Every finding on record at West Hills Health & Rehabilitation

Based on observation, interview, and record review it was determined the facility failed to ensure proper personal hygiene practices and safe food storage handling techniques for 1 of 1 facility kitchen and 2 of 2 facility ice machines reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illnesses. Findings include: On 4/21/25 at 9:50 AM, Staff 29 (Cook) was observed to have head and facial hair exposed with no facial and head hair restraints. Staff 30 (Cook) was observed to have with facial hair exposed and no facial hair covering. Staff 29 and Staff 30 were actively prepping the lunch meal. On 4/21/25 at 10:20 AM, Staff 8 (AM Dining Services Director) acknowledged hair and beard nets were to be worn at all times when working in the kitchen. She stated the facility provided hair restraints for all staff. On 4/23/25 at 11:10 AM, Staff 7 (PM Dining Services Director) was observed to pick up a pen off the floor and then changed her gloves without performing hand hygiene. Staff 7 confirmed she did not wash her hands after removing her gloves and putting new gloves on. On 4/23/25 at 11:20 AM, Staff 8 was observed plating food for the lunch meal. Staff 8 did not performed hand hygiene. On 4/25/25 at 9:56 AM, Staff 8 stated there were multiple signs in the kitchen to remind staff to practice proper hand hygiene and agreed hand hygiene was required after the removal of gloves. On 4/24/25 at 2:45 PM, a sealed plastic bag of raw chicken dated 4/21/25 was observed in a gray bin on the bottom shelf of the kitchen refrigerator. An undated plastic container with sliced tomatoes was observed on a shelf in the refrigerator. On 4/24/25 at 2:47 PM, Staff 29 stated frozen food could thaw in the refrigerator for up to five days. Staff 7 stated raw poultry needed to be used within one to two days. Staff 7 confirmed the lack of proper labeling for the chicken and tomatoes and stated undated food items were to be discarded. On 4/25/25 at 9:56 AM, Staff 8 stated all meat and poultry transferred into the refrigerator from freezer to thaw, should be discarded within three days. Staff 8 confirmed staff did not properly label and did not properly perform food storage practices. On 4/23/25 from 2:05 PM to 2:26 PM, observations of the facility's unit refrigerators found the following: - [NAME] unit: an undated banana cream pie and a plastic container of unidentifiable food. - East unit: an undated plastic container with unidentifiable food and decorated Easter eggs on a plate. - East Bistro unit: an undated partial eaten container of sushi and a plastic container of unidentifiable food. On 4/23/25 at 2:26 PM, Staff 37 (CNA) was observed placing an undated soup container in the East unit refrigerator. On 4/24/25 at 2:34 PM, Staff 37 (LPN) stated staff were to label food items with the resident's name and opened date. She stated the kitchen staff discarded undated food items. On 4/24/25 at 2:56 PM, Staff 7 stated it was the responsibility of unit staff to discard undated items in the unit refrigerators. On 4/25/25 at 9:56 AM, Staff 8 stated the cook was responsible to discard all undated food items in the unit refrigerators. Staff 8 stated this was an ongoing problem. On 4/24/25 at 9:45 AM, the automatic ice machine, located outside the kitchen entry area, was observed draining condensation into a transparent plastic container which was placed inside the drain area. The plastic container was observed to contain a pool of dirty water from the ice machine. There was also a sealed plastic wrapped food item in the plastic container. The upper inside section of the ice maker was observed to have black spotting. On 4/24/25 at 10:06 AM and at 10:15 AM, Staff 8 stated the Dining Services Director who works in the evening sanitizes the ice machine located in the kitchen. Staff 8 was unable to identify the plastic wrapped food found under the ice machine. Staff 8 discarded the plastic container and unidentified wrapped food item. Staff 8 used a paper towel to wipe the inside of the ice machine lid, and a black substance transferred to the paper towel. Staff 8 confirmed the black spotting on the inside of the ice machine lid. Staff 8 immediately stopped use of the ice machine and proceeded to clean it. On 4/24/25 at 9:15 AM, the drain pipes under the east bistro automatic ice machine was observed to be covered in dark brown and black speckles with slimy substance upon touch. Some areas appeared to have been covered with black mold. The area where the ice maker releases the ice was covered with a pink mold substance that touched the ice when dispensed. On 4/24/25 at 09:38 AM, Staff 34 (CNA) was observed getting ice from the east bistro ice machine and took it to a resident. Staff 34 was asked to remove the cup of ice from the resident's room. On 4/24/25 at 10:00 AM, Staff 32 (Maintenance Director) stated maintenance staff was responsible for sanitizing the ice machine located at the east Bistro. Staff 32 touched the two drain pipes under the ice machine, and she confirmed it was covered with debris and chunks of dark grain. With her left index finger, Staff 32 touched the inside of the dripping pipe, and her finger was covered with slime. On 4/25/25 at 11:09 AM, Staff 1 (Administrator) was informed of the findings and stated it was a great learning opportunity.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled resident (#293) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration. Findings include: The facility's Self-Administration of Medications policy, dated 11/20/16, revealed: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident 293 admitted to the facility in 4/2025 with diagnoses including spinal stenosis (a condition were the spaces within the spine narrow). A review of Resident 293's record revealed there was no assessment for Resident 293 to self-administer medications. On 4/21/25 at 9:57 AM Resident 293 was observed alone in her/his room with a small cup on her/his bedside table, the cup contained multiple medications. On 4/21/25 at 12:23 PM Resident 293 was in her/his room, the same cup with medications was on the bedside table. Resident 293 stated she/he was waiting for someone to tell her/him what the medications were. On 4/21/25 at 12:29 PM Staff 39 (LPN) confirmed the medications were on Resident 293's bedside table and stated she passed medications that morning but Resident 293 was in the restroom when the morning medications were delivered to the room. Staff 39 confirmed the following medications were in the cup on Resident 293's bedside table: - Cholecalciferol Oral Tablet (Vitamin D supplement) - Lansoprazole (medication for indigestion and acid reflux) - Docusate Sodium (stool softener) - Duloxetine HCl (an antidepressant) - Probiotic - Sennoside (a medication used to treat constipation). On 4/24/25 at 11:13 AM Staff 2 (DNS) confirmed Resident 293 was not assessed for self administration of her/his medications and should not have medications left in her/his room.

Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 3 of 3 sampled residents (#s 45, 62 & 392) reviewed for advance directives. This placed residents at risk for not having health care decisions honored. Findings include: a. Resident 45 admitted to the facility in 2/2025 with diagnosis including chronic inflammatory demyelinating polyneuritis (an autoimmune disease that leads to weakness). Resident 45's care plan initiated 4/24/25 indicated advance directives are in effect, and they will be carried out in accordance with the wishes on an ongoing basis. A 2/26/25 care conference note indicated an advanced directive was reviewed. A review of Resident 45's clinical record found no advanced directive. During an interview on 04/22/25 11:45am Resident 45 stated she/he had not completed an advanced directive. During an interview on 4/23/24 at 2:31pm Staff 11 (Social Services Coordinator) stated Resident 45 did not have an advanced directive on file, could not remember whether Resident 45 had an advanced directive, and she/he should have followed up with Resident 45 about this, but had not. b. Resident 62 admitted to the facility in 4/2025 with diagnosis including sepsis (an extreme inflammatory response to an infection) and metabolic encephalopathy (a disease that alters brain function). Resident 62's care plan initiated 4/7/25 indicated advance directives are in effect, and they will be carried out in accordance with the resident's wishes on an ongoing basis. An 2/22/24 Care conference note indicated Resident 62's advance directive was reviewed. A review of resident 62's clinical record found no advanced directive. During an interview on 4/22/25 at 11:50am Resident 62 stated she/he was not sure if she had an advance directive completed. An interview with Staff 11 (Social Services Coordinator) on 4/24/25 at 12:02pm confirmed Resident 62 did not have an advanced directive on file. c. Resident 392 admitted to the facility in 3/2025 with diagnoses including stroke. Resident 392's care plan initiated on 3/28/25 indicated advance directives are in effect, and they will be carried out in accordance with the resident's wishes on an ongoing basis. A 3/31/25 Care conference note indicated Resident 392's advanced directive was reviewed and documentation was needed from the POA. A review of Resident 392's clinicial record found no advanced directive and no evidence a POA was contacted. During an interview on 4/22/25 at 9:50am Resident 392 stated she/he had an advanced directive but wasn't sure if the facility had a copy of it. She/he said it would benefit the facility to know his/her wishes. During an interview on 4/23/25 at 2:31pm Staff 11 (Social Services Coordinator) confirmed Resident 392 did not have an Advanced Directive on file. She/he stated the initial checkmark in the 3/31/25 care conference indicated that it was requested or discussed and that she/he should have followed up with the resident to get the advanced directive since the care conference and had not. During an interview on 4/25/25 at 9:27am Staff 1 (Executive Director) stated during the admission process the facility provided a blank advanced directive in the paperwork and further stated ideally all advance directive follow-up was documented.

Based on interview and record review it was determined the facility failed to provide education and training for the self-administration of an anticoagulant subcutaneous medication prior to discharge for 1 of 3 sampled residents (#2) reviewed for discharge. This placed residents at risk for an unsafe discharge. Findings include: The 10/14/24 Facility Discharge Planning Policy stated it is the facility's responsibility to develop and implement an effective discharge planning process that focused on the resident's discharge goals, and the preparation of residents to be active partners so they may be effectively transitioned into post-discharge care to prevent readmissions. This included an evaluation of the resident's discharge needs, the development of a final discharge plan, and continuous education to be provided to the resident and the resident's family to ensure any unnecessary delays in the resident's care post discharge. Resident 2 was admitted to the facility in 2024, with diagnosis including left femur fracture and stroke. Resident 2's Care Plan revealed the resident received subcutaneous injectable anticoagulant therapy with interventions that included resident, family and caregiver training and education on medication administration. A review of Resident 2's July MAR revealed the resident was prescribed a subcutaneous injectable medication upon admission that was used to treat blood clots. The medication prescribed was noted with an end date of use by 7/10/24. Resident 2 was noted to have discharged from the facility on 7/1/24 with the prescription still in active use. Additional review of Resident 2's progress notes and assessments revealed no documentation Resident 2 or her/his representative were trained and educated on self-administration of the injectable medication. On 12/10/24 at 10:21 AM, Staff 4 (LPN) stated she was the nurse responsible for discharge planning. Staff 4 stated it was the facility's procedure for the nurse to review all medications including how to administer medications upon discharge. Staff 4 stated she could not confirm if Resident 2 received training and education on how to administer injectable anticoagulant therapies. On 12/10/24 at 11:48 AM, Staff 3 (RNCM) stated the facility had no documentation to show the resident safely discharged from the facility with the training on how to self-administer the injectable anticoagulant medication. Staff 3 stated it was the expectation of care staff to document, train and educate residents on self-administration of medication prior to discharge. On 12/11/24 at 11:09 AM, Staff 2 (DNS) confirmed findings and stated the facility was responsible in ensuring residents and resident representatives were to be trained on how to administer medications prior to discharge.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#5) reviewed for medication administration. This placed residents at risk for adverse medication consequences. Findings include: The Facility's 10/14/24 Medication Administration Procedure revealed the following: Medication Incidents are to be reported to the Director of Nurses so that an investigation can be initiated. Medication incidents are incidents where medication is omitted from the order, administered to the incorrect resident, provided with the wrong dosage, form, route or time of administration, and/or provided with unprescribed medications. When the incident is made, the person committing the incident shall: - Notify the nurse of the resident (if this incident is made by the nurse, then the supervisor or DON is to be notified immediately). - Complete a medication incident form when appropriate which will go directly to the DNS and the ED. - Notify the MD, family, and relay physician response. - Record the facts in the resident chart, indicate physician notified regarding medications and family and clinical outcomes as appropriate. When the incident is discovered on a subsequent shift, the person discovering the incident will be responsible for notifying the charge nurse and the physician and initiating the medication incident form. The DON will follow facility protocol including follow up with any person or persons involved in medication error and ensure the completion of the incident report. Resident 5 was admitted to the facility in 2024, with diagnosis including hypothyroidism and hypertension. A review of Resident 5's December MAR revealed the resident was ordered levothyroxine 25 mcg (a thyroid hormone medication) and spironolactone 25 mg (a blood pressure medication) that was to be administered at 6 AM before meals. The MAR indicated the resident was not administered any of the medications. On 12/10/24 at 3:09 PM, Staff 6 (LPN) confirmed Resident 5 was not administered his/her thyroid medication or blood pressure medication. Staff 6 stated she wasn't aware of when or what time Resident 5's morning medications should be administered. Staff 6 stated it was not her responsibility to review any previous medication passes to confirm if they had been completed by the last shift. Staff 6 stated she did not report this missed medication administration to the RCM, DNS or the Physician. On 12/11/24 at 11:03 AM, Staff 2 (DNS) confirmed findings and indicated the oncoming nurse failed to review the previous med pass to ensure they were completed. Staff 2 stated it was the responsibility of the oncoming facility nurse to ensure all medications had been passed when beginning their shift. Staff 2 indicated it is the expectation of the facility that any nurse who discovered a medication error should report it to the DNS, RCM, and Physician and file an incident report.

Based on interview and record review it was determined the facility failed to ensure sufficient dietary staff were available to ensure food service was delivered in a timely manner for 1 or 1 kitchens reviewed. This placed residents at risk for unmet nutritional needs. Findings include: A public complaint was made to the state agency on 10/9/23 which alleged all meals were served late daily and timeliness had been an issue for several months. Witness 2 (Complainant) stated meals were served hours after the posted times and residents complained to staff their meals were late. On 5/1/24 at 2:51 PM, the Resident Council President stated the food was always served late and at times was cold. On 5/7/24 at 11:30 AM, Staff 10 (Cook) stated the dining room was served meals first, then east hall due to several residents who required one to one assistance with eating, then west hall and lastly, the skilled hall. Staff 10 stated there were staffing shortages in the facility. On 5/8/24 at 1:15 PM, Staff 5 (CNA) stated there was a shortage of dietary staff last fall and CNA's were told meals would be late due to the staff shortages. Staff 5 stated the meals were still served late on weekends and could be up to 45 minutes late. On 5/9/24 at 9:08 AM, Staff 6 (CNA) stated meals were served at least 45 minutes late and it was worse on weekends. Staff 6 stated there currently was still a shortage of dietary staff. On 5/9/24 at 1:30 PM, Staff 1 (Administrator) acknowledged meals were served late and she was in the process of hiring a new Dietary Manager.

Based on interview and record review it was determined the facility failed to implement care plan interventions to ensure adequate supervision was provided to prevent accidents for 1 of 3 sampled residents (#100) reviewed for hot beverage safety. This placed residents at risk for accidents. Findings include: Resident 100 was admitted to the facility in 2020 with diagnoses including encephalopathy (a disturbance of brain function) and dementia. Resident 100's care plan dated 3/22/23, revealed she/he was on an altered diet and required one to one supervision for meals to encourage intake. A care plan revision dated 4/11/23, noted that staff were not to leave cups in front of her/him without supervision. On 3/27/23 the facility submitted a report to the state agency which revealed Resident 100 was given a hot cup of tea on 3/26/23. Resident 100 picked up the cup, dropped it and some of the hot liquid splashed on her/his left thigh which resulted in a first degree burn. Resident 100 was not interviewed due to she/he was discharged from the facility. On 5/8/24 at 1:15 PM, Staff 5 (CNA) recalled the incident from 3/26/23 and stated an agency staff was assigned to supervise Resident 100 while she/he was eating in the dining room. Staff 5 stated she saw the resident grab the cup and it looked like the resident was about to throw it down. Staff 5 stated she walked to the nurse's station for about 30 seconds and by the time she walked back into the dining room, Resident 100 had dropped the cup and had hot liquid on her/his leg. Staff 5 did not recall where the agency staff was but confirmed the staff was not assisting Resident 100 with eating or drinking. On 5/9/24 at 11:44 AM, Staff 2 (DNS) stated she completed the risk management form related to Resident 100's burn. She stated the resident sustained a first degree burn with no blisters as a result of the liquid spill on 3/26/23.

Based on observation, interview and record review it was determined the facility failed to ensure meals were served in a palatable and at appetizing temperatures for 2 of 2 sampled residents (#s 105 and 106) reviewed for food. This placed residents at risk for unmet nutritional needs. Findings include: The facility's Food Temperature policy, revised 8/2023, noted food should be transported as quickly as possible to maintain temperatures for delivery and service. The facility's 3/2024 Resident Council notes documented the food is always cold and tasteless, have to ask for coffee 2X (two times) because it's cold and portions are inconsistent. Resident 105 was admitted to the facility in 2022 with diagnoses including acute cystitis (bladder infection) and weakness. On 5/1/24 at 3:16 PM, Resident 105 stated the food was terrible and she/he usually ate peanut butter and jelly sandwiches for lunch and oatmeal and cinnamon rolls for dinner. She/he stated the scalloped potatoes were hard and most meals were not palatable. Resident 106 was admitted to the facility in 2023 with diagnoses including transverse myelitis (inflammation of the spinal cord) and Hepatitis B. On 5/7/24 at 11:49 AM, Resident 106 stated the food was horrible after the menus changed and the quality of the food had gone downhill. Resident 106 stated she/he ate salads the majority of the time due to the poor food quality. On 5/1/24 at 2:51 PM, the facility's Resident Council President stated the food was always late and at times was cold. She/he stated there had been complaints during Resident Council meetings about the food. On 5/2/24 at 12:53 PM, Staff 7 (CNA) stated almost all the residents complained the food was too cold, too salty, the meat was overcooked and the food was not palatable. On 5/7/24 at 1:25 PM a test tray was sampled. The meal consisted of shrimp coated in breading, salad, rice with vegetables, and sauteed vegetables. The shrimp's coating did not appear to be cooked and the shrimp was lukewarm, the rice was bland, had no taste and the sauteed vegetables were mushy and unappetizing. On 5/7/24 at 4:20 PM, Staff 9 (National Culinary Director for The [NAME] Group) stated the company used a standardized program across the country. Staff 9 stated he met with residents on 5/7/24 to discuss the food situation and the company was in the process of hiring a new dietary manager and acknowledged residents had complained about the food's palatability. On 5/9/24 at 9:08 AM, Staff 6 (CNA) stated about 90% of the residents complained the food was not palatable. On 5/9/24 at 1:30 PM, Staff 1 (Administrator) acknowledged there were multiple complaints about the food and she was working on hiring a new dietary manager.

Based on interview and record review it was determined the facility failed to administer medication as ordered for 1 of 6 sampled residents (#485) reviewed for medication administration. This failure resulted in an increased potassium level and required Resident 485's hospitalization . Findings include: On 6/14/23, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and staff were trained on steps to take if a medication was thought to be missing which included: -Performing a thorough search of all med carts and the med room including the refrigerator to find the missing medication. -Placing notes on or in the med cart to advise oncoming workers of a medication's location. -Providing detailed documentation of why the medication was not given beyond only writing unavailable. -Notifying the provider and documenting when the provider was notified. According to the National Library of Medicine, revised 6/20/23, the normal range for potassium is 3.7 milliequivalent per liter (mEq/L) to 5.2 mEq/L. High levels of potassium can result in decreased heart muscle activity and can lead to life-threatening heart problems. Resident 485 was admitted to the facility in 5/2023 with diagnoses including chronic kidney disease. Hospital discharge orders from 5/9/23 included instructions for Resident 485 to receive patiromer sorbitex calcium (used to treat high blood potassium) at 8.4 grams once a day for hyperkalemia (a high potassium level). A review of Resident 485's 5/2023 medication orders included documentation the medication was received at the facility on 5/10/23. A 5/2023 MAR revealed Resident 485 did not receive patiromer sorbitex calcium on 5/10/23, 5/11/23, 5/12/23, 5/13/23, 5/14/23, 5/15/23, 5/16/23 and 5/17/23. A review of Resident 485's progress notes from 5/10/23 through 5/17/23 revealed daily notes which stated the patiromer sorbix calcium medication was unavailable. A 5/17/23 hospital progress note indicated Resident 485 underwent a blood lab test while at a doctor's appointment. Lab results revealed Resident 485's potassium level was 6.6 mEq/L. A Progress Note from 5/17/23 at 7:48 PM reported Resident 485's nephrologist (a physician specializing in kidney function) contacted the facility to inform staff Resident 485's potassium was at a critical level and wanted her/him to be admitted to the emergency department for treatment. A review of hospital records revealed Resident 485 was admitted to the hospital on 5/17/23 and required hospital care until she/he discharged home on 5/31/23. On 12/15/23 at 11:29 AM Staff 2 (DNS) stated Resident 485's kidneys did not function properly and required patiromer sorbix calcium to allow Resident 485 to have controlled potassium levels. Staff 2 stated heart problems were the biggest concern as a result of Resident 485's high potassium level. Staff 2 confirmed a major mistake was made with Resident 485 not receiving the patiromer sorbix medication as ordered to control potassium levels which resulted in Resident 485 requiring emergency hospitalization .

Based on interview and record review, it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of waterborne pathogens for 1 of 1 facility reviewed for infection control. This placed all residents at risk for exposure to waterborne pathogens. Findings include: On 12/14/23 at 9:53 AM Staff 20 (Maintenance Director) confirmed he was in charge of the facility's legionella program and reported he did not receive any training on how to protect the facility from waterborne pathogens such as legionella. He also stated was not aware of the need to complete a thorough analysis of the facility's water systems to identify and address the risk of waterborne pathogens such as legionella. Staff 20 reported he did not know where to find a water flow chart that would help to identify problem areas within the facility's system. He added, It's probably in a set of plans somewhere. Staff 20 confirmed he tested water temperatures but did not complete any other testing of the facility's water supply nor did the facility contract with an agency to conduct a risk assessment or testing of the water supply on their behalf. Staff 20 confirmed the absence of a sustainable plan to mitigate the risks associated with the waterborne pathogens in the facility's water system. On 12/14/23 at 10:45 AM Staff 1 (Administrator) acknowledged these findings and confirmed she expected Staff 20 to understand the risks associated with waterborne pathogens and to have a plan in place to minimize risks to the facility's residents. 47000 Based on observation, interview and record review it was determined the facility failed to ensure appropriate hand hygiene was performed for 1 of 1 sampled staff (#7) and 1 of 1 sampled resident (#74) observed during respiratory and stoma care. This placed residents at risk for acquiring an infection. Findings include: The facility's 10/2023 Hand Hygiene Policy revealed the following: -Hand hygiene was required before and after manipulation of intravenous therapy sites, tube feeding sites and/or tubing and after contact with blood, urine, feces, oral secretions, mucous membranes or broken skin. -The facility would follow current CDC recommendations for hand hygiene techniques and recommended hand hygiene products. 1. The CDC's 1/20/20 Hand Hygiene in Healthcare Settings Guidance directed healthcare personnel to use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Before handling invasive medical devices. -After contact with blood, body fluids or contaminated surfaces. -Immediately after glove removal. Resident 74 was admitted to the facility in 6/2023 with diagnoses including acquired absence of larynx (voice box). Resident 74's 9/2023 Quarterly MDS indicated the resident was cognitively intact and received tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help with breathing) care. Resident 74's 12/2023 Physician Orders directed the following: -Laryngectomy tube (a soft flexible silicone tube that fits inside the opening between windpipe and food pipe) care four times a day for respiratory care. -Remove laryngectomy tube, run in running water and dry before reinserting. -Apply lubrication to tube to ease reinsertion. -Notify physician of any issues. On 12/13/23 at 12:39 PM Staff 7 (RN) was observed to perform laryngectomy care for Resident 74. After donning gloves, Staff 7 removed the resident's laryngectomy collar (a medical device used to secure a laryngectomy tube in its position) and tube and cleaned the blood out of the tube. After the tube was cleaned, Staff 7 removed her soiled gloves, donned a pair of clean gloves, reinserted the resident's tube and replaced her/his collar. Staff 7 was not observed to perform hand hygiene prior to reinserting the resident's tube. Staff 7 stated she did not perform hand hygiene following the removal of soiled gloves and prior to a sterile procedure as it made it difficult to get a new pair of gloves on and she felt changing gloves without performing hand hygiene was adequate. On 12/14/23 at 3:45 PM Staff 2 (DNS) acknowledged the findings and stated she expected staff to perform hand hygiene following the removal of soiled gloves and prior to starting a sterile procedure. 2. Resident 74 was admitted to the facility in 6/2023 with diagnoses including acquired absence of larynx (voice box). Resident 74's 9/2023 Quarterly MDS indicated the resident was cognitively intact and used a feeding tube. Resident 74's 12/2023 TAR indicated the following: -Begin teaching resident to do cares in preparation to going home. Teach hands on training for cleaning and replacing G-tube (a gastronomy tube inserted through the belly that brings nutrition directly to the stomach) and J-tube (a jejunostomy tube that delivers food and medicine) dressings. -Cleanse G-tube site with wound cleanser. Pat dry, apply skin prep (a skin protectant wipe), apply split drain gauze (dressings designed to fit around tubing) and secure with tape. Change BID. -Cleanse J-tube site with wound cleanser. Pat dry, apply skin prep, apply split drain gauze and secure with tape. Change BID. On 12/13/23 at 12:39 PM Staff 7 (RN) was observed to assist Resident 74 with the replacement of her/his G and J-tube dressings. Without being offered or performing any hand hygiene and with bare hands, Resident 74 removed the tape and gauze from her/his G and J-tube sites and cleaned the stoma areas with soaked gauze provided by Staff 7. Staff 7 then put cream on Resident 74's bare finger, and Resident 74 applied the cream to the stoma sites. Staff 7 then provided Resident 74 with clean gauze which she/he applied to the stoma sites. Staff 7 did not offer or provide Resident 74 an opportunity for hand hygiene before, during or after the entire procedure. When asked about offering Resident 74 an opportunity for hand hygiene , Staff 7 stated that had not crossed [her] brain and [the resident] should hand sanitize prior to. On 12/13/23 at 2:44 PM Resident 74 stated she/he had been performing her/his own G and J-tube dressing changes for months. Resident 74 stated she/he was only sometimes offered hand hygiene prior to completing her/his dressing changes. On 12/14/23 at 3:45 PM Staff 2 (DNS) acknowledged the findings and stated she expected nurses to offer Resident 74 an opportunity for hand hygiene when changing her/his dressings.

Based on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to showers and lighting were accommodated for 4 of 6 sampled residents (#s 3, 4, 21 and 440) reviewed for ADLs and accommodation of needs. This placed residents at risk for lack of personal hygiene, an unhomelike environment and not honoring preferences. Findings include: The facility's 10/22/23 Accommodation of Needs policy indicated: -The facility would assist residents in maintaining or achieving independent functioning, dignity and well-being to the extent possible. -The facility would make efforts to reasonably accommodate the needs and preferences of the resident. 1. Resident 4 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis (a progressive neurological disease). Resident 4's 9/27/23 Quarterly MDS revealed she/he had moderate cognitive impairment, required total assistance for bathing/showering and had no rejection of care. An 11/15/23 Progress Note written by Staff 15 (LPN) indicated Resident 4 refused her/his evening shower because she/he did not like to shower in the evening. The note revealed Resident 4 refused showers quite often. An 11/16/23 Progress Note written by Staff 21 (LPN) indicated Resident 4 refused a bed bath and shower because she/he preferred to shower during the day. Staff 21 reminded Resident 4 her/his showers were in the evening now but the resident continued to refuse a bath/shower. Resident 4's 11/22/23 through 12/16/23 Shower Task Logs indicated the resident received bathing/showering on the following days: -12/2/23 and -12/9/23. On 12/11/23 at 2:48 PM and 12/12/23 at 8:39 AM Resident 4 looked disheveled. The resident had an area at the crown of her/his head with a large tangled, untidy mass of hair (hair matte) and the front portion of her/his hair was stringy and greasy. On 12/11/23 at 3:21 PM Witness 5 (Family) reported Resident 4 did not receive showers frequently enough which resulted in the resident having poor hygiene. Witness 5 stated Resident 4 used to be scheduled for showers in the morning but about six to eight months ago, her/his showers were changed to evening shift. Witness 5 stated Resident 4 began refusing showers so she spoke with several staff regarding the resident's showering preferences but nothing changed. On 12/13/23 at 8:25 AM Staff 13 (CNA) stated Resident 4 required extensive assistance to meet her/his care needs. Staff 13 stated Resident 4 was scheduled for evening showers but the resident preferred to shower in the morning. Staff 13 stated Resident 4's hair tangled up into a matte at the back of her/his head and she told the resident she/he needed to shower in order to get the hair matte out but the resident often refused evening showers. On 12/13/23 at 10:13 AM Resident 4 stated she/he always showered in the morning but now her/his showers were scheduled for evenings. Resident 4 stated she/he did not understand why her/his showers were in the evening but by evening time she/he was too tired to take a shower so she/he often refused showering. Resident 4 stated she/he would take showers in the morning if they were scheduled at that time. On 12/14/23 at 1:26 PM Staff 15 stated on 11/15/23, Resident 4 informed her that she/he preferred to receive showers in the morning. Staff 15 stated her usual process was to relay information regarding changes in showering preferences to Staff 5 (LPN/Resident Care Coordinator) and she notified Staff 5 of Resident 4's shower preferences. On 12/14/23 at 1:56 PM Staff 5 stated she was notified in 11/2023 that Resident 4 refused showers because she/he preferred showering in the morning. Staff 5 stated Resident 4 was scheduled for evening showers but she had to wait until a resident moved or discharged from the unit in order to accommodate Resident 4's preference for morning showers because there was not enough staff to add any more residents to the day shift shower schedule. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) stated she expected residents' shower preferences to be accommodated. Refer to F725. 46053 2. Resident 3 was admitted to the facility in 5/2023 with diagnoses including a fractured ankle. A review of Resident 3's 11/7/23 Quarterly MDS revealed she/he was cognitively intact. On 12/11/23 at 10:08 AM Resident 3 was observed to have two plastic trash bags tied to her/his overbed light cord. Resident 3 stated she/he was unable to get out of bed to reach the cord so a caregiver tied the trash bags there to serve as an extension. Resident 3 stated she/he preferred to have a regular pull cord instead of a trash bag to turn her/his light on and off. On 12/13/23 at 12:53 PM Staff 20 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short. On 12/18/23 at 11:57 AM Staff 1 (Executive Director) acknowledged that some residents had trash bags tied to their light cords. She confirmed she expected the light cords to be fixed relatively quickly when they were broken. 43690 3. Resident 440 was admitted to the facility in 12/2023 with diagnoses including chronic obstructive pulmonary disease (lung disease). On 12/12/23 at 3:02 PM plastic bags were observed tied together which extended from the cord of Resident 440's overbed light to the right side of her/his bed to assist the resident with using the light. On 12/13/23 at 12:53 PM Staff 20 (Maintenance Director) stated he expected staff to report to him when overbed light cords were too short. Staff 20 observed the plastic bags tied to cords and stated the cords needed the proper extensions on them. 47000 4. Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/20/23 Admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The MDS also indicated the resident was dependent on staff for personal hygiene and lower body dressing and required substantial/maximal assistance with upper body dressing. Observations of Resident 21 conducted from 12/11/23 through 12/13/23 from 8:59 AM to 4:16 PM revealed the resident to be dressed in a hospital gown with approximately one inch of white and gray on her/his upper lip. On 12/13/23 at 9:03 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated she/he preferred to wear clothing instead of a gown but she/he had not been given a choice with regards to getting dressed. Resident 21 further stated she/he wanted her/his facial hair shaved but no one had offered any assistance. On 12/13 /23 at 9:27 AM Staff 22 (CNA) stated Resident 21 did not have any personal clothing items at the facility so she/he wore hospital gowns. Staff 22 stated the facility had a donation area where staff would get clothing for residents who came to the facility without clothing. Staff 22 stated she was unaware of Resident 21's preferences for getting dressed, she had not asked the resident and she had not retrieved any clothing for Resident 21 from the facility's donation area. Staff 22 further stated she was unaware of Resident 21's preferences for facial hair and she had not asked the resident if she/he wanted her/his facial hair removed. On 12/13/23 at 11:03 AM Staff 24 (CNA) stated he was not aware of Resident 21's preferences for getting dressed and had only seen the resident dressed and out of a hospital gown on one occasion since she/he came to the facility. Staff 24 further stated he was unaware of Resident 21's preferences for facial hair and he had not asked the resident if she/he wanted her/his facial hair removed. On 12/14/23 at 11:41 AM Staff 6 (RNCM) stated she was unaware of Resident 21's preferences for getting dressed and facial hair. On 12/14/23 at 4:02 PM Staff 2 (DNS) acknowledged the finding and stated Resident 21 should have been asked about her/his preferences for getting dressed and facial hair.

Based on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs and to ensure resident call lights were answered timely for 1 of 1 facility and 3 of 4 sampled residents (#s 2, 68 and 71) reviewed for sufficient nurse staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include: 1. Resident 2 was admitted to the facility in 7/2022 with diagnoses including dementia. Resident 2's 11/1/23 through 12/12/23 call light tracking records indicated the following delayed call light response times: -Call light response times between 20 minutes and 30 minutes: 7 -Call light response times between 31 minutes and 45 minutes: 2 -Call light response times between 46 minutes and one hour: 2 On 12/14/23 at 8:41 AM Witness 3 (Family) reported the facility did not have enough staff which resulted in long call light response times and Resident 2 sitting in soiled garments for extended periods of time. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) reported the facility struggled with long call light response times which continued to be a problem. Staff 1 stated her expectation was staff would respond to call lights as close to 20 minutes as possible. 2. Resident 68 was admitted to the facility in 7/2023 with diagnoses including dementia. Resident 68's 11/1/23 through 12/12/23 call light tracking records indicated the following delayed call light response times: -Call light response times between 20 minutes and 30 minutes: 19 -Call light response times between 31 minutes and 45 minutes: 6 -Call light response times between 46 minutes and one hour: 3 On 12/14/23 at 11:02 AM Witness 4 (Family) reported Resident 68's call light response times were frequently delayed, especially during or after meals. Witness 4 stated the biggest concern related to staffing was agency staff not knowing the residents or their care needs. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) reported the facility struggled with long call light response times which continued to be a problem. Staff 1 stated her expectation was staff would respond to call lights as close to 20 minutes as possible. Interviews with staff revealed the following staffing concerns: -On 12/14/23 at 9:39 AM Staff 10 (CNA) stated CNA staff were not able to get the staffing help they needed because the facility goes by the minimums. Staff 10 stated some of the CNAs had a heavier load than others because the facility did not assign the residents to CNA staff equally which resulted in some CNAs having more residents than other CNA staff. Staff 10 stated on the long-term care units there were many residents who required two-person mechanical lift transfers and many residents with behaviors. Staff 10 stated low staffing resulted in residents not being changed as frequently as needed, long call light response times and staff getting burned-out and snappy. -On 12/14/23 at 10:01 AM Staff 11 (CNA) stated the facility was always short staffed and used a lot of agency staff. Staff 11 stated the facility typically staffed to the minimums and the long-term care units were staffed the worst. Staff 11 reported there were not enough staff to take care of the acuity needs of the residents because many residents had mental health issues and there were residents who required extra supervision. Staff 10 stated low staffing resulted in residents eating meals in their beds without supervision which was a choking concern and residents not being changed timely. Staff 11 stated weekends were a nightmare with long call light response times and poor quality of care provided to residents. -On 12/13/3 at 8:56 AM Staff 14 (CNA) stated with the current staffing model, residents had to wait until their next scheduled shower time if they refused or missed a shower because there were not enough staff and it would be helpful if more CNA staff were scheduled. -On 12/13/23 at 12:08 AM and 12/14/23 at 1:56 PM Staff 5 (LPN/Resident Care Coordinator) stated if residents refused showers the CNA staff could not usually make up the shower because there was not enough CNA staff since they already had six showers on the day and evening shift. Staff 5 stated residents had to wait until a resident moved or discharged from the unit in order to accommodate shower preferences because there was not enough staff to add any more residents to the shower schedule. Staff 5 stated it would be wonderful if the facility was staffed to acuity so she would not have to manipulate the shower schedule. Staff 5 stated the long-term care units often ended up short staffed because CNA staff got pulled to the skilled unit. Staff 5 stated the facility should staff to the needs of the residents but that was currently not happening. -On 12/15/23 at 10:54 AM Staff 2 (DNS) stated there were two staffing coordinators who were responsible to staff at least to the state minimums. Staff 2 stated she was aware of long call light response times but was unsure of the root cause. Staff 2 stated staff reported concerns with low staffing but she thought the facility was adequately staffed. Staff 2 acknowledged the facility was supposed to staff to the acuity needs of the residents. She stated her expectation was for staff to respond to call lights within 20 minutes. 43691 3. Resident 71 was admitted to the facility in 5/2023 with diagnoses including acute transverse myelitis (a spinal cord disorder which often causes weakness, sensory deficits, and bowel/bladder dysfunction). Resident 71's 11/1/23 through 12/12/23 call light tracking records indicated the following delayed call light response times: -Call light response times between 20 minutes and 30 minutes: 35 -Call light response times between 31 minutes and 45 minutes: 21 -Call light response times between 46 minutes and one hour: 3 On 12/12/23 at 11:27 AM Resident 71 stated nursing response to call lights was often delayed beyond 20 minutes. Resident 71 stated she/he often required brief changes and was required to wait for extended periods to receive care. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) reported the facility struggled with long call light response times which continued to be a problem. Staff 1 stated her expectation was staff would respond to call lights as close to 20 minutes as possible.

Based on observation, interview and record review it was determined the facility failed to ensure medically related social services were provided to support residents' individual needs through the assessment process and obtain personal items for 1 of 2 sampled residents (#21) reviewed for communication needs. This placed residents at risk for unmet needs and decreased dignity. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/17/23 Trauma Screening Tool indicated the resident experienced multiple traumas, including physical assault and combat or exposure to a war zone. Resident 21's 11/20/23 Admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The BIMS, Staff Assessment for Mental Status, Resident Mood Interview and Staff Assessment of Resident Mood were all marked as not assessed. The Psychosocial Well-Being CAA indicated doing her/his favorite activities was not very important to Resident 21. No evidence was found in Resident 21's clinical record to indicate a care plan was developed to address the resident's history of trauma, her/his cognitive abilities or mood state were assessed or her/his psychosocial well-being was evaluated. Observations of Resident 21 conducted from 12/11/23 through 12/13/23 from 8:59 AM to 4:16 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair and dressed in a hospital gown. The resident's television was observed on and tuned to the Hallmark channel with English language audio. On 12/11/23 at 4:01 PM Witness 6 (Family Member) stated Resident 21 understood very little English. On 12/13/23 at 9:03 AM and on 12/14/23 at 9:18 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated she/he spoke Russian and only understood some English. Resident 21 stated she/he had experienced trauma in her/his lifetime and no one at the facility spoke to her/him about triggers of her/his trauma. Resident 21 stated staff did not regularly use the translator service when interacting with her/him nor had anyone from the facility asked her/him about her/his mood. Resident 21 stated she/he was sad all of the time because of the way [the staff] treat[ed] [her/him]. Resident 21 stated she/he had not been invited to activities at the facility and she/he often did not like watching the programs the staff put on her television. Resident 21 further stated she/he preferred to wear clothing instead of a gown but she/he had not been assisted to get dressed. On 12/13/23 at 3:14 PM and on 12/18/23 at 9:12 AM Staff 3 (Social Services Director) stated he completed the trauma screen for Resident 21 and confirmed the resident expressed she/he had experienced multiple traumas. Staff 3 stated he did not create a trauma-informed care plan for Resident 21 as she/he did not express any triggers related to her/his trauma. Staff 3 stated he was not really sure why [the Psychosocial Well-Being CAA] triggered on Resident 21's Admission MDS and confirmed he did not create a CAA or have any follow-up conversations with the resident about her/his psychosocial well-being. Staff 3 stated he was responsible for completing staff assessments of resident cognition and mood in those cases when a resident interview was unable to be completed on the MDS. Staff 3 stated he was unaware the cognition and mood interviews were not completed on Resident 21's Admission MDS and confirmed a staff assessment of the resident's cognition and mood should have been completed. Staff 3 further stated he was unaware of the resident's preference for getting dressed and he had not assisted the resident in obtaining any personal clothing. On 12/14/23 at 12:43 PM Staff 23 (Social Services Assistant) stated an assessment of a resident's cognition and mood should always be completed as part of the MDS. Staff 23 stated she attempted to complete an assessment of Resident 21's cognitive abilities and mood state for the resident's Admission MDS using Witness 6 (Family Member) as the translator. Staff 23 stated Witness 6 refused to help translate after only a few questions related to cognition were asked, so she stopped the interview. Staff 23 stated she did not follow up with the resident to assess either her/his cognition or mood with an outside translation service or complete a staff assessment of the resident's cognitive abilities or mood state. On 12/18/23 at 10:25 AM Staff 1 (Executive Director) acknowledged the findings and did not provide any additional information.

Based on observation, interview and record review it was determined the facility failed to ensure resident personal refrigerators were free of expired and/or unlabeled foods for 1 of 5 residential halls and dishwasher water temperature was monitored for 1 of 1 kitchen reviewed for food safety and sanitation. This placed residents at risk for food-bourne illness. Findings include: 1. On [DATE] at 11:28 AM Resident 15's personal refrigerator was observed to have a turkey sandwich dated [DATE], an undated ham and cheese sandwich, three small containers of undated and unlabeled ranch dressing, one container of mayonnaise with a use by date of [DATE] and four containers of peach yogurt with a use by date of [DATE]. On [DATE] at 11:35 AM Staff 19 (CMA/CNA) stated the items should have been dated or thrown away. On [DATE] at 11:49 AM Resident 14's personal refrigerator was observed to have a small container of orange juice dated [DATE], a small container of Kool Aid gel snack dated [DATE], a small container of mandarin oranges with an expiration date of [DATE], one 12 pack of cheese sticks dated [DATE], one 12 pack of cheese sticks dated [DATE], a medium size container of prunes dated ,d+[DATE], a 32 ounce bottle of coffee sweetener dated ,d+[DATE] and unidentifiable yellow substance on a plate not dated or labeled. On [DATE] at 12:18 PM Staff 14 (CNA) stated there was not a cleaning schedule for the personal refrigerators and it was the responsibility of the CNAs to clean out the personal refrigerators. Staff 14 stated the food and drink items should have been labeled and dated. On [DATE] at 12:43 PM Staff 2 (DNS) stated it was her expectation to make sure all food and drink items were dated and not expired. 49677 2. According to U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code, High Temperature Dishwasher (heat sanitization methods) the wash cycle should be ,d+[DATE] degrees F and final rinse should be 180 degrees or 165 degrees F for a stationary rack single temperature machine. Facilities are mandated to log the dishwasher temperatures during each shift (documented three times daily) to ensure compliance with temperature regulations for safety and sanitation. On [DATE] at 9:46 AM the High Temperature Dishwasher Log was observed, it lacked consistent documentation of temperatures. Documentation of temperatures were recorded on only three days from [DATE] through [DATE]. Staff 33 (Dining Services Director) confirmed the temperatures were not monitored as required. 3. The facility Food and Nutrition Services Food Safety policy indicated that food, including leftovers, will be labeled and dated in the refrigerator. On [DATE] at 1:25 PM the Bistro refrigerator was observed to have reddish-colored food spillage dried on the bottom section of the refrigerator. The refrigerator contained the following improperly labeled and expired food items: * Small [NAME] cake dated [DATE] (eight days old) * One package of Pita bread dated [DATE] (12 days old) * Three undated containers of food and one undated foil-wrapped item (contents unknown) with a room number written on the package * Small chef salad, undated * Greek yogurt labeled room [ROOM NUMBER] expired on [DATE] * A small container of potato salad, undated * An undated cup of uncovered, dried-out formally fresh fruit * A package of 14 yogurts with an expiration date of [DATE] On [DATE] at 1:26 PM these findings were reviewed with Staff 1 (Executive Director) who confirmed the food was outdated and nursing staff were responsible to date foods they placed in refrigerators. She also stated that kitchen staff were responsible for stocking nourishments and cleaning the refrigerator.

Based on observation, interview, and record review it was determined the facility failed to provide a person-centered activity program for 1 of 1 sampled resident (#21) reviewed for activities. This placed residents at risk for a diminished quality of life. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/20/23 Admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The MDS also indicated listening to music she/he liked and being around animals, such as pets, were important activities to Resident 21. Resident 21's 11/21/23 Activities Initial Assessment completed with the resident indicated she/he liked music, dogs, playing cards and board games and getting her/his nails done. Resident 21's 11/22/23 Activity Care Plan revealed the following interventions: -Provide the resident with a television guide to watch movies and television shows. -Encourage the resident to attend bingo when scheduled. -Invite the resident to music performances when scheduled. -Schedule one-to-one pet therapy and provide magazines from the life enrichment cart. The facility's posted Activity Schedule for 12/10/23 through 12/13/23 included the following activities: -12/10/23: Christian fell owship, Movie Social and Life Enrichment Visits. -12/11/23: Life Enrichment Visits East, Chapel with [NAME], Music Therapy with Daisie and [NAME] Bingo. -12/12/23: 1:1 Visits with Life Enrichment. -12/13/23: Life Enrichment Visits. A review of Resident 21's Individual Activity Engagement and Group Activity Engagement Tasks from 11/2023 and 12/2023 revealed the resident participated in a religious/spiritual activity on 11/16/23. No evidence was found to indicate the resident was invited to, or participated in, any other activity since her/his admission to the facility. Observations of Resident 21 from 12/11/23 through 12/13/23 from 8:59 AM to 4:16 PM revealed the resident to be in her/his room either in bed or in her/his wheelchair with the television on and tuned to the Hallmark channel with English language audio. On 12/11/23 at 4:01 PM Witness 6 (Family Member) stated Resident 21 understood very little English. On 12/13/23 at 9:03 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated she/he could only understand some English and she/he enjoyed music, church and television. Resident 21 stated she/he especially enjoyed listening to classical music and watching Russian television. Resident 21 stated she/he had not been invited to activities at the facility and she/he often did not like or understand the programs the staff put on her television. On 12/13/23 at 10:45 AM Staff 22 (CNA) and at 11:03 AM Staff 24 (CNA) stated they were unsure of Resident 21's activity interests and the resident usually spent most of the day in bed. On 12/14/23 at 1:04 PM Staff 26 (Life Enrichment Assistant), Staff 27 (Life Enrichment Director) and Staff 28 (Life Enrichment Assistant) were present for an interview. Staff 28 stated activity preferences learned during the resident's initial activity assessment and from the completion of the Preferences for Routine and Activities interview on the Admission MDS should be included in a resident's activity care plan. Staff 28 further stated the life enrichment team completed one-to-one visits for residents who were bed bound or did not participate in group activities and their goal was to complete one-to-one visits at least weekly. Staff 26 stated she considered Resident 21 appropriate for one-to-one visits and confirmed no one-to-one visits had been completed with Resident 21 outside of the visit on 11/16/23. Staff 26, Staff 27 and Staff 28 confirmed they had not attempted board or card games, painting nails, pet therapy or Russian television with Resident 21 and Resident 21's care plan did not include all of the resident's activity interests. On 12/14/23 at 4:06 PM Staff 2 (DNS) acknowledged the findings and stated Resident 21 should have been involved in more activities, including music and pet therapy.

Based on observation, interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 4 sampled residents (#s 3, 4 and 21) reviewed for ADLs. This placed residents at risk for unmet ADL needs and loss of dignity. Findings include: 1. Resident 3 was admitted to the facility in 5/2023 with diagnoses including a broken ankle. A review of Resident 3's 11/7/23 Quarterly MDS revealed she/he was cognitively intact. On 12/11/23 at 10:05 AM Resident 3 was observed sitting up in her/his bed with a tuft of facial hair that was longer than an inch growing from her/his chin. She/he reported, I wish they would trim it. They never offer. Resident 3's Care Plan dated 5/9/23 indicated she/he had a self-care deficit and required assistance to complete ADL tasks due to her/his limited mobility. A review of Resident 3's 11/7/23 Quarterly MDS revealed she/he required moderate assistance to complete personal hygiene tasks. On 12/13/23 1:07 PM Staff 29 (CNA) stated she worked with Resident 3 today and last week. Staff 29 stated Resident 3 was dependent on staff to assist her/him to shave her/his face. Staff 29 stated CNAs were supposed to ask residents if they wanted to be shaved. Staff 29 confirmed she noticed Resident 3's long facial hairs last week but did not ask if she/he wanted them removed. On 12/14/23 at 12:45 PM Staff 5 (LPN/Resident Care Coordinator) confirmed Resident 3 was dependent on her/his caregivers to shave her/his facial hair. She also stated CNAs were supposed to document when they offered to assist Resident 3 to shave and if she/he refused. She confirmed there was no documentation in Resident 3's chart to indicate she/he was offered assistance to shave. On 12/18/23 at 11:57 AM Staff 1 (Executive Director) confirmed she expected residents be assisted to shave their facial hair if the residents wanted to shave. 41458 2. Resident 4 was admitted to the facility in 2/2021 with diagnoses including multiple sclerosis (a progressive neurological disease). Resident 4's 2/2/22 Care Plan, revised 12/23/23, revealed the resident required extensive assistance for grooming and personal hygiene and preferred showers so she/he could have her/his hair shampooed. The staff were to brush Resident 4's hair daily. Resident 4's 9/27/23 Quarterly MDS revealed she/he had moderate cognitive impairment, required total assistance for bathing/showering, required extensive assistance for personal hygiene and had no rejection of care. Resident 4's 11/22/23 through 12/16/23 Shower Task Logs indicated the resident received bathing/showering on the following days: -12/2/23 and -12/9/23. A review of Resident 4's health record from 11/22/23 through 12/16/23 revealed no documentation that Resident 4 was provided with additional bathing/showering opportunities when bathing/showering was not provided. On 12/11/23 at 2:48 PM and 12/12/23 at 8:39 AM Resident 4 looked disheveled. The resident had an area at the crown of her/his head with a large tangled, untidy mass of hair (hair matte) and the front portion of her/his hair was stringy and greasy. On 12/11/23 at 2:48 PM and 12/13/23 at 10:13 AM Resident 4 stated staff did not regularly brush her/his hair which resulted in a large hair matte at the back of her/his head that was painful to brush out. Resident 4 stated her/his family brushed her/his hair when they visited but they did not visit daily. Resident 4 stated her/his showers were scheduled for evening shift but by evening time she/he was too tired to take a shower so she/he often refused showering. Resident 4 stated she/he would take showers if they were offered in the morning. On 12/11/23 at 3:21 PM Witness 5 (Family) reported Resident 4 did not receive showers frequently enough which resulted in the resident having poor hygiene. Witness 5 stated Resident 4 used to be scheduled for showers in the morning but about six to eight months ago, her/his showers were changed to evening shift. Witness 5 stated Resident 4 began refusing showers so she spoke with several staff regarding the resident's showering preferences but nothing changed. Witness 5 stated Resident 4 always had a large hair matte at the back of her head, which was full of ants last month, because staff did not routinely brush the resident's hair. On 12/13/23 at 8:25 AM Staff 13 (CNA) stated Resident 4 required extensive assistance to meet her/his care needs. Staff 13 stated Resident 4 was scheduled for evening showers but the resident preferred to shower in the morning thus the resident often refused showers. Staff 13 stated Resident 4's hair tangled into a matte at the back of her/his head and she told the resident she/he needed to shower in order to get the hair matte out. On 12/13/3 at 8:56 AM Staff 14 (CNA) stated Resident 4 frequently refused evening showers and staff were unable to make showers up because they had too many showers already scheduled for each shift. Staff 14 stated with the current staffing model, residents had to wait until their next scheduled shower time if they refused or missed a shower and it would be helpful if more CNA staff were scheduled. Staff 14 stated Resident 4's hair was often matted. On 12/13/23 at 12:08 AM and 12/14/23 at 1:56 PM Staff 5 (LPN/Resident Care Coordinator) stated there was an ongoing issue with Resident 4's hair tangling and becoming matted because Resident 4 often refused showering. Staff 4 stated if residents refused showers the CNA staff could not usually make up the shower because there was not enough CNA staff since they already had six showers on the day and evening shift. Staff 5 stated she was notified in 11/2023 that Resident 4 refused showers because she/he preferred showering in the morning but Staff 5 had to wait until a resident moved or discharged from the unit in order to accommodate Resident 4's preference for morning showers because there was not enough staff to add any more residents to the day shift shower schedule. Staff 5 confirmed Resident 4 did not receive showers on a regular basis and often had matted hair. On 12/18/23 at 10:09 AM Staff 1 (Executive Director) stated she expected staff to accommodate showers at alternative times and make up showers if a resident refused or missed a shower. Refer to F725. 47000 3. Resident 21 was admitted to the facility in 11/2023 with diagnoses including a lower back fracture. Resident 21's 11/20/23 Admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. The MDS also indicated the resident was dependent on staff for personal hygiene and lower body dressing and required substantial/maximal assistance with upper body dressing. Observations of Resident 21 conducted from 12/11/23 through 12/13/23 from 8:59 AM to 4:16 PM revealed the resident was dressed in a hospital gown with approximately one inch of white and gray hair on her/his upper lip. On 12/13/23 at 9:03 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated she/he preferred to wear clothing instead of a gown and staff had not assisted her/him to get dressed. Resident 21 further stated she/he wanted her/his facial hair shaved but no one offered any assistance. On 12/13/23 at 9:27 AM Staff 22 (CNA) stated Resident 21 did not have any personal clothing items at the facility so she/he wore hospital gowns. Staff 22 stated the facility had a donation area where staff would get clothing for residents who came to the facility without clothing. Staff 22 stated she had not retrieved any clothing for Resident 21 from the facility's donation area or assisted the resident to get dressed. Staff 22 further stated she had not asked the resident if she/he wanted her/his facial hair removed. On 12/13/23 at 11:03 AM Staff 24 (CNA) stated he had only seen the resident dressed and out of a hospital gown on one occasion since she/he came to the facility. Staff 24 further stated he had not assisted the resident with facial hair grooming. On 12/14/23 at 4:02 PM Staff 2 (DNS) acknowledged the findings and stated she expected staff to assist the resident to get dressed and with grooming her/his facial hair.

Based on observation, interview and record review it was determined the facility failed to ensure resident care plans were revised to accurately reflect resident needs for 1 of 1 sampled resident (#18) reviewed for skin conditions. This placed residents at risk for unmet care needs. Findings include: Resident 18 was admitted to the facility in 5/2017 with diagnoses including hemiplegia (muscle weakness or partial paralysis on one side of the body). On 12/11/23 at 3:34 PM Resident 18 was observed to have multiple red marks that appeared to be scabbed over on her/his right shoulder. Resident 18 stated she/he did not know what they were. On 12/13/23 at 3:01 PM Resident 18 was observed to have similar red marks and scabs on her/his leg. Resident 18 stated the sores were healing and she/he thought they were dry skin. She/he stated staff applied cream to them but she/he did not remember when. On 12/15/23 at 9:29 AM Staff 15 (LPN) stated Resident 18 had really dry skin and she/he picked at it. She confirmed Resident 18's skin sores were treated with calamine (a lotion used to treat mild itchiness) and hydroxyzine (antihistamine tablets used to treat skin rashes) as ordered by her/his physician. An alert nursing progress note on 9/29/23 indicated Resident 18 had a new diagnosis of scabies (a contagious, intensely itchy skin condition caused by a tiny burrowing mite). A review of Resident 18's 10/2/23 Care Plan revealed the facility was to provide resident, family, and caregiver education regarding precautions to minimize the risk of transferring the infestation. On 12/15/23 at 9:55 AM Staff 31 (CMA) stated Resident 18 was on precautions when she/he first received the diagnosis of scabies. She did not know when the scabies diagnosis was resolved but stated, it's been a few weeks. On 12/15/23 at 10:08 AM Staff 5 (LPN/Resident Care Coordinator) stated she did not believe Resident 18 actually had scabies but she/he was treated with the medications as ordered by her/his provider. Staff 5 stated the precautions for scabies needed to come off of the care plan because it was resolved. On 12/15/23 at 11:00 AM Staff 2 (DNS) acknowledged Resident 18's Care Plan still contained the precautions related to scabies. She confirmed she expected residents' care plans to be updated when their conditions and needs changed.

Based on interview and record review, it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 2 sampled residents (#10) reviewed for respiratory care. This placed residents at risk for unmet needs. Findings include: Resident 10 was readmitted to the facility in 10/2022 with diagnoses including tracheostomy (an artificially created opening in the windpipe to help air reach the lungs) status. Resident 10's 10/2023 Annual MDS indicated the resident was severely cognitively impaired. Resident 10's 10/2023 Respiratory Care Plan revealed the following: -The resident required a long term tracheostomy to maintain airway and adequate oxygen levels. -Report any signs of respiratory distress, decreased saturations, fever, changes in mentation, increased vital signs and purulent (thick fluid caused by infection) tracheostomy secretions. -Check settings on air compressor- oxygen and temperature 80-85 degrees. -Check tubing and clear if water present. -Check tracheostomy strap (a band that goes around the neck to hold the tracheostomy tube in place) each shift and alert nurse of any redness or changes in skin under strap. -Routine tracheostomy care per protocol. -Check tracheostomy for signs of plugging if any signs of respiratory distress, tracheostomy care per orders. -Check stoma (opening in the body) for signs of infection or pressure. Resident 10's 12/2023 Physician Orders directed the following: -Suction tracheostomy immediately if patient vomits and notify physician. -Change oxygen tubing and related equipment on Monday. Clean concentrator filter. -Tracheostomy care: clean inner cannula (a thin tube inserted into a person's body cavity to drain fluid, administer medication or provide oxygen) via sterile technique each shift and PRN for respiratory distress. Do not suction unless there is an emergency due to previous issues from suction. If changing tracheostomy straps, please check to make sure straps are not tight against the skin. Should be able to easily put fingers between strap and skin. -Check water connected to tracheostomy mister. Ensure it is full to the fill line and use distilled water when needed. Check this at the beginning of every shift and as needed throughout shift. Do not run dry. -Patient may be off tracheostomy mist for four hours a day and PRN. No evidence was found in Resident 10's care plan or physician orders related to specifications of the resident's type and size of cannula or instructions for what staff should do in the case of tracheostomy complication. On 12/14/23 at 3:36 PM Staff 2 (DNS) confirmed specifications of the resident's type and size of cannula and tracheostomy emergency procedures were not in Resident 10's health record and should have been.

Based on interview and record review it was determined the facility failed to comprehensively assess cognitive abilities and mood state for 1 of 2 sampled residents (#21) reviewed for communication. This placed residents at risk for unassessed needs. Findings include: Resident 21 was admitted to the facility in 11/2023 with diagnoses including lower back fracture. Resident 21's 11/20/23 Admission MDS indicated the resident's preferred language was Russian, the resident wanted an interpreter to communicate with health care staff and the resident did not experience any difficulties with communication. No evidence was found in Resident 21's clinical record to indicate her/his cognitive abilities or mood state was assessed. On 12/13/23 at 9:03 AM and on 12/14/23 at 9:18 AM an interview was conducted with Resident 21 with the use of a translation service. Resident 21 stated staff did not regularly use the translator service when interacting with her/him nor had anyone from the facility asked her/him about her/his mood. Resident 21 further stated she/he was sad all of the time because of the way [the staff] treat[ed] [her/him]. On 12/13/23 at 9:27 AM Staff 22 (CNA) stated she thought the resident was pretty with it and able to understand more basic questions. Staff 22 stated she observed the resident to be depressed during the previous week as she noticed the resident to eat and smile less and the resident reported she/he wanted to die to another CNA. On 12/14/23 at 12:43 PM Staff 23 (Social Services Assistant) stated an assessment of a resident's cognition and mood should always be completed as part of the MDS. Staff 23 stated she attempted to complete an assessment of Resident 21's cognitive abilities and mood state for the resident's Admission MDS using Witness 6 (Family Member) as the translator. Staff 23 stated Witness 6 refused to help translate after only a few questions related to cognition were asked so she stopped the interview. Staff 23 stated she did not follow up with the resident to assess either her/his cognition or mood with an outside translation service or complete a staff assessment of the resident's cognitive abilities or mood state. On 12/14/23 at 3:59 PM Staff 2 (DNS) acknowledged the findings and stated assessments of Resident 21's cognition and mood should have been attempted using an outside translation service. On 12/18/23 at 9:12 AM Staff 3 (Social Services Director) stated he was responsible for completing staff assessments of resident cognition and mood in those cases when a resident interview was unable to be completed on the MDS. Staff 3 stated he was unaware the cognition and mood interviews were not completed on Resident 21's Admission MDS and confirmed a staff assessment of the resident's cognition and mood should have been completed.

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 12/11/23 through 12/18/23 identified the following issues: -Rooms 106, 121, 127, 129 and 134 had wood wall protectors behind resident beds that were chipped with sharp/jagged edges and missing paint. -room [ROOM NUMBER] had a screen door that lead to the patio area with the door off the tracks that was unable to open or close properly. -room [ROOM NUMBER] had an approximate three inch piece of wood missing on the resident door with sharp/jagged edges. -room [ROOM NUMBER] had a missing transition strip from the hall to the room exposing a gap in the flooring which was not a cleanable surface. -Ceiling tiles in the library had a green/brown substance on them above the fish tank. -A wall near room [ROOM NUMBER] had veneer that was torn and peeling. -The west [NAME]-[NAME] hall transition strip had carpet lifting and torn rubber stripping. -The main dining area across from the front reception area had three broken tiles on the floor with large gaps of missing tile which were not a cleanable surface. On 12/15/23 at 12:50 PM Staff 1 (Executive Director) acknowledged the identified concerns needed to be repaired.

Based on observation, interview and record review it was determined the facility failed to provide properly maintained assistive devices to prevent falls and implement the resident care plan for 2 of 3 sampled residents (#s 100 and 105) reviewed for accidents. As a result of staff not following care planned interventions, Resident 100 fell , fractured her/his right hip, sustained a [CONDITION(S)], required hospitalization and surgery. Findings include: 1. Resident 100 admitted to the facility in 2/2021 with diagnoses including [CONDITION(S)] and malnutrition. Resident 100's most recent MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Resident 100 was care planned for a two person extensive assist for dressing, grooming, toileting, bed mobility and transfers. She/he also required a mechanical lift for all transfers. The facility submitted a FRI on 3/14/22 which revealed Resident 100 fell from the mechanical lift during a transfer. At the time of the report, the resident and Staff 22 (CNA) stated they did not know how the resident fell . The facility's investigation completed on 3/17/22 by Staff 25 (Former DNS) revealed Staff 22 attempted to transfer Resident 100 from the wheelchair to the resident's bed without assistance from another staff, which resulted in her/him falling out of the mechanical lift's sling to the floor. Resident 100's vitals were checked and the resident stated she/he heard her/his head crack when she/he hit the floor and felt pain all over her/his body with a pain level of 10/10. Resident 100 agreed to go to the hospital, was diagnosed with a fractured hip which required surgery on 3/15/22 and staples were placed in the back of her/his head for the laceration. On 11/1/22 at 3:10 PM Resident 100 confirmed she/he fell out of the mechanical lift's sling in March 2022, reported she/he cracked her/his head and was yelling in pain. Resident 100 confirmed two people were supposed to assist her/him with transfers. On 11/3/22 at 2:11 PM Staff 22 confirmed she transferred Resident 100 by herself because the resident reported feeling ill. There was nobody on the unit to help her. She was aware Resident 100 was a two person transfer. On 11/10/22 at 2:00 PM Staff 1 (Administrator) was notified of the findings of this investigation and no further information was provided. Refer to F725. 2. Resident 105 admitted to the facility in 7/2020 with diagnoses including Alzheimer's Disease with late onset, rib fractures on the left side and unspecified fracture of the left femur. Resident 105's most recent MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident 105 was care planned for one person extensive assist for bathing, dressing and transfers. She/he was considered a high fall risk due to a history of falls prior to admission, urinary incontinence and poor safety awareness due to cognitive impairment. A review of Resident 105's fall history from 7/2020 through 10/2022 revealed multiple falls due to the resident's attempts to transfer herself/himself out of her/his wheelchair or falling after attempting to sit down in the wheelchair. Maintenance requests were reviewed for Resident 105 from 11/20/21 through 12/28/21 and revealed: -11/20/21: Left brake on wheelchair is not there at all - huge safety risk -11/25/21: W/C brakes too tight and right wheel is very loose and wobbly -12/18/21: Left brake on W/C is gone -12/28/21: Both brakes on W/C are broken-right brake will not stay locked very long-unlocks itself On 12/28/21 the facility completed a fall occurrence report which revealed Resident 105 was found on the floor of her/his room. Staff 24 (Former nurse) noted CNA said the wheelchair brake looks like it needs to be fixed. The report further revealed the resident was interviewed and told staff she/he finished brushing her/his teeth, attempted to sit down in the wheelchair but it rolled backwards due to the brakes not working, which caused the resident to fall. Staff 24 checked the wheelchair brakes and found one brake was completely missing. On 12/31/21 Staff 23 (Former RCM) noted in the occurrence report to replace resident's w/c with new w/c which fits resident and is fully functional. On 11/1/22 at 12:50 PM, Resident 105 was observed in her/his room, seated in her/his new wheelchair. On 11/1/22 at 12:55 PM, Witness 100 (Complainant) stated Resident 105 experienced multiple falls due to slow call light response times and improperly working equipment. Witness 100 revealed Resident 105 was not assisted to bed timely and this resulted in the resident attempting to put herself/himself to bed and falling several times. Witness 100 confirmed the resident's wheelchair had malfunctioned since November 2021 until it was replaced. On 11/9/22 at 10:05 PM Staff 12 (Maintenance Director) stated he was on medical leave when the maintenance requests were received in November 2021. He further stated he was the only maintenance staff during November and most of December. No maintenance repairs were completed during his absence. Staff 12 said he reviewed the maintenance requests when he returned from medical leave and stated the first thing I thought was why didn't somebody just change the wheelchair; why didn't anybody in the care staff get a different wheelchair? Staff 12 was unable to recall the number of repairs needed for the wheelchair but recalled he fixed the chair after the resident's fall on 12/28/21. Staff 12 stated if resident medical equipment needed too many repairs, he recommended new equipment to the care manager. Staff 12 confirmed it was expected the resident's wheelchair should have been replaced in November 2021 and resident medical equipment be in proper working condition. On 11/9/22 at 11:02 AM Staff 19 (RNCM) revealed she was not working at the facility in 2021 but was familiar with Resident 105. She revealed the resident was confused, frequently tried to transfer herself/himself but was not physically able to and had poor safety awareness. Staff 19 confirmed long call light times were an issue and may have contributed to the resident's attempts to self transfer. On 11/10/22 at 2:00 PM, Staff 1 (Administrator) was notified of the findings of this investigation and no further information was provided.

Based on interview and record review it was determined the facility failed to ensure continence was maintained for 1 of 3 residents (#1) reviewed for incontinence. Resident 1 was left on a bed pan resulting in deep tissue injuries and pressure ulcers. As a result Resident 1 was unable to use the bed pan due to pain. This change in continence status caused Resident 1 a loss of dignity and embarrassment. Resident 1 admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 9/5/18 Admission MDS indicated Resident 1 was always incontinent of bowel and bladder, was at risk for pressure ulcers, did not have current pressure ulcers and required a two person physical assist with toileting. The 8/25/18 Care Plan with updates on 9/5/18 indicated Resident 1 was incontinent of bowel and bladder post stroke and did not have recognition of the need to urinate or have bowel movements. Interventions included to monitor the resident frequently for any incontinent episodes and cleanse promptly. A Progress Note dated 10/19/18 indicated during rounds staff found a bedpan on Resident 1 and it was noted to be on the resident all night. The investigation to the incident dated 10/19/18 indicated Resident 1 was found to have a Stage I pressure ulcer and deep tissue injury on her/his sacrum (triangular bone just above the coccyx) and, a deep tissue injury to each buttock. The investigation further indicated the night before, on 10/18/18 between 7:30 pm and 7:45 pm, Resident 1 requested a bedpan and Staff 21 (CNA) put the resident on a bed pan. Staff 21 then went on break and stated she told another CNA (Staff 23) to remove the bed pan. When interviewed Staff 23 stated she was not told by Staff 21 to remove Resident 1's bedpan. The investigation further indicated Staff 21 did not check, change or reposition Resident 1 through the rest of her shift which ended at 11:00 pm. The investigation further indicated Staff 22 (CNA) came on shift at 11:00 pm and did not identify the bed pan under Resident 1 until 6:30 am on 10/19/18. The wound assessments dated 10/19/18 indicated the following: * A Stage I wound on the sacrum measured 6 cm x 18.50 cm * A deep tissue injury on the sacrum measured 1.3 cm x 15 cm * A deep tissue injury on the right buttock measured 83 cm x 13 cm * A deep tissue injury on the left buttock measured 88 cm x 20 cm Subsequent wound assessments indicated the following: * On 10/24/18 one sacral wound was healed the other decreased in size to 1 cm x 6 cm. By 10/31/18 both sacral deep tissue injury wounds were healed. * On 10/24/18 the deep tissue injury on the right buttock was noted to develop into a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed,without slough. (MONTH) also present as intact or open/ruptured serum-filled blister) measuring 10.2 cm x 7.5 cm. * On 10/24/18 the deep tissue injury on the left buttock measured 10.2 cm x 1.5 cm and on 10/31/18 was noted to develop into a Stage II pressure ulcer measuring 4.2 x .4 cm. On 10/25/18 at 1:10 pm Staff 6 (CNA) stated Resident 1 used to use a bed pan for toileting but was not using one currently because of skin breakdown on her/his bottom. Staff 6 further stated just recently Resident 1 told her she/he was going to have a bowel movement but no longer wanted to use the bed pan. On 10/25/18 at 1:35 pm and 11/1/18 at 9:30 am Resident 1 stated she/he had sores on her/his bottom that were caused by being left for too long on a bed pan. Resident 1 further stated she no longer used a bed pan for toileting because it was too painful and currently used a brief. Resident 1 stated it was embarrassing for her to use a brief when she/he needed to go to the bathroom. On 10/26/18 at 11:55 am Staff 10 (CNA) stated Resident 1 used to ask to use the bed pan for toileting. On 10/26/18 at 12:30 pm Staff 11 (CNA) stated she used to put Resident 1 on a bed pan for toileting, it was mainly used for bowel movements and Resident 1 was able to ask staff for it when she/he needed it. Staff 11 further stated Resident 1 no longer used a bed pan because of the sores on her/his bottom, it was too painful for the resident and currently Resident 1 used her/his brief for toileting. On 11/06/18 at 12:26 pm Staff 1 (Administrator) acknowledged Resident 1 was no longer able to use the the bed pan for toileting because of the pressure injuries on her/his bottom. Refer to F686

Based on interview and record review it was determined the facility failed to ensure the prevention of pressure injury development for 1 of 3 residents (# 1) reviewed for pressure ulcers. This resulted in avoidable pressure ulcers for Resident 1 and placed other residents at risk for pressure ulcers. Findings include: Resident 1 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 9/5/18 Admission MDS indicated Resident 1 did not have pressure ulcers and was at risk for developing pressure ulcers. The 8/25/18 Care Plan updated on 9/5/18 indicated Resident 1 was at risk for developing pressure ulcers due to left sided paralysis and limited use of her/his right hand which affected bed mobility and turning. The care planned goal was for the resident's skin to remain intact. Interventions included to turn and reposition the resident frequently and to check her/him for incontinence and change if wet or soiled. A Progress Note dated 10/19/18 at 7:45 am indicated during rounds staff found a bedpan on Resident 1 and it was noted to be on the resident all night. The skin assessment indicated two Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence ) pressure ulcers, one on the right and left buttock. On the right side of the lower buttocks a non-blanchable pressure ulcer measured 88 cm x 20 cm and the left side measured 83 cm x 13 cm. The investigation to the incident dated 10/19/18 indicated Resident 1 was found to have a Stage I pressure ulcer and deep tissue injury on her/his sacrum (triangular bone just above the coccyx) and, a deep tissue injury to each buttock. The investigation further indicated the night before between 7:30 pm and 7:45 pm Resident 1 requested a bedpan and Staff 21 (CNA) put the resident on a bed pan. Staff 21 then went on break and stated she told another CNA (Staff 23) to remove the bed pan. When interviewed Staff 23 stated she was not told by Staff 21 to remove Resident 1's bedpan. The investigation further indicated Staff 21 did not check, change or reposition Resident 1 through the rest of her shift which ended at 11:00 pm. The investigation further indicated Staff 22 (CNA) came on shift at 11:00 pm and did not identify the bed pan under Resident 1 until 6:30 am. Staff 21 and Staff 22 were immediately suspended and subsequently terminated and, the incident was reported to the local state agency. A 10/19/18 NP/CWS (Nurse Practitioner, Certified Wound Specialist) note indicated the facility requested her to assess and treat Resident 1's wounds. The NP further noted purple areas on the resident's buttocks were reported on 10/19/18 after the use of a bed pan at night. The wound assessments dated 10/19/18 indicated the following: * A Stage I wound on the sacrum measured 6 cm x 18.50 cm * A deep tissue injury on the sacrum measured 1.3 cm x 15 cm * A deep tissue injury on the right buttock measured 83 cm x 13 cm * A deep tissue injury on the left buttock measured 88 cm x 20 cm Subsequent wound assessments indicated the following: * On 10/24/18 one sacral wound was healed the other decreased in size to 1 cm x 6 cm. By 10/31/18 both sacral deep tissue injury wounds were healed. * On 10/24/18 the deep tissue injury on the right buttock was noted to develop into a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as intact or open/ruptured serum-filled blister) measuring 10.2 cm x 7.5 cm. * On 10/24/18 the deep tissue injury on the left buttock measured 10.2 cm x 1.5 cm and on 10/31/18 was noted to develop into a Stage II pressure ulcer measuring 4.2 by .4 cm. Resident 1 requested the use of a bed pan for toileting. Staff 21 left the bed pan under the resident and did not check, change or reposition Resident 1 again during her shift. Staff 22, who worked the following shift beginning at 11:00 pm did not discover the bedpan under the resident until 6:30 am. Consequently Resident 1 developed multiple deep tissue injuries two of which opened and developed into Stage II pressure ulcers. On 10/25/18 at 1:10 pm Staff 6 (CNA) stated Resident 1 had skin issues from being left on a bed pan and was not currently using one. Staff 6 stated she made sure to stay on top of turning, checking and changing the resident. Staff 6 further stated prior to being left on the bed pan Resident 1 did not have skin breakdown. On 10/25/18 at 1:35 pm Resident 1 stated she/he had sores on her/his bottom caused by being left on a bed pan. Resident 1 further stated the bed pan was left on too long, for hours. On 10/25/18 at 2:25 pm Staff 1 (Administrator) acknowledged the bed pan was left too long under Resident 1 and caused the pressure injuries/wounds.

Based on interview and record review it was determined Staff 21 (CNA) and Staff 22 (CNA) failed to meet professional standards of care for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. Resident 1 developed deep tissue injuries and pressure ulcers. Findings include: 851-063-0020 Definitions . (16) Nursing Assistant means a person who assists licensed nursing personnel in the provision of nursing care . 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard and accepted standards of the nursing assistant profession, or who may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to . (2) Conduct related to achieving and maintaining clinical competency: (a) Failing to conform to the essential standards of acceptable and prevailing nursing assistant performance of duties. Actual injury need not be established; (3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing assistant knowledge, skills, and abilities; (b) Failing to implement the plan of care developed by the registered nurse; (d) Jeopardizing the safety of a person under the CNA's care; (e) Leaving or failing to complete a nursing assistant assignment without properly notifying appropriate supervisory personnel. Resident 1 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. The 9/5/18 Admission MDS indicated Resident 1 did not have pressure ulcers and was at risk for developing pressure ulcers. The 8/25/18 Care Plan updated on 9/5/18 indicated Resident 1 was at risk for developing pressure ulcers due to left sided paralysis and limited use of her/his right hand which affected bed mobility and turning. The care planned goal was for the resident's skin to remain intact. Interventions included to turn and reposition the resident frequently and to check her/him for incontinence and change if wet or soiled. A Progress Note dated 10/19/18 at 7:45 am indicated during rounds staff found a bedpan on Resident 1 and it was noted to be on the resident all night. The investigation to the incident dated 10/19/18 indicated Resident 1 was found to have a Stage I pressure ulcer and deep tissue injury on her/his sacrum (triangular bone just above the coccyx) and, a deep tissue injury to each buttock. The investigation further indicated the night before, on 10/18/18 between 7:30 pm and 7:45 pm, Resident 1 requested a bedpan and Staff 21 (CNA) put the resident on a bed pan. Staff 21 then went on break and stated she told another CNA (Staff 23) to remove the bed pan. When interviewed Staff 23 stated she was not told by Staff 21 to remove Resident 1's bedpan. The investigation further indicated Staff 21 did not check, change or reposition Resident 1 through the rest of her shift which ended at 11:00 pm. The investigation further indicated Staff 22 (CNA) came on shift at 11:00 pm and did not identify the bed pan under Resident 1 until 6:30 am. Staff 21 and Staff 22 were immediately suspended and subsequently terminated and the incident was reported to the local state agency. The wound assessments dated 10/19/18 indicated the following: * A Stage I wound on the sacrum measured 6 cm x 18.50 cm * A deep tissue injury on the sacrum measured 1.3 cm x 15 cm * A deep tissue injury on the right buttock measured 83 cm x 13 cm * A deep tissue injury on the left buttock measured 88 cm x 20 cm Subsequent wound assessments indicated the following: * On 10/24/18 one sacral wound was healed the other decreased in size to 1 cm x 6 cm. By 10/31/18 both sacral deep tissue injury wounds were healed. * On 10/24/18 the deep tissue injury on the right buttock was noted to develop into a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as intact or open/ruptured serum-filled blister) measuring 10.2 cm x 7.5 cm. * On 10/24/18 the deep tissue injury on the left buttock measured 10.2 cm x 1.5 cm and on 10/31/18 was noted to develop into a Stage II pressure ulcer measuring 4.2 x .4 cm. On 10/18/18 during the evening shift Resident 1 requested the use of a bed pan for toileting. Between 7:30 pm and 7:45 pm Staff 21 place the bed pan under the resident and did not check, change or reposition Resident 1 again during her shift. Staff 22, who worked the following shift beginning at 11:00 pm did not discover the bed pan under the resident until 6:30 am on 10/19/18. Consequently Resident 1 developed multiple deep tissue injuries, two of which opened and developed into Stage II pressure ulcers. On 10/25/18 at 1:10 pm Staff 6 (CNA) stated Resident 1 had skin issues from being left on a bed pan and was not currently using one. Staff 6 further stated prior to being left on the bed pan Resident 1 did not have skin breakdown. On 10/25/18 at 1:35 pm Resident 1 stated she/he had sores on her/his bottom caused by being left on a bed pan. Resident 1 further stated the bed pan was left on too long, for hours. On 10/25/18 at 2:25 pm Staff 1 (Administrator) stated Staff 21 was suspended because after the investigation they felt there was enough time left during her shift to identify Resident 1 was still on the bed pan. Staff 1 stated Staff 21's shift began at 3:00 pm and ended at 11:00 pm. Staff 1 further stated Staff 21 would be terminated as soon as they were able to get in contact with her. Staff 1 stated Staff 22 was terminated because they did not feel she did sufficient rounding during her 11:00 pm to 7:00 am shift. Refer to F686

Based on interviews and record review it was determined the facility failed to ensure Resident 1's bedside table was within reaching distance for 1 of 1 sampled residents (#1) reviewed to prevent a fall. The fall caused the resident a fracture in the right knee. Findings include: Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The care plan identified the resident was at very high risk for falls with injuries. The fall interventions included attempt to anticipate needs, frequent checks, low bed and perimeter mattress. A 7/2/18 fall occurrence report indicated Staff 2 (CNA) assisted Resident 1 with toileting by placing the resident on a bed pan on the resident's bed. The resident reached for her/his bed side table and fell out of bed onto the floor. Resident 1 stated she/he fell on to her/his right knee but not her/his head. Resident 1 stated the right knee was painful. The Nurse Practitioner ordered an X-ray. Tylenol and ice packs were used for pain and swelling. The vitals were stable. A message was left for the family. A 7/2/18 clinical note indicated an X-ray report was completed on the right knee which showed a subtle impacted supracondylar femur fracture. Resident 1 was sent to the hospital. In an interview on 7/2/18 at 11:20 am Staff 3 (RN) stated Resident 1 was reaching for something from her/his table but the table was to far away and the resident fell . In an interview on 7/2/18 at 12:00 pm Staff 4 (LPN) stated she was informed of the fall by Staff 2 (CNA). Staff 4 went into to check on Resident 1. The bed was a couple clicks above the lowest position. In an interview on 7/2/18 at 1:00 pm Staff 2 (CNA) stated he had placed the resident on the bed pan. The bed was in a lowered position, a couple of inches from the frame to the floor. Staff 2 stated he left the room for privacy. Staff 2 stated he heard Resident 1 yell for help and saw the resident lying on the floor on the right side of her/his bed. A 7/3/18 hospital discharge summary indicated Resident 1 had a closed mildly displaced right supracondylar femur fracture. The summary continued that Resident 1's knee was non operative and Resident 1 was to wear a knee immobilizer full time. In an interview on 7/10/18 at 11:45 am Staff 3 (RN) stated she was not on shift when Resident 1 fell . When she came on shift, she called for an X-ray, a fracture was found and the resident was sent to the hospital. In an interview on 7/10/18 at 12:33 pm Staff 2 (CNA) stated Resident 1 had to go to the rest room. Staff 2 placed Resident 1 on a bed pan on the bed and lowered the bed a couple of inches above the floor. Staff 2 gave the resident the call light, closed the door for privacy and left the room. Staff 2 stated he was gone about 10 minutes and heard a bang. The resident said she/he had fallen of the bed pan and hit the floor. The resident said she/he was trying to reach something of her/his bedside table but it was out of reach. Staff 2 stated that he had forgotten to place the bedside table back next to Resident 1 after he placed the resident back on the bed pan. In an interview on 7/10/18 at 1:10 pm Staff 4 (LPN) stated Resident 1 reached for something off of the bed side table, the resident could not reach the table and the resident fell out of bed.

Based on interview and record review it was determined the facility failed to follow physician orders [REDACTED].#1, 2, and 3) reviewed for care and services. Resident 1 had multiple weight gains, [MEDICAL CONDITION], and a decline in condition resulting in hospitalization for decompensated heart failure. Residents 2 and 3 were at risk for unmet care needs. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. The December 2017 and January 2018 Physician order [REDACTED]. Related to [MEDICAL CONDITION] staff were directed to weigh the resident daily and report to the physician weight gains of two pounds in two days or five pounds in one week. Always check previous weight. Per the 12/2017 and 1/2018 MARs the [MEDICATION NAME] was given as ordered. The 12/29/17 Clinical Admission Documentation noted the resident was alert and oriented times three. The resident had [MEDICAL CONDITION] of the right and left legs. There was no further documented assessment or monitoring of the resident's [MEDICAL CONDITION]. Per the weight record on 12/30/17 the resident weighed 187.1 pounds. The 1/2/18 and 1/3/18 Speech Therapy Encounter Notes indicated the resident was easily fatigued. On 1/3/17 the resident was very fatigued but maintained sustained attention to task for 16 minutes. Per the weight record on 1/3/18 the resident weighed 183.2 pounds. On 1/4/18 the resident weighed 197.0 pounds, a weight gain of 13.8 pounds. There was no documented notification to the physician of the resident's 13.8 pound weight gain. The 1/4/18 at 11:26 AM Progress Note disclosed therapy reported the resident's oxygen saturations on 4 Liters of oxygen was in the mid 80's. Upon assessment the resident had an oxygen saturation level of 85% on exertion, wheezing, and diminished lung sounds. The resident stated she/he could not catch her/his breath and reported experiencing labored breathing for about two days. The physician was informed of the resident's status. The 1/4/18 physician progress notes [REDACTED]. There was no documentation regarding the resident's 1/4/18 weight gain and the physician addressed the resident's left lower extremity jerking. Witness 2 (Physician) documented no [MEDICAL CONDITION]. The 1/4/18 chest x-ray report noted bilateral lower lobe pneumonia with effusions which was faxed to the physician on 1/5/18. On 1/5/18 the physician ordered [MEDICATION NAME] injection (an antibiotic) 250 mg one dose and [MEDICATION NAME] (an antibiotic) 500 mg one dose followed by 250 mg once a day for three days. Per the 1/2018 MAR indicated [REDACTED] The 1/5/18 Cardiologist Visit Summary noted the reason for the visit was [MEDICAL CONDITION]. While the TAR which accompanied the resident on the visit documented tracking of multiple care areas including the resident's weight record there was no documented evidence the physician was explicitly informed of the resident's 1/4/18 weight gain. The cardiologist documented during the resident's hospitalization prior to 12/29/17 facility admission the resident had bilateral pleural effusion large volume, likely in setting of fluid overload . The cardiologist documented at the time of the 1/5/18 visit the resident exhibited 1+ ankle [MEDICAL CONDITION] and trace [MEDICAL CONDITION] at the mid tibia bilaterally. The cardiologist noted the resident had multiple cardiopulmonary issues that required the resident be closely followed for decompensation. Per the weight record the resident refused weights on 1/5/18 and 1/6/18. On 1/7/18 the resident weighed 200.1 pounds, a weight gain of three pounds from 1/4/18. There was no documented notification to the physician of the resident's three pound weight gain. Per the weight record on 1/8/18 the resident weighed 201.6 pounds. On 1/9/18 the resident weighed 209.8 pounds, a weight gain of 8.2 pounds. There was no documented notification to the physician of the resident's 8.2 pound weight gain. The 1/8/18 Physical Therapy Treatment Encounter Note documented the resident complained of fatigue and was somnolent. The resident was easily aroused but challenged with keeping his/her eyes opened. Barriers during the therapy session included fatigue and somnolence with complaints of not feeling well .coughing all night. Per the weight record on 1/10/18 no weight was obtained due to the resident not being available. However, per physical, occupational, and speech therapy notes the resident was available and participated in therapy that day. The 1/10/18 physician progress notes [REDACTED]. There was no documented evidence the physician was explicitly informed of the resident's 1/4/18, 1/7/18, and 1/9/18 weight gains. The physician noted the resident reported a new cough which she/he had for approximately one and a half weeks and the completion of antibiotic treatment for [REDACTED]. given the severe heart failure and recent substantial right sided pleural effusion. The physician documented the resident exhibited 2+ bilateral lower extremity [MEDICAL CONDITION] to above the resident's knees. The 1/2018 TAR noted on 1/11/18 PCP (Primary Care Physician) notified of significant wt gain. The 1/12/18 at 4:14 PM RD Progress Note documented Significant weight changes in context of [MEDICAL CONDITION] observed: notable fluctuations with 8.9% increase overall since admit - a two week period . MD aware of weight changes per RN report. Per the RD the resident's fluid status was complicated due to [MEDICAL CONDITION] with [MEDICAL CONDITION] and diuretic use. Staff 17 (RN) documented on 1/15/18 at 2:29 AM the resident was alert and oriented and slept throughout the night. The 1/15/18 PT Treatment Encounter Note described the resident as falling asleep while on the New Step machine and required a second person assist due to decreased alertness and instability. While attempting to use the standing frame it was discontinued due to safety concerns and the resident falling asleep. The 1/15/18 Nutritional Status CAA noted the resident's weight was likely affected by the bilateral lower extremity [MEDICAL CONDITION]. The 1/16/18 OT Therapy Treatment Encounter Note disclosed the resident reported frustrations stating I feel like I am not getting better. Staff 28 (OT) spent extensive time consulting with Staff 20 (RN) and Staff 24 (RN), consulted with the Director of Rehab regarding the resident's medical changes, weight gain, and appropriate therapy participation due to the resident falling asleep during treatment, and discussed changes, with the physician. Staff 20 (RN) documented on 1/16/18 at 6:13 PM the resident was alert and oriented but very drowsy. The resident had difficulty participating with therapy and was falling asleep in the chair. The resident's lack of sleep was discussed with the physician who changed a medication administration to mid morning instead of at night. On 1/17/18 at 3:08 AM Staff 17 (RN) documented the resident slept throughout the night. The 1/17/18 Speech Therapy Treatment Encounter Note revealed the resident .presents with limited sustained attention and could not continue with session. The 1/17/18 Physical Therapy Treatment Encounter Note documented the resident exhibited [MEDICAL CONDITION] on the feet which was reported to the nurse. The 1/17/18 Occupational Therapy Treatment Encounter Note documented the resident voiced her/his frustrations about weight gain and not getting any answers. The resident was educated on the possible discharge from therapy due to medical changes. The resident's oxygen saturation level decreased to 86% with exercise and the resident was described as very short of breath, fatigued, and had trouble breathing. On 1/18/18 at 2:43 AM Staff 17 (RN) documented the resident was alert and oriented, able to make needs known, with vital signs stable. The resident slept throughout the night. The 1/18/18 Physical Therapy Treatment Encounter Note disclosed the resident required frequent tactile cues for wakefulness and had [MEDICAL CONDITION] to the feet. During therapy set up .it became apparent the pt (patient) could not stay awake and alert enough to participate in therapy. Pt returned to room . The resident stayed awake for the transfer to bed but immediately fell asleep when laid down. Staff 6 (LPN) documented on 1/18/18 at 3:59 PM therapy reported the resident was drowsy during therapy sessions and often fell asleep in the middle of therapy. The resident reported her/his days and nights seemed to be switched and a medication was switched from night to morning due to keeping the resident awake. Noted increase in [MEDICAL CONDITION] in BLE (bilateral lower extremities). MD notified of both of these issues during visit to facility this afternoon. The physician stated the resident was on an adequate dosage of [MEDICATION NAME] and drowsiness was baseline for the resident. Per the weight record on 1/18/18 the resident weighed 201.0 pounds. On 1/19/18 the resident weighed 217.0 pounds, a 16 pound weight gain and a 29.9 pound overall weight gain from 12/30/17. There was no documented notification to the physician of the resident's 16 pound weight gain. The 1/20/18 at 8:06 PM Progress Note disclosed This nurse and other nurses on duty discussed the resident's steady cognitive decline, increase in weight gain, respiratory issues . since the resident's admission. All agreed that there was notable issues that needed to be addressed. This nurse spoke with PCP and after reporting all the evidence PCP made the decision to send resident to ED (Emergency Department). The 1/20/18 ED Provider Notes documented over the last four weeks the resident gained 30 pounds. The resident reported the lower extremity and scrotal [MEDICAL CONDITION] had significantly worsened. The physical examination revealed significant scrotal [MEDICAL CONDITION] and 4+ pretibial [MEDICAL CONDITION] ([MEDICAL CONDITION] of the lower leg) with venous stasis changes bilaterally. The physician noted the resident presented with worsening anasarca (generalized swelling throughout the body) and a mildly abnormal Troponin level (a lab that measures heart damage), I believe the troponin elevation is due to cardiac strain from volume overload. The resident was admitted to the hospital. The 1/20/18 hospital History and Physical noted the resident was treated for [REDACTED].without improvement so could have been all related to . heart failure. The resident had 2+ [MEDICAL CONDITION] to at least above the knee and her/his abdomen was slightly protruded. Labs were notable for acute kidney injury. The physician noted the [MEDICATION NAME] administration, .however, (Resident 1) likely has gut [MEDICAL CONDITION] and has probably not been absorbing the med for at least a few weeks. The resident was treated with IV [MEDICATION NAME] 80 mg but was expected to require higher doses. The 1/28/18 hospital Discharge Summary noted during the resident's hospitalization she/he had a [MEDICAL CONDITION]. It was unclear if the cause of arrest was ischemic vs decompensation from heart failure. Discharge [DIAGNOSES REDACTED]. The resident's change of condition including lack of obtaining daily weights, weight gains and physician notification, and [MEDICAL CONDITION] were discussed with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Quality Improvement RN) on 2/5/18 at 3:26 PM. Staff 3 stated she was not aware the cardiologist and new PCP expressed concerns regarding the pneumonia [DIAGNOSES REDACTED]. Staff 1 stated the facility did not always obtain the physician progress notes [REDACTED]. Staff 1 stated the resident's TARs with the weights noted were sent with the resident for the 1/5/18 and 1/10/18 physician visits. No additional documentation was provided which documented the physicians were explicitly informed of the resident's weight gains. Staff 3 stated they were not aware of the resident's [MEDICAL CONDITION] until the end of her/his stay in the facility. Regarding monitoring and assessment of [MEDICAL CONDITION] Staff 2 stated staff were to place the resident on alert and document the status on the [MEDICAL CONDITION] monitor. In interview on 2/6/18 at 12:10 PM Staff 21 (LPN) stated the resident was very ill during her/his stay and the fatigue improved a little. CNAs obtained the resident's weight and she entered the weight in the electronic record. Staff 21 stated when entering the 1/19/18 weight she probably did not look back at the previous weight as she was training that day. Staff 21 stated she was not aware of the weight gain, obviously I missed that and did not notify the physician regarding the weight increase. On 1/20/18 the resident had a harder time breathing, looked like she/he was retaining fluid, and had a bigger girth which was new. The resident stated she/he was fine but seemed like she/he was struggling to breath. Staff 21 did not have information about the resident's bilateral lower extremity [MEDICAL CONDITION] other than she did not think it was extreme. In interview on 2/6/18 at 12:27 PM Staff 11 (LPN) stated when the resident was first admitted to the facility she/he was lethargic, had unstable oxygen saturation levels, pneumonia, and [MEDICAL CONDITION]. An [MEDICAL CONDITION] monitor or progress notes were used for [MEDICAL CONDITION] documentation. Staff 11 stated she only worked with the resident once a week. The resident's weight increased each week and on 1/11/18 Staff 11 informed the physician about the resident's 20 pound weight gain, [MEDICAL CONDITION], and lethargy. The physician directed her to continue monitoring the resident and notify her of critical changes. During the resident's last week in the facility the fatigue worsened. Staff 11 was not aware the resident experienced the 1/19/18 16 pound weight gain. On 1/20/18 the resident reported experiencing increased shortness of breath over the past week, had +2 to +3 [MEDICAL CONDITION] in the lower extremities, abdominal distension, and she contacted the physician. In interview on 2/6/18 at 12:41 PM Staff 19 (RN) stated he did not recall if the resident had [MEDICAL CONDITION]. Staff 19 stated on 1/4/18 he did not look back at the previous weight and did not report the weight gain to the physician. In interview on 2/6/18 at 1:10 PM Staff 25 (PT) stated on 1/17/18 and 1/18/18 he observed the resident's [MEDICAL CONDITION] in the lower legs which he reported to nursing. On 1/18/18 the PT session was too much for the resident and he questioned if the resident was medically able to participate in therapy. In interview on 2/6/18 at 1:41 PM Staff 20 (RN) stated the resident was ill and had a lot of co-morbidities including heart and kidney failure. The resident was admitted with +2 to 3+ [MEDICAL CONDITION] in the hip and thigh area but did not believe it worsened over the resident's stay in the facility. Staff 20 stated she did not think there was an [MEDICAL CONDITION] monitor for Resident 1. The resident never complained of shortness of breath when oxygen was in place. On 1/9/18 she noted the resident's weight increased, documented the weight increase on a hand-written communication form, and placed it in the physician's box at the facility. Per Staff 20 physician notification was documented in progress notes but she did not document the 1/9/18 notification. Staff 20 stated she could not recall if she received a response from the physician. Regarding the lack of a documented weight on 1/10/18 Staff 20 stated the resident was probably not available for the CNA and she did not know why she did not attempt to get the weight. In interview on 2/6/18 at 2:00 PM Staff 24 (RN) stated fatigue was the resident's baseline. The resident had pneumonia and she thought the resident needed a couple of days of rest and antibiotics. Per Staff 24 stated the resident did not improve with antibiotic treatment. Staff 24 did not recall information about [MEDICAL CONDITION]. Staff 24 stated she did not know the resident had a significant weight gain and she did not check the resident's previous weight on 1/7/18. Staff 24 stated because she did not check the previous weight she did not notify the physician. In interview on 2/6/18 at 2:19 PM Staff 6 (LPN) stated the resident initially improved a little after admission then declined a couple of weeks before being sent to the hospital. Therapy reported the resident slept during sessions and the resident's weight and fatigue increased. Staff 6 stated in discussion with Staff 25 (PT) and Staff 28 (OT) a week before the 1/20/18 hospitalization they stated they did not think the resident's fatigue was from the resident mixing up her/his nights and days and was more related to medical changes. Later that week Staff 3 (Quality Improvement RN) mentioned the resident's weight gain and told her to make sure the physician new about the weight gain. On 1/18/18 she reported concerns to the physician regarding the resident's fatigue, [MEDICAL CONDITION], and weight gain. The physician stated the resident's [MEDICATION NAME] dosage was fine with no new orders given. A few days later the resident was sent to the hospital for IV [MEDICATION NAME]. In interview on 2/7/18 at 9:54 AM Staff 22 (CNA) stated the resident had slight [MEDICAL CONDITION] in one of her/his legs that went half way up the resident's calf. The resident's fatigue varied but overall declined and the resident was weaker during the week before the 1/201/8 hospitalization . In interview on 2/7/18 at 10:10 AM Staff 29 (ST) stated the resident declined over the last two weeks in the facility. Staff 29 stated she mainly worked with the resident on her/his ability to sustain participation with any therapeutic task. At admission the resident could participate on a low level but over time she/he could not sit up and keep her/his eyes open. The resident had [MEDICAL CONDITION] in her/his feet and ankles and the ankles were significantly swollen during the last two weeks of her/his stay. In interview on 2/7/18 at 10:18 AM Staff 28 (OT) stated before pneumonia the resident had fatigue but was more alert and not as lethargic. After the pneumonia the resident deteriorated. The resident was lethargic, not alert, had difficulty remaining awake, and therapy sessions were terminated. The [MEDICAL CONDITION] worsened, the resident's feet were really swollen and the [MEDICAL CONDITION] went up to the resident's thighs. The resident voiced frustrations about weight gain and she learned from nursing the resident gained 20 pounds. Staff 28 stated she notified nursing about the resident's mobility related to weight gain and [MEDICAL CONDITION]. Nursing reported the physician would follow up. Staff 28 stated she spoke with the physician about the resident's leg spasms and falling asleep in sessions but did not report the weight gain to the physician as she only reported what she observed in therapy. In interview on 2/6/18 at 11:48 PM Staff 5 (RNCM) stated during the last two weeks of the resident's stay the resident worked with therapies, had a harder time with fatigue, and was not able to do the exercises as before. Staff 5 learned of the resident's shortness of breath and low oxygen saturation levels on 1/4/18. Staff 5 stated after the pneumonia treatment staff did not report the resident had difficulty breathing. Staff 5 stated therapy staff completed Stop and Watch reports regarding resident concerns with copies of the form given to the nurse and herself. Staff 5 stated she did not remember if she received the form from OT on 1/17/17 regarding the resident's respiratory issues and did not retain those reports at that time. Staff 5 stated the therapy interview statements regarding the resident's decline after the pneumonia and inability to participate in therapy were accurate. Staff 5 stated she was not aware the resident had [MEDICAL CONDITION]. The resident had weight fluctuations initially but had a large weight gain on 1/19/18. Staff 5 stated based on the documentation staff did not notify the physician of the complete status of the resident. Staff 5 stated she was not aware the resident was seen by the cardiologist and did not have the progress note after the physician visit. Staff 5 stated it was standard for nursing to call and get the physician progress notes [REDACTED]. Staff 5 stated she did not check the resident for [MEDICAL CONDITION] and only focused on pneumonia. Staff 5 stated because of the 1/19/18 weight gain the resident should have been sent to the hospital that day. In interview on 2/6/18 at 12:56 PM Witness 2 (Physician) stated regarding the 1/4/18 physician visit her main concern was regarding the resident's lower extremity movements and the resident's [MEDICAL CONDITION] was not that prominent in her/his legs and was more prominent in the abdomen. Witness 2 stated she was aware the resident's weight was slowly increasing and the resident was diagnosed with [REDACTED]. The resident was treated with [MEDICATION NAME] 40 mg and she was concerned about increasing the dosage related to [MEDICAL CONDITION]. The resident had a history of [REDACTED]. Witness 2 stated she knew the resident was getting sick but did not recall when she became aware of it. Regarding the 1/19/18 weight gain along with the resident's current status Witness 2 stated she expected staff to call the cardiologist, review the resident's status, and ask for direction. The resident should have been sent to the hospital on [DATE] as the oral [MEDICATION NAME] was not adequate. The facility failed to follow physician orders [REDACTED]. They did not ensure physicians were explicitly informed of the resident's weight gains when the resident went to physician appointments. The 1/5/18 and 1/10/18 physician visit notes which identified concerns regarding the resident's cardiopulmonary status were not obtained by the facility. The resident's [MEDICAL CONDITION] was not monitored or assessed. The resident did not improve after treatment of [REDACTED]. The resident had a significant weight gain on 1/19/18 which was not reported to the physician. The resident was not sent to the hospital until 1/20/18. Hospital records noted the resident was admitted for decompensated heart failure. b. On 1/5/18 the physician ordered [MEDICATION NAME] 500 mg for one day and 250 mg for three days starting 1/6/18 for pneumonia. The 1/6/18 at 8:17 PM Progress Note disclosed the resident was accidentally given 500 mg of the [MEDICATION NAME] instead of the 250 mg. The facility's correlating investigation noted the nurse observed the medication card was full and none of the [MEDICATION NAME] was administered. After administering the 1/6/18 500 mg dose the nurse realized the initial 500 mg dose of [MEDICATION NAME] was obtained from the E-Kit (emergency medication kit) and administered on 1/5/18. The 1/6/18 medication error was discussed with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Quality Improvement RN) on 2/6/18 at 3:26 PM. No additional information was provided. 2. Resident 2 was admitted to the facility in 2017 with [DIAGNOSES REDACTED]. The 12/5/17 physician order [REDACTED]. The 12/2017 and 1/2018 TARs directed staff to notify the physician for five pound weight gains in one week. Always check previous weight. From 12/21/17 to 1/29/18 the weight record, 12/2017 TAR, and 1/2018 TAR lacked documentation of weights obtained on 13 occasions. For example: On 12/22/17 Only on weight schedule for [MEDICAL TREATMENT] days .Not completed. On 12/29/17, 1/5/18, 1/7/18, 1/12/18, and 1/14/18, Not Administered (Did not occur). On 1/15/18 AM the resident was noted as Not completed (Uncooperative). There was no documented evidence the facility made additional attempts to obtain the resident's weight later that day. The weight record noted on 12/23/17 the resident weighed 155 pounds. On 12/24/17 the resident weighed 175 pounds. There was no documented evidence a re-weight was obtained to ensure an accurate weight nor of physician notification. On 12/25/17 the resident weighed 155.2 pounds. The weight record noted on 1/6/18 the resident weighed 152.6 pounds. There were no documented weights for 1/7/18 or 1/8/18. On 1/9/18 the resident weighed 183.6 pounds. There was no documented evidence a re-weight was obtained to ensure an accurate weight nor of physician notification. There was no documented weight on 1/10/18. On 1/11/18 the resident weighed 154.0 pounds. The weight record noted on 1/24/18 the resident weighed 149.6 pounds. On 1/25/18 the resident weighed 156.0 pounds. There was no documented evidence a re-weight was obtained to ensure an accurate weight nor of physician notification. On 1/26/18 the resident weighed 151.6 pounds. The 2/2/18 at 5:12 PM Progress Note disclosed the resident was sent to the hospital for an unrelated concern. The resident was still in the hospital during the 2/14/18 complaint survey. The lack of following physician orders [REDACTED]. Staff 4 stated she did not know if the facility had a standard of when to notify the physician regarding weights and was waiting on direction from Staff 2 (DNS). When asked what nurses were expected to do when the resident had a weight gain Staff 4 stated they were to follow the TAR. Regarding the resident's weight gains Staff 4 stated it was a problem with the scale and staff should use a different scale to verify the weight. Staff 4 stated on 12/24/17 Staff 13 (RN) did not check the previous weight and she did not know if the 12/24/17 weight was accurate. In interview on 2/12/18 at 2:37 PM Staff 13 (RN) stated he did not recall information regarding the lack of obtaining daily weights in 12/2017 or 1/2018. Regarding the 12/24/17 documented weight gain Staff 13 stated the re-weigh was completed the next day and must have been an outlier. Staff 13 stated he could not recall if he notified the physician. In interview on 2/13/18 at 9:12 am Staff 23 (LPN) stated regarding the documented 1/9/18 weight gain she may have entered the wrong weight and must not have checked the previous weight. Regarding a re-weigh or physician notification Staff 23 stated staff would have followed up on it the next day. In interview on 2/13/18 at 9:20 AM Staff 14 (RN) stated she did not recall specific information about obtaining daily weights in 12/2017 or 1/2018. There was a note at the nurses' station directing staff to obtain the resident's weights on [MEDICAL TREATMENT] days, Tuesdays, Thursdays, and Saturdays. When asked about the TAR directive for daily weights Staff 14 stated she thought the information at the nurses' station was the most recent order. Staff 14 did not recall details regarding the 1/25/18 documented weight gain. 3. Resident 3 was admitted to the facility in 1/12/18 with [DIAGNOSES REDACTED]. On 1/31/18 the physician ordered daily weights. The weight record and 2/2018 TAR lacked documentation of weights obtained on 2/2/18. The lack of a documented 2/2/18 weight was discussed with Staff 2 (DNS) on 2/12/18 at 2:18 PM. No additional information was provided.

Based on interview and record review it was determined the facility failed to consult with physicians timely and notify the resident's representative regarding changes in weight for 1 of 4 sampled residents (#1) reviewed for weight monitoring. The resident had multiple weight gains, [MEDICAL CONDITION], and a decline in condition resulting in hospitalization for decompensated heart failure. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The December 2017 and January 2018 Physician order [REDACTED]. Related to [MEDICAL CONDITION] staff were directed to weigh the resident daily and report to the physician weight gains of two pounds in two days or five pounds in one week. Always check previous weight. Per the weight record on 1/3/18 the resident weighed 183.2 pounds. On 1/4/18 the resident weighed 197.0 pounds, a weight gain of 13.8 pounds. There was no documented notification to the resident's representative or consultation with the physician of the resident's 13.8 pound weight gain. The 1/5/18 at 9:31 AM and 7:38 PM Progress Notes documented the resident was diagnosed with [REDACTED]. The 1/5/18 Cardiologist Visit Summary noted the reason for the visit was [MEDICAL CONDITION]. While the TAR which accompanied the resident on the visit documented tracking of multiple care areas including the resident's weight record there was no documented evidence the physician was explicitly informed of the resident's 1/4/18 weight gain. The cardiologist documented during the resident's hospitalization prior to 12/29/17 facility admission the resident had bilateral pleural effusion large volume, likely in setting of fluid overload . The cardiologist noted the resident had multiple cardiopulmonary issues that required the resident be closely followed for decompensation. Per the weight record the resident refused weights on 1/5/18 and 1/6/18. On 1/7/18 the resident weighed 200.1 pounds, a weight gain of three pounds from 1/4/18. There was no documented notification to the resident's representative or consultation with the physician of the resident's three pound weight gain. Per the weight record on 1/8/18 the resident weighed 201.6 pounds. On 1/9/18 the resident weighed 209.8 pounds, a weight gain of 8.2 pounds. There was no documented notification to the resident's representative or consultation with the physician of the resident's 8.2 pound weight gain. The 1/10/18 physician progress notes [REDACTED]. There was no documented evidence the physician was explicitly informed of the resident's 1/4/18, 1/7/18, or 1/9/18 weight gains. The physician noted the resident reported a new cough which she/he had for approximately one and a half weeks and the completion of antibiotic treatment for [REDACTED]. given the severe heart failure and recent substantial right sided pleural effusion. The 1/2018 TAR noted on 1/11/18 PCP (Primary Care Physician) notified of significant wt gain. The 1/12/18 at 4:14 PM RD Progress Note documented Significant weight changes in context of [MEDICAL CONDITION] observed: notable fluctuations with 8.9% increase overall since admit - a two week period . MD aware of weight changes per RN report. Per the RD the resident's fluid status was complicated due to [MEDICAL CONDITION] with [MEDICAL CONDITION] and diuretic use. The 1/16/18 OT Therapy Treatment Encounter Note disclosed the resident reported frustrations stating I feel like I am not getting better. Staff 28 (OT) spent extensive time consulting with Staff 20 (RN) and Staff 24 (RN), consulted with the Director of Rehab regarding the resident's medical changes, weight gain, and appropriate therapy participation due to the resident falling asleep during treatment, and discussed changes, with the physician. Staff 6 (LPN) documented on 1/18/18 at 3:59 PM therapy reported the resident was drowsy during therapy sessions and often fell asleep in the middle of therapy. Noted increase in [MEDICAL CONDITION] in BLE (bilateral lower extremities). MD notified of both of these issues during visit to facility this afternoon. The physician stated the resident was on an adequate dosage of [MEDICATION NAME] and drowsiness was baseline for the resident. Per the weight record on 1/18/18 the resident weighed 201.0 pounds. On 1/19/18 the resident weighed 217.0 pounds, a 16 pound weight gain. There was no documented notification to the resident's representative or consultation with the physician of the resident's 16 pound weight gain. The 1/20/18 at 8:06 PM Progress Note disclosed This nurse and other nurses on duty discussed the resident's steady cognitive decline, increase in weight gain, respiratory issues . since the resident's admission. All agreed that there was notable issues that needed to be addressed. This nurse spoke with PCP and after reporting all the evidence PCP made the decision to send resident to ED (Emergency Department). The 1/20/18 ED Provider Notes documented over the last four weeks the resident gained 30 pounds. The resident reported the lower extremity and scrotal [MEDICAL CONDITION] had significantly worsened. The physical examination revealed significant scrotal [MEDICAL CONDITION] and 4+ pretibial [MEDICAL CONDITION] ([MEDICAL CONDITION] of the lower leg) with venous stasis changes bilaterally. The physician noted the resident presented with worsening anasarca (generalized swelling throughout the body) and a mildly abnormal Troponin level (a lab that measures heart damage), I believe the troponin elevation is due to cardiac strain from volume overload. The resident was admitted to the hospital. The 1/20/18 History and Physical noted the resident was treated for [REDACTED].without improvement so could have been all related to . heart failure. The resident had 2+ [MEDICAL CONDITION] to at least above the knee and her/his abdomen was slightly protruded. Labs were notable for acute kidney injury. The physician noted the [MEDICATION NAME] administration, .however, (Resident 1) likely has gut [MEDICAL CONDITION] and has probably not been absorbing the med for at least a few weeks. The resident was treated with IV [MEDICATION NAME] 80 mg but was expected to require higher doses. The 1/28/18 Discharge Summary noted during the resident's hospitalization she/he had a [MEDICAL CONDITION]. It was unclear if the cause of arrest was ischemic vs decompensation from heart failure. Discharge [DIAGNOSES REDACTED]. The lack notification to resident's representative and consultation with the physician regarding weight gains were discussed with Staff 1 (Administrator), Staff 2 (DNS), and Staff 3 (Quality Improvement RN) on 2/5/18 at 3:26 PM. Staff 1 stated they were unable to locate documentation of physician notification of the resident's weight gains except for one RN who notified the physician on 1/11/18. Staff 1 stated the resident's TARs with the weights noted were sent with the resident for the 1/5/18 and 1/10/18 physician visits. No additional documentation was provided which documented the physicians were explicitly informed of the resident's weight gains. In interview on 2/6/18 at 12:10 PM Staff 21 (LPN) stated CNAs obtained the resident's weight and she entered the weight in the electronic record. Staff 21 stated when entering the 1/19/18 weight she probably did not look back at the previous weight. Staff 21 stated she was not aware of the weight gain, obviously I missed that and did not notify the physician regarding the weight increase. On 1/20/18 the resident had a harder time breathing, looked like she/he was retaining fluid, and had a bigger girth which was new. In interview on 2/6/18 at 12:27 PM Staff 11 (LPN) stated she only worked with the resident once a week. The resident's weight increased each week and on 1/11/18 Staff 11 informed the physician about the resident's status including the 20 pound weight gain. The physician directed her to continue monitoring the resident and notify her of critical changes. During the resident's last week in the facility the fatigue worsened. Staff 11 was not aware the resident experienced the 1/19/18 16 pound weight gain. On 1/20/18 the resident reported experiencing increased shortness of breath over the past week, had +2 to +3 [MEDICAL CONDITION] in the lower extremities, abdominal distension, and she contacted the physician. In interview on 2/6/18 at 12:41 PM Staff 19 (RN) stated on 1/4/18 he did not look back at the previous weight and did not report the weight gain to the physician. In interview on 2/6/18 at 1:41 PM Staff 20 (RN) stated on 1/9/18 she noted the resident's weight increased, documented the weight increase on a hand-written communication form, and placed it in the physician's box at the facility. Per Staff 20 physician notification was documented in progress notes but she did not document the 1/9/18 notification. Staff 20 stated she could not recall if she received a response from the physician. In interview on 2/6/18 at 2:00 PM Staff 24 (RN) stated she did not know the resident had a weight gain and she did not check the resident's previous weight on 1/7/18. Staff 24 stated because she did not check the previous weight she did not notify the physician. In interview on 2/6/18 at 2:19 PM Staff 6 (LPN) stated the resident initially improved a little after admission then declined a couple of weeks before being sent to the hospital. Therapy reported concerns regarding the resident's status including weight gain. Staff 3 (Quality Improvement RN) mentioned the resident's weight gain and told her to make sure the physician new about the weight gain. On 1/18/18 she reported concerns to the physician regarding the resident's fatigue, [MEDICAL CONDITION], and weight gain. The physician stated the resident's [MEDICATION NAME] dosage was fine with no new orders given. A few days later the resident was sent to the hospital for IV [MEDICATION NAME]. In interview on 2/7/18 at 10:18 AM Staff 28 (OT) stated the resident voiced frustrations about weight gain and she learned from nursing the resident gained 20 pounds. Staff 28 stated she spoke with the physician about the resident's status but did not report the weight gain to the physician as she only reported what she observed in therapy. Refer to F675, example 1a.

Based on observation, interviews and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (#170) who received [MEDICATION NAME], an anticoagulant medication. The resident experienced increased leg pain, a decrease in weight bearing status, and received hospital treatment. Findings include: Resident 170 was admitted in 12/2012 with [DIAGNOSES REDACTED]. Hospital records indicated the resident had received [MEDICATION NAME] (anticoagulant medication) for blood clot prevention. On 12/24/12 the admission physician orders directed to hold [MEDICATION NAME] on 12/24/12 and 12/25/12 then recheck INR (a blood test to determine blood clotting time) on 12/26/12. If the INR result was less than 2, the physician directed to restart [MEDICATION NAME] 2 mg at hs. There was no documented evidence in facility records the INR was completed on 12/26/12 to determine the need for the [MEDICATION NAME] to be restarted as the physician ordered. The resident's 12/2012 MAR indicated [REDACTED]. The Coagulation Flow Sheet identified on 12/31/12 an INR was test was done. There was no physician order found in facility records for the INR test. According to clinical nursing notes, on 12/31/12 at 5:18 pm, the resident's physician was notified of INR results of 1.0. A physician telephone order directed that [MEDICATION NAME] 2 mg be administered daily. There was no documented evidence that [MEDICATION NAME] was administered on 12/31/12 as the physician ordered. There was no evidence the physician was notified of the 12/31/12 missed dose. It was documented in a 1/3/13 P. A.- C (Physician Assistant, Certified) visit note, the resident had complained of left hip and leg pain and had missed a week of [MEDICATION NAME] medication. The resident had calf tenderness and 2+ [MEDICAL CONDITION] in the left lower extremity. The resident was sent for doppler ultrasound testing and then to the hospital emergency room for evaluation. The 1/3/13 hospital report identified a new [DIAGNOSES REDACTED].) The resident was placed on [MEDICATION NAME] (an injectable anticoagulant) 40 mg daily and increased dose of [MEDICATION NAME] from 2 mg to 5 mg daily. The physician also directed to keep the resident's leg elevated. On 1/4/13 at 6:20 pm, it was documented in clinical nursing notes it was "verified" the resident had [MEDICAL CONDITION] in two different veins of the left lower leg. According to Physical Therapy notes, on 12/25/12 the resident's weight bearing status on the left lower extremity was as tolerated. On 1/4/13 it was documented the nurse had informed the therapist of the [MEDICAL CONDITION] and requested the resident avoid ambulation or left lower extremity exercises. On 1/7/13 it was identified the resident's status was non-weight bearing and with no activity of the left lower leg. On 1/8/13 at 1:54 pm, the resident was observed awake and lying in bed with her lower legs elevated. In an interview at that time, Resident 170 stated she/he had been participating with therapy but had a recent set back due to increased pain in her/his leg. The resident further stated it was discovered a few days ago she/he had blood clots and she/he needed to keep her/his leg elevated. In an interview on 1/10/13 at 7:43 am, Staff 2, RNCM, stated the 12/26/12 INR physician order was missed. Staff 2 further stated that an investigation had been done. The order had been put in the computer but it was not known why the order was not activated. This was discussed with Staff 1, DNS on 1/10/13 at 9:55 am and 1:44 pm. Staff 1 stated the 12/26/12 physician order for [REDACTED]." It had to be approved by a nurse before it would be scheduled. Apparently it was not seen or approved by the nurse. Staff 1 confirmed the PT/INR was not done, [MEDICATION NAME] had not been given on 12/31/12 as ordered, and confirmed no evidence the MD was notified of the missed dose on 12/31/12. Three attempts to contact Witness 1, the prescribing physician, were unsuccessful. .

Based on interview and record review it was determined the facility failed to follow fall care planned interventions for 1 of 3 sampled residents (#2) reviewed for falls. Resident 2 sustained a right hip fracture. Findings include: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/5/12 Care Plan indicated the resident was at risk for falls as evidenced by a history of falls. The goal was noted as "The resident will be monitored and appropriate safety measure will be implemented to decrease the risk of significant injury..." Care planned interventions included a low bed, non skid footwear and call light within reach. A 9/7/12 Progress Note revealed the resident was found sitting on the floor, with her/his back against the bed. The resident stated she/he "didn't think to call for assistance." The resident was described as "forgetful at times per baseline." The corresponding facility investigation indicated the use of a bed alarm was added after the fall. On 9/7/12 the physician ordered a "bed alarm on for safety." The intervention was added to the care plan. A 9/9/12 Progress Note (a late entry for 9/8/12) revealed the resident was found on the floor at 6:00 am, lying on her/his back, with the right arm bleeding. The corresponding facility investigation revealed no alarm was present on the bed at the time of the fall. The resident had not used the call light and stated she/he "slid out of bed." A 9/8/12 10:53 pm Progress Note disclosed Resident 2 complained of "pain that is progressing upon movement on the right groin area." The physician was contacted and x-rays were ordered. 9/9/12 Progress Notes indicated the resident continued to complain of right hip pain. The 9/9/12 Final X-Ray Report revealed Resident 2 had an acute right femoral neck (hip) fracture with modest displacement and osteoporosis. A 9/9/12 5:50 pm Progress Note disclosed Resident 2 was transported to the hospital for treatment. In interviews on 9/25/12 at 7:32 am and 9/27/12 at 7:15 am, Staff 9, RN, stated Resident 2 had been non-compliant with using the call light and fell on [DATE]. Staff 2 stated after that fall, she recommended the use of a bed alarm to alert staff the resident was getting up. In interview on 9/25/12 at 9:52 am, Staff 6, RN, stated on 9/8/12 it was reported to her Resident 2 had a fall. Staff 6 stated she went into the room, found the resident lying on her/his back and there was no alarm in the resident's room. Staff 6 stated the "day nurse" had reported she put an alarm in place. Staff 6 was unable to identify the day nurse. Staff 6 called the physician regarding the alarm, who informed her he had given an order for [REDACTED]. In interview on 9/25/12 at 10:32 am, Staff 10, CNA, stated when she came on shift prior to the fall, there was no alarm in the resident's room. Staff 10 stated while doing her rounds, she found the resident on the floor. In interviews on 9/25/12 at 10:50 am and 9/26/12 at 9:25 am, Staff 3, RNCM, stated after Resident 2's fall on 9/7/12, she walked the alarm down to the resident's room herself and placed it on the bed for the aide to set it up. Staff 3 stated she did not know why the alarm was not in place. Staff 3 stated the alarm was to alert staff to the resident's movements and attempts to get out of bed, for possible staff intervention.

Based on observations, interviews and record review, it was determined that the facility failed to conduct a comprehensive assessment, obtain treatment orders, adequately monitor and revise the care plan for 1 of 1 sampled resident (#101) who was reviewed for a facility acquired pressure ulcer. As a result of this deficient practice, the resident's wound worsened and required debridement. Findings include: Resident 101 was admitted to the facility in 10/2010, with [DIAGNOSES REDACTED]. A nursing note on 3/2/12 documented "...the (wheelchair) cushion in the power chair is custom fit, but because of prolonged use a lot of the pressure reducing properties are no longer effective....After some discussion back and forth it was decided to use the power chair with frequent monitoring of the skin area..." The resident's current 5/2012 quarterly MDS, Section M - Skin Conditions, identified the resident as "at risk for developing pressure ulcers." The resident's current care plan identified "...alteration in skin integrity related to decreased mobility and need for assistance, history of skin breakdown." And included interventions such as, "cushion in wheelchair; observe skin for s/s (signs/symptoms) of redness, drainage, blisters or evidence of skin breakdown...notify MD if noted...weekly skin assessments...treatment to skin impairment per MD order..." A nursing note on 5/11/12, documented "...notified by CNAs of reddened area on resident's left upper thigh/lower buttock. Area is approx. (approximately) 7 cm x 8 cm, firm and warm to touch. Two smaller darker red areas in middle. No open areas or drainage noted. Resident denies pain to site. MD notified." A 5/11/12 Skin Issue Details Report concluded "...based on the warmth it is likely that this area is either an area of [MEDICAL CONDITION] or a boil that has not yet come to head..." A nursing note on 5/31/12, documented "...resident has skin issues...lower buttock and upper left thigh there is a 9 cm by 7 cm. Within the reddened area, there is a dark red/black colored area that has uneven edges and measures about 5 cm by 3 cm at the widest. The depth of the lesion varies and is approx. 0.3 cm at the deepest point. MD notified." The resident's 5/2012 TAR noted "skin audit 7-3" and "house barrier cream apply Q shift to protect." There were no other treatment interventions identified specific to the resident's left ischial wound. A 6/2/12 nursing note at 5:03 am documented "...contacted MD to give and update on the left hip base gluteal fold sore, it appears to be extending 7.6 x 5.2 cm of red area to the center of the site is open area 5.8 cm x 3.5 cm, with an area of eschar tissue to mid of wound bed of 1.6 cm x 1.0 cm, on call MD suggested to have a wound nurse consult during the week.." On 6/2/12 (three weeks after the initial skin event) a physician order [REDACTED]. On 6/19/12 the resident's Wound Care - Skin Integrity Evaluation, conducted by Witness 1, Certified Wound Specialist, and signed by Staff 2, DNS, identified the resident had a "ischial, left pressure - unstageable...5.00 x 4.00 cm, depth - utd (undetermined)...facility acquired..." The evaluation further assessed the wound as "moist grey eschar covers entire bed...resident developed small dried blister on left ischial site about 3 weeks ago. Has increased in size and started draining s/s exudate around edges of necrotic tissue. Wound needs debridement..." Observations on 7/11/12 at 11:50 am, 12:35 pm, 12:52 pm, and 1;29 pm, on 7/12/12 at 7:48 am, and on 7/13/12 at 9:35 am and 1:40 pm, revealed the resident lying in bed. A skin observation on 7/13/12 at 10:42 am, revealed the resident had a left ischial ulcer with the wound bed pink in color, with granulation tissue present. In a 7/11/12 interview at 1:57 pm, Staff 3, RNCM, when asked if the resident had a pressure ulcer, stated the resident had a "surgical wound" and she "isn't calling it a pressure ulcer...told not to code it as a pressure..." Staff 3 further stated "...it started as a pressure ulcer...I think it was caused by his wheelchair cushion...don't think it was fitting correctly..." During five separate interviews on 7/12/12 at 8:00 am and 3:26 pm, on 7/16/12 at 9:56 am, on 7/17/12 at 3:34 pm and on 7/19/12 at 9:08 am, Staff 4, LPN, stated that the resident had an unstageable pressure area that had been debrided on 6/26/12 and again at the beginning of July. Staff 4 stated that the resident's skin started like a light scab, flat area, like a blister, and she felt it might be from an incontinent brief or lift where the sling rested, "things that would create a pressure..." Staff 4 further stated that during May the resident's wound was "being monitored, but left open to air" and the resident continued to leave the facility 3 to 5 days a week to a socialization group and physical therapy using his electric wheelchair. Facility sign out records reflected that the resident left the faciity on eight days during this time period. The wheelchair cushion which had been identified as ineffective in reducing pressure in March was still in use until the resident was placed on bedrest by order of wound clinic staff. In three separate interviews on 7/13/12 at 10:27 am, on 7/16/12 at 10:38 am, and on 7/17/12 at 9:21 am, Staff 3, RNCM, stated she had observed the resident's skin, however could not recall when, stating "it was shortly after it had been reported", and when she had observed the resident's area "...it looked like a reddened area, with not real defined edges, warm, potentially a fluid filled blister in the center of the red area..." Staff 3 was unable to provide any documented evidence to the specific treatment interventions from 5/11 to 5/31/12 for the resident's left ischial wound. In a 7/17/12 interview at 11:06 am, Staff 2, DNS, stated that a reassessment should have been done to determine if the wound was [MEDICAL CONDITION], pressure, or a boil. In a 7/17/12 interview at 10:51 am, Witness 1, Consulting Wound Specialist, confirmed she had assessed the resident on 6/19/12. Witness 1 stated that 3 weeks prior to 6/19/12 the resident had a small blister on L ischial site increased in size, began to drain and looked necrotic. Witness 1 stated that when she saw the resident's wound "...it definitely needed to be debrided, it was infected and inflamed..." Witness 1 stated that the facility never told her it was a boil "...otherwise I would have noted that, they told me it started as a blister...." Witness 1 stated that seldom will a boil start to look necrotic, and that is what it looked like on 6/19/12, a boil will be raised, hard, bright red, extremely painful..."it didn't look at all like a boil." Witness 1 further stated that when she saw the resident's wound it was very typical of a pressure wound and "boils 99% of the time are very round, this was irregular shape...what I saw was typical of pressure damage...a boil is an abscess...when it's on a typical pressure site, you would really need to prove that it isn't pressure...." In a 7/17/12 interview at 4:15 pm, Staff 2, DNS, when asked about the monitoring of the resident's skin in May, stated "...what should of happened is a weekly assessment tool should have been done to document weekly...it can be for anything....my RCMs should view weekly skin issues..." In a 7/18/12 phone interview at 11:05 am, Witness 2, the resident's doctor, stated that the facility did not inform him the resident's skin area could be from [MEDICAL CONDITION] or boil, and there seemed to be a gap, "I didn't get a call saying that it was getting worse..."