Every finding on record at Westchester Village of Lenexa

The facility identified a census of 26 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident rights training. This placed the residents at risk for impaired care and decreased quality of life. Findings included: - On 03/19/25 at 08:40 AM a review of the training provided by the facility for agency Certified Nurse Aide (CNA) N, CNA O, CNA P, and Certified Medication Aide (CMA) R revealed the following: The facility was unable to provide documentation of CNA N had completed on resident rights training. The facility was unable to provide documentation of CNA O had completed on resident rights training. The facility was unable to provide documentation of CNA P had completed on resident rights training. The facility was unable to provide documentation of CMA R had completed on resident rights training. On 03/19/25 at 10:11 AM, Administrative Staff A stated the facility would start having the charge nurse ensure the agency staff had the required education before working at the facility. The facility failed to provide a policy related to required staff education. The facility failed to ensure the completion of the required resident rights training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 26 residents. The sample included 12 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 19 was appropriately clothed when his bare thigh and leg were showing, and his door was left open. This deficient practice placed R19 at risk for impaired dignity and decreased psychosocial well-being. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficient (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), difficulty in walking, hypertension (high blood pressure), transient ischemic attack (TIA - temporary episode of inadequate blood supply to the brain), malnutrition (not enough calories), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (inability to sleep), and hypokalemia (low level of potassium in the blood). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R19 impaired on one side of his body and used a wheelchair or walker. The MDS documented R19 required set up or clean up for eating, oral hygiene, and toileting. The MDS documented he required supervision or touching for dressing and required setup or clean up for lying to sitting on the side of the bed. The Modified Significant Change MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R19 was independent with oral hygiene and toileting and used a walker or wheelchair. The MDS documented R19 required substantial to maximum assistance of staff for upper body dressing and need staff to setup or cleanup for eating. The MDS documented R19 was independent for the lying to sitting on the side of the bed. R19's The Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 08/09/24 documented R19 was alert and oriented with some forgetfulness and confusion. R19 had difficulty hearing, and usually understands others. R19 had clear speech and could make himself understood. R19 required staff assistance with his activities of daily living (ADL), he self-propels in his wheelchair and will walk short distances in his room with his walker and assistance. R19 was at risk for fall related a history of falling, not calling for assistance when he was wanting to transfer, and he takes psychotropic (alters mood or thought) medications. R19's Care Plan dated 06/19/23 documented R19 walked with a gait belt in his room with staff assistance and used his wheelchair for the rest of the time. R19 was able to self-propel his wheelchair and at times might ask staff to push him. R19's plan of care dated 09/09/23 documented he needed assistance of one staff for toileting, transfers, and dressing. On 03/17/25 at 07:24 AM, R19 laid in his bed on his back, staff members where assisting R19 with sitting on the side of his bed. R19's right thigh and leg were visible from the hall, through his room door. On 03/19/25 at 11:16 AM, Certified Nursing Aide (CNA) M stated all staff should close the curtains, talk to the resident, and ensure the door was closed when a resident was not completely dressed. On 03/19/25 at 11:22 AM, Licensed Nurse (LN) G stated all staff were to train to ensure residents have privacy, doors were closed, and curtains are pulled when residents were dressing. On 03/19/25 at 11:33 AM, Administrative Nurse D stated the facility addressed privacy and dignity daily in their huddles. Staff should talk to residents while doing cares, pull curtains if the residents was in a double occupancy room, and ensure the door was closed if the resident is not clothed. The facility's Quality of Life revised on 01/25 policy documented resident would be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be always treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed. Residents shall be encouraged and assisted to dress in their own clothes. Residents would be assisted in attending the activities of their choice, including activities outside the facility. Residents' private space and property shall be always respected. Staff would knock and request permission before entering residents' rooms. Staff would not handle or move a resident's personal belongings (including radios and televisions) without the resident's permission. dignity and assist residents as needed. The facility failed to ensure R19 was appropriately clothed while his door was open. R19's bare leg and thigh were showing when his door was left open. This deficient practice placed R19 at risk for impaired dignity and decreased psychosocial well-being.

The facility identified a census of 26 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to administer Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial pneumonia infections) vaccination after obtaining a signed consent for Resident (R) 4. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R4's clinical record lacked documentation the PCV20 was given, after obtaining a signed consent or a physician documented contraindication. On 03/18/25 at 08:33 AM, Administrative Nurse E stated the facility had begun putting the consent for vaccinations in the admission packet. He stated the charge nurse would get the consent and order the medication. On 3/19/25 at 11:33 AM, Administrative Nurse D stated the facility was ensuring all immunizations were offered and given, by putting the consent and declination in the admission packet. Administrative Nurse D stated it was ultimately the charge nurse's responsibility to ensure the consent was signed or declined and then order the vaccine from the pharmacy. The facility's Pneumococcal Vaccine policy undated documented all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents were assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, were offered the vaccine series within thirty days of admission to the facility unless medically contraindicated, or the resident has completed the current recommended vaccine series. Assessments of pneumococcal vaccination status are conducted within five working days of the resident's admission, if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative received information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. Residents/representatives have the right to refuse vaccination. If refused, appropriate information was documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. For each resident who receives the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination are documented in the resident's medical record. Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. The facility failed to offer the PCV20 after a consent was obtain for R4. This placed the resident at increased risk for complications related to pneumonia.

The facility identified a census of 26 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for as needed Voltaren (topical pain reliever medication) gel and failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 2. The facility also failed to follow a physician order for blood sugar monitoring for R15. The facility further failed to ensure R6's anticoagulant (a class of medications sued to prevent the blood from clotting) medication was administered as ordered. These deficient practices placed the residents at risk of unnecessary medication use, side effects, physical complications, and fluid overload. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R2 had received an anticoagulant, antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), hyperglycemic (medication that raises blood sugar levels), medication to regulate blood sugar), and opioid (a class of controlled drugs used to treat pain) medications. R2's Nutritional Status Care Area Assessment (CAA) dated 01/03/25 documented her weight would fluctuate related to her diagnosis of CHF and diuretic medication. R2's Care Plan dated 02/01/24 documented the nursing staff would obtain and monitor her lab work and diagnostic work as ordered. The plan of care also documented the nursing staff would report results to the physician and follow up as indicated with the physician. R2's EMR under the Orders tab revealed the following physician orders: Spironolactone (diuretic medication) oral tablet 25 milligrams (mg) give a half of tablet by mouth in the morning for edema (swelling resulting from an excessive accumulation of fluid in the body tissues) dated 12/22/23. Daily weight related to CHF in the morning for edema. Notify physician of weight gain of two pounds in 24 hours. Document accordingly dated 01/29/24. Lasix (diuretic medication) oral tablet 40 mg (Furosemide) give one tablet by mouth in the morning for CHF dated 04/18/24. Voltaren arthritis pain external gel one percent (diclofenac sodium (topical)) applies to right distal scapula (shoulder blade) topically every six hours as needed for pain management. Apply round dressing and use dosing card to measure dose dated 02/03/25. The order lacked a dosing instruction. Review of R2's EMR under the Weights/Vital Sign tab, review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) from 01/01/25 through 03/16/25 (75 days) revealed five times R2 refused on the following dates: 01/04/25, 01/05/25, 01/07/25, 01/08/25, and 02/08/25. Documented Other, See Progress Notes four times on the following dates: 01/09/25, 01/11/25, 01/15/25, and 01/16/25. R2's MAR and TAR lacked documentation four times on the following dates: 01/19/25, 01/23/25, 01/28/25, and 02/07/25. Weight gain was noted greater than two pounds eight times on the following dates: 01/20/25, 01/25/25, 01/29/25, 03/03/25, 03/06/25, 03/09/25, 03/10/25, and 03/14/25. The clinical record lacked documentation of physician notification of daily weight was not obtained or outside the ordered parameter. On 03/18/25 at 11:02 AM, R2 sat in her wheelchair in her room as she looked through her dresser drawers. On 03/19/25 at 11:19 AM, Licensed Nurse (LN) G stated the physician should be notified of any daily weight that are not obtained or outside the physician ordered parameter for R2 related to her CHF. LN G stated the notification should be documented in R2's clinical record and the physician response should also be documented. On 03/19/25 at 11:35 AM, Administrative Nurse D stated she would expect the physician order to be followed. Administrative Nurse D stated she would expect the physician to be notified of any daily weights not obtained for any reason and if the weight was outside the physician ordered parameter. Administrative Nurse D stated she would expect the nurse to document a note under the progress notes with physician's response. The facility's Guidelines for Notifying Physician of Clinical Problems policy last revised 09/2017 documented these guidelines are intended to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in resident/patient status are assessed and documented in the medical record. The facility failed to ensure dosing instructions for Voltaren gel and to follow a physician order for daily weights to monitor weight gain for fluid overload for R2. This deficient practice placed R2 at risk for unnecessary medication use, side effects, physical complications, and fluid overload. - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and hypertension (HTN - elevated blood pressure). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R15 had received insulin (medication to regulate blood sugar) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R15 had received insulin and antidepressant medication. R15's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/16/24 documented required assistance with activities of daily living. R15's Care Plan last revised 03/17/25 documented nursing staff would administer diabetic medication as ordered. The plan of care documented the nursing staff would monitor for side effects and document the effectiveness. R15's EMR under the Orders tab revealed the following physician orders: -Check blood glucose (BG) before meals and at bedtime for DM. Notify physician if BG less than (<) 70 and greater than (>) 350. Document in a progress note dated 09/03/24. -Insulin lispro injection solution (Insulin) Inject six unit subcutaneously (SQ) with meals for DM. Give with food, not before meal arrives. Hold if BG is < 80 or he has not eaten (contact provider) dated 09/19/24. -Insulin lispro injection solution inject as per sliding scale for DM: If BG 151 - 200 = give 4 units SQ; If BG 201 - 250 = give six units SQ; If BG 251 - 300 = give eight units; If BG 301 - 350 = give 10 units SQ; If BG 351- 399 = If BG give 12 units SQ, If BG 400 - 9999 = give 14 units SQ. If > 400, give 14 units SQ and contact provider. Rotate injection sites dated 10/29/24. -Lantus (insulin) solo star subcutaneous solution pen-injector 100 unit/milliliters (ml) (insulin glargine) inject 16-unit SQ at bedtime for DM. Contact provider if BG < 80 prior to administration. Rotate injection sites dated 01/10/25. Review of R15's Medication Administration Record (MAR) from 01/01/25 to 03/16/25 (75 days) revealed R15's BG was > 350 26 times on the following dates: 01/01/25, 01/02/25, 01/04/25, 01/05/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/13/25, 01/14/25, 01/21/25, 01/22/25, 01/25/25, 01/28/25, 02/01/25, 02/07/25, 02/08/25, 02/13/25, 02/18/25, 02/23/25, 02/27/25, 03/05/25, 03/07/25, 03/09/25, 03/11/25, and 03/14/25. The clinical record lacked documentation of physician notification of out of parameter BG. On 03/18/25 at 07:43 AM, R15 sat at the dining room table in his wheelchair. R15 visited with the other residents at the dining room table as he ate his breakfast. On 03/19/25 at 11:19 AM, Licensed Nurse (LN) G stated the physician should be notified of any BG that was outside the physician ordered parameter for R15 related to DM. LN G stated the notification should be documented in R15's clinical record and the physician response should also be documented. On 03/19/25 at 11:35 AM, Administrative Nurse D stated she would expect the physician order to be followed. Administrative Nurse D stated she would expect the physician to be notified of any BG outside the physician ordered parameter. Administrative Nurse D stated she would expect the nurse to document a note under the progress notes with physician's response. The facility's Guidelines for Notifying Physician of Clinical Problems policy last revised 09/2017 documented these guidelines are intended to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in resident / patient status are assessed and documented in the medical record. The facility failed to ensure to follow a physician order for blood glucose to monitor diabetic mellitus for R15. This deficient practice placed R15 at risk for unnecessary medication use, side effects and physical complications. 49634 - R6's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), hemiplegia (paralysis of one side of the body) affecting the right dominant side, open wound, anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and venous insufficiency (a condition where the veins in the legs fail to return blood effectively to the heart). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R6 needed partial to moderate assistance with bathing and dressing. The MDS documented R6 took anticoagulant during the observation period. R6s Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 03/26/25 documented R6 needs assistance with activities of daily living (LTC) and uses a wheelchair for locomotion. The CAA documented R6 Was at risk for falls due to generalized weakness and unsteady gait. The CAA documented R6 had incontinence of bowel and bladder and required staff assistance with toileting. R6's Care Plan dated 09/01/24 documented R6 was able to perform her personal hygiene at times she might need staff to hand her a towel. R6's plan of cart documented R6 needed assistance of two staff for dressing and transfers. R6 plan of care documented R6 required set up assistance for eating. R6's plan of care documented R6 was able to help with upper body dressing and required staff to put on her socks. The EMR under Physician Encounter dated 01/16/24 documented therapeutic drug level monitoring. Prothrombin Time (PT) with International Normalized Ratio (INR), (a blood test that measures how long it takes for blood to clot, and interpret results) PT 13.8 and INR 1.2, INR subtherapeutic. New order given: increase total dose to 24 milligrams (mg) previously 21 mg: give warfarin (medication used to thin blood) three mg Tuesday, Thursday, Saturday, and Sunday. Give warfarin four mg Monday, Wednesday, and Friday, follow up with lab the following week. The EMR under Progress Note Orders Entered dated 01/16/25 documented the order you have entered Warfarin Sodium Oral Tablet three mg (Warfarin Sodium). Give one tablet by mouth at bedtime for atrial fibrillation (a-fib), (irregular heartbeat) anticoagulation. R6 Warfarin order of three mg was transcribed incorrectly. R6's EMR under Medication Administration Record MAR documented from 01/17/25 to 01/31/25 Warfarin Sodium Oral Tablet three mg (Warfarin Sodium) Give one tablet by mouth at bedtime every Tuesday, Thursday, Saturday and, Sunday for a-fib anticoagulation Start Date of 01/16/25 and discontinued (D/C) date of 02/03/25. The EMR under Physicians Encounter dated 01/24/25 documented labs on 01/23/25 subtherapeutic PT with INR 1.1. Orders not implemented as entered last week so R6 had only received warfarin three mg Tuesday, Thursday, Saturday, and Sunday. Reviewed with the facility administrator and nursing, reordered warfarin four mg Monday, Wednesday, and Friday, and three mg Tuesday, Thursday, Saturday, and Sunday. The orders were confirmed to be present in facility MAR and in medication list. Staff to repeat lab in one week. The Monthly Medication Review (MMR) dated 01/27/25 documented Per provider progress noted dated 01/16/25 R6 was to receive warfarin three mg on Tuesday, Thursday, Saturday, and Sunday, and four mg on Monday, Wednesday, and Friday. This order was transcribed on the chart correctly and R6 received three mg. Subsequent INR was subtherapeutic and dose was corrected at that time. Please ensure transcription of orders was verified accuracy. On 03/18/25 at 08:21 AM, R6 laid in her bed looking at her phone. On 03/18/25 at 10:24 AM, Consultant GG stated the physician now puts the orders in, and the nurse was the double check. Consultant GG stated she would expect the nursing facility to call her if an order was put in wrong. On 03/19/25 at 11:22 AM, Licensed Nurse (LN) G stated the physician now puts the or the facility has a nurse on staff for both sides of the building, the other nurse could be the second check. On 03/19/25 at 11:33 AM, Administrative Nurse D the physician inters orders in the facilities system, she stated a nurse had to verify the order after the physician puts the order in Administrative Nurse D stated if a nurse takes a verbal order, there was not a second check to ensure the medication order was accurate. The facility's Notifying the Physician of Clinical Problems dated 09/17 documented guidelines were intended to help ensure that medical care problems were communicated to the medical staff in a timely, efficient, and effective manner. All significant changes in resident or patient status were assessed and documented in the medical record. The immediate and non-immediate problems were not meant to be all-inclusive. The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management. The facility failed to ensure the transcription of R6's blood thinner was transcribed correctly according to physician orders. This deficient practice placed R6 at risk for blood clots from forming or growing larger.

The facility identified a census of 26 residents. The sample included 12 residents, with one resident observed for bowel and bladder. Based on observation, record reviews, and interviews, the facility failed to ensure Resident (R) 14's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) tubing did not drag on the floor. This deficient practice placed R14 at risk of complications and possible urinary tract infections due to potential urine backflow. Finding included: - R14's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hydroureter (a condition where the ureter, the tube that carries urine from the kidney to the bladder, becomes dilated (enlarged) due to a blockage in the urinary tract), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), retention of urine, need for assistance with persona care, weakness, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R14 had an impairment on both sides of his body. The MDS documented R14 was dependent on staff for eating, oral hygiene, bathing, toileting, and dressing. The MDS documented R14 had a neurogenic bladder. The Significant Change MDS dated [DATE] documented a BIMS of 14 which indicated intact cognition. The MDS documented R14 had no impairment of his body and used a wheelchair for mobility. The MDS documented R14 required substantial to maximum assistance with eating, and was dependent on staff for bathing, toileting, and dressing. R14's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 06/13/24 documented R14 had a Significant Change done because he had recently lost weight. R14 was requiring more assistance with activities of daily living (ADL) and had a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) on his sacrum (large triangular bone/area between the two hip bones). R14 was alert and oriented with forgetfulness at times. He had clear speech, could make himself understood, and understood others. He had adequate hearing and vision with his glasses. He uses a wheelchair that staff pushed for mobility, a sit to stand lift for transfers, and he needed assistance from staff with his ADLs. He was at risk for falls related to generalized weakness and requiring staff assistance for transfers. He had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) and had bowel incontinence. His incontinence and needed assistance with bed mobility and repositioning which puts him at risk for pressure ulcers and other skin break down. R14's Care Plan revised on 01/31/24 documented R14 had a neurogenic bladder and had a supra pubic catheter. Staff were to monitor for signs and symptoms of urinary tract infection (UTI - an infection in any part of the urinary system) such as pain, blood-tinged urine, and cloudiness. The plan of care dated 06/14/24 documented staff would complete catheter care each shift and as needed (PRN), catheter bag was emptied each shift, and place catheter bag inside a dignity bag. R14's EMR under Orders tab documented change supra pubic catheter dressing every shift, cleanse site with normal saline pat dry, cover with a 4x4 dressing and secure with tape, may change PRN and every shift dated 07/07/2023. R14's EMR under Orders tab documented may use leg bag during the day, and use large bag at night, rinse out bag when not in use and place in a plastic bag in the bathroom for bladder health dated 07/07/23. On 03/17/25 at 07:23 AM, R14 sat at the breakfast table in his wheelchair awaiting breakfast. R14's catheter bag tubing was dragging on the floor. On 03/17/25 at 11:24 AM, R14 sat at the dining room table awaiting lunch, visiting with peers. R14's catheter bag tubing was on the floor. On 03/19/25 at 11:16 AM, Certified Nurse Aide (CNA) M stated all catheter bags should have a dignity bag, and staff should wear gloves when taking care of a resident with a catheter. CNA M stated all tubing should be off the floor. On 03/19/25 at 11:22 AM, Licensed Nurse (LN) G stated the catheter bag tubing had a clamp to curl the tubing off the floor. She stated all catheter bag tubing should be on the floor. On 03/19/25 at 11:33 AM, Administrative Nurse D stated all catheter tubing should be off the floor, she stated the facility was doing staff competences for catheter care. The facility failed to provide a policy for catheter care. The facility failed to ensure R14's catheter tubing was placed below the level of the bladder. This deficient practice placed R14 at risk of complications and further urinary tract infections due to potential urine backflow.

The facility identified a census of 26 residents. The sample included 12 residents, with one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 7 or to their family representative when R7 was transferred to the hospital. This deficient practice placed R7 at risk for impaired ability to return to the facility or his same room. Finding include: - The electronic medical record (EMR) documented diagnoses of malnutrition (not enough calories to maintain), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), over active bladder, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Significant Change Minimum Data Set (MDS) dated 01/17/25 documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS indicated R7 was independent with eating and needed setup and cleanup from staff with oral hygiene and required substantial to maximum assistance from staff for bathing and toileting. R7's Functional Abilities (Self-Care Mobility) Care Area Assessment (CAA) dated 01/17/25 documented R7 required staff assistance with mobility and repositioning and was at risk for wounds, pressure ulcers and other skin breakdown related to incontinence and needing more assistance. The Discharge MDS dated 11/07/24 for R7 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R7's Entry MDS dated 11/10/24 documented a reentry to the facility from an acute hospital. R7's Care Plan dated 12/10/24 documented R7 was at risk of unintentional weight loss due to COPD and CHF. R7's weight fluctuated due to edema and diuretic use. R7's plan of care documented R7 would maintain her weight, have no signs of malnutrition, and consume at least 50 percent of two meals daily. Staff were to provide R7's diet as ordered and record intake of each meal. A Progress Note dated 11/07/24 documented R7 was lethargic and would be going to the hospital emergency department for evaluation. The provider gave a verbal order to send R7 to the emergency department by ambulance. A Progress Note dated 11/10/24 documented that R7 was readmitted to the facility from an acute care hospital visit. The facility was unable to provide evidence a bed hold notification was provided to the legal representative when R7 was transferred to the hospital from [DATE] to 11/10/24. On 03/17/25 at 08:00 AM, R7 set at the dining room table waiting for her breakfast. On 03/19/25 at 11:22 AM, Licensed Nurse (LN) G stated the nurse on duty was to try to get the bed hold signed by the resident or the guardian. On 03/19/25 at 11:33 AM, Administrative Nurse D stated it was the nurse's duty to ensure the bed hold was signed either by the resident or their guardian. She stated if the nurse does not get the bed hold signed, the social worker would ensure the bed hold was signed. Administrative Nurse D stated the facility started a notebook that has all information to be signed before the resident left the facility. The facility Bed Hold and Returns policy undated documented prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Residents may return to and resume residence in the Community after hospitalization or therapeutic leave as outlined in this policy. The current bed-hold and return policy established by the state (if applicable) will apply to Medicaid residents in the Community. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: The rights and limitations of the resident regarding bed-holds; The reserve bed payment policy as indicated by the state plan (Medicaid residents). The Community per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents. The details of the transfer (per the Notice of Transfer). Medicaid residents who exceed the state's bed hold limit and/or non-Medicaid residents who request a bed-hold are responsible for the Community's Standard Daily Rate while his or her bed is held. If a Medicaid resident exceeds the state bed-hold period, he or she will be permitted to return to the Community, to his or her previous room (if available) or immediately upon the first availability of a bed in a semi-private room provided that the resident: The facility failed to provide a bed hold with the required information to R7 and his family representative when R7 transferred to the hospital. This deficient practice placed R7 at risk for impaired ability to return to the facility or his same room.

The facility identified a census of 26 residents. The sample included 12 residents, with two residents reviewed for treatment and services to prevent and heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9's heels were offloading while in bed to prevent pressure ulcers. This placed R9 at increased risk for pressure ulcer development. Findings Included: - R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic pain, overactive bladder, major depressive disorder (major mood disorder that causes persistent feelings of sadness), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), dementia (a progressive mental disorder characterized by failing memory and confusion), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS) for R9 dated 02/06/25 recorded a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R9 was dependent on staff for bathing, R9 required substantial to maximum assistance for toileting, and dressing. The MDS documented R9 was at risk for pressure ulcers and had a pressure reducing device in wheelchair and her bed. The MDS documented R9 had moisture associated skin damage during the observation period. The Significant Change MDS for R9 dated 08/16/24 recorded a BIMS score of four, which indicated severely impaired cognition. The MDS documented R9 required set up or clean up for eating and oral hygiene and was dependent on staff for toileting. The MDS documented R9 required substantial to maximum assistance for dressing. The MDS documented R9 was at risk for pressure ulcers and had a pressure reducing device in her wheelchair and bed. R9's Pressure Ulcer/ Injury Care Area assessment dated [DATE] documented R9 was removed from hospice due to her overall health/condition improving. R9 had started therapy and was working on developing a restorative program. R9 was alert and oriented with some confusion. R9 required assistance with her activities of daily living (ADL) and was a one-to-two-person lift. R9 uses a wheelchair for mobility and propels herself. R9 incontinence and needing assistance with bed mobility and repositioning puts her at risk for pressure ulcers and other skin break down. R9's Care Plan dated 11/15/23 documented R9 was at risk for wounds, pressure ulcers, and other skin break down related to incontinence and needing assistance with ADLs, nursing was to administer treatment to skin as ordered. R9's plan of care documented R9 used a low air loss mattress pressure reduction mattress on her bed. Nursing was to complete weekly skin assessment sand report any skin issues to the physician. R9's Braden Scale for Prediction Pressure Sore Risk dated 02/01/25 documented a score of 16 indicating a risk for pressure ulcers. R9's physician's orders under the Orders tab revealed the following orders: Low air loss mattress:390 alternating every shift for mattress functioning dated 01/26/25. Offload bilateral (both sides) heels while in bed every shift for wound prevention dated 02/01/24. Apply Skin-prep (liquid skin protectant) to bilateral heels twice daily for wound prevention, please report any signs or symptoms of deterioration to physician immediately dated 02/01/24. On 03/18/25 at 07:05 AM, R9 laid on her bed covered up, R9's heels laid directly on the mattress. On 03/19/25 at 07: 19 AM, R9 laid on her bed, Licensed Nurse (LN) applied skin prep to R9's heels. R9's heels laid directly on the mattress. On 03/19/25 at 11:16 AM, Certified Nurse's Aide (CNA) M stated it was the charge nurse's responsibility to ensure a resident's heels were floating. CNA M stated the nurse could as the CNAs to help with those duties. On 03/19/25 at 11:22 AM, LN G stated all nursing staff could ensure a resident's heels were floated. LN G stated she believed the charge nurse was the one who would sign off on the Treatment Administration Record (TAR) to ensure the heels were being floated. On 03/19/25 at 11:33 AM, Administrative Nurse D stated the task was on the TAR for the charge nurse to be the final check, to ensure the task was performed. The facility's Prevention of Pressure Injuries dated 08/24 documented review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Use a standardized pressure injury screening tool to determine and document risk factors. Supplement the use of a risk assessment tool with assessment of additional risk factors. The facility failed to ensure pressure R9's heels were offloading while in bed to prevent pressure ulcers. This placed R9 at increased risk for pressure ulcer development.

The facility identified a census of 26 residents. The sample included 12 residents. Based on record review, interview, and observation, the facility failed to ensure the physician was notified of Resident (R) 2's daily weights that were missed or notified related to weight gain which could lead to fluid overload. The facility further failed to notify R15's physician related to his blood sugar monitoring. This deficient practice placed the residents at risk for further decline and a delay in treatment. - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R2 had received an anticoagulant, antidepressant (a class of medications used to treat mood disorders), diuretic (a medication to promote the formation and excretion of urine), hyperglycemic (medication that raises blood sugar levels), and opioid (a class of controlled drugs used to treat pain) medications. R2's Nutritional Status Care Area Assessment (CAA) dated 01/03/25 documented her weight would fluctuate related to her diagnosis of CHF and diuretic medication. R2's Care Plan dated 02/01/24 documented the nursing staff would obtain and monitor her lab work and diagnostic work as ordered. The plan of care also documented the nursing staff would report results to the physician and follow up as indicated with the physician. R2's EMR under the Orders tab revealed the following physician orders: Spironolactone (diuretic) oral tablet 25 milligram (mg) give a half of tablet by mouth in the morning for edema (swelling resulting from an excessive accumulation of fluid in the body tissues) dated 12/22/23. Daily weight related to CHF in the morning for edema. Notify physician of weight gain of two pounds in 24 hours. Document accordingly dated 01/29/24. Lasix (diuretic) oral tablet 40 mg (Furosemide) give one tablet by mouth in the morning for CHF dated 04/18/24. Review of R2's EMR under the Weights/Vital Sign tab, review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) from 01/01/25 through 03/16/25 (75 days) revealed five times R2 refused on the following dates 01/04/25, 01/05/25, 01/07/25, 01/08/25, and 02/08/25. Documented Other, See Progress Notes four times on the following dates 01/09/25, 01/11/25, 01/15/25, and 01/16/25. R2's MAR and TAR lacked documentation four times on the following dates 01/19/25, 01/23/25, 01/28/25, and 02/07/25. Weight gain was noted greater than two pounds eight times on the following dates 01/20/25, 01/25/25, 01/29/25, 03/03/25, 03/06/25, 03/09/25, 03/10/25, and 03/14/25. The clinical record lacked documentation of physician notification of daily weight was not obtained or outside the ordered parameter. On 03/18/25 at 11:02 AM, R2 sat in her wheelchair in her room as she looked through her dresser drawers. On 03/19/25 at 11:19 AM, Licensed Nurse (LN) G stated the physician should be notified of any daily weight that are not obtained or outside the physician ordered parameter for R2 related to her CHF. LN G stated the notification should be documented in R2's clinical record and the physician response should also be documented. On 03/19/25 at 11:35 AM, Administrative Nurse D stated she would expect the physician order to be followed. Administrative Nurse D stated she would expect the physician to be notified of any daily weights not obtained for any reason and if the weight was outside the physician ordered parameter. Administrative Nurse D stated she would expect the nurse to document a note under the progress notes with physician's response. The facility's Guidelines for Notifying Physician of Clinical Problems policy last revised 09/2017 documented these guidelines are intended to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in resident / patient status are assessed and documented in the medical record. The facility failed to ensure R2's physician was notified of his missed weights or weights that recorded more then a two pound weight gain within 24 hours. This deficient practice placed R2 at risk for complications related to his CHF for further decline and a delay in treatment. - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and hypertension (HTN - elevated blood pressure). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R15 had received insulin (medication to regulate blood sugar) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R15 had received insulin and antidepressant medication. R15's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/16/24 documented required assistance with activities of daily living. R15's Care Plan last revised 03/17/25 documented nursing staff would administer diabetic medication as ordered. The plan of care documented the nursing staff would monitor for side effects and document the effectiveness. R15's EMR under the Orders tab revealed the following physician orders: -Check blood glucose (BG) before meals and at bedtime for DM. Notify physician if BG less than (<) 70 and greater than (>) 350. Document in a progress note dated 09/03/24. -Insulin lispro injection solution (Insulin) Inject six unit subcutaneously (SQ) with meals for DM. Give with food, not before meal arrives. Hold if BG is < 80 or he has not eating (contact provider) dated 09/19/24. -Insulin lispro injection solution inject as per sliding scale for DM: If BG 151 - 200 = give 4 units SQ; If BG 201 - 250 = give six units SQ; If BG 251 - 300 = give eight units; If BG 301 - 350 = give 10 units SQ; If BG 351- 399 = If BG give 12 units SQ, If BG 400 - 9999 = give 14 units SQ. If > 400, give 14 units SQ and contact provider. Rotate injection sites dated 10/29/24. -Lantus (insulin) solo star subcutaneous solution pen-injector 100 unit/milliliter (ml) (insulin glargine) inject 16-unit SQ at bedtime for DM. Contact provider if BG<80 prior to administration. Rotate injection sites dated 01/10/25. Review of R15's Medication Administration Record (MAR) from 01/01/25 to 03/16/25 (75 days) revealed R15's BG was > 350 26 times on the following dates: 01/01/25, 01/02/25, 01/04/25, 01/05/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/13/25, 01/14/25, 01/21/25, 01/22/25, 01/25/25, 01/28/25, 02/01/25, 02/07/25,02/08/25,02/13/25, 02/18/25, 02/23/25, 02/27/25, 03/05/25, 03/07/25, 03/09/25, 03/11/25, and 03/14/25. The clinical record lacked documentation of physician notification of out of parameter BG. On 03/18/25 at 07:43 AM, R15 sat at the dining room table in his wheelchair. R15 visited with the other residents at the dining room table as he ate his breakfast. On 03/19/25 at 11:19 AM, Licensed Nurse (LN) G stated the physician should be notified of any BG that was outside the physician ordered parameter for R15 related to DM. LN G stated the notification should be documented in R15's clinical record and the physician response should also be documented. On 03/19/25 at 11:35 AM, Administrative Nurse D stated she would expect the physician order to be followed. Administrative Nurse D stated she would expect the physician to be notified of any BG outside the physician ordered parameter. Administrative Nurse D stated she would expect the nurse to document a note under the progress notes with physician's response. The facility's Guidelines for Notifying Physician of Clinical Problems policy last revised 09/2017 documented these guidelines are intended to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and that all significant changes in resident / patient status are assessed and documented in the medical record. The facility failed to notify R15's physician of BG that was out of parameters 26 times over 75 days. This deficient practice placed R15 at risk for further decline and a delay in treatment.

The facility identified a census of 35. The sample included 12 residents. Based on interview and record review, the facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life. Findings included: - Review of the facility's activity calendars for April 2023 and May 2023 revealed each Saturday had activities of snacks and chat, and family visits except for 04/08/23 when an Easter egg hunt and a musical Yakety [NAME] Quartet was provided. The activity calendar for April, May, and June 2023 revealed no activities scheduled on any Sunday except afternoon church services. On 07/11/23 at 03:37 PM, in a confidential interview with the resident council, several residents reported that though the weekday activities were ongoing and fun, the facility did not provide any activities on Sundays. The council reported the facility had church on Sundays, but the rest of the day had no scheduled activities, and Sundays were often boring. On 07/13/2023 at 03:14 PM Activities Staff Z reported that she was at the facility Monday through Friday but usually staff would coordinate activities for Saturday. She stated Sunday was church services. She stated the residents also have computers access, music, and television. The facility did not provide an activities policy. The facility failed to provide activities on the weekends which reflected the residents' interests, and preferences. This placed the residents at risk for boredom, isolation, and decreased quality of life.

The facility identified a census of 35 residents. The sample included 16 residents which five residents reviewed for immunizations. Based on record review and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations, or administration information for Residents (R) 7 and R22. This deficient practice placed residents at increased risk for pneumonia and related complications. Findings included - Review of the Electronic Medical Record (EMR) for R7 and R22 revealed the clinical record lacked documentation indicating that the residents had been offered, consented, refused, or had received the pneumonia vaccination. The facility was unable to provide a consent, declination, or record of administration of pneumonia vaccination for R7 and R22. On 07/12/23 at 03:32 PM Administrative Nurse E stated at the time of admission residents were asked about their immunization status and that information was documented under the Immunization tab in the clinical record. Administrative Nurse E stated the admitting nurse would notify her if a resident needed a vaccination after admission. Administrative Nurse E stated she would now start tracking the immunization status of all new admission. On 07/12/23 at 04:02 PM Administrative Nurse D stated the facility was unable to locate the consent, declination, or administration of the pneumonia vaccination for R7 and R22. Administrative Nurse D stated each resident at the time of admission are offered vaccinations or interviewed about their vaccination status and that information would be entered into the clinical record. Administrative Nurse D stated the Infection Preventionist (IP) would be tracking the new admission immunizations and their consent or declination would be placed in the resident's clinical record The facility's Pneumococcal Vaccine policy last revised August 2016 documented all residents would be offered the pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. The facility failed to provide pneumococcal vaccinations or informed refusals for R7 and R22. This deficient practice placed the residents at risk for complication related to pneumonia.

The facility identified a census of 35 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the physician indicated an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits, for the use of an antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions) for Resident (R) 22, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed R22 at risk for administration of unnecessary psychotropic (alters mood or thought) medications and adverse side effects. Findings Included: - The Medical Diagnosis section within R22's Electronic Medical Records (EMR) included diagnoses of dementia,, major depressive disorder (major mood disorder), restlessness (the inability to relax), agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), reduced mobility, and benign prostatic hyperplasia (BPH- a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections). R22's Minimum Data Set (MDS) completed 06/03/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated he required extensive assistance from staff for transfers, bed mobility, personal hygiene, toileting, locomotion, dressing, and bathing. The MDS indicated he had frequent bowel and bladder incontinence with no toileting program. The MDS indicated he was taking antipsychotic medication. R22's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 12/21/22 indicated he required extensive assistance from staff for his ADLs due to his medical and prevent injuries and falls. R22's Psychotropic Medication CAA completed 12/21/22 indicated he took Risperdal (antipsychotic) medication. The CAA instructed staff to monitor R22 for side effects and notify the medical provider of issues. R22's Care Plan created initiated 06/29/22 indicated he took antipsychotic medication related to his paranoid personality disorder and behaviors. The plan instructed staff to completed monitoring of side effects and follow the recommended medical providers orders. The plan also instructed staff to monitor for abnormal behaviors or changes in cognitive status. R22's EMR under Physicians Orders revealed an order dated 06/26/23 for staff to administer 0.5 milligrams (mg) of Risperdal by mouth two times a day for unspecified dementia. A review of the Consultant Pharmacist (CP) Note to Attending Physician medication regimen review (MRR) dated 12/19/22 documented R22's antipsychotic Risperdal lacked an allowable diagnosis to support its use. A review of the CP 's 01/30/23 MRR for R22 recommended to the physician an allowable diagnosis to support the use of Risperdal. The physician responded on 02/02/23 stating the medication was ordered per psychiatry and marked depression with psychotic features for an appropriate diagnosis. A review 06/19/23 CP's MRR Note to Attending Physician stated R22 was currently taking Risperdal with a diagnosis of restlessness. Per Centers for Medicaid & Medicare Services (CMS) guidelines only approved indications for use were allowed for the continued use of antipsychotics in patients with dementia due to the increased rate of mortality and lack of efficacy when used in patients with dementia-related psychosis. The CP recommended to consider a trial reduction to Risperdal in an attempt to reduce inappropriate antipsychotic use. R22's clinical record lacked a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits. On 07/11/23 at 10:00AM R22 laid in his bed. R22 had pressure reduction mattress on his bed. His wheelchair had pressure reduction mat on it. R22 reported he did have incontinence and used a urinal during the nighttime. He reported he had limited range of motion and sometimes spills his urinal. On 07/12/23 at 02:15 PM Certified Medication Aide (CMA) R stated she could not say what an appropriate diagnosis or indication for use for Risperdal would be. On 07/12/23 at 02:48 PM Licensed Nurse (LN) H stated a correct diagnosis for Risperdal might be depression, but it should not be given for residents with dementia. On 07/12/23 at 03:58 PM Administrative Nurse D stated they based the order on the physician's order and physician indication for use. Administrative Nurse D stated that dementia was not an appropriate indication for use for R22's Risperdal. The Psychoactive Drug Monitoring policy dated 01/21 documented: For deviation from the recommended dosage and dosage reduction criteria, the clinical record contains evidence to support justification for use of a drug not meeting the dosage criteria but considered clinically appropriate. Examples include: A medical or psychiatric consultation or evaluation supporting the physician's conclusion. The physician, nurse, or other health professional documentation that the resident was being monitored for adverse consequences or complications of therapy. The Consultant Pharmacist reviewed and analyzed data related to psychoactive drug use in the facility as part of the quality assurance process. The facility utilizes the data presented by the consultant pharmacist (and others) to formulate and monitor psychoactive drug use improvements plans. The facility failed to ensure an appropriate indication or appropriate documentation for R22's antipsychotic medication Risperdal. This placed R22 at risk for risk for unnecessary medication administration and adverse side effects.

The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)6 was weighed weekly per his physician's orders. This deficient practice placed R6 at risk for complications related to unintended weight loss. Findings included: - The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of insomnia (inability to sleep), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling), major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), muscle weakness, and neuropathy (pain caused by nerve damage). R6's Quarterly Minimum Data Set (MDS) completed 04/01/23 noted a Brief Interview for Mental Status (BIMS) assessment could not be competed due to severe impaired cognition. The MDS indicated he required extensive assistance from staff for all his activities of daily living (ADLs). The MDS indicated he used a wheelchair for mobility. The MDS indicated he was on hospice services. The MDS indicated he had no weight loss. The MDS indicated he had coughing and choking during swallowing. R6's Nutritional Care Area Assessment (CAA) completed 01/10/23 indicated he was on a puree diet with nectar thick liquids. The CAA indicated he was at risk of weight loss due to his medical diagnoses, decreased mobility, and continued decline. R6's Care Plan revised 12/16/22 indicated he was at risk for weight loss related to his dementia diagnosis and diuretic medication. The instructed staff to monitoring his weight weekly and report significant weight loss. R6's EMR under Physician's Orders noted an order dated 02/20/23 for staff to weigh R6 every Monday for weight management. R6's Weight History and Medication Administration Report revealed he was not weighed on six (weekly) occasions as ordered (02/27/23, 03/13/23, 03/27/23, 04/09/23, 04/23/23, and 06/25/23). A review of his EMR revealed no refusals or notes for the missed weights. On 07/11/23 at 12:04PM R6 sat in the dining room with staff. R6 consumed his pureed chicken meal and beans. R6 had thickened juice with his meal. R6 consumed his meal whole meal and drink. R6 reported he enjoyed his meal. On 07/12/23 at 02:27 PM Licensed Nurse (LN) G reported the nurses were responsible for ensuring the weights were reviewed and entered in the EMR. She reported if a resident refused the nurse would attempt to intervene, but the action would be documented in the EMR. She reported R6's weight was closely monitored due to his medications and cognitive decline. She stated if a weight loss occurred, she would report it to the nurse immediately. On 07/12/23 at 02:34 PM Certified Nurse's Aide (CNA) N stated the nurse provided the daily weight schedule for all residents. She stated each resident is weighed based on their orders. She stated if a resident refused to be weighed it would be noted in the EMR. She stated R6 had never refused his weights or care. She stated R6 was at risk for weight loss due to his dementia. She stated she would report a significant weight loss to Registered Dietician (RD). On 07/12/23 at 03:50PM Administrative Nurse D reported staff were expected to report when weight was not being completed and documented. She stated that if a resident missed being weighed, staff were expected to get the weight the next day. A review of the facility's Weight Assessment and Intervention policy revised 03/2022 indicated all residents would be monitored and assessed for the risk of undesirable weight loss. The policy noted the residents will be monitored. The facility failed to ensure R6 was weighed weekly per his physician's orders. This deficient practice placed R6 at risk for complications related to unintended weight loss.

The facility identified a census of 35 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to ensure adequate interventions were in place to address hazards on Resident (R)4's wheelchair and failed to to provide safety provisions, including use of gait belt and foot pedals, for R4. The deficient practice placed R4 at risk for accidents and injuries. Findings included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, dysphagia (swallowing difficulty), myocardial infarction (heart attack), and unsteadiness on feet. A review of R4's Quarterly Minimum Data Set (MDS) completed 06/03/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required extensive assistance from one staff for all activities of daily living (ADLs). The MDS indicated she had one non-injury fall. The MDS noted she weighed 109 pounds (lbs.) and had no weight loss. The MDS indicated she had skin tears noted and used preventative bed and chair devices. R4's ADLs Care Area Assessment (CAA) completed 12/25/22 indicated she required extensive assistance from one staff for ADL's related to her medical diagnoses and recent COVID-19 (highly contagious viral infection) illness. R4's Pressure Injuries CAA completed 12/25/22 indicated she was at risk for potential skin issues related to her incontinence and mobility issues. The CAA instructed staff to assist with all ADLs to prevent falls and skin injuries. R4's Care Plan initiated 06/28/23 indicated she had full thickness traumatic wounds to her right and left legs. The plan instructed staff to identify and resolved causative factors for her wound and monitor for infections. The plan indicated wound care treatments would be carried out by nursing staff per wound care providers orders. The care plan lacked documentation showing the causative factors of the wound and how to prevent further injuries. The plan instructed staff to encourage good nutrition and hydration and provide weekly skin assessments. The plan instructed staff to provide dressing changes per providers orders. The plan indicated she required assistance from one staff for all ADL activities. The plan indicated staff were to use a gait belt for transfers. The plan lacked interventions related to identified injuries caused by R4's wheelchair. R4's EMR under Wound Care Note completed on 07/11/23 indicated R4 had three established wounds identified on her treatment plan. The report indicated she had a right anterior lower leg full thickness traumatic wound measuring 3.8 centimeters (cm) in length, 1.8cm in width, and 0.1cm in depth (3.8cm x 1.8cm x 0.1cm). The report indicated she had a right posterior (back) lower leg traumatic wound measured at 2.2cm in length, 1.2cm in width, and 0.1cm in depth. The report indicated she had a lower lateral (side of leg) traumatic wound measured at 6.7cm in length, 2.7cm in width, and 0.1cm in depth. The report indicated she had a new wound assessed as a full thickness open wound measured at 0.7cm in length, 0.7cm in width, and 0.1cm in depth. The report indicated on 05/16/23 and 05/23/23 R13's wheelchair was identified as rubbing the back of her leg and causing erythema (redness or inflammation of the skin). The report did indicate R4 had a history of taking off her dressing and bandages. On 07/11/23 at 11:14AM Consultant HH and Administrative Nurse E completed wound care for R4. R4 sat in her chair in her room. Staff asked R4 if wound care could be completed before lunch and R4 approved. R4 sat in her chair with her feet on the ground and her foot pedals in the up position. At 11:16AM an unidentified CNA came into the room and pushed R4 from the center of the shared room to her bed causing her feet to drag. The staff member then transferred R4 from her wheelchair to a seated position on her bed without using a gait belt. Upon assessment of R4's wounds staff identified a new opened area below R4's initial right leg injury and stated it may have been from hitting against her wheelchair. Staff completed wound care and assisted her to lunch. On 07/12/23 at 09:34AM Certified Nurse's Aide (CNA) N stated R4 probably hit her legs during transfer on the foot pedals or the side of the wheelchair. She stated R4 sometimes transfered herself to her bed without asking for help. She stated staff should be using her foot pedals when pushing her and putting them up when transferring her to her bed. On 07/12/23 at 02:27 Licensed Nurse (G) stated the direct care staff should ensure that foot pedals were removed before attempting to transfer R4. She stated staff should have used a gait belt. She stated R4 had very fragile skin and easily could have skin tears but not sure what caused the tears on her legs. On 07/12/23 at 03:41PM Administrative Nurse E reported R4 may have been caused by rubbing of her wheelchair. She stated R4 refused to wear legging and socks and would often take her dressings off. She stated staff were expected to move the foot pedals out of the way before transferring and ensuring she did not attempt to self-transfer. She stated the facility will attempt putting a nylon blocking on her chair over hard parts. A review of the facility's Safe Handling and Mobility policy revised 07/2017 indicated the facility will ensure staff follow the correct and safe method of transferring each resident as indicated by the individualized care plan. A review of the facility's Falls/Accidents Prevention policy revised 03/2018 indicated the facility will identify and provide interventions resident risks. The policy indicated the facility will ensure each residents environment, medical equipment/devices, and cares is evaluated to minimize the consequences of injuries and accidents. The facility failed implement interventions to prevent injuries caused by R4's wheelchair. The facility additionally failed to safety utilize medical devices (wheelchair foot pedals and gait belt) while providing care to R4. These deficient practices placed R4 at risk for preventable injuries and accidents.

The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for non-pressure related skin conditions. Based on observations, record review, and interviews, the facility failed to implement interventions to identify, treat, and prevent Resident (R)4's traumatic skin injuries. These deficient practices placed R4 at risk for complications related to skin injuries and infections. Findings included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, dysphagia (swallowing difficulty), myocardial infarction (heart attack), and unsteadiness on feet. R4's Quarterly Minimum Data Set (MDS) completed 06/03/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated she required extensive assistance from one staff for all activities of daily living (ADLs). The MDS indicated she had one non-injury fall. The MDS noted she weighed 109 pounds (lbs.) and had no weight loss. The MDS indicated she had skin tears noted and used preventative bed and chair devices. R4's ADLs Care Area Assessment (CAA) completed 12/25/22 indicated she required extensive assistance from one staff for ADL's related to her medical diagnoses. R4's Pressure Injuries CAA completed 12/25/22 indicated she was at risk for potential skin issues related to her incontinence and mobility issues. The CAA instructed staff to assist with all ADLs to prevent falls and skin injuries. R4's Care Plan initiated 06/28/23 indicated she had full thickness traumatic wounds to her right and left legs. The plan instructed staff to identify and resolved causative factors for her wound and monitor for infections. The plan indicated wound care treatments would be carried out by nursing staff per wound care providers orders. The care plan lacked documentation showing the causative factors of the wound and how to prevent further injuries. The plan instructed staff to encourage good nutrition and hydration and provide weekly skin assessments. The plan instructed staff to provide dressing changes per providers orders. The plan indicated she required assistance from one staff for all ADL activities. The plan indicated staff were to use a gait belt for transfers. The plan lacked interventions related to identified injuries caused by R4's wheelchair. R4's EMR under Wound Care Note completed on 07/11/23 indicated R4 had three established wounds identified on her treatment plan. The report indicated she had a right anterior lower leg full thickness traumatic wound measuring 3.8 centimeters (cm) in length, 1.8cm in width, and 0.1cm in depth (3.8cm x 1.8cm x 0.1cm). The report indicated she had a right posterior (back) lower leg traumatic wound measured at 2.2cm in length, 1.2cm in width, and 0.1cm in depth. The report indicated she had a lower lateral (side of leg) traumatic wound measured at 6.7cm in length, 2.7cm in width, and 0.1cm in depth. The report indicated she had a new wound assessed as a full thickness open wound measured at 0.7cm in length, 0.7cm in width, and 0.1cm in depth. The report indicated on 05/16/23 and 05/23/23 R13's wheelchair was identified as rubbing the back of her leg and causing erythema (redness or inflammation of the skin). The report did indicate R4 had a history of taking off her dressing and bandages. On 07/11/23 at 11:14AM Consultant HH and Administrative Nurse E completed wound care for R4. R4 sat in her chair in her room. Staff asked R4 if wound care could be completed before lunch and R4 approved. R4 sat in her chair with her feet on the ground and her foot pedals in the up position. At 11:16AM an unidentified CNA came into the room and pushed R4 from the center of the shared room to her bed causing her feet to drag. The staff member then transferred R4 from her wheelchair to a seated position on her bed without using a gait belt. Upon assessment of R4's wounds, staff identified a new open area below R4's initial right leg's injury and stated it may have been from hitting against her wheelchair. Staff completed wound care and assisted R4 to lunch. On 07/12/23 at 09:34AM Certified Nurse's Aide (CNA) N stated she probably hit her legs during transfer on the foot pedals or the side of the wheelchair. She stated R4 sometimes transfers herself to her bed without asking for help. She stated staff should be using her foot pedals when pushing her and putting them up when transferring her to her bed. On 07/12/23 at 02:27 Licensed Nurse (LN) G stated the direct care staff should ensure that foot pedals were removed before attempting to transfer R14. She stated staff should have used a gait belt. She stated R4 had very fragile skin and easily could have skin tears but not sure what caused the tears on her legs. On 07/12/23 at 03:41PM Administrative Nurse E reported R4 may have been caused by rubbing of her wheelchair. She stated R4 refused to wear legging and socks and would often take her dressings off. She stated staff were expected to move the foot pedals out of the way before transferring and ensuring she did not attempt to self-transfer. She stated the facility will attempt putting a nylon blocking on her chair over hard parts. A review of the facility's Safe Handling and Mobility policy revised 07/2017 indicated the facility will ensure staff follow the correct and safe method of transferring each resident as indicated by the individualized care plan. A review of the facility's Preventative Skin Care policy revised 09/2013 indicated the facility will identify, assess, and implement care planned interventions for residents at risk for skin impairments and injuries. The policy indicated the facility will ensure avoidable injuries and hazards are identified to prevent falls, accidents, and infections. The facility failed to implement measures to identify, treat, and prevent R4's traumatic skin injuries. The deficient practice placed R4 at risk for complications related to skin injuries and infections.

The facility identified a census of 35. The sample included 12 with 12 reviewed for comprehensive care plans. Based on observation, record review and interview, the facility failed to develop a comprehensive care plan related to preventative wound care for Resident (R)22. This deficient practice placed him at risk for complication related to skin injuries and pressure ulcers due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R22's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), restlessness, agitation, reduced mobility, and benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections). R22's Quarterly Minimum Data Set (MDS) completed 06/03/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated he required extensive assistance from staff for transfers, bed mobility, personal hygiene, toileting, locomotion, dressing, and bathing. The MDS indicated he had frequent bowel and bladder incontinence with no toileting program. The MDs indicated he was at risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The MDS indicated no unhealed pressure ulcers at the time of assessment. R22's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 12/21/22 indicated he required extensive assistance from staff for his ADLs due to his medical and prevent injuries and falls. R22's Urinary Incontinence CAA completed 12/21/22 indicated he had frequent bladder incontinence due to general weakness and depended on staff for toileting. The MDS indicated most of the time he called staff too late for incontinence assistance. The CAA indicated staff were to assist with transfers, toileting, and peri-care to prevent skin issues. R22's Pressure Injury CAA completed 12/21/22 indicated he was a risk for potential skin issues and pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) due to incontinence and mobility issues. The CAA indicated staff were to assist him to prevent skin issues. R22 Care Plan indicated 06/29/22 indicated he required assist from two staff for bed mobility, toileting, transfers, and bathing. The plan noted he used a wheelchair for mobility and sit-to-stand (mechanical lift) for transfers. The plan indicated he was incontinent of bladder and used a portable urinal. The plan indicated he sometimes would spill the urinal. The plan lacked preventative interventions related to his coccyx (small triangular bone at the base of the spine) wound. R22's EMR under Physician's Orders revealed an order dated 09/03/22 for weekly skin assessments every Saturday. R22's EMR under Physician's Orders revealed an order dated 04/25/23 instructing staff to provide skin treatment for his coccyx area every other day. The order instructed staff to cleanse, pat dry, and apply zinc cream. The order instructed staff to apply an Opti-Foam dressing (silicone bordered adhesive dressing). R22's Skin Assessment Note dated 05/20/23 indicated he had continued excoriation (injury to the skin) on his coccyx. R22's EMR indicated a Braden Assessment (scale used to assess the risk of developing pressure ulcers) was completed on 06/29/23. The assessment revealed a score of 14 (Moderate Risk). On 07/11/23 at 10:00AM R22 lay in his bed. R4 had pressure reduction mattress on his bed. His wheelchair had a pressure reduction pad on it. R4 reported he did have incontinence and used a urinal during the nighttime. He reported he had limited range of motion and sometimes spilled his urinal. He reported no concerns related to bathing. On 07/12/23 at 02:27PM Certified Nurse Aide (CNA) M reported all staff had access to the care plans. She stated staff had access to the care plan. She stated skin interventions should be provided for staff in the plans. She stated if a care plan is missing interventions or needs something added she would notify the charge nurse. On 07/12/23 at 02:44PM Licensed Nurse (LN) G reported R22 had frequent incontinence and used a urinal due to mobility issues. She stated his coccyx excoriation went away but came back recently. She stated the care plan should have interventions to prevent it from declining. She stated he had orders. She stated staff should be repositioning him, providing peri-care, and wound care cares weekly to assess him. She stated if the care plan is missing interventions, she would contact Administrative Nurse F. On 07/12/23 at 03:14PM Administrative Nurse F stated care plans haven't been updated as quickly as they should have due to lack of staffing. She stated established care plans should be updated immediately as an issue had been identified. She stated all direct care staff have access to the care plans and should report if information is outdated or missing. A review of the facility's Pressure Ulcer revised 07/2017 indicated the facility will identify risk factors related to pressure injuries and provide preventive skin treatments. The policy indicted the facility will assess and identify interventions and ongoing assessments of residents at risk. The facility failed to develop a comprehensive care plan related to preventative wound care for R22. This deficient practice placed him at risk for complication related to skin injuries and pressure ulcers due to uncommunicated care needs.

The facility had a census of 28 residents. The sample included 12 residents. Based on observation, record review, and interviews the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff obtained Resident (R) 23's blood pressure and R7's oxygen saturation at the dining room table, and administered a topical cream to R7's neck at the dining room table, with multiple residents in full view. This created the risk for impaired dignity and psychosocial wellbeing for R23 and R7. Findings included: - On 12/27/21 at 11:27 AM, observation revealed Licensed Nurse (LN) G obtained R23's blood pressure at the dining room table, while eating her meal, with five residents at the same table. On 12/29/21 at 11:38 AM, observation revealed Certified Medication Aide (CMA) R obtained R23's blood pressure at the dining room table, with five residents at the same table. On 12/30/21 at 08:48 AM, observation revealed LN H obtained R7's oxygen saturation and administered a topical cream to R7's neck, with four residents at the same table. On 12/30/21 at 08:20 AM, Administrative Nurse D stated vitals and treatments were not to be done in the dining room because it was a dignity issue. The facility's undated Resident Rights, policy documented the resident had a right to a dignified existence and be treated with respect, dignity, and care for each resident in manner and in an environment that promotes maintenance or enhancement of his or her quality of life. The facility failed to promote care for R23 and R7 in a manner to maintain and enhance dignity and respect.

The facility had a census of 28 residents. The sample included 12 residents with one reviewed for positioning and mobility. Based on observation, record review, and interview the facility failed to recognize and provide the necessary cares and services to ensure appropriate wheelchair and bed positioning for Resident (R) 10 which placed R10 at increased risk for increased pain and decreased function. Findings included: - R10's Electronic Medical Record (EMR) listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R10 required total staff assistance with toileting, extensive staff assistance with bed mobility, transfer, dressing, personal hygiene, limited staff assistance with locomotion on and off the unit, and supervision with eating. The MDS documented R10 had upper and lower extremity impairment on one side, was on a turning/repositioning program, and used a wheelchair for mobility. The Activity of Daily Living (ADL) Care Plan, revised on 10/22/2, documented R10 had limited range of motion (ROM) of left upper and lower extremities, muscle weakness, and poor balance. The Care Plan instructed staff to reposition the resident in bed or wheelchair frequently. The Care Plan instructed staff to position R10 with proper body alignment. On 12/28/21 at 12:40 PM, observation revealed R10 rested in bed with her eyes closed, Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R repositioned the resident by using a bed pad to lift her up in bed. R10's head was positioned to the right with her neck stretched to the right and her torso was straight . On 12/28/21 at 03:11 PM, observation revealed R10 rested in bed on her back, with her head positioned to the right, neck stretched to the right, and her torso straight. On 12/28/21 at 03:58 PM, observation revealed staff entered R10's room, provided incontinent cares, placed a pillow behind each side of the resident's upper torso. R10's legs werestraight, and her head bent to the right, with her neck stretched to the right. On 12/29/21 at 08:11 AM, observation revealed R10 rested in bed with her eyes closed. She was positioned on her back. Herhead leaed to the right, and her neck stretched to the right. On 12/29/21 at 09:32 AM, observation revealed Licensed Nurse (LN) J and CNA N entered R10's room, provided a dressing change and incontinent cares, and repositioned R10 onto her back with her head bent to the right, stretching her neck. R10' torso was straight and her legs were positioned to the right. CNA N started to cover the resident up. When R10 was asked by the surveyor if she was comfortable, R10 stated No. CNA N and LN J then repositioned the R10's torso, but left her head bent to the right with neck stretched to the right . On 12/29/21 at 01:46 PM, observation revealed R10 sat in a wheelchair in her room with her head leaning to the right, stretching her neck. On 12/30/21 at 08:15 AM, observation revealed R10 sat in a wheelchair with a neck pillow supporting her head. On 12/29/21 at 01:43 PM, CNA O stated R10 required extensive staff assistance with most ADLs. CNA O stated she did not know how long the resident had a neck pillow. On 12/30/21 at 03:04 PM, Administrative Nurse D stated she observed R10 in R10's room on 12/29/21 at noon, and R10 appeared uncomfortable. Administrative Nurse D offered R10 a neck pillow, and the resident accepted it. Administrative Nurse D stated R10 had a neck pillow since she was first admitted to the facility on [DATE]. Upon request the facility did not provide a policy regarding positioning. The facility failed to provide the necessary cares and services to ensure appropriate wheelchair and bed posture and positioning for R10, placing the resident at risk for pain and decreased function.

The facility had a census of 28 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to follow Resident (R)7's toileting and fall interventions as directed in the plan of care. This placed R7 at increased risk for injuries related to accidents and/or hazards. Findings included: - The Electronic Medical Record (EMR) for R7 recorded diagnoses of overactive bladder (sudden need to urinate), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R7's Admission Minimum Data Set(MDS) dated [DATE], documented R7 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, and toileting. R7 had unsteady balance, no functional impairment, frequently incontinent of bladder, and had one non injury fall. The Quarterly MDS, dated [DATE], documented the resident had intact cognition and required extensive assistance of one staff for bed mobility, transfers, and toileting. R7 had unsteady balance, had no functional impairment, frequently incontinent of bladder, and had no falls. The Fall Risk Assessments, dated 01/10/21, 04/11/21, 07/07/21, 08/05/21,10/11/21, and 10/22/2, documented R7 was at high risk for falls. The revised Fall Care Plan. dated 12/07/21, originally dated 01/08/21, directed staff to assist R7 with toileting, and make sure there was an unobstructed pathway to the bathroom. The update, dated 02/10/21, directed staff to check and offer toileting to R7 before and after meals. The update, dated 07/23/21, directed staff to ensure the bed was at wheelchair height. The update, dated 11/30/21, directed staff to offer to assist R7 to the restroom at or around 06:30 AM. The Fall Investigation, dated 07/23/21, at 10:45 PM, documented R7 fell trying to go to the bathroom. R7 told staff she was trying to get to her wheelchair to go to the bathroom, got weak, and lowered herself to the floor. The Fall Investigation, dated 10/22/21 at 02:15 PM, documented the resident fell in the bathroom. R7 stated she took herself to the bathroom and forgot to lock her brakes during her transfer. The investigation documented the resident had a skin tear (a traumatic wound caused by mechanical forces) to her right elbow 1 centimeter (cm) long. The October Toileting Log documented R7 was last toileted at 11:05 AM. The Fall Investigation, dated 10/28/21 at 10:48 AM, documented R7 was seated on the floor towards the end of the bed. R7 told staff she was trying to go to the bathroom and slid off the bed. The October Toileting Log documented R7 was last toileted at 05:59 AM. The Fall Investigation, dated 11/20/21 at 07:30 AM, documented the resident was on the floor in her room. R7 told staff she was trying to go to the bathroom and slid off the bed. The investigation documented R7 was reminded to call for assistance and directed staff to offer to take her to the bathroom near or around 07:30 AM. The November Toileting Log documented the resident was last toileted at 03:16 AM. The Fall Investigation, dated 11/30/21 at 07:25 AM, documented the resident was on the floor in her room and had last been toileted at 04:00 AM. R7's pajamas and socks were soaking wet, and R7 stated she was trying to go the bathroom. The staff were directed to take the resident to the bathroom around 06:30 AM. On 12/29/21 at 01:12 PM, observation revealed Certified Nurse Aide (CNA) P pushed R7 into her room after lunch and placed her beside the bed. CNA M placed a gait belt around her waist and transferred the resident into bed, put a pillow under her feet, and gave the resident her call light. CNA P took the control to the bed and laid it by the resident. CNA M put R7's wheelchair beside the bed and told her not to go to the bathroom by herself. Observation revealed R7 was not offered toileting before she was transferred into bed. On 12/30/21 at 09:50 AM, R7 told Certified Medication Aide (CMA) S that she was finished with her lunch. CMA S stated ok, and left the resident at the dining room table. Further observation revealed R7 propelled herself down the hall, nearly running into the walls several times, and into her room. Continued observation revealed Activity Aide Z came into R7's room and took her to an activity. R7 was not offered toileting after the breakfast meal or before going to the activity. On 12/28/21 at 08:14 AM CNA M stated R7 was at risk for falls and staff toileted the resident during the night and between 05:00 and 06:00 AM On 12/29/21 at 11:45 AM Licensed Nurse (LN) I stated R7 had a camera in her room so staff can visualize her when she was in her room. LN I further stated the night shift toileted the resident between 05:30 AM and 06:00 AM because of her history of falls. On 12/29/21 at 01:24 PM, CNA P verified R7 was not offered toileting after lunch. On 12/30/21 at 08:25 AM, Administrative Nurse D stated staff should follow R7's care plan and the toileting plan to prevent further falls. On 12/30/21 at 09:54 AM, R7 stated she often forgo to call for assistance and has had falls from her bed trying to go to the bathroom. R7 stated she was unsure when staff were supposed to take her to the bathroom. The facility's Accidents and Occurrences undated policy, documented each resident received adequate supervision and assistive devices to prevent occurrences. All occurrences on the facility premises must be investigated and reported to the Director of Nursing (DON) or designee. Immediate interventions are communicated, and the care plan was updated to prevent further falls. The DON or designee would review documentation to ensure relevant individualized interventions had been added to the care plan. The resident is reviewed at a weekly risk meeting to evaluate effectiveness of the interventions and to revise interventions if needed. The staff are notified via the 24-hour report of any new interventions. The facility failed to follow R7's toileting schedule as directed by her plan of care to prevent falls placing the resident at increased risk for injuries related to accidents and/or hazards.

The facility had a census of 28 residents. The sample included 12 residents with one resident reviewed for discharge. Based on interview and record review, the facility failed to complete a discharge summary for Resident (R)32 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R32 at risk for miscommunication or interruptions in the continuum of care after. Findings included: - R32's medical record revealed the resident admitted to facility on 08/20/21. The Admission Minimum Data Set, (MDS), dated [DATE], documented R32 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, personal hygiene, and extensive assistance of one staff for locomotion on and off the unit and dressing. The MDS documented ambulation did not occur during the look back period and R32 expected to be discharged to independent living. The Discharge Care Plan, dated 09/16/21, documented R32 had impaired cognition and directed staff to evaluate, discuss with R32 and her family the prognosis for independent or assisted living, identify limitations, risks and benefits needed for maximum independence. The Care Plan directed staff to establish a pre-discharge plan with R32 and her family, evaluate progress and revise the plan of care if needed. The Care Plan further directed staff to make arrangements with required community resources to support independence post-discharge or outpatient therapy. The Admission Nurse's Note, dated 08/19/21 at 09:06 AM, documented R32 was admitted due to a [CONDITION(S)] (broken hip), had skilled therapy orders, and was alert with some forgetfulness. The Nurse's Note, dated 10/02/21 at 07:05 PM, documented R32 was discharged from the facility. The Recap Discharge Summary, dated 10/04/21, lacked a summary of R32's overall wellness, to include significant changes identified throughout the assessment process, and current condition at time of discharge. On 12/29/21 at 10:07 AM, Social Service X verified the Recap Discharge Summary lacked the recapitulation of the resident's stay in the facility. The facility's Discharge Summary Checklist, dated 05/1917, documented the checklist to be completed with course of illness, treatment, therapy during nursing stay , reconciliation of all pre-discharge medications and post discharged medications, post discharge medical and non-medical services, radiology or other tests and results most recent, consultations along with findings and recommendations. The facility failed to develop a discharge summary that included a recapitulation summary of the resident's stay in the facility for R32.

The facility had a census of 28 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of blood pressures outside of physician ordered parameter for Resident (R)8. This placed R8 at risk for physical decline and complications related to low blood pressure. Findings included: - R8's Physician Order Sheet (POS), dated 11/22/21, documented diagnoses of chronic diastolic heart failure (occurs when your left ventricle can no longer relax between heartbeats because the tissues have become still and won't fill up with blood before the next heart beat), [CONDITION(S)] (damage or disease in the hearts major blood vessels), pulmonary hypertension (high blood pressure), and [CONDITION(S)] (rapid, irregular heart beat). The Admission Minimum Data Set (MDS), dated [DATE], documented R8 had intact cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, dressing and personal hygiene. The assessment further documented R8 received three days of a diuretic (medication to promote the formation and excretion of urine) during the lookback period. The [CONDITION(S)] Care Plan, dated 10/13/21, directed staff to monitor blood pressure and notify physician of any abnormal readings. The Physicians Order, dated 10/01/21, directed staff to notify the physician if weekly vital signs were outside of the following parameters : systolic blood pressure (SBP-the maximum pressure the heart exerts while beating) greater than 200 or less than 90 beats per minute (bpm), diastolic blood pressure (DBP-the amount of pressure in the arteries between beats) greater than 115 bpm or less than 50 bpm. The Vital Sign Record, dated 12/02/21, documented R8's blood pressure was 85/50. The medical record lacked documentation the physician was notified of the out of parameter blood pressure. The Vital Sign Record, dated 12/08/21, documented R8's blood pressure was 89/42. The medical record lacked documentation the physician was notified of the out of parameter blood pressure. The Vital Sign Record, dated 12/12/21, documented R8's blood pressure was 83/51. The medical record lacked documentation the physician was notified of the out of parameter blood pressure. The Medication Regimen Review, dated 12/21/21, lacked evidence the CP identified and reported R8's blood pressures outside of physician ordered parameters. On 12/29/21 at 12:00 PM, observation revealed R8 in the hallway talking with staff. On 12/29/21 at 11:45 AM, Licensed Nurse (LN) I verified the blood pressures were out of the physician ordered parameters and verified the physician had not been notified. On 12/30/21 at 08:30 AM, Administrative Nurse D stated staff were to follow the orders set by the physician and should notify the physician when the residents' vital signs were outside of ordered parameters and was unaware the pharmacist did not address the concern On 01/03/22 at 10:22 AM, Consultant Pharmacist GG stated she was aware of the low blood pressures and verified she had not notified the facility. The facility's Medication Regimen Review Monthly Report policy, dated January 2021, documented the facility assured that the consultant pharmacist had access to resident's medical record, and the providers medication profiles. The Medication Regimen Review of each resident would occur at least monthly; however a more frequent review may be deemed necessary and the consultant would identify irregularities through a variety of sources including, prescribes orders, progress notes, care plan, lab, diagnostic test results, behavior monitoring, interviews, assessing, and observations. The facility's CP failed to identify and report to the director of nursing, physician, and/or medical director R8's blood pressures outside of the physician ordered parameters, placing the resident at risk for physical decline.

The facility identified a census of 22 residents, with 17 residents and 16 employees diagnosed with [REDACTED]. The sample included nine residents. The facility failed to protect residents from further exposure to the Covid-19 virus when they did not separate residents in semi-private rooms when one became positive for Covid-19. The facility's failure to move or segregate Covid-19 positive residents and/or Covid-19 symptomatic residents from Covid-19 negative residents in the same room placed those residents into Immediate Jeopardy. Findings included: - Review of the Census tab in the electronic medical record (EMR) and of the facility provided list of admissions and discharges revealed the following admissions from outside the long term care facility: The facility admitted a male resident on [DATE], a female on [DATE], a female resident on [DATE], and another female resident on [DATE]. The Census revealed an empty semi-private bed on ,[DATE] and two empty private rooms on [DATE]. R1's electronic medical record (EMR), under the Census Tab, indicated R1 resided in a semiprivate room since [DATE]. A nurse's Progress Note, in the EMR, dated [DATE] revealed R1 had a stomachache and had not eaten much. She had congestion in the morning. She denied shortness of breath and her respirations were not labored. The facility obtained a Polymerase Chain Reaction (PCR) test (a test used to detect Covid-19 via a nasal swab to collect mucus sample) that afternoon with results expected within 48 hours. R1's laboratory reports revealed a PCR test collection date of [DATE], received by the laboratory on [DATE], and a result of negative on [DATE]. A Point OF Care (POC- a rapid test used to detect Covid-19 via a nasal swab to collect a mucus sample in which results were obtained in about 15 minutes) test obtained on [DATE] was positive. A nurse's Progress Note in R2's EMR under the Census Tab indicated R2 resided with R1 in a semi-private room. R2's EMR revealed a nurse's progress note, dated [DATE], which documented the facility informed her family on [DATE] that R2 tested for Covid-19 on [DATE] and she was negative. Record review revealed the facility did not separate Covid-19 symptomatic R1 from the Covid-19 asymptomatic and negative R2 upon identifying R1 had symptoms of Covid-19. R3's EMR, under the Census Tab, indicated R3 resided in a semi-private room since [DATE]. The facility's PCR Testing Logs indicated R3 was negative for Covid-19 on [DATE], [DATE] and positive on [DATE]. She remained in the semi-private room until discharged to the hospital on [DATE]. R4's EMR, under the Census Tab indicated R4 resided in room a semi-private room since [DATE]. The facility's PCR Testing Logs indicated R4 had negative Covid-19 tests on [DATE] and [DATE]. The [DATE] sample was rejected due to an insufficient sample. A nurse's Progress Note dated [DATE] for R4 revealed a rapid Covid-19 test performed on [DATE] at 12:36 PM was negative. Despite the Covid-19 positive test for R4's roommate (R3), R4 remained in the same room with R3 for four days after R3 tested positive for Covid-19. R5's EMR, under the Census Tab indicated R5 resided in a semi-private room since [DATE]. A nurse's Progress Note dated [DATE] documented R5 was seen by the nurse practitioner , due to complaints of cough, sore throat, shortness of air, and a runny nose. A rapid Covid-19 test was performed, and the results were negative at 12:58 PM. A PCR test was done on [DATE] with negative results. R5's [DATE] PCR test had positive results. She remained in the semi-private room. R6's EMR, under the Census Tab indicated R6 resided in a semi-private room since [DATE]. Per the facility's PCR Testing Logs R6 had a positive PCR test on [DATE]. She remained in the room. Despite R5 becoming symptomatic of Covid-19, she remained in the room with R6 who became Covid-19 positive five days later. R7's EMR under the Census Tab indicated R7 resided in a semi-private room. The facility's PCR Testing Logs indicated R7 was positive for Covid-19 on [DATE]. A nurse's Progress Note dated [DATE] indicated R7tested positive for Covid-19 and staff isolated the resident to her room. She continued to reside in the same room as R8. R8's EMR under the Census Tab indicated R8 resided in a semi-private room since [DATE]. Per the facility's PCR Testing Logs R8 had a negative test on [DATE] and was positive for Covid-19 on [DATE]. She remained in the same room until her death on [DATE]. R8, who was Covid-19 negative at the time, remained in the same room with Covid-19 positive R7 for three days. R8 subsequently tested positive for Covid-19 and died in the facility. On [DATE] at 12:40 PM R4 sat in a recliner in her room. She was alert, cheerful, and showed no signs of respiratory distress. R4 stated she worried about her roommate, since she was in the hospital and she was not able to see R3. R4 stated she was not afraid of getting sick. On [DATE] at 11:27 AM Administrative Staff A stated the facility interpreted the Centers for Medicare and Medicaid Services (CMS) guidelines as when a resident tested positive, there was the potential for the roommate to be positive and the resident which tested negative did not necessarily have to be moved to another room. The facility started a plan for a Covid-19 isolation hall, but due to limited room availability and the fast spread of the disease they were unable to dedicate a hall for isolation. On [DATE] at 01:10 PM R4's responsible party stated the facility updated the family on positive Covid-19 cases and knew R4's roommate had Covid-19. The facility kept the family updated on R4's condition and so far, she did not have Covid-19. The facility had not offered to move the resident after her roommate had tested positive. On [DATE] at 01:31 PM R2's responsible party stated their family had been apprised of the Covid-19 cases in the facility. The facility updated the family on R2's condition regularly. He could not confirm the exact date they were informed of R2's roommate was positive for Covid-19 and since there were multiple children involved, was not certain if a new room had been offered to R2. The facility's Coronavirus Disease (Covid-19) -Identification and Management of Ill Residents policy dated [DATE] documented with signs and/or symptoms of Covid-19 were identified and isolated to help control the spread of infection to other residents, staff, and visitors. The Centers for Medicare and Medicaid (CMS) document COVID-19 Long-Term Care Facility Guidance dated [DATE] recorded Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status . long-term care facilities should work with State and local community leaders to identify and designate facilities dedicated to patients and residents with known COVID-19-positive and those with suspected COVID-19, ensuring they are separate from patients and residents who are COVID-19-negative. The facility failed to protect residents from further exposure to the Covid-19 virus when they did not separate resident's positive for Covid-19 and/or had symptoms consistent with Covid-19 from roommates with negative Covid-19 test results. This deficient practice placed all facility residents residing in semi-private rooms in immediate jeopardy. The facility removed the immediacy by completing the following: The remaining negative resident that was in a shared room with a presumptive positive resident (tested positive on a rapid test, not PCR confirmed) was moved to a private room. All residents on the health care unit are in private rooms. The facility will be creating a separate area where negative residents can be cohorted away from positive residents. This area is separated from the rest of the unit by fire doors. These doors will remain closed. Once this outbreak is cleared, that area will remain unoccupied and will only be used to house any future residents who test positive for COVID-19. Staff will be educated on this COVID-19 Cohorting policy and infection control guidelines The deficient practice remained at scope and severity of an E

The facility identified a census of 34 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 1 received the necessary dementia care and services that were person-centered, reflected the resident's goals for care, and maximized the resident's dignity and well-being while providing cares. As a result, staff caused skin tear injuries to both R1's hands while providing cares. Findings included: - R1's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R1 required extensive assistance from one staff member with activities of daily living (ADL). R1 received antipsychotics (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions), antidepressants (class of medications used to treat mood disorders and relieve symptoms of depression), and diuretics (medication to promote the formation and excretion of urine) seven out of seven days during the look back period. There was no gradual dose reduction (GDR) attempted and the primary care physician documented that a GDR was clinically contraindicated on 06/10/19. The Quarterly MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. Behaviors that were noted one to three days of the assessment period included physical behavioral symptoms directed towards other such as hitting, kicking, pushing, scratching, grabbing, abusing other sexually. Other behaviors recorded four to six days of verbal behaviors directed towards others such as threatening, screaming, and cursing at others. R1 also had behaviors of rejection of care and wandering for one to three days. R1 required extensive assistance from two staff members for bed mobility, transfers, and personal hygiene; and extensive assistance from one staff member for toilet use and locomotion on and off the unit. R1 received the same medication as noted on the Admission MDS, and the primary care physician documented GDR was clinically contraindicated on 12/10/19. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 06/13/19 documented R1 had periods of disorganized thoughts and inattention. The Behavioral Symptoms CAA dated 06/13/19 documented R1 was to be redirected by staff and was usually easily redirected. The Behavior Care Plan dated 07/09/19 directed staff to provide an opportunity for positive interaction, attention, and to explain each care before it was given. The Impaired Cognitive Function, Dementia or Impaired Thought Processes Care Plan related to dementia dated 06/10/19 directed staff when communicating with R1 to provide necessary cues, and stop and return if agitated. The Progress Note dated 02/09/20 at 09:00 PM documented the Certified Nurse Aid (CNA) reported the resident was combative when being put to bed and sustained two skin tears on the top of both hands. Upon assessment, the resident's skin was generally very thin and fragile. Staff cleansed and steri-stripped the areas. This Nurse re-educated the CNA when the resident was non-compliant with care in any way to step away and come get the nurse. The CNA informed this nurse that the resident was not in a physically safe position for her to step away at the time. The director of nursing (DON) and on call clinician were notified and a message was left for resident's daughter. The clinical record lacked measurements of the skin tears. On 02/11/20 at 10:41 AM R1 sat in her wheelchair holding a doll. She had bruising to the back of both hands. R1's bruising to the hands was red around the outside and purple to the middle area. R1's right and left hand had four steri-strips on each hand holding the skin tears together, the skin tear on the right hand was approximately 2.5 inches long and the skin tear on the left hand was approximately 2 inches long. On 02/11/20 at 10:55 AM R1 pointed to the top of her hand and stated to an unidentified staff member it keeps bothering. On 02/11/20 at 11:43 AM CNA M stated during cares R1 rolled onto her back and started swinging at CNA M. CNA M stated she grabbed R1's hands and asked R1 to let her change her. After that, CNA M stated she continued to change R1 and then lowered the bed to the floor. At that time CNA M noted R1 had a skin tear (ST) to one of her hands and further stated that she did not realize that both hands had STs. CNA M notified Licensed Nurse (LN) G about the STs on R1s' hands and went to finish her work. CNA M revealed that she should not have grabbed R1s' hands. She said she should have just backed away. CNA M further revealed that when R1 had behaviors, staff would normally back away. On 02/11/20 at 02:18 PM CNA O stated that R1 can turn on staff in a second and become upset and refuse cares. When that happens, staff will get someone else to help R1. CNA O revealed that staff were aware that R1 had these behaviors and would get on the walkie (communication device) and ask for help. She further revealed all nursing staff should wear a walkie when at work. On 02/11/20 at 02:29 PM Administrative Nurse D stated he expected staff to back away from a resident that had behaviors of swinging and kicking at staff, refusing cares, and to get someone else to provide cares for that resident. On 02/11/20 at 02:40 PM Administrative Staff A stated that staff can use the walkie to communicate and ask for help. She revealed that CNA M did have her walkie on at the time. Administrative Staff A stated that she expected CNA M to back away from R1 when she was having behaviors or being resistive to cares, keep her in line of sight, and use her walkie to call for help. CNA M was documented to have dementia training on behavior management, abuse prevention, and philosophy of care, family and staff issues on 01/24/19. The facility's policy Behavioral Assessment, Intervention and Monitoring dated (MONTH) (YEAR) directed staff to be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. The facility failed to implement appropriate dementia interventions for R1 when staff attempted to hold R1's hands during a period of R1's behaviors. This deficient practice caused multiple skin tear injuries to R1's hands.

The facility reported a census of 31 residents. Based on interview and record review the facility failed to clearly identify and implement policies and procedures to ensure the safe use of recliner lift chairs, a functional call light system, investigations of potential abuse/neglect, and the protection of residents during investigations of suspected or alleged abuse. Findings included: - Review of an unwitnessed event investigation dated 1/5/2016 at 5:15 P.M. documented staff found resident #36 face down on the floor, cyanotic (a blue or purple color to the skin), no pulse, and unresponsive with his/her lift recliner in the highest (standing) position. The resident had a small abrasion to his/her forehead and a scant amount of blood from his/her nose. The resident scored a 12 on his/her Brief Interview for Mental Status (BIMS) dated 11/29/2015, which indicated moderate cognitive impairment. Review of the clinical record dated 11/16/2015 through 1/5/2016 lacked an assessment to determine if the resident could safely use his/her electric recliner and lacked a plan to ensure the resident's safety when his/her call light did not function as reported by facility staff on the night shift of 12/30/2015, 1/2/2016, and 1/4/2016 and the day shift of 1/3/2015 and 1/5/2016. Review of the facility's undated Abuse, Neglect, and Exploitation Policy documented the facility had comprehensive policies and procedures developed to identification of occurrences and patterns of potential mistreatment/abuse and completed timely and thorough investigations. The facility's policy failed to clearly identify how the facility investigated potential incidents of abuse/neglect. The facility lacked a policy on the use of recliner lift chairs. The facility lacked a policy on call light monitoring. The facility failed to clearly define and implement Abuse, Neglect, and Exploitation policies to thoroughly and timely investigation all potential abuse/neglect incidents, assess residents for the safe use of electric recliners, and ensure a functional call light system. - On 1/11/2016 at 7:10 A.M. administrative staff AA said a facility staff member phoned administrative staff A on 1/9/16 and informed him/her direct care staff S abused residents at the facility. Staff AA said he/she had no details regarding the allegations of abuse. Staff AA said he/she phoned the state and made a police report of the reported allegations of abuse. During an interview on 01/11/2016 at 9:20 A.M. administrative nursing staff D said administrative staff A reported licensed nursing staff K made an allegation of abuse that direct care staff S abused residents on 1/9/2016 and staff A made a police report. Staff D said if staff K suspected abuse, he/she should have sent staff S home and immediately contacted administration. Staff D said staff S worked with residents on the floor 1/9 and 1/10/2016. Staff D said he/she had no knowledge of abuse allegations until reported to him/her by staff A on 1/9/2016. During an interview on 01/11/2016 at 9:50 A.M. administrative staff A said he/she spoke with licensed staff K on 1/9/2016 at 5:00 P.M., when staff K reported direct care staff S abused residents. Staff A said staff K did not give specific resident names and he/she told staff K he/she needed specifics in order to investigate. Staff A said staff K also texted him/her on 19/2016 that staff S abused residents. Staff A said he/she did not know of any abuse prior to this conversation on 1/9/2016. At 11:48 A.M. on 1/11/2016, staff A said he/she filed an informational police report, and did not hear back from the police department. Staff A said he/she felt the allegation of abuse was a disgruntled employee and if the allegations came from a resident or an employee with substance, he/she would suspend the staff pending an investigation. Staff A said staff S was not suspended because he/she felt staff S and staff K had a personality conflict. Staff A said the decision not to suspend staff S was a judgement call made by him/her because he/she was concerned the facility could get into trouble with labor relations. At 1:22 P.M. on 1/11/2016 staff A confirmed staff S worked the night shift on 1/9/2016 and 1/10/2016 from 7:00 P.M. to 7:00 A.M. and was scheduled for 11:00 P.M. to 7:00 A.M. on 1/11/2016. Staff A said he/she did not speak to staff S and planned to call him/her sometime today. He/she said night staff were assigned a hall, but helped each other cover the other hall for breaks, residents needing 2 person assistance, and as needed. Review of the facility's undated Abuse, Neglect, and Exploitation Policy documented the facility had comprehensive policies and procedures developed to aid the facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The policy failed to clearly identify how the facility investigated and protected the residents during abuse/neglect investigations. The facility failed to clearly define and implement Abuse, Neglect, and Exploitation policies and procedures to thoroughly investigate and protect residents during allegations of abuse. The facility abated the immediate jeopardy on 1/14/2016 after the facility revised their Abuse, Neglect, and Exploitation policy and trained staff on the following: abuse prevention program, reporting abuse to facility management, and protection of residents during abuse allegations. This deficiency remains at the scope and severity of a F.

The facility reported a census of 31 residents. Based on interview and record review the facility failed to thoroughly investigate an incident of potential abuse/neglect, which ended in resident #36's death. The facility also failed to protect all residents during investigation of allegations of abuse, when the facility allowed the alleged perpetrator to continue working after they were made aware of the allegation. This deficient practice placed the residents in the facility in immediate jeopardy. Findings Included: - Review of an unwitnessed event investigation dated 1/5/2016 at 5:15 P.M. documented staff found resident #36 face down on the floor, cyanotic (a blue or purple color to the skin), no pulse, and unresponsive with his/her lift recliner in the highest (standing) position. The resident had a small abrasion to his/her forehead and a scant amount of blood from his/her nose. The resident scored a 12 on his/her Brief Interview for Mental Status (BIMS) dated 11/29/2015, which indicated moderate cognitive impairment. Review of the clinical record dated 11/16/2015 through 1/5/2016 lacked an assessment to determine if the resident could safely use his/her electric recliner, and lacked a plan to ensure the resident's safety when his/her call light did not function as reported by facility staff on the night shift of 12/30/2015, 1/2/2016, and 1/4/2016 and the day shift of 1/3/2015 and 1/5/2016. Review of laboratory test results dated 12/25/2015 documented the resident had confirmed clostridia difficile (a contagious bacteria characterized by foul smelling frequent bowel movements) and he/she had physician orders [REDACTED]. Review of the facility video tape recorded the facility staff entered and exited the resident's room on 1/5/2016 at 3:44 P.M. and did not reenter until 5:17 P.M. Review of a nursing progress note dated 1/5/2015 documented the resident was pronounced dead at 5:31 P.M. Review of the facility's undated Abuse, Neglect, and Exploitation Policy documented the facility had comprehensive policies and procedures developed to aid the facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The policy failed to clearly identify how the facility investigated potential incidents of abuse/neglect, or how the facility would protect residents during investigations of alleged abuse. The facility failed to protect this cognitively impaired resident with an active infection and malfunctioning call light and other facility residents at risk for serious injury, including death, when they failed to assess the resident's ability to safely use an electric recliner, ensure his/her call light worked continuously, and provide appropriate supervision to ensure his/her needs were met. The facility also failed to assess other residents in the facility with electric lift recliners to ensure they were safe to use their electric lift recliners. - On 1/11/2016 at 7:10 A.M. administrative staff AA said a facility staff member phoned administrative staff A and informed him/her direct care staff S abused residents at the facility. Staff AA said he/she had no details regarding the allegations of abuse. Staff AA said he/she phoned the state and made a police report of the reported allegations of abuse. During an interview on 01/11/2016 at 9:20 A.M. administrative nursing staff D said administrative staff A reported licensed nursing staff K made an allegation of abuse that direct care staff S abused residents on 1/9/2016 and staff A made a police report. Staff D said if staff K suspected abuse, he/she did not send staff S home and he/she did not immediately contact administration. Staff D said staff S worked with residents on the floor 1/9 and 1/10/2016. Staff D said he/she had no knowledge of abuse allegations until reported to him/her by staff A on 1/9/2016. During an interview on 01/11/2016 at 9:50 A.M. administrative staff A said he/she spoke with licensed staff K on 1/9/2016 at 5:00 P.M., when staff K reported that direct care staff S abused residents. Staff A said staff K did not give specific resident names and he/she told staff K he/she needed specifics in order to investigate. Staff A said staff K also texted him/her on 1/9/2016 that staff S abused residents. Staff A said he/she did not know of any abuse prior to this conversation on 1/9/2016. At 11:48 A.M. on 1/11/2016 staff A said he/she filed an informational police report, and did not hear back from the police department. Staff A said he/she felt the allegation of abuse was a disgruntled employee and if the allegations came from a resident or an employee with substance, he/she would suspend the staff pending an investigation. Staff A said staff S was not suspended because he/she felt staff S and staff K had a personality conflict. Staff A said the decision not to suspend staff S was a judgement call made by him/her because he/she was concerned the facility could get into trouble with labor relations. At 1:22 P.M. on 1/11/2016 staff A confirmed staff S worked the night shift on 1/9/2016 and 1/10/2016 from 7:00 P.M. to 7:00 A.M. and was scheduled for the 11:00 P.M. to 7:00 A.M. on 1/11/2016. Staff A said he/she did not speak to staff S and planned to call him/her sometime today. He/she said night staff were assigned a hall, but helped each other cover the other hall for breaks, residents needing 2 person assistance, and as needed. Review of the facility's undated Abuse, Neglect, and Exploitation Policy documented the facility had comprehensive policies and procedures developed to aid the facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The policy failed to identify how the facility investigated and protected the residents during abuse/neglect investigations. The facility failed to ensure residents were protected from potential abuse/neglect after the facility was made aware of allegations of abuse and continued to allow the alleged perpetrator to work two 12 hours shifts without investigating the allegations. This deficient practice placed the residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 1/14/2016 after the facility trained staff on the following: ensuring the continuous and proper functioning of the nurse call light system, ensuring the complete, timely, and thorough investigations of falls and all injuries of unknown origin, timely and thorough investigations of any reports of suspected abuse, neglect, or exploitation of residents, and ensuring the safety of residents who desire to possess and use recliner lift chairs. This deficiency remains at the scope and severity of a F.

The facility reported a census of 31 residents. The sample included 23 residents. Based on observation, interview, and record review the facility failed to develop and implement timely and effective interventions to prevent accidents for 3 of 3 residents sampled for accidents (#36, #16 and #22). Staff found resident #36 deceased on the floor in front of the lift recliner chair, which was in the upright, or lift position. The facility failed to complete an assessment to ensure the resident was safe to use the electric lift recliner, and the facility failed to check on the resident with a known infection which required frequent toileting in a timely manner when his/her call light was known to be malfunctioning. This deficient practice placed the resident in immediate jeopardy. The facility also failed to protect #16 and #22 from accident hazards resulting in immediate serious harm and to implement safety measures to prevent accidents and falls. Findings included: - Review of the signed admission physician order [REDACTED].#36) documented the following Diagnoses: [REDACTED]. the type of tissue called Lewy bodies replacing normal brain tissue) and [DATE] documented laboratory confirmation of clostridium difficile (contagious bacteria characterized by foul smelling frequent bowel movements) and contact precautions. Review of the admission MDS (Minimum Data Set) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The MDS documented the resident required the extensive assistance of 2 staff for bed mobility, transfers, locomotion by wheelchair on and off unit, dressing, toileting, personal hygiene and bathing. The resident also used a Hoyer lift (assistive device used to transfer residents by lifting and moving from one place to another, such as bed to chair) for transfers. The resident had an indwelling urinary catheter and was frequently incontinent of stool. The resident did not reject cares. There were no reported incidences of falls. The resident received antianxiety, antidepressant and diuretic medications for 7 days during the 7-day observation period. Review of the Cognitive Loss CAA (Care Area Assessment) dated [DATE] documented the resident was alert, stated the year, participated in conversation and was able to make simple decisions. He/she had short-term memory loss. Review of the Falls CAA dated [DATE], documented the resident was free from falls but was at risk for falls due to poor safety awareness. He/she leaned too far forward at times in his/her wheelchair and needed verbal cues to sit up. He/she required a Hoyer lift to transfer and was non-ambulatory. Review of the care plan dated [DATE] with revision on [DATE] directed staff with the following interventions: The resident required extensive to total assist of 2 for ADLs (activities of daily living) and transfers using a Hoyer lift, due to the [DIAGNOSES REDACTED]. The resident was incontinent of bowel and bladder and had an indwelling catheter for urinary incontinence. He/she needed 2 person assistance for toileting. The resident liked to sit reclined in his/her own chair lift recliner and was able to control his/her lift chair recliner position. The resident's Morse Fall Scale on [DATE] identified the resident scored 15, which indicated a low risk for falling. Review of the clinical record revealed the resident fell on [DATE], complained of pain in the right elbow but the x-ray reports revealed no fracture. Review of the Fall Investigation form dated [DATE] documented the resident had an unwitnessed fall but lacked a root cause analysis. Review of the [DATE] progress note timed at 7:23 P.M. written by licensed staff I documented the resident was found on the floor by direct care staff who called licensed staff I for help assisting the resident back to bed from the floor. The assessment tool included vital signs, neurological checks and a nursing assessment but lacked a fall investigation with root cause analysis. The Fall Protocol dated [DATE] failed to include a root cause analysis should be done in the fall investigation for unwitnessed falls to try to determine the cause of falls. Review of the facility videotape dated [DATE] at 3:43 P.M. revealed staff went into the resident's room at 3:44 P.M. and exited at 3:44 P.M. The videotape had no instances of staff going into or leaving the resident's room after 3:44 P.M. until 5:16 P.M. (1 hour and 30 minutes later) Review of the videotape dated [DATE] at 5:16 P.M. documented a staff member entering and exiting rapidly at 5:16 P.M. and then two staff re-entering the resident's room at 5:17 P.M. Review of the videotape documented staff entering and leaving the room between 5:22 to 5:24 P.M., and when emergency personnel (ambulance and fire department) entered the resident's room at 5:24 P.M. and left at 5:34 P.M. Review of the documents dated [DATE] at 5:45 P.M. and [DATE] at 10:43 A.M. and written by licensed staff I documented events that occurred when the resident had an unexplained significant change in position resulting in the resident's death. The resident was found face down on the floor and the resident's recliner was in the lift or upright position. The written documentation and notarized statements by direct care staff HH, who administered the resident's medications on [DATE] at 3:44 P.M., said the resident was sitting in his/her recliner in the reclining position with the head and feet raised with his/her call light in their lap. The incident dated [DATE] was an unwitnessed fall, but staff did not do an investigation to determine the cause. Review of the facility provided call light alerts from [DATE] at 9:51 A.M. to [DATE] at 5:18 P.M. documented call light alerts had varying durations with the longest on [DATE] at 9:11 A.M. for over 49 minutes prior to staff answering. Review of the progress notes dated [DATE] at 5:45 P.M. and [DATE] at 10:43 A.M. that pertained to events of [DATE] from 5:05 P.M. to 5:31 P.M. and both signed by licensed staff I and stated around 5:05 P.M. direct care staff R went to the resident's room to take dinner order. (However, review of the video footage did not support this) At that time, the resident was sitting in his/her recliner chair with his/her feet elevated. At approximately 5:10 P.M. direct care staff Q took resident a dinner tray and found resident on the floor lying face down, cyanotic and his/her recliner chair was in the lift or upright position and the staff yelled for help. Licensed staff M alerted licensed staff I about the incident and ran to the resident's room. Licensed staff I and direct care staff ZZ, U, and HH turned the resident over on his/her back. The resident did not have a pulse, and staff called 911. The resident was pronounced dead at 5:31 P.M. on [DATE]. Review of a statement dated [DATE] and written by medical director KK stated the resident's family requested he/she use the chair he/she had previously used at home to be also used in the facility and also stated the use of this chair was the safest way for the resident to change positions. During an interview on [DATE] at 7:16 A.M. direct care staff Q said that the resident could press the bed, call light, and recliner controls in the beginning of [DATE] but at the end of [DATE], he/she was no longer able to use the controls as well. He/she said direct care staff had concerns about his/her safety when the resident was in the wheelchair in their room, as there were instances when the resident slipped while sitting in the wheelchair and attempting to get out of bed. He/she said they found the resident with his/her feet touching the floor and he/she was lying diagonally on the bed when staff answered the call light on [DATE]. Direct care staff Q said he/she had concerns with safety when the resident sat in the recliner lift chair. An interview with direct care staff Q on [DATE] at 9:25 A.M. revealed direct care staff R and YY transferred the resident from the bed to the recliner with a Hoyer on [DATE] about 11:00 A.M. He/she described the sequence of events when the resident went to the resident's room on [DATE] at about 5:10 P.M. to take the resident his/her dinner tray and stood at the door to their room. The resident was lying face down on the floor and their feet were viewed at the end of their bed. The room was dark and the resident's recliner was in the upright position or lift position. The staff member said that they left to get help. During an interview on [DATE] 3:16 P.M. direct care staff Q said when the resident's recliner was in the upright position that meant in a lift or almost straight position which was the correct position for a resident to ambulate. During an interview on [DATE] at 3:20 P.M., direct care staff HH said he/she administered medications to the resident on [DATE] around 3:,[DATE]:00 P.M. During an interview on [DATE] at 3:19 P.M. direct care staff R said he/she entered the room of the resident on [DATE] at 5:05 P.M. to take the resident's meal order for supper. (However, review of the video footage did not support this) During an interview on [DATE] at 7:17 A.M. direct care staff T he/she said on the night shift on [DATE] (11:00 P.M. to 7:00 A.M.), licensed staff N informed the staff that the resident's call light did not consistently work and those staff assigned to that resident were to check on the resident every 2 hours and included staff that passed the resident's room should go in and double-check on him/her between the watches. During an interview on [DATE] at 7:21 A.M. licensed staff N said there were problems with the resident's call light on [DATE], [DATE] and [DATE] during the night shift (11:00 P.M. to 7:00 A.M.). It did not consistently signal and staff did every two hour watches. During an interview on [DATE] at 4:09 P.M. licensed staff M said the family brought the resident's recliner in to the facility between [DATE]-[DATE] and he/she did not know if the facility assessed the resident for safe use of the recliner lift chair. An interview with licensed staff M on [DATE] at 4:11 P.M. said the night nurse reported on [DATE] at 7:00 A.M. the call light in resident's room was not working and licensed staff said he/she could not operate the call light the morning of [DATE] and reported this to maintenance staff Y on [DATE]. Licensed staff M said the call light operated intermittently on [DATE]. During an interview on [DATE] at 4:33 P.M. licensed staff M said the nurse who worked the night shift on [DATE] also reported the call light did not work on [DATE] at 7:00 A.M. and reported the non-working call light to licensed staff I on [DATE] at 8:15 A.M. He/she also replaced the call light. He/she said there were concerns about putting another call light in this room because the resident was in isolation. The call light in this resident's room was operational intermittently on [DATE] and [DATE]. Staff replaced the call light twice and still was not operational. He/she said there were problems with the call light again in that room for another resident on [DATE] and [DATE]. Maintenance staff Y replaced the plate at the wall and administrative nursing staff D replaced the call light on both [DATE] and [DATE]. With further discussion licensed staff M confirmed that on [DATE], [DATE] and [DATE] at the 7:00 A.M. shift each day the call light in resident #36's room was not operational at all times. Review of the written statement of licensed staff M said the timing was [DATE] to [DATE] at 7:00 A.M. each day and this staff member was not working on [DATE] at 7:00 A.M. During an interview on [DATE] at 4:58 P.M. licensed staff I said the resident's family member brought in the recliner between [DATE] and [DATE] and the facility did not assess the safety of the recliner, or the resident's ability to use the recliner. He/she also said that the upright position of the recliner was the lift position because the resident used this recliner lift chair at home when he/she was ambulatory. He/she added that the resident had only been seen in the reclining position since the chair was brought in. He/she said staff transferred the resident from their bed to their recliner with a Hoyer lift on [DATE] around 11:00 A.M. Licensed staff I said that the resident was last seen by staff seated in their recliner in the reclining position on [DATE] at 5:05 P.M. until the resident was found on the floor face down and the recliner was in the lift position. During an interview on [DATE] at 8:14 A.M. administrative nursing staff D said the resident's call light did not work on [DATE] and staff replaced it on [DATE] and replaced it again on [DATE] and [DATE] when a new resident admitted to that same room. He/she said there were no safety assessments for residents recliners or lift chairs. During an interview on [DATE] at 3:32 P.M. medical director KK said the significant and unexplained change in position was unavoidable due to the resident's history of impulsiveness. He/she also said that the recliner or lift chair was an appropriate assistive device for this resident and the resident had the right to the type of device he/she wished to use. He/she was not aware of any assessment done by the facility for the resident's safe use of the electric recliner lift chair. Review of the facility Fall Protocol policy dated [DATE] documented specifics regarding witnessed and unwitnessed falls. The Fall Protocol failed to include a root cause analysis for each fall that occurred. The facility failed to follow the Fall Protocol policy. The facility lacked a fall policy prior to [DATE] (initiated after this resident's fall). The facility lacked a policy regarding resident call light function. The facility failed to assess a resident to ensure he/she was able to safely operate an electric lift recliner, failed to ensure a consistent fully functional call light system and failed to ensure the resident received adequate care and supervision. The resident fell from the electric lift recliner chair and was found dead. This placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] when they implemented the following: the facility completed all staff training, ensured the continuous and proper function of the nurse call light system, ensured complete, timely and thorough fall investigations and injuries of unknown origin, and ensured safety for resident use of electric lift recliners, timely and thorough investigations of any reports of suspected abuse, neglect or exploitation of residents, management, participation, monitoring, review and oversite of investigations to ensure they were complete, timely and thorough. This deficiency remains at the scope and severity of a G. - Review of resident #16's signed history and physical dated [DATE] included the following Diagnoses: [REDACTED]. response to pressure). Review of the admission MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she required extensive assistance of 2 or more staff with bed mobility, transfers, and toileting; extensive assistance of one staff with bathing, dressing, personal hygiene, and locomotion on and off the unit; and limited assistance of 2 or more staff with walking. The resident was only able to stabilize his/her balance with staff assistance and used a walker and wheelchair for mobility. The resident was frequently incontinent of urine, occasionally incontinent of bowel, and had no toileting program. The resident had falls prior to admission and had no falls since his/her admission. Review of the 30 Day MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. He/she required extensive assistance of 2 or more staff with bed mobility, transfers, and toileting; extensive assistance of one staff with bathing, dressing, and locomotion on and off the unit; limited assistance of one staff with personal hygiene; and walked only once or twice with assistance of 2 or more staff. The resident was only able to stabilize his/her balance with staff assistance and used a walker and wheelchair for mobility. The resident was occasionally incontinent of urine, continent of bowel, and had no toileting program. The resident had no falls since admission. Review of the ADL (Activities of Daily Living) CAA (Care Area Assessment) dated [DATE] documented the resident needed staff assistance with ADL, worked with therapy, and made slow progress. Review of the Urinary Incontinence CAA dated [DATE] documented the resident needed assistance with toileting transfers due to weakness, poor balance, and recent falls. He/she was frequently incontinent of urine, was aware of toileting needs, had problems holding his/her urine, and asked for staff assistance. Review of the Falls CAA dated [DATE] documented the resident had multiple falls at home, had poor balance, and weakness. The resident worked with therapy for transfer needs, was aware of his/her safety needs and asked for staff assistance. Review of a fall risk assessment dated [DATE] documented the resident scored a 75, which indicated the resident was at high risk for falling. Review of the care plan dated [DATE] documented the resident had mild confusion, mild memory loss, and mild cognitive deficits and needed staff assistance with transfers and ambulation. The care plan directed staff to cue, reorient, and supervise the resident if needed. Staff revised the care plan on [DATE] and documented the resident had a fall with no injury when he/she attempted to ambulate on his/her own. The care plan lacked an immediate intervention to prevent falls following falls on [DATE], [DATE], and [DATE] and lacked staff direction on the resident's needs for toileting tasks. Review of fall investigations documented the following: On [DATE] at 8:05 A.M. staff in the hall heard a thump from the resident's room. Staff found the resident on the floor next to the door. He/she held wipes and had feces on his/her nightgown. The resident said he/she had an accident trying to clean him/herself up and thought he/she was able to get from the bed to the bathroom using a walker. The resident reported getting clothing out of the chest of drawers and began walking to the bathroom when his/her legs gave out and bumped his/her head on the door. The resident's call light was not on. The investigation lacked a root cause analysis. On [DATE] at 2:15 P.M. staff found the resident in the bathroom next to the toilet in a seated position. The resident said he/she tried to change his/her pants, took off his/her shoes, then stood up, and slid to the floor. Staff reported the pager went off at 1:40 P.M., checked on the resident and he/she was on the floor. The resident thought he/she could transfer him/herself to the toilet from her wheelchair without his/her shoes on. The investigation lacked a root cause analysis. On [DATE] at 4:36 P.M. staff found the resident seated on the bathroom floor in front of the doorway to the bathroom. The resident said he/she tried to walk to the bathroom using his/her walker when his/her legs got weak, and he/she lowered him/herself to the floor. The resident said an aide was in his/her room ,[DATE] minutes prior, but he/she did not push the call light to ask for bathroom assistance even though he/she knew to ask for help. The investigation lacked an analysis of findings. The resident discharged on [DATE] to another facility. During an interview on [DATE] at 5:12 A.M. direct care staff T said the resident was alert, able to ask for staff assistance as needed, and fell on ce due to trying to walk to the bathroom on his/her own. Staff T said the resident had no fall interventions. During an interview on [DATE] at 11:30 A.M. direct care staff Q said the resident was a fall risk and had ,[DATE] falls when admitted . Staff Q said the resident did not want to discharge, sat down in the bathroom, pushed his/her wheelchair to the doorway, turned on his/her call light and said he/she fell . Staff Q said the resident was not on a toileting program. During an interview on [DATE] at 11:34 A.M. licensed nursing staff J said the resident had a fall history, fell during his/her admission due to weak knees, and had an unstable gait. Staff J said the resident had behaviors because he/she did not want to discharge and would sit him/herself down on the floor. Staff J reported staff kept the resident's call light within reach, reminded him/her to ask for staff assistance, and staff checked on him/her frequently . The resident had a grabber and he/she used a walker and a wheelchair. Staff J said the resident was incontinent, had no toileting program, and knew when he/she had to use the bathroom. During an interview on [DATE] at 3:27 P.M. the resident said he/she fell twice because staff did not respond to his/her call light and he/she waited up to 45 minutes for staff assistance. The resident reported staff did not routinely offer him/her bathroom assistance and he/she needed help. During an interview on [DATE] at 4:39 P.M. administrative nursing staff D said the resident was a fall risk and had falls since admission due to attempts to self-transfer to the bathroom and attempts to dress him/herself. Staff D confirmed the resident was incontinent, had no toileting program, and the fall investigations lacked a root cause analysis. The facility failed to ensure this incontinent resident who required staff assistance with ADLs received the necessary care and services to prevent accidents. - Review of resident #22's signed physician order [REDACTED]. Review of the significant change in status MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 6, which indicated severe cognitive impairment. He/she required limited assistance of one staff with bed mobility, transfers, toileting, and personal hygiene; extensive assistance of one staff with walking, locomotion off the unit, dressing, and bathing; and supervision of one staff with locomotion on the unit. The resident was able to stabilize balance with staff assistance and used a wheelchair for mobility. The resident had 2 or more non injury falls. Review of the quarterly MDS dated [DATE] documented a BIMS score of 4, which indicated severe cognitive impairment. He/she required extensive assistance of one staff with bed mobility, transfers, walking, locomotion off the unit, dressing, toileting, and bathing; and limited assistance of one staff with locomotion on the unit and personal hygiene. The resident had 2 or more non injury falls. Review of the Cognitive Loss CAA (Care Area Assessment) dated [DATE] documented the resident was alert and oriented to self and had periods of inattention and disorganized thoughts. Review of the ADL (Activities of Daily Living) CAA dated [DATE] documented the resident had a slight improvement in ADL performance, needed limited to extensive assistance with ADL, needed verbal cues for directions, and was not able to participate in a retraining program due to his/her cognitive deficits. Review of the Falls CAA dated [DATE] documented the resident was at risk for falls due to Parkinson's, dementia, and his/her recurrent fall history. The resident was impulsive and not aware of his/her safety needs. Review of Fall Risk Assessments documented the resident was a high risk for falls on [DATE] and [DATE]. Review of the care plan dated [DATE] documented the resident needed staff assistance with ADLs due to Parkinson's, had impaired cognition due to dementia, and was at risk for falls. The care plan directed staff to assist the resident with toileting upon rising, before and after meals, at bedtime, and as needed; assist with proper toileting hygiene, remind the resident to ask for assistance with toileting transfers, assist bed mobility especially when he/she was weak/tired, and keep the bed in the lowest position when in bed. Review of fall investigations documented the following: On [DATE] at 4:34 P.M. the resident's family member notified the nurse the resident was on the floor. Staff found the resident sitting on the floor. The resident and family member said the resident tried to pull the sheet from his/her bed and take them to the laundry. The investigation lacked a root cause analysis. On [DATE] at 9:15 A.M. staff found resident #22 on the floor, on his/her back, in his/her room, in between the bed and the wheelchair. The resident was not able to describe what occurred. The investigation lacked a root cause analysis. On [DATE] at 11:40 P.M. staff found the resident on the floor in his/her room, half dressed with pants at knees, seated on his/her buttocks. The resident said he/she tried to get dressed to get up and did not know how he/she fell . Staff documented the resident was confused, anxious, weak, did not use his/her call , and had continuous attempts to self transfer. The investigation lacked an analysis of findings. On [DATE] at 5:30 P.M. resident's family member notified staff the resident was in the bathroom on his/her knees. The resident said he/she missed the wheelchair when he/she tried to transfer him/herself from the toilet seat. The investigation lacked a root cause analysis. On [DATE] at 11:00 A.M. the resident's family member informed a housekeeper the resident was on the floor. Staff found the resident on the floor by his/her bed. Prior to the incident the resident slept in his/her recliner. The investigation lacked an analysis of findings. On [DATE] at 11:00 A.M. staff found the resident on the floor of the bathing in his/her room. The resident said he/she tried to pick up a piece of tissue off the floor. The investigation lacked an analysis of findings. On [DATE] at 11:30 P.M. staff found the resident lying on the floor, in front of the wheelchair and beside his/her bed. The resident asked for a pillow and thought he/she was in bed. Staff observed a bruise to the resident's upper right lip. The investigation lacked a root cause analysis. On [DATE] at 1:10 P.M. the resident's family member notified staff the resident fell in his/her room. Staff found the resident seated on the floor by his/her bed. The investigation lacked a root cause analysis. On [DATE] at 9:45 A.M. the resident's family member notified staff the resident slid to the floor from his/her wheelchair. The investigation lacked a root cause analysis. On [DATE] at 1:45 P.M. activity staff notified nursing the resident fell in the hallway. The resident tried to reach something from his/her floor and slid to his/her knees from the wheelchair. He/she found the resident seated on the floor and the resident was not able to describe how he/she fell . Activity staff said he/she saw the resident in front of his/her wheelchair grasping cups and trash and did not see the resident hit his/her head. The investigation lacked a root cause analysis. On [DATE] at 6:09 P.M. the resident's family member said the resident tried to transfer him/herself from the recliner to the wheelchair and slid to the floor in front of the recliner. He/she did not hit his/her head. The resident said he/she tried to transfer him/herself, slid to the floor, and did not know why. Staff reported the room was dark, he/she was asleep, and tried to transfer without assistance. The investigation lacked a root cause analysis. On [DATE] at 7:15 P.M. staff found the resident on the floor, next to his/her bed with the wheelchair beside him/her, seated on his/her bottom, legs in front of him/her, and hands to his/her side. The resident was not able to state why he/she got up. The investigation lacked a root cause analysis. On [DATE] at 5:05 P.M. staff found the resident on the floor in the utility room. The resident said he/she tried to look for clothes when he/she slid to the floor. The investigation lacked a root cause analysis. On [DATE] at 7:52 A.M. staff found the resident in his/her room seated on his/her bottom leaning on his/her left hand with his/her arm extended. The resident said he/she slid out of the wheelchair as he/she reached for a tub of popcorn, landed on his/her bottom and braced him/herself with his/her left arm. Staff documented the resident had balance issues, possibly related to his/her vision. The investigation lacked a root cause analysis. On [DATE] at 7:52 A.M. staff found the resident in his/her room seated on his/her bottom leaning on his/her left hand with his/her arm extended. The resident said he/she slid out of the wheelchair as he/she reached for a tub of popcorn, landed on his/her bottom and braced him/herself with his/her left arm. Staff documented the resident had balance issues, possibly related to his/her vision. The investigation lacked a root cause analysis. During an observation on [DATE] at 7:46 A.M. the resident laid in bed with the bed in the lowest position. During an observation on [DATE] at 8:36 A.M. the resident laid in bed and the bed was not in the lowest position. At 10:39 A.M. the resident remained in bed and the bed was not in the lowest position. At 10:39 A.M. the resident's family member exited the resident's room and asked the housekeeping staff Z if staff was available to assist the resident. Staff Z replied, I don't see one and the family member returned to the resident's room. At 10:45 A.M. direct care staff W entered the room and asked the family member what he/she wanted. The family member requested staff assist the resident out of bed. Staff Z attempted to wake the resident and asked him/her if he/she wanted to wait another 15 minutes to get out of bed and the resident said yes . Staff Z left the room and the bed was not in the lowest position. At 11:10 A.M. direct care staff Q entered the room and asked the resident if he/she wanted to get up. The resident mumbled and asked the staff to sit at the window. The staff offered a room tray for lunch and the resident said okay . Staff Q left the room at 11:12 A.M. and did not put the bed in the lowest position. During an observation on [DATE] at 2:21 P.M. the resident sat on the toilet, had on regular socks, pants lay on the floor, and his/her wheelchair was next to him/her. The resident's family member sat in a chair in the bedroom. The resident pushed the wheelchair backwards, walked to the sink, and wet a washcloth. His/her balance was unsteady. The resident used the washcloth and wiped him/herself, rinsed the washcloth in the sink, and feces remained on the washcloth. He/she used the wheelchair to walk backwards to the toilet

The facility identified a census of 31 residents, and the sample size was 23. Based on observation, interview, and record review, the facility failed to develop and implement timely and effective interventions to prevent the development of a Stage II pressure ulcer, failed to develop and implement interventions to promote healing and prevent worsening of the Stage II pressure ulcer which progressed to an unstageable ulcer for resident #4, and implement timely interventions and education on wound healing for resident #63, for 2 of 3 residents sampled for pressure ulcers. Findings Included: - Review of the resident #4's unsigned care plan dated 12/7/15 documented the following Diagnoses: [REDACTED]. Review of the 5 day admission MDS (Minimum Data Set) dated 12/8/15 documented the resident was rarely or never understood, had adequate short and long term memory, and was independent with cognitive skills for decision making. The MDS lacked a BIMS (Brief Interview for Mental Status) score. The resident required extensive assistance of one staff with bed mobility, locomotion on and off the unit, dressing, and personal hygiene; extensive assistance of two staff with transfer and toilet use; supervision of setup with eating; and walking in room and corridor only occurred once or twice with one staff assistance. The resident was at risk for pressure ulcers, had a healed pressure ulcer, and a Stage I ( intact skin with non-blanchable redness of a localized area usually over a bony prominence) or greater pressure ulcer to include one Stage I pressure ulcer affecting the [MEDICATION NAME] (a membranous tissue made up of one or more layers of cells closely packed together and serves as a covering of internal and external surfaces of the body) tissue. The resident had a pressure reducing device for his/her chair, a pressure reducing device for the bed, received applications of ointments and medications, and was on a turning/repositioning program. The resident was not on a toileting program, and was frequently incontinent of bladder. Review of the Activities of Daily Living (ADL) function/Rehab Potential Care Area Assessment (CAA) dated 12/8/15 documented the resident needed extensive assist from 1-2 staff for bed mobility, transfers, dressing, and toileting. He/she did not want to bear weight on the right lower extremity. The resident needed encouragement to participate in ADL performance. He/she preferred to lay in bed and not get up. Review of the resident's Pressure Ulcer CAA dated 12/8/15 documented the resident was currently free from breakdown. He/she was at risk for breakdown due to decreased mobility and incontinence. Staff applied moisture barrier as a preventative measure, and was to wear heel lift boots when in bed. The resident had a pressure reduction mattress on his/her bed and cushion in his/her wheelchair. The staff assessed the resident's skin weekly, and staff assisted him/her with repositioning and turning. The Urinary Incontinence/Indwelling catheter CAA dated 12/8/15 documented the resident was frequently incontinent of bladder. He/she was not always aware of urinary toileting needs, and wore briefs for dignity. The resident needed extensive assist from 1 staff for toileting, transfers, and hygiene. The resident had decreased ability to transfer impaired continence and he/she was not always able to reach the toilet in time to prevent urinary incontinence. Staff must anticipate his/her toileting needs due to some issues with language barrier. The Interim Care plan dated 12/1/15 documented the resident had no impaired skin integrity upon admission, was cognitively impaired, could not communicate easily or be understood by staff, required total dependence with toileting, bathing, bed mobility, transferring, dressing, and assistance with locomotion, personal hygiene, and eating. The resident was not continent of bladder but was continent with bowel. The care plan lacked documentation of assistance needed with repositioning or assistive devices to be used when in bed for skin breakdown prevention. The care plan dated 12/14/15 documented the resident needed extensive assistance with bed mobility, transfers, toileting, bathing, hygiene, and dressing. The resident was frequently incontinent. The resident was at risk for wounds on 12/16/15, and staff were instructed to apply lotion to the resident's dry skin, provide a basic pressure reduction mattress on the bed, change linens whenever wet or soiled, encourage active and passive range of motion to prevent wounds, float heels while in bed, heel lift boots while in bed, and keep the resident's bed sheets dry and free from debris and wrinkles. The resident's Braden (a tool used to determine risk for pressure ulcer development) was 14, meaning moderate risk. Staff were to monitor for signs of pain due to pressure, perform Braden's scale on admission and quarterly, reposition in bed or wheelchair frequently, use heel and or elbow protectors as needed, and use a pressure reduction cushion in wheelchair when up. Review of the resident's clinical record lacked documentation for an Incontinence Voiding Pattern/Toileting assessment, a turning schedule, and lacked [MEDICATION NAME]/[MEDICATION NAME] (a lab ordered when signs and symptoms of malnutrition may be present) laboratory levels. The Pain assessment dated [DATE] documented the resident frequently had pain in the last 5 days, which made it hard to sleep and affected day to day activities. The facility rated the resident's pain as a 7 out of 10 (meaning severe pain) and used Tylenol 500 milligrams (mg) as needed every 6 hours for pain. The Braden scale dated 12/1/15 documented a moderate risk of 14 for skin breakdown due to slightly limited sensory perception, skin occasionally moist, chair fast activity, very limited mobility, probably inadequate nutrition, and potential problem with friction & shear. The Kardex Report (electronic information report used by nursing aids) dated 12/1/15 documented for staff to place the call light within the resident's reach, provide extensive assistance of 1-2 staff for bed mobility, use a wheelchair for mobility, and provide assistance from 2 staff for transfers using gait belt, transfer disc, or walker. The resident was frequently incontinent of bladder, and needed assistance with toileting, transfers, and hygiene. The Admission Assessment on 12/1/15 documented coccyx redness, right hand bruising, right trochanter (hip) bruising, and documented a lot of bruises from last fall. On 12/4/15 the resident's physician ordered for staff to do Weekly Skin Assessments. The Skin Observation Tool dated 12/11/15 documented no new skin issues noted. A physician order [REDACTED]. The clinical record lacked documentation of the reason the staff initiated the skin prep. A physician order [REDACTED]. An Orders Administration Note (nursing note for medications and treatments) dated 12/17/15 documented the resident refused to wear the boot. The clinical record lacked documentation of staff education to the resident on the risks of not wearing the boots. The Skin Observation Tool dated 12/18/15 documented a blister on the right heel, and staff applied skin prep twice a day. Staff noted a small scab right above each foot, and no other issues at this time. The resident's skin remained intact. The Skilled assessment dated [DATE] documented staff applied skin prep to the right heel per treatment orders and the resident refused to wear boots while in bed. The clinical record lacked documentation of staff education to the resident on the risks of not wearing the boots. The Orders-Administration Note dated 12/19/15 documented the resident refused boot while in bed. The clinical record lacked documentation of staff education to the resident on the risks of not wearing the boots. The Skin/ Wound Note dated 12/19/15 documented the resident rested quietly in bed this evening with heel protector boots in place. A pillow was between his/her knees for comfort while in bed, and cooperative with cares. The Weekly Wound assessment dated [DATE] documented a right heel, pressure wound 3.1 centimeter (cm) length, 4.5cm width, 0 depth, and unstageable (pressure ulcer not stageable due to not-removable dressing/device or due to the coverage of the wound by slough or eschar, or dead tissue). The resident had 1 or more unhealed pressure ulcers at Stage 1 or higher, and specifically the unstageable pressure ulcer present. This area was soft and fluid filled. Pressure ulcer interventions included a multivitamin,Vitamin C, heel boots, and skin prep to the wound. The Skin/Wound Note dated 12/23/15 documented the resident had a 2x2 cm round,purple in color, fluid filled wound to right heel. The current treatment was for staff to apply of skin prep. Staff left a communication for the physician to evaluate the area and to recommend a new treatment or to continue with current treatment plan. The resident had heel boots in place bilaterally and the left lower extremity anterior ankle had a scabbed area approximately 0.5 cm with red edges. The physician progress notes [REDACTED]. The wound was 3.1 x 4.5 centimeters and intact. A physician order [REDACTED]. A note to the physician dated 12/24/15 documented for the physician to clarify if the resident was to have skin prep in addition to the foam dressing for the right heel. There was no response for additional treatment noted in the resident's chart. Skin observation tool dated 12/25/15 documented a right heel blister with treatment in progress. An Orders Administration Note dated 1/11/16 documented the heel boot on the right leg when the resident was in bed two times a day; the resident was up this morning. The Nutrition/Dietary Note dated 1/13/16 documented the the resident was on a regular diet and his/her oral intake improved some. His/her weight was 111pounds, up 6.2 percent (%) in 30 days. His/her needs estimated at 1620 kilocalories, 70 grams protein and 1620 milliliters of fluid to promote wound healing. The resident would benefit from multivitamins with minerals and 500 mg Vitamin C twice a day. During an observation on 01/11/2016 at 7:54 A.M. the resident drank his/her coffee and cranberry juice. Staff served him/her a bowl of oatmeal, eggs, sausage, waffles, and a fruit cup. The resident ate 100% of the eggs and waffles independently, but no sausage. During an observation on 01/11/2016 at 10:50 A.M. the resident sat in his/her wheelchair, watching television and had slippers on. During an observation on 01/11/2016 at 12:16 P.M. the resident fed self, and staff served him/her soup, manicotti, mixed veggies, and a breadstick. He/she ate 100% of the breadstick, 50% of the mixed veggies, and a small amount of the manicotti. During an observation on 01/12/2016 at 8:27 A.M. the resident sat in his/her wheelchair with a cushion in place and slippers on. During an observation on 01/12/2016 at 10:26 A.M the resident sat in the wheelchair watching television with the room door open. During an observation on 01/12/2016 at 10:35 A.M. staff entered the room, and did not offer the resident a change of position. The resident wheeled him/herself to the door and sat there. During an observation on 01/12/2016 at 10:56 A.M. the resident sat in wheelchair by the door entrance to room. During an observation on 01/12/2016 at 11:05 A.M. family entered the room to visit with the resident. During an observation on 01/12/2016 11:09 A.M. a staff member entered the room to talk to another staff member. The resident was in his/her wheelchair watching television. Position change was not offered to the resident. During an observation on 01/12/2016 at 11:19 A.M. staff entered the room to get a shower chair and then exited. The resident sat in his/her wheelchair next to the bed with call light in reach. During an observation on 01/12/2016 at 11:24 A.M. the resident sat in the wheelchair next to his/her bed. During an observation on 01/12/2016 at 11:38 A.M. the staff took the resident to lunch. During an observation on 01/12/2016 at 11:43 A.M., 11:58 A.M., 12:16 P.M., and 12:31 P.M. the resident sat at the dining table eating lunch. During an observation on 01/12/2016 at 12:40 P.M. the resident wheeled him/herself down the hall to room. His/her feet were in the wheelchair pedals and he/she had slippers on. During an observation on 01/12/2016 at 12:56 P.M. the resident sat in the wheelchair in his/her room, with no change of position. During an observation on 01/12/2016 at 1:17 P.M. licensed staff M and direct care staff O assisted the resident to the restroom. The resident's skin under his/her brief did not have any red areas and skin was intact. The nurse and aid provided peri care after the resident urinated. The resident had a hard, black circular wound with a dark purple center covering his/her right ankle, covered with a dressing. The wound was painful to touch for the resident. The dressing was clean, dry, and intact. A red bump with a white center was on the outer side of the left foot by the ankle. Staff failed to reposition the resident for a total of 2 hours and 43 minutes. During an observation 01/13/2016 at 9:54 A.M. the resident sat in his/her wheelchair by the room door, and wore his/her slippers. During an observation 01/13/2016 at 10:10 A.M. the resident sat in his/her wheelchair by the door with no position change. During an observation 1/13/15 at 10:22 A.M. staff entered the room after the resident pushed his/her call light. The staff could not determine what the resident needed. The resident remained seated in his her wheelchair and watched television. During an observation on 01/13/2016 at 10:38 A.M. the resident sat by his/her bed with the call light in reach. During an observation on 01/13/2016 at 10:53 A.M. the resident sat by his/her bed with the call light in reach, slippers on and his/her feet in the wheelchair pedals. The resident continued to sit in the wheelchair at 11:01 A.M., 11:07 A.M., 11:08 A.M. and then at 11:25 A.M. staff entered the resident's room and took him/her to lunch. During an observation on 01/13/2016 at 11:44 A.M., 12:02 P.M., 12:11 P.M., 12:24 P.M. the resident sat in the dining room eating lunch. The resident sat 2 hours and 33 minutes without a position change. During an observation on 01/13/2016 12:27 P.M. staff did not perform a skin assessment due to increased anxiety of the resident and the inability to communicate. During an interview on 01/12/2016 at 8:39 A.M. a family member explained that the resident stated he/she wore heel boots in bed at night. The family stated the resident had thin skin on heels, no wounds on heels or feet, and he/she was able to reposition his/herself with little assistance. During an interview on 01/12/2016 at 5:21 A.M. direct care staff T stated the resident wore foot boots at night and had a blister on right foot. He/she stated the resident could turn his/herself, and when the resident laid on his/her back, the resident could reposition self to the side. The direct care staff stated staff checked all residents every two hours and when residents used their call lights. An interview on 01/12/2016 at 3:42 P.M. direct care staff P stated he/she believed the resident had skin issues with his/her feet from shoes rubbing on the skin, and thought it healed. During an interview on 01/13/2016 at 1:53 P.M., direct care staff R stated the resident was not continent and required toileting every two hours. He/she stated staff toileted the resident about 7 minutes ago and before lunch. The direct care staff was not aware the resident had any skin issues but believed the right foot had a dressing on it, but had not seen it before. During an interview on 01/12/2016 8:39 A.M., licensed staff M stated the resident's wound was never opened and it was now healed and scabbed over. There was never any drainage and the resident wore heel boots at night. An interview on 01/12/2016 at 1:17 P.M. licensed staff M stated that staff applied lotion to dry skin on legs and feet. The dressing was clean, dry, and intact. The licensed staff stated the red bump on the left outer ankle on the left foot was a new skin issue the podiatrist would address. During an interview on 01/13/2016 at 5:18 P.M., licensed staff I stated the resident's wound was soft skin, not opened, and in the beginning it had blood inside of it. The resident had an order for [REDACTED]. Staff were to toilet the resident before and after meals. He/she explained staff should check the resident every 2 hours and reposition between every 2-3 hours. He/she stated he/she would follow up with the aids to ensure they did this. An interview on 01/14/2016 at 1:49 P.M. administrative nursing staff D stated the resident's wound progressed from a blister and was now unstageable. He/she said he/she was not sure about what time frame reposition frequently in wheelchair and bed referred to from the resident's care plan. The resident was not on a toileting schedule. Administrative nursing staff D stated the nurses and the Director of Nursing performed skin assessments weekly. Nursing did the weekly skin assessments for the resident on Fridays, and he/she confirmed that there was not an assessment done on 1/1/16. He/she said when a resident developed a wound, staff notified the dietician and the physician. The resident used heel lift boots when in the bed and a dressing covered the wound. Administrative nursing staff D stated repositioning would help to prevent further wound development, but would not help the current wound to heal. During an interview on 01/14/2016 at 4:17 P.M. physician extended staff JJ stated he/she last looked at the resident's wound around the end of December and classified it as an unstageable wound. He/she expected staff to relieve pressure to the areas by floating the heels, helping the resident with rolling, and heel protectors when in bed. He/she said that any relief of pressure, such as repositioning helped wounds to heal and prevented wounds from developing. During an interview on 01/21/2015 at 2:50 P.M. administrative nursing staff D stated that when the wound was found, it was an intact blister, which was a Stage II ( partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed without slough, may also present as an intact or open/ruptured blister) pressure ulcer. He/she confirmed that the most recent weekly skin assessment with measurements was last completed on 12/23/15 and none have been completed since, but he/she was working to complete those now. He/she stated that upon admission a cushion for the resident's wheelchair was used to prevent pressure ulcers, as well as a pressure reduction mattress and foot cradle pillow. The interventions of heel boots and skin prep were added on 12/16/15 for treatment of [REDACTED]. He/she stated that the resident was able to reposition his/her self, and was not on a turning schedule. The resident was to only wear the heel boots while in bed. The Pressure Ulcer Prevention Policy dated 1/13/16 stated pressure ulcer prevention and healing include implementing individualized interventions to attempt to stabilize, reduce, or remove underlying risk factors. Skin assessments were done by the nurse weekly . They were to report any changes in skin condition to the Director of Nursing and /or designee for a treatment plan. Staff placed a resident who acquired a Stage 3 or greater wound on a low air loss mattress unless otherwise indicated. Residents at risk for heel breakdown wore a heel lift or boots to relieve pressure while in bed. The facility ensured all residents that used a wheelchair had a cushion in their wheelchair as a preventative measure. Nursing performed Braden scales on admission, quarterly, annually, and with a significant change in status. All mattresses were foam pressure reduction mattresses. The facility failed to provide the appropriate care and services to prevent this resident who developed one Stage II pressure ulcer from progressing to an unstageable pressure ulcer and failed to prevent this resident from developing a pressure ulcer after admission. - Review of resident #63's signed history and physical dated 12/1/2015 documented the following Diagnoses: [REDACTED]. Review of the admission MDS (Minimum Data Set) dated 12/7/2015 documented a BIMS (Brief Interview for Mental Status) score of 4, which indicated severe cognitive impairment. He/she required extensive assistance of 2 or more staff with bed mobility, transfers, dressing, toileting, and bathing; extensive assistance of one staff with locomotion on and off the unit; limited assistance of one staff with personal hygiene; and supervision and set up assistance with eating. He/she did not reject cares. The resident was at risk for the development of pressure ulcers, had 2 stage one pressure ulcers, and had the following ulcer treatments in place: pressure relieving device for bed and chair, turning/repositioning program, and application of ointments/medications applied to and area other than feet. Review of the 14 Day MDS (Minimum Data Set) dated 12/12/2015 documented a BIMS score of 5, which indicated severe cognitive impairment. He/she required extensive assistance of 2 or more staff with bed mobility, transfers, and toileting; extensive assistance of one staff with walking, locomotion on the unit, and bathing; dependent on one staff with locomotion off the unit; limited assistance of one staff with personal hygiene; and supervision and set up assistance with eating. The resident was at risk for the development of pressure ulcers, had 1 stage one pressure ulcers and had the following ulcer treatments in place: pressure reliving device for bed and chair, nutrition or hydration interventions, turning/repositioning program, and application of ointments/medications applied to area other than feet. Review of the Cognitive Loss CAA (Care Area Assessment) dated 12/9/2015 documented the resident had dementia, confusion, short term memory deficits, and impaired decision making. Review of the Pressure Ulcer CAA dated 12/9/2015 documented the resident was free from skin breakdown, had slightly red heels, which resolved, and he/she wore heel lift boots at bedtime, which he/she did not always want to wear, and had a pressure reducing mattress on his/her bed and a cushion in his/her wheelchair. Staff assisted the resident with repositioning as needed. He/she was able to feel pain and pressure and asked staff for assistance if needed. Review of a Braden Skin Risk assessment dated [DATE] documented the resident scored a 13, which indicated a moderate risk for skin breakdown. Review of the care plan dated 11/30/2015 documented the resident was cognitively impaired and had impaired skin integrity on admission. The care plan directed staff to cue, reorient, and supervise as needed. Review of skin observation assessments documented the following: On 12/16/2016- the resident had no redness or indication of pressure ulcers. On 12/23/2015- a right heel pressure wound measured 3 cm (centimeters) x 3.2 cm. and identified as a stage 2 pressure ulcer. Staff documented the resident admitted with a stage 1 pressure ulcer, had [MEDICAL CONDITION], and the wound increased to a stage 2. Interventions included: multivitamin, repositioning program, heel lift boots, and a dressing change. On 12/30/2015- a right heel pressure ulcer. The assessment lacked characteristics and measurements of the wound. On 1/6/2016- a right heel pressure ulcer. The assessment lacked characteristics and measurements of the wound. Review of a nursing admission assessment dated [DATE] documented the resident had right and left heel redness. The assessment lacked characteristics and measurements. Staff documented the resident needed a protection dressing for his/her heels. Review of a dietitian nutritional risk assessment dated [DATE] documented the resident had no change in his/her BMI (Body Mass Index), his/her intake met 26-75% (percent) of estimated needs, had a [MEDICATION NAME] (protein in the blood that measured nutrition) of 12.7 (low), and his/her skin was intact. The resident scored 8, which indicated he/she was a high nutritional risk. The resident would benefit from Ensure (a nutritional supplement) or boost (a nutritional supplement) twice daily to promote healing. Review of a dietitian's progress note dated 1/7/2016 documented the resident refused Ensure and received [MEDICATION NAME] (a medication used to pull excess fluid from the body). The resident's weight loss was due to [MEDICAL CONDITION] (swelling) from fracture, fluid from [MEDICATION NAME], and poor intake. Review of weights documented the following: On 11/30/15- 116 lbs (pounds) On 12/20/15- 108.6 (started on [MEDICATION NAME] 12/24/2015) 12/27/15- 102.3 (-12.0 % in 30 days) 1/3/16- 103.8 (-10.3 % in 30 days) Review of physician orders [REDACTED]. [MEDICATION NAME] 10 mg (milligrams) by mouth every morning for [MEDICAL CONDITION], 12/24/2015 Ensure twice daily for wound care, 1210/2015 Multivitamin one by mouth daily for supplement, 12/20/2015 Place heel lift boots when in bed, 12/19/2015 Review of December 2015 MAR (Medication Administration Record) documented the resident refused the morning dose of Ensure on 12/20/2015, 12/25/2015, and 12/28/2015 and refused the evening dose on 12/12/15, 12/13/15, 12/14/15, 12/17/15, 12/18/15, 12/22/15, 12/25/15, 12/26/15, 12/27/15, and 12/30/15. Review of the January 2016 documented the resident refused the morning dose of Ensure on 1/2/16, 1/3/16, and 1/4/16. The resident discharged on home on 1/8/2016. During an interview on 01/13/2016 at 11:40 A.M. direct care staff said Q said the resident had no skin breakdown and he/she knew if a resident had skin breakdown by providing personal cares, from communication with the nurse, and the care plan. Staff Q said staff repositioned the resident every 2 hours and staff kept the resident dry. During an interview on 01/13/2016 at 5:36 P.M. direct care staff U said the resident had no skin breakdown and was occasionally incontinent of urine. Staff U said he/she had experience with his/her job so he/she did not wait for the nurse to tell him/her if a resident had skin breakdown and he/she knew by providing personal cares to residents. During an interview on 01/14/2016 at 11:41 A.M. licensed nursing staff J said if a resident had skin breakdown staff documented the information on the TAR (treatment administration record), discussed it in shift report, and it was on the nursing admission note. He/she said the charge nurse did skin assessments weekly, usually on bath days He/she did not recall this resident. During an interview on 01/14/2016 at 4:50 P.M. administrative nursing staff D said the resident admitted with redness on his/her right and left heel and the left heel redness resolved. Staff D said the resident fell and sheared his/her right heel on 12/21/2015, which caused the wound to progress to a stage 2. Staff D said he/she last assessed and measured the resident's right heel on 12/23/2015 and tried to complete weekly wound assessments. Review of the facility's Pressure Ulcer policy dated 1/13/2016 documented staff would use the nursing admission assessment and Braden scale to determine if a resident was at risk for skin breakdown and staff would perform skin assessments weekly on all residents. The facility failed to timely implement heel lift boots and provide education on the risks and benefits of ordered nutritional supplements for this resident who entered the facility with redness to his/her right heel, which progressed to a stage 2 pressure ulcer.