worked at the facility in (MONTH) 2019 (no exact date given) and had been working with resident in therapy for [MEDICAL CONDITION] management of his/her legs. Resident reported pain on the back of right thigh. Upon standing resident allowed me to examine his/her leg and he/she was noted to have small red area. Nursing was notified to examine posterior thigh in mid-February 2019. Later that week, the resident was noted to have a large bruise on his/her buttocks and it was reported by the resident that he/she laid on the bedpan all night and confirmed by a former DON. Within 1-2 weeks there was an open area reported and they stated they were not aware of. Interview on 4/1/19 at 2:30 P.M. with administrative licensed nurse E revealed he/she was new to the facility (March 1, 2019) and heard rumors the resident was left on a bedpan and had a wound and he/she started a timeline to try to put the events together. Licensed nurse D stated the facility began their investigation on 3/21/19. The best we could narrow it down was around 2/19/19 that the staff placed the resident on the bedpan around 8:00 P.M. fell asleep and nobody knew it was there until the morning (2/20/19). Licensed nurse D stated he/she did not know until 3/21/19 that was the cause of the wound. Administrative licensed nurse D stated in hindsight we should have called the State Agency. Interview with administrative license nurse D on 4/1/19 at 2:30 P.M. revealed there had been a change in the facilities administrative licensed nursing staff and we were trying to get this sorted out. Administrative license nurse D stated he/she and administrator were first made aware of the situation on 3/21/19 and immediately started to put together a time line and corrective actions. We immediately interviewed staff and residents, educated residents and staff on pressure sore development and use of bedpans. Administrative license nurse D stated there was only one other resident in the facility who used a bedpan, he/she was ambulatory and did not use very often, (confirmed with sampled resident #4). Nurse D stated we hoped to complete our investigation today 4/1/19. During a telephone interview on 4/2/19 at 2:10 P.M. Physician Z stated based on the information he/she received and observation of the resident's wound, it was consistent with someone who sat on bedpan for a period of time and based on the residents medical complications, he/she felt it could develop into something serious and so that is why we ordered a wound care center consult. The facility Abuse Neglect and Exploitation policy revised (YEAR) documented: It is the facility's policy to provide for the safety and dignity of all its' residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility Policy contained the Elder Justice Act (law enacted (MONTH) 2010) which defined Neglect as: the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to maintain health or safety of a resident and to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to prevent an episode of abuse when facility staff neglected to remove a bedpan from under sampled resident #1 causing an avoidable pressure ulcer that required hospital treatment for [REDACTED]. This deficient practice placed resident (#1) in Immediate Jeopardy on 2/19/19 at approximately 8:30 P.M. On 4/2/19 at 4:03 P.M. administrative staff A, administrative nursing staff D and administrative nursing staff E were informed the deficient practice placed resident #1 in Immediate Jeopardy. The facility provided an acceptable plan for removal of the immediate jeopardy on 4/2/19 at 6:30 P.M. The onsite review on 4/3/19 at 11:45 A.M. revealed the facility removed the Immediate Jeopardy when it completed the following: *Identified and assessed other residents who require use of bedpans *Licensed nursing staff completed BRADEN skin assessments on active residents *Reviewed and updated resident care plans for use of bedpans *Staff would check residents at 10 minutes use of bedpan and assure the bedpan was removed. Staff would notify the charge nurse that a resident has used a bedpan and licensed nursing staff would visualize the resident's skin after bedpan use. The deficient practice remained at a scope and severity of a G following the removal of the immediate jeopardy.

The facility had a census of 44 residents. The sample included 20 residents. Based on observation, interview, and record review the facility failed to provide adequate, effective interventions to prevent the development and worsening of pressure ulcers for 3 of 3 residents sampled for pressure ulcers. Resident #48 developed a facility acquired Stage 3 pressure ulcer which became infected. Residents #12 and #33 both developed facility acquired Stage 2 pressure ulcers. Findings included: - The facility admitted Resident #48 on 1/31/17. The admission (MDS) Minimum Data Set assessment, dated 2/7/17, documented the resident cognitively intact with a (BIMS) Brief Interview of Mental Status score 15. The MDS further documented the resident was independent with eating, personal hygiene, and required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting. The assessment documented the resident had no (ROM) Range of Motion impairment, used a walker and wheelchair, received scheduled and (PRN) as needed pain medication, and reported occasional, severe pain. The assessment documented the resident was at risk for pressure ulcers, had no skin issues, and interventions included a pressure reduction device for the bed and chair, repositioning, and physical therapy. The 2/7/17 (CAA) Care Area Assessment stated the resident had the potential for pressure ulcers related to urinary incontinence, mobility problems, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with [MEDICAL CONDITION] (diabetic [MEDICAL CONDITION] most often damages nerves in your legs and feet), and heart failure (failure of the heart to function properly) with [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues), and these conditions increased the risk for skin problems. The significant change MDS, dated [DATE], documented the same except the resident now had 1 Stage 2 pressure ulcer (partial thickness loss of skin, presenting as a shallow open ulcer with a red pink wound bed), initially noted 2/22/17, which was not present on admission. The assessment documented added interventions included nutrition, pressure ulcer care, dressing, and ointments. The 3/1/17 CAA for pressure ulcers documented the resident had a pressure ulcer on his/her left heel, and had the potential for other problems with pressure ulcers related to urinary incontinence and mobility problems. The 1/31/17 initial care plan directed staff to transfer the resident with a total lift until cleared by therapy. The care plan directed staff to provide a pressure reducing device for the resident's chair and bed, and a repositioning program. The 2/1/17 care plan directed staff to provide assistance for activities of daily living, related to: recent hospital stay resulting in fatigue, activity intolerance, weakness, and mobility problems. The care plan directed staff to assess skin integrity daily with care, report abnormalities, conduct a comprehensive skin inspection weekly, monitor for signs and symptoms of infection, and report as indicated. The care plan directed staff to monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche (becomes white or pale in appearance) easily. The care plan directed staff to provide pressure redistribution surfaces (used to redistribute pressure on skin tissue or alternate parts of the body exposed to pressure) to the resident's bed and chair, as per protocol. The 2/22/17 care plan update directed staff to provide a low air loss mattress, on the bed, and to ensure the resident had a heel boot on his/her left foot, on in AM and off in PM, or when up in chair and to use a foot stool. The 1/31/17 Braden scale (tool used to assess the risk of pressure ulcers) documented the resident at high risk for pressure ulcers with a score of 12. (9 or less indicated severe risk, 10-12= high risk, 13-14= moderate risk, 15-18= mild risk, 19-23= no risk) The 1/31/17 admission assessment documented the resident had 3+ (moderate) [MEDICAL CONDITION] in his/her lower feet and legs, his/her mobility very limited, and he/she was unable to make significant position changes independently. The assessment documented the resident required extensive assistance with mobility, was chairfast, slides down in bed, and does not lift up completely during moves. The assessment documented the resident had weakness in both legs and left arm, and had no skin impairment. The 2/2/17 nutrition assessment by the registered dietician documented the resident had intact skin. The 2/20/17 Braden scale documented the resident had a score of 18 (mild risk). The 2/21/17 at 2:24 PM nurse's note documented the resident had chronic 4+ (severe) [MEDICAL CONDITION] to both feet and legs, and remained on extra [MEDICATION NAME] (medication designed to increase the amount of water and salt expelled from the body as urine) for 3 days. Review of the medical record revealed no documentation of skin changes prior to 2/22/17. The 2/22/17 at 11:33 AM, nurse's note documented a skin injury/wound to the resident's right and left heels, dressings (undocumented) intact, and heels floated. (no documentation of size or wound characteristics) The 2/22/17 at 12:31 PM, nurse's note documented the resident was able to ambulate to the bathroom using a walker and complained of left heel pain. The note stated the opening to the resident's inner heel was approximately dime sized, clean in appearance. The 2/22/17 physician's orders [REDACTED]. The physician orders [REDACTED]. The February 2017 (TAR) Treatment Administration Record documented the following: 1) heel suspension device to be placed on right and left foot while in bed, remove for cleansing as needed, remove every 2 hours for skin inspection while in bed. Prafo boots (very soft interior, offering gentle pressure relief) every shift, to be on in bed and off when up, initiated 2/22/17. Apply skin prep (forms a film upon application to intact or damaged skin which provides a long [MEDICATION NAME], waterproof barrier) to right heel and ensure heels are offloaded, initiated 2/22/17. 2) cleanse the wound to the left heel with wound cleanser, apply A & D ointment (skin protectant that works by moisturizing and sealing the skin, and aids in skin healing) and abdominal pad every day shift, initiated 2/23/17. 3) low air loss mattress (setting #4) to the bed, initiated 2/24/17. 5) monitor the left heel wound daily for status of surrounding tissue and wound pain, every day shift, initiated 2/25/17. (no documentation on the care plan) The 2/23/17 at 1:10 PM, nurse's note documented the resident's feet and legs had 4+ [MEDICAL CONDITION], and the resident had an open area on the bottom of his/her left heel, the size of a pencil eraser, and an air mattress on the bed at all times. The 2/24/17 at 10:30 AM, facility fax to the physician stated the resident's left heel wound was caused by shoes, and nursing requested an order to have the resident evaluated at the wound clinic. (the medical record lacked direction to staff regarding the use of the shoes) The 2/24/17 at 10:50 AM, wound assessment documented the resident had a pressure ulcer, Stage 2 (partial thickness loss of skin, presenting as a shallow open ulcer with a red pink wound bed), on his/her left heel, acquired in the facility, with light serosanguiness drainage (wound drainage of a semi-thick reddish fluid), measuring 3 (cm) centimeters by 3 cm by 0.2 cm deep. The wound assessment documented treatment included moisture ointment, dry, clean dressing, and interventions included foam mattress, heel suspension device, and chair cushion. The assessment documented the wound area was red/moist. The 2/24/17 at 1:12 PM, nurse's note documented the resident had [MEDICAL CONDITION] to both feet and legs. The note stated the resident was to leave his/her shoes off for now, when not ambulating in therapy, and to wear the Prafo boot on the left leg. The note further stated the resident had an air mattress on his/her bed at all times, and remained on [MEDICATION NAME] for [MEDICAL CONDITION]. The note stated the resident reported he/she had pain when walking. The 2/27/17 physical therapy note documented the resident progressing well with a minor set back of a small wound developed on the left foot, for which he/she would see a wound doctor. The note stated the resident was able to bear weight for transfers and ambulation at this time. The 3/1/17 at 10:30 AM, nurse's note documented the open area, on the resident's left heel, 1 cm by 1 cm, with moist white skin surrounding the area, to total 2 cm by 4 cm, and painful only when touched in the open area. The 3/1/17 wound assessment documented the resident had a Stage 2 left heel ulcer, 1 cm by 1 cm, with slight serosanguiness drainage. The 3/1/17 Braden scale documented the resident had a score of 16, mild risk. The 3/2/17 at 1:27 PM, resident at risk meeting (8 days after the pressure ulcer was discovered) note stated the resident had a new pressure ulcer on the left heel, and new orders for a low air mattress. The 3/3/17, registered dietitian assessed the resident, recommended Vitamin C, and Prostat (liquid protein), after checking with the resident's transplant doctor first. (9 days after staff found the pressure ulcer) The 3/4/17 at 10:06 PM, nurse's note stated the resident stands and walks a short distance with a walker, propels short distances in a wheel chair, and had [MEDICAL CONDITION] in both legs and feet. The note further stated the resident wore the Prafo boots while in bed, and also when up. The 3/6/17 physician order [REDACTED]. The 3/7/17 at 3:00 PM, nurse's note documented the nursing director changed the dressing to the resident's left foot and the pressure area that morning. The note stated the wound appeared to be quarter sized in appearance with sero-sanguiness drainage, and slight odor. The note stated staff collected a wound culture from the wound (the medical record lacked results of the culture). physician's orders [REDACTED]. The 3/7/17 Wound Clinic summary documented a [DIAGNOSES REDACTED]. The summary directed staff to keep Prafo boots on while in bed, ensure the resident wears treaded socks for physical therapy, and keep wound clean, dry and covered at all times (do not get wound wet when bathing). Further orders included: clean the wound with Normal Saline solution (solution most like bodily water), pat dry, apply Santyl (a sterile enzymatic [MEDICATION NAME] ointment) topically, to the wound base and cover with dry gauze. Further instruction included: elevate legs to the level of the heart, or above, for 30 minutes, 3 times per day, avoid prolonged periods of sitting, and to use pillows to float heels when in bed and sitting. The summary documented the left heel wound measured 2.2 cm by 3.5 cm by 0.1 cm. The 3/8/17 facility skin assessment documented the wound measured 3 cm by 3 cm by 0.2 cm deep. (increased in size from the last documented measurements on 3/1/17) The 3/15/17 at 3:38 PM, nurse's note stated staff notified the wound physician the pressure ulcer on the resident's left foot had become bigger. The 3/15/17 at 6:34 PM, nurse's note stated the physician ordered a wound culture of the left heel wound and directed staff to apply [MEDICATION NAME] (zinc cream) to the wound edges. The 3/16/17 lab result of the left heel wound culture documented a rare [MEDICATION NAME] species (bacterium that can cause a variety of infections) was identified and results called to the wound physician. On 3/20/17 the laboratory informed the physician of the antibiotic susceptibility results. The 3/16/17 skin assessment documented the pressure ulcer measured 3 cm by 3 cm by 0.2 cm, and the wound deteriorated. The 3/16/17 physician visit note stated the resident had recent difficulties with his/her left foot wound and was seen at the wound clinic for that. The note stated another little wound had started right beside the wound on the left heel. The 3/19/17 at 1:20 PM, nurse's note documented the resident's left heel wound had yellow/brown drainage. The 3/21/17 Wound Clinic summary of the pressure ulcer of the left heel, Stage 3 (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed). The summary documented the left heel wound measured 2.9 cm by 2.8 cm by 0.2 cm. The 3/21/17 physician's orders [REDACTED]. The 3/22/17 skin assessment documented the left heel wound macerated (softening and breaking down of skin as a result from prolonged exposure to moisture), and measured 3 cm by 5 cm. The 3/24/17 physician's orders [REDACTED]. The 3/26/17 at 4:17 PM, nurse's note documented the resident's left heel pressure ulcer had some drainage. (no documentation of color, odor, or amount) Unable to observe the resident due to he/she was discharged from the facility on 3/31/17. On 6/1/17 at 3:20 PM, Nurse F stated the resident had a lot of [MEDICAL CONDITION] in his/her legs and was not able to walk when admitted to the facility. Nurse F stated the resident had weakness after surgery, but once out of bed he/she moved better. Nurse F stated staff placed blue booties on the resident soon after admission, but the resident would sit, with the blue booties on and with his/her heels resting the floor. On 6/1/17 at 2:50 PM, Administrative Nurse A verified the resident acquired the pressure ulcer in the facility and the 1/31/17 admission assessment documented 3+ [MEDICAL CONDITION] in lower feet and legs, mobility very limited, unable to make significant position changes independently, chairfast, slides down, and does not lift up completely during moves. Administrative Nurse A stated the resident had special shoes for wide feet, but the shoes were older, and staff thought the shoes may have caused the pressure ulcer. Administrative Nurse A verified the lack of documentation regarding the continued use of the same shoes during ambulation. Administrative Nurse A verified staff had not developed a care plan to include individualized, specific interventions to prevent the development of the facility acquired Stage 3 pressure ulcer, prior to the first observation of the wound. On 6/6/17 at 11:10 AM, Physician D (wound physician) stated he/she would expect the facility staff to provide interventions to prevent pressure ulcers for the resident, who had 4+ [MEDICAL CONDITION] in his/her feet and legs. Physician D stated staff should have ensured the resident's shoes were not too tight and Prafo boots are not to be used for ambulation (walking). Physician D stated since the resident was a transplant recipient, staff should use every precaution to prevent infection for the immunocompromised resident. On 6/6/17 at 11:25 AM, Physician E stated the resident always had a lot of [MEDICAL CONDITION] in his/her feet/legs and he/she would expect staff to check the resident's shoes to ensure they did not fit too tightly. Physician E stated he/she would expect staff to use precautions to prevent infection. The facility's 1/2/14 Skin Integrity Care Delivery Process directed staff to check for pressure, related to positioning or shoes daily, evaluate risk factors such as decreased mobility, comorbid conditions, impaired blood flow, or recent surgery. The policy directed staff to care plan approaches to limit the effects of risk factors associated with pressure ulcers and notify the dietician of actual wounds. The The policy directed staff to perform wound observations and measurements upon initial identification and weekly, and develop a comprehensive plan of care, including prevention and wound treatments. The facility failed to provide interventions to prevent the development and worsening of Resident #48's facility acquired Stage 3 pressure ulcer, which became infected, placing the resident at risk for serious health consequences. - Resident #33's admission (MDS) Minimum Data Set assessment, dated 11/9/16, documented the resident had moderately impaired cognition with a (BIMS) Brief Interview of Mental Status score of 10. The MDS documented the resident required extensive assistance of 1 staff with bed mobility, transfers, walking in room and corridor, toilet use, and personal hygiene. The resident had no (ROM) range of motion impairment, used a walker or wheelchair, had shortness of breath when lying flat, weighed 137 (#) pounds, not at risk for pressure ulcers and had no pressure ulcers. He/She had a pressure reducing device for his/her chair and bed, and repositioning program. The 11/9/16 CAA for pressure ulcers stated the resident had the potential for pressure ulcers related to his/her mobility problems. The resident had pain which increased the risk for pressure ulcers related to impaired mobility. The significant change (MDS) Minimum Data Set assessment, dated 2/8/17, documented the same information except the resident had a stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS documented the resident had a pressure reducing device for his/her chair and bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, and pressure ulcer care. The quarterly (MDS) Minimum Data Set assessment, dated 4/22/17, documented the same information. The 11/15/16 care plan for skin directed staff to apply barrier cream after toileting care, and reposition the resident every 2-3 hours as he/she allowed. The care plan documented the resident preferred to lay on his/her back with the head of the bed elevated due to pain and difficulty breathing. The care plan directed the staff to evaluate for skin risk factors per protocol, monitor the resident's skin for signs/symptoms of breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche (to press on a person's skin to push blood away and wait for return to determine blood circulation) easily. The care plan directed the staff to provide redistribution surfaces to the bed / wheelchair as per protocol, complete weekly skin assessments by a licensed nurse, and obtain a dietitian consult as needed/ordered. The 1/30/17 care plan update directed staff to apply A&D ointment to both heels when in bed, 3 times per day, and place heel boots to both heels when in bed for prevention, however, the Kardex Report (the care plan printed out for the nurse aides) lacked direction to include Prevalon boots (a soft, comfortable boot designed to lift the heel off of the mattress, minimizing pressure on the heel) to both feet when in bed, and no shoes, until 2/3/17. The 2/2/17 update directed staff to provide a house supplement as ordered. The pressure ulcer care plan, dated 2/3/17, stated the resident had actual skin breakdown related to vascular disease, limited mobility, and new, tight shoes, and directed staff to assist the resident in repositioning every 2-3 hours. The 02/10/2017 care plan update directed staff to evaluate the wound area daily, including surrounding tissue and presence or absence of drainage/infection and/or new wound pain, and report to the physician as indicated. The update further directed staff to float the resident's heels while in bed, and place heel boots on him/her when in bed. Additional 2/10/17 care plan updates directed staff to monitor for verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered, monitor skin for signs/symptoms of skin breakdown , and provide wound treatment as ordered. The 2/14/17 care plan update directed staff to ensure the resident wore soft house slippers or socks while the wound healed. The care plan lacked updates to include physician ordered interventions dated 3/15/17, 5/10/17, and 5/30/17. The 11/22/16 admission Braden scale (a tool used by medical professionals to evaluate if a person is at risk for pressure ulcers) documented the resident had a score of 14 (moderate risk). The 1/18/16 through 1/26/17 skin assessments documented no skin issues. The 1/30/17 at 2:15 PM, nurse's note stated the resident reported that his/her left heel hurts some.The note stated the resident's left heel showed a darker pink area that blanched. The note stated staff notified the physician and received new orders to apply A&D ointment, 3 times per day, and place heel boots on the resident when in bed. The facility's weekly wound observation sheet documented the following: 2/3/17 (initial) the resident had a facility acquired stage 2 pressure ulcer to his/her right, outer heel. The assessment documented the pressure ulcer had no drainage, no odor, had wound pain, and the surrounding tissue was inflamed (red and warm to touch). The assessment documented the primary dressing was moisture barrier, and interventions included low air loss mattress and a heel suspension device. The assessment lacked documentation of measurements of the pressure ulcer. 2/10/17 the resident's right heel pressure ulcer, with serosanguinous (semi-thick reddish) drainage, granulation (tissue formed during wound healing) 75-99%, indistinct wound edges, measured 2 (cm) centimeters long by 1 cm wide by 0.5 cm depth. 2/15/17 the resident's right heel pressure ulcer had serosanguinous drainage with red granulation, [MEDICATION NAME] (new skin growing in a superficial wound), wound edges distinct, and measured 2 cm long by 1.5 cm wide with no depth. The observation sheet documented the wound treatment consisted of hydrogel (water based gel which donates moisture and aides autolytic (the destruction of a cell through the action of its own enzymes) debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). 2/21/17 the resident's right heel pressure ulcer had distinct wound edges, measured 1 cm long by 2 cm wide. 2/28/17 the resident's right heel pressure ulcer skin had [MEDICATION NAME] tissue, distinct edges, measured 1 cm long by 1.5 cm wide, and continued the same treatment. 3/8/17 the right heel ulcer had [MEDICATION NAME], [MEDICAL CONDITION] (excessive accumulation of fluid) tissue, indistinct edges, measured 1.5 cm long by 1.4 cm wide. The facility lacked documentation of a weekly skin assessment for 3/15/17. 3/22/17 the right heel pressure ulcer had intact/pink healthy skin, measured 1 cm long by 1.5 cm wide, and had no dressing. 3/30/17 the right heel pressure ulcer had intact/pink healthy skin, measured 1 cm long by 1.5 cm wide. 4/5/17 the right heel pressure ulcer was scabbed over, had no odor, no drainage, measured 1 cm long by 1.3 cm wide, the peri wound (surrounding skin) area was light pink and approximated (to bring close together) with no inflammation and the treatment consisted of cleanse with normal saline, pat dry and cover with dry dressing. 4/12/17 the right heel pressure ulcer was improving, dry, no drainage, no odor, periwound tissue light pink, wound edges well defined, well approximated, no inflammation present, and measured 5 cm long by 3 cm wide. The treatment was the same. The facility lacked documentation of a weekly skin assessment for 4/19/17. 4/26/17 the right heel pressure ulcer had no drainage, no odor, no depth, no tunneling, and measured 3 cm long by 3 cm wide. The treatment was the same. 5/3/17 the right heel pressure ulcer was dry no depth, well approximated, no inflammation, and measured 3 cm long by 2 cm wide. 5/11/17 the right heel pressure ulcer had no depth, no tunneling , well defined approximated wound edges,and measured 3 cm long by 3 cm wide. The treatment remained the same. 5/18/17 the right heel pressure ulcer had no drainage, no odor, no tunneling, well defined wound edges, no inflammation, and measured 3 cm long by 3 cm wide. The treatment was changed to cleanse the wound area with normal saline, apply A and D ointment, cover with dry dressing, wrap with Kerlix (white gauze dressing), and top with netting. 5/25/17 the right heel pressure ulcer had no odor, no drainage, and lacked documentation of the size of the wound. The treatment remained the same. 6/1/17 the right heel pressure ulcer had no drainage, no odor, no depth, no tunneling, and measured 3 cm long by 2 cm wide. The 3/15/15 physician order [REDACTED]. The 3/15/17 at 10:56 AM, discharge instruction sheet from the wound clinic physician documented the resident had an unstageable pressure ulcer, fully covered with eschar (dead tissue), and measured 0.8 cm long by 0.6 cm wide by 0.1 cm deep. The physician instructed staff to use wedges to ensure no pressure to the lateral (side) heel area, provide an air mattress to the resident's bed and cushion (minimum of 4 inches dense foam) for sitting. The physician instructed staff to provide the resident with weight shifts every 15 minutes while in chair, ensure he/she wore Prevalon boots (pressure relief boot maintains neutral foot position and prevents leg rotation) when in bed, keep the resident up for 1 hour for meals and in the evening, and do not keep the resident up for prolonged periods of sitting. The physician instructed staff to not prop the resident up in bed more than 39 degrees, pillow float his/her heels when in bed and sitting, and pilot brace (wedge used for body positioning) the resident 30 degrees off of hips when turned in bed. The physician instructed staff to not get the wound wet when bathing or showering, clean the wound with normal saline, pat dry, apply dry gauze dressing, secure with netting and change the dressing daily. The 3/30/17 at 1:33 PM, discharge instruction sheet from the wound clinic physician documented the resident had unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, usually cream or yellow in color), and/or eschar in the wound bed) right heel pressure ulcer, with eschar fully covered extensive slough, necrotic (pertaining to the death of tissue in response to disease or injury) tissue, wound base black, no granulation, no odor, no drainage, an measured 1.1 cm long by 1.5 cm wide by 0.1 cm deep. The sheet instructed staff to continue the same treatment. The 5/10/17 discharge instruction sheet from the wound physician documented the resident had an unstageable right heel pressure ulcer, with extensive slough, yellow wound base, no granulation, no odor, scant drainage, and measured 0.5 cm long by 0.6 cm wide by 0.1 cm deep. The physician instructed staff to use bracing wedge to maintain neutral position, keep the wound clean, dry, and covered at all times, do not get wound wet, avoid prolonged periods of sitting, use a pillow to float heels when in bed and sitting, and use the same treatment. The 5/30/17 at 9:38 AM, discharge instruction sheet from the wound care physician documented the resident had an unstageable pressure ulcer on the right heel, with skin intact, and measured 0.5 cm long by 0.6 cm wide by 0.1 cm deep. The physician instructed staff to elevate the resident's feet to level of the heart, or above, for 30 minutes, and continue the same instructions from 5/10/17. On 6/1/17 at 1:02 PM, observation revealed Nurse G entered the resident's room to provide a dressing change to the resident's right heel. Nurse G laid out supplies on a clean pad on the bedside table, washed hands, applied gloves, removed the resident's Prevalon boot, gripper sock, and then removed his/her gloves. Observation revealed Nurse G applied gloves, removed the old dressing from the resident's outer right heel which revealed no drainage on the dressing. The wound area was dime sized with no drainage, pink in color, skin intact, with blackish purple area from the wound to the inner part of the heel, approximately 2 cm wide by 3-4 cm long. Nurse G stated The blackish purple area was not there the last time he/she changed the resident's dressing. Observation revealed Nurse G cleansed the area with normal saline, wiped it dry, applied A&D ointment with a sterile q-tip to the wound, covered it with an ABD dressing (used for large wounds or for wounds requiring high absorbency), topped with a netted stocking. Continued observation revealed Nurse G removed gloves, washed hands, applied new gloves, placed Prevalon boots on the resident, and placed a pillow under the resident's knees. On 6/1/17 at 1:20 PM, Nurse G stated the resident's right heel pressure ulcer was facility acquired due to the way the resident kept his/her foot on the pedals of his/her wheelchair. On 6/5/17 at 1:13 PM, Administrative Nurse A, stated he/she was the only nurse that completed the wound measurements and the weekly wound assessments and he/she had no specialized training regarding wound care. Administrative Nurse A stated he/she staged the resident's pressure ulcer as a stage 2 because that is what the prior wound nurse staged it. On 6/5/17 at 3:32 PM, Administrative Nurse A stated the resident had compression fractures to his/her back on admission, and he/she felt the facility interventions to prevent the resident from acquiring a pressure ulcer, at that time, were sufficient. Administrative Nurse A stated the reason the resident acquired a pressure ulcer to his/her right heel was due to the resident's shoes were too small. On 6/6/17 at 11:15 AM, Wound Physician D stated, when the resident admitted to the facility on [DATE], with compression fractures to his/ her back, the resident spent time in bed on his/her back, he/she would have expected staff to implement the following intervention: float the resident's heels, place protective boots on the resident's feet, provide off trochanter at 30 degree offloading (not totally on hip, shifting from side to side) every 2 hours. Wound Physician D stated he/she would expect the facility to follow his/her wound care orders. Wound Physician D stated on his/her initial assessment at the wound care clinic, he/she noted the resident acquired the pressure ulcer to his/her right heel from pressure and immobility. On 6/6/17 at 11:28 AM, Physician E stated he/she would have expected staff to implement, on admission, assessment of the resident's skin (especially his/her feet and heels), and off loading his/her feet and heels. Physician E stated when the resident first admitted he/she tried to stay ambulatory, and was up some. The facility's 1/2/14 Skin Integrity Care Delivery Process policy documented staff would evaluate the resident for the presence of specific risk factors and develop a plan of care to address individual risk factors including impaired/decreased mobility or function, and bed mobility problems. The facility failed to implement timely interventions on admission to the facility, to prevent the development of an unstageable pressure ulcer, to his/her right heel for Resident #33, who was weak, had impaired mobility, and pain from compress

The facility identified a census of 47 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to provide supervision and implement effective interventions to prevent multiple falls for two of three sampled residents. Residents #1 and #3 were identified at high risk for falls and experienced repetitive falls. Resident #1 suffered a fracture of the cervical spine and nose and a laceration which required sutures. Findings included: The physician order [REDACTED].#1's [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] identified the resident with long and short term memory problems, required extensive to total assistance of one staff for all activities of daily living except eating. This MDS identified the resident as not steady, only able to stabilize with staff assistance and a fall history. The Care Area Assessment for falls dated 9/26/14 identified the resident with a history of falls, unsteady gait and poor safety awareness. The 1/19/15 significant change Minimum Data Set (MDS) identified the resident with short and long term memory problems, required extensive to total assistance of one staff for all activities of daily living; incontinent of bowel and bladder, not steady and only able to stabilize with staff assistance. This MDS identified two falls with no injury and minor injury and one with major injury. The fall Care Area Assessment (CAA) dated 1/19/15 identified the resident as at risk for injuries due to a history of falls, impulsive behavior and poor safety awareness. A fall risk assessment dated [DATE] identified the resident as high risk for falls. A care plan dated 9/30/14 identified the resident as at risk for falls and included the following interventions: Frequent visual checks Toileting as needed Personal items in reach Diversional activity as needed Keep routine as consistent as possible Occupational and physical therapy for four weeks, discontinued 10/16/14 The medical record revealed the resident had 12 falls in 4 months. The post fall assessments, fall reports, nurses' notes and the care plan revealed the following incidents and interventions: 10/4/14 8:45 AM Tripped over feet when attempted to sit in chair in family room, no injury 10/10/14 laceration to left eye brow, found on right shoulder in room, fall mat in place 10/10/14 1:49 AM emergency room report revealed a 2 centimeter laceration above the left eyebrow from a fall that required three sutures 10/14/14: Ensure that fall mat is in place 10/25/14 12:45 PM attempted to get out of bed, observed on floor on floor mat, laceration no treatment 12/13/14 6:30 PM found on floor laying on right side in the television area, reported by another resident, had removed left sock and shoe, put into bed; action taken, fall mat by bed, bed in lowest position and resident checked often, resident continued to wander without purpose, continue 30 minute checks, keep environment clean and clutter free 12/16/14 8:13 AM resident observed on landing mat in room, had laceration on the forehead with minimal bleeding 1/3/15 2:00 PM nurse at desk giving report at change of shift, heard resident yelling help, nurse stood up from desk and observed the resident in television room laying on left side on floor, had non-skid socks on, attempted to pick trash up 1/6/15 2:10 PM in television room, got up to stand and fell on right side, appropriate footwear on, no injury, at 7:07 PM, called to area by another resident who stated the resident had fallen and hit the back of his/her head, all interventions in place, 30 minute visual checks continued, monitor closely, keep floor clear of clutter, bed low position, fall mat, call light in reach, may use wheelchair if gait unsteady 1/7/15 2:05 AM 30 minute checks, areas should be free of clutter 1/8/14 2:30 PM found on floor, face down in day/television room, bloody nose, right facial abrasion, sitting in wheelchair leaning forward, appeared to be trying to move his/her wheelchair, nurse looked up and saw him/her laying on floor with the wheelchair on top of him/her, bleeding from nose and small cut below the left eye, fall not witnessed, in wheelchair due to unsteady gait, resident bent over in wheelchair and fell to floor, resident transferred to emergency room 1/8/15: Action plan for fall check every 15 minutes and repositioned, up in chair for only one hour at a time, continue bed in lowest position, landing mat on floor, ambulate as tolerated, may be up in wheelchair with cushion 1/8/15 emergency room report, timed 4:30 PM: computerized tomography (radiological technique that produces images of cross sections through a patient's body using low levels of radiation) acute displaced fracture (broken bone) of the nasal arch (bridge of the nose) and septum (The wall dividing the nasal cavity into halves), cervical (related to the neck) fracture and cervical collar (provide substantial motion restriction) applied 1/17/15 3:30 PM found by visitors passing by door, all interventions in place, visual checks every 15 minutes with repositioning, up in chair for one hour only, low bed, landing mat at bedside, 15 minute rounds 1/19/15 1:00 PM on knees beside bed on fall mat, bed in lowest position, non-injury, interventions in place, 15 minute checks, up in chair for one hour, toilet often before and after meals, and if restless or requests 1/23/15 2:00 PM found on fall mat next to bed laying on right side, found by another resident, small laceration outer right eye, action taken fall mat, 15 minute visual checks, call light in reach 1/28/15 3:00 AM found lying on floor on back on mat beside bed, reddish/purple area above right eye, action taken, 15 minutes checks, taken to toilet Observations on 2/6/15 revealed the following: 9:20 AM Resident #1 sat in a wheelchair in the day/television room and wore a cervical collar. A tray table with tools and gadgets were on the table. Resident #1 was not engaged in the activity and pushed the tray table forward as he/she propelled the wheelchair. 9:37 AM Direct care staff (DCS) A propelled Resident #1 to his/her room Direct care staff (DCS) A and B applied a gait belt and transferred him/her to the toilet, back to the wheelchair and then transferred the resident into bed. Staff placed in the lowest position, with a fall mat directly beside it and the call light provided to the resident. At 12:02 PM Resident #1 sat in his/her wheelchair in the dining room with staff present until 1:03 PM when DCS C wheeled him/her to the room. DCS B and C then toileted the resident and put him/her to bed. Staff placed the mat on the floor, lowered the bed and provided the call light. In an interview with DCS A on 2/6/15 at 9:37 AM she/he stated the resident usually pulled the call light out of the wall when he/she was restless and wanted out of bed. DCS A stated the resident wore the cervical collar at all times, required total care with all activities of daily living (ADLs), and staff checked the resident every 15 minutes. Further interview revealed that prior to the fall when the resident fractured his/her nose and neck the resident was on 30 minute checks. In an interview with DCS B on 2/6/15 1:17 PM she/he stated Resident #1 required total care for all activities of daily living and wore a neck collar at all times. Prior to the fall on 1/8/15 when the resident suffered the fractures, the resident was up walking around, staff took the resident for walks and the resident also used a wheelchair when he/she was unsteady. In an interview with DCS C on 2/6/15 1:27 PM, it was stated that at the time of Resident #1's fall on 1/8/15, she/he was at the end of 100 hallway. She/he stated the resident was in the television room and was not sure what happened. At the time of the fall, interventions were the same as they currently were. DCS C stated the resident required total care and walked with his/her walker previously and on occasion became unsteady. In an interview with Licensed Nurse (LN) A on 2/6/15 at 2:30 PM, Resident #1 was unsteady when he/she walked and should not have been walking by him/herself. She/he stated interventions used for fall precautions included low beds, floor mats, and recently staff began to place residents at high risk at the nurses' station. She/he stated Resident #1 fell twice when she/he was on duty and both times nurses were at the desk getting report. When Resident #1 fractured his/her nose and neck, she/he heard the resident fall but did not actually see the incident. In an interview with Licensed Nurse (LN) B on 2/9/15 at 3:02 PM and 6:20 PM, it was stated she/he was at the nurses' station getting report and the resident sat in a wheelchair in the television/day room. LN B stated the resident could not be visualized where he/she sat behind the desk. Further interview revealed she/he observed the resident earlier leaning over in the wheelchair as if propelling the wheelchair. At the time of the observation, she/he could not remember if staff attempted to sit the resident in an upright position. LN B stated Resident #1 must have fallen forward out of the wheelchair as the wheelchair was on top of the resident. Staff was not present in the television/day room at the time of the fall. Prior to the last few falls Resident #1 used a walker, would ambulate throughout the facility, at times would be unsteady when ambulating. LN B stated just the past 3 to 4 weeks the facility began to keep wandering residents at the nurses' station for closer observation. During interviews on 2/6/15 at 4:42 PM and 2/10/15 at 3:35 PM administrative nurse (AN) A stated Resident #1 wandered about the facility looking for his/her spouse and it was difficult to determine exactly what to do for the resident's multiple falls due to his/her dementia. He/she stated at the time of the cervical and nose fractures Resident #1 sat in a wheelchair in the television/day room. Nurses were at the station giving report but were not able to visualize the resident. Further interview revealed the facility reached a point when they did not know what other intervention to implement for fall prevention and the facility attempted to keep Resident #1 safe. AN A also stated recently the facility implemented that at the time of shift change and in the early afternoon, staff placed residents at risk for falls were placed in the television/day room area for closer observation. An additional intervention included to place residents at the nurses' station around supper time so they could be observed closer. Further interview revealed the facility recently implemented that ancillary staff would be in the television/day room or the dining room for closer observation of residents. AN A stated the facility's interdisciplinary team met weekly to go over falls trying to determine why residents were falling and at that time went over residents' care plans. AN A confirmed the facility had not completed an assessment of Resident #1's numerous falls until recently to determine causal factors and appropriate interventions. It was also confirmed the 15 minute checks were not effective for this resident. The October 2014 facility policy and procedure for Incident/Accident Management recorded the following: Identify environmental hazards and individual resident risk of an accident, including the need for supervision, evaluate/analyze the hazards and risks, and implement interventions, including adequate supervision, and monitor the effectiveness of the interventions and modify the interventions as necessary. The policy further identified the interdisciplinary team would meet to review circumstances, determine causal factors if possible and make recommendations for additional interventions as appropriate. Assign responsibility to team members to assure follow through and effectiveness of new interventions. The facility failed to provide adequate supervision, evaluate and determine potential causal factors, and develop appropriate interventions to prevent further falls for Resident #1, who had multiple falls, sustained a laceration that required sutures and nasal and cervical fractures. - The physician order [REDACTED].#2's [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident with a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition and required extensive to total assistance of one staff for all activities of daily living. The MDS also identified the resident as not steady, only able to stabilize with staff assistance, and a fall history with 2 non-injury falls. The 1/14/15 annual Minimum Data Set (MDS) identified the resident with short and long term memory problems, required extensive to total assistance of one staff for all activities of daily living; frequently incontinent of bowel and bladder, not steady and only able to stabilize with staff assistance. This MDS identified two falls with no injury and two with minor injury. The Care Area Assessment for falls dated 1/14/15 identified the resident with a history of falls, poor safety awareness and impulsive. The fall risk assessment revealed the resident was at high risk for falls on 11/30/14. The care plan dated 1/31/14 identified the resident as at risk for falls and included the following interventions: Frequent visual checks when walking by room Physical and occupational therapy 5 times a week Leave night light on in room at night Assist with stand by assist with ambulation as needed Encourage use of roller walker and keep within reach The post fall assessments, fall reports, nurses' notes and the care plan revealed the following incidents and added/changed interventions: 6/21/14, no time documented on care plan, on floor in doorway of bathroom in room, had brief around ankles, nursing to assist with toileting needs 7/21/14 encourage resident to wear gripper socks at all times, if refuses place shoes on feet 8/14/14 padded floor mat beside bed at all times 8/30/14 review medications 11/6/14 continues to be noncompliant and leaves recliner in a semi sitting position, nursing to continue to keep chair in the lowest seated position 11/28/14 6:45 PM found sitting beside recliner in room, encourage call light, gripper socks, toilet 12/7/14 11:00 AM walking unassisted in hallway with walker, found on floor 12/14/14 5:30 PM found by another resident on knees next to recliner, right knee abrasion 12/19/14 6:30 PM found on floor next to recliner 1/1/15 12:40 PM found sitting on floor at the end of 100 hallway 1/13/15 4:00 AM sitting on floor between recliner and door to hallway, skin tear on right elbow, resident stated he/she was cold 1/19/15 8:20 AM found on floor by housekeeping laying on right side and had his/her pants around ankles, incontinent of bowel, hit buttocks on trash can beside chair, moderate bleeding from abrasion, hematoma on left buttocks The plan of care was updated on 1/27/15 to include check and assist with toileting 3 to 4 times per shift and stay in bathroom with resident The post fall assessments and nurses' notes revealed the following incidents: 2/1/15 7:25 AM loud noise heard, found resident in middle of room, large skin tear left forearm and open area on crown of head 2/1/15 4:25 PM resident taken to bathroom to toilet by certified nurse aid (CNA), CNA left the resident in the bathroom for a minute to answer another call light and returned to find this resident sitting on the floor in front of the commode. Action taken: monitor closely, wanderguard bracelet, call light in reach. Resident has no recall of what had happened or why he/she fell secondary to dementia. Continue to receive physical and occupational therapy 2/8/15 5:30 PM found sitting on floor next to recliner in room sitting on buttocks, skin tear left arm, the resident stated, "I was trying to get up". Action taken included fall mat, monitor frequently, call light in place Observations on 2/6/15 revealed the following: 10:25 AM Resident #2 sat in a recliner in his/her room with eyes closed and the floor mat was visible in front of the recliner. The family was present at the resident's side. 11:12 AM Resident #2 remained in the recliner with his/her feet up and eyes closed. The call light was on the bed and out of reach of the resident. At 11:37 AM Resident #2 sat upright in the recliner with a tray table in front of him/her with the lunch meal on the table. The resident sat with eyes closed and not eating. At 11:43 AM staff removed the meal, reclined the resident in the recliner and provided the call light for use. At 12:30 PM the resident sat in the recliner, restless and fidgeted with the call light. In an interview with DCS B on 2/6/15 at 1:17 PM she/he stated Resident #2 was confused, required total care, could be combative, and tried to elope on occasion. DCS B also stated fall precautions for this resident included fall mat, low bed, ate in room always, and most recently added was the resident was the first resident to be fed, which helped a lot with his/her behaviors and falls. Further interview revealed today the resident was sleepier than normal. In an interview with DCS A on 2/6/15 1:24 PM she/he stated Resident #2 required total care for all activities of daily living and had falls. DCS A also stated Resident #2 ate in his/her room for all meals. Fall precautions for Resident #2 included a fall mat, low bed and 30 minute checks. It was further stated that during the most recent fall the resident got up from the recliner, fell backwards and hit his/her head. He/she was not aware of any additional interventions added since the fall. Interview with DCS D on 2/6/15 at 2:07 PM it was stated Resident #2 will get up from his/her recliner and walked around the room. She/he stated the resident required total care with all ADLs and could become combative with staff. Further interview revealed the resident was unsteady when he/she ambulated. In an interview with Licensed Nurse (LN) A on 2/6/15 at 2:30 PM, Resident #2 was unsteady when he/she walked but she/he had observed the resident become combative if staff attempted to walk with him/her. In an interview with Licensed Nurse (LN) B on 2/6/15 at 3:02 PM, he/she stated Resident #2 could be redirected if he/she exhibited behaviors. LN B stated Resident #2 walked around but was unsteady and will occasionally used a walker. She/he stated this resident should not be left alone in the bathroom due to being unsteady with balance and gait. During an interview on 2/6/15 at 4:42 PM administrative nurse (AN) A stated Resident #2 wandered about the facility looking for his/her spouse and became agitated if staff attempted to intervene. The resident did not handle the walker well and became unsteady. Further interview revealed Resident #2 should not be left alone on the toilet and at the time of the interview was not aware of the incident on 2/1/15 when a DCS left the resident alone and fell . AN A staff added a rubber mat was added in front of the recliner because the resident would slide out of the recliner. AN A also stated recently the facility implemented a different meal time for Resident #2 and he/she was now served first. Further interview revealed the facility recently implemented that ancillary staff would be in the television/day room or the dining room for closer observation of residents. AN A stated the facility's interdisciplinary team met weekly to go over falls trying to determine why residents were falling and at that time went over the care plan. The October 2014 facility policy and procedure for Incident/Accident Management recorded the following: Identify environmental hazards and individual resident risk of an accident, including the need for supervision, evaluate/analyze the hazards and risks, and implement interventions, including adequate supervision, and monitor the effectiveness of the interventions and modify the interventions as necessary. The policy further identified the interdisciplinary team would meet to review circumstances, determine causal factors if possible and make recommendations for additional interventions as appropriate. Assign responsibility to team members to assure follow through and effectiveness of new interventions. The facility failed to provide adequate supervision, follow the care plan, evaluate and determine potential causal factors, and develop appropriate interventions to prevent further falls for Resident #2, who had multiple falls.