Every finding on record at Wheat State Manor

The facility identified a census of 31 residents. The sample included 12 residents. Based on record reviews and interviews, the facility failed to establish and implement an admissions agreement that protected residents' right to personal property when the facility's admission agreement, signed by residents or their representatives at time of admission, asked the resident to waive facility responsibility for loss of personal property while being a resident in the facility.Findings included:- The facility's admission and Care Agreement revealed under Resident's Valuables on page eight, the Care Center maintains a secure area where personal articles of small size and limited dollar value may be stored. It is agreed by all parties that money, jewelry, documents, furs, and other personal articles of significant monetary value which are brought into the Care Center by the resident and third parties are in violation of the paragraph and shall not be the responsibility of the Care Center. During an interview on 01/08/26 at 09:45 AM, Administrative Staff A stated the admission Agreement statement was incorrect and would be removed. Administrative Staff A said residents were encouraged not to bring highly valuable items, but lock boxes were provided and encouraged for use, and the agreement would be changed immediately. Administrative Staff A further stated residents were allowed to bring and have whatever valuables they would like. The facility's admission Agreement policy, last revised August 2018, directed the facility did not ask or require residents/potential residents to waive facility liability of personal property. The facility policy Resident Funds and Valuables Policy, dated 06/21/17, documented valuables would be inventoried, but it was suggested valuables not be brought to the facility.

The facility identified a census of 31 residents over four resident halls. Based on observation, record review, and interviews, the facility failed to ensure an adequate resident call system when the two call light visual display monitors, which were the only alert system for resident bedroom and bathroom call lights, were left unmonitored resulting in extended call light response times. Finding included:- Observation on 01/06/26 at 07:55 AM revealed an egressed nurse station on the 200-hall. A display monitor on the station displayed call requests. There was no staff present at the station. Observation on 01/06/26 at 07:56 AM revealed another egressed nurse station on the 400-hall. A display monitor on the station displayed call requests. There was no staff present at the station. Observation on 01/07/26 at 01:13 PM in the egressed nurse station on the 200-hall revealed there was no staff present at the station. Observation on 01/07/26 at 01:13 PM in the egressed nurse station on the 400-hall revealed there was no staff present at the station. The call light display monitor showed a help call alert from Resident (R) 27's room, which indicated the light had been on 35 minutes and 17 seconds. Another help call indicator listed R33's call light had been activated for 24 minutes and 49 seconds. Review of the facility's Call Light Log revealed the lights were last checked in December 2025 with no issues noted. On 01/07/26 at 12:40 PM, Certified Nurse Aide (CNA) M stated staff had to walk by the monitors to know whether a resident's call light was activated. She said there were only two monitors, one in the 200 hall and one in the 400 hall. She confirmed there was no other way to know the lights were activated, as there were no audible alarms or lights on the individual rooms or halls to indicate a call for help. CNA M said there used to be another monitor on the 100 hall, but it been removed. She verified the staff were not always present at the stations where the displays were and said it was sometimes a real problem to know which lights were going off, and said whoever walks by and sees it might call it out on the walkie (two-way radio). She stated the staff were advocating for more display screens in the other halls. On 01/08/26 at 09:45 AM, Administrative Staff A stated the facility was moving the display monitor from the 200-hall to the centralized nurse station in the main lobby area. He confirmed the display monitor was typically at the 200-hall nurse cubby. Administrative Staff A stated staff were visually alerted to a resident help call when they walked by the monitors; he verified there was no audible or other way to know the call light was activated. Administrative Staff A stated moving the 200-hall monitor to the main nurse station would allow the nurse to monitor the display and make a call out if a light was activated, instead of staff having to walk by the board. The facility did not provide a policy.

The facility reported a census of 31 residents. Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included an effective system to monitor antibiotic use, and/or an effective system to track and trend infections in the building for the facility's Infection Prevention and Control Program (IPCP). Findings included:- During an interview on 01/08/26 at 2:25 PM, Administrative Staff D stated at the time the facility did not have an effective infection control program, which included an Antibiotic Stewardship Program. Administrative Nurse D stated she was working on starting logs but had not started them yet. Administrative Nurse D stated the doctor tried to enforce the McGeer criteria (a set of surveillance definitions for infections in long-term care facilities) for documenting the appropriateness of antibiotics, but acknowledged if a resident saw another doctor, they would give what the other doctor prescribed, even if it did not meet the criteria. The Policies and Procedures- Infection Prevention and Control, undated, documented the objective of the policy is to monitor, prevent, detect, investigate, and control infections in the facility and to maintain a safe, sanitary place.

The facility reported a census of 31 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to use adequate hand hygiene when caring for residents including during a dressing change and intravenous (IV-administered directly into the bloodstream via a vein) treatment. Findings included:- On 01/07/26 at 11:46 AM, Licensed Nurse (LN) I obtained scissors from the desk and other dressing supplies from the cart. Without cleaning the scissors, LN I entered Resident (R) 33's room, washed her hands, and applied gloves. LN I removed R33's sock and removed the old bandage. LN I poured normal saline into a cup with gauze and washed the wound. Wearing the same soiled gloves, LN I applied normal saline to a Hydrofera Blue (a type of moist wound dressing which provides wound protection and addresses bacteria and yeast), cut it to size and placed it on the wound, then placed the Optifoam dressing (a multi-layered, silicone-bordered foam dressing for advanced wound care, used for partial to full-thickness wounds with moderate drainage, preventing skin breakdown from friction and shear, and promoting a moist healing environment) over the wound. LN I then threw away the trash, removed her gloves, and grabbed the supplies which were not used. LN I took the supplies with her to the bathroom and laid them on the back of the commode as she washed her hands. She then took the supplies and returned them to the cart. On 01/08/26 at 01:08 PM, LN G entered R34's room to administer his intravenous (IV-administered directly into the bloodstream via a vein) antibiotic. LN G verified the medication rights and placed the medications along with a syringe of normal saline and alcohol pads into a basket. At the entrance, LN G donned gloves and a gown without performing hand hygiene first. LN G entered the room and placed the basket on the bedside table. LN G then touched the bed and bedding with her right gloved hand and proceeded to hang the bag of medication on the IV pole and set up the line and pump. Wearing the same gloves, LN G opened an alcohol pad, cleaned the hub of R34's peripherally inserted central catheter (PICC-a thin, flexible tube which is inserted into a vein in the upper arm and threaded into a large vein above the heart), and attempted to attach the syringe, but accidentally dropped it, and it fell into the trash can. LN G explained to R34 she would need to leave and get another syringe. LN G removed her gown and hung it on a hook in the room, and then removed her gloves. She exited R34's room without performing hand hygiene, walked to another hall, entered the Injection Room, obtained a new syringe of normal saline, then went back to R34's room. LN G then donned gloves, again without performing hand hygiene, entered R34's room, donned her gown, and proceeded to flush R34's PICC line and start administration of the IV antibiotic. After the initiation of the IV medication and wearing the same gloves, she emptied R34's catheter urine collection bag. LN G did not clean the urine collection port before or after access. LN G dumped the urine in the bathroom, removed her gown and gloves, then exited the room. She did not perform hand hygiene but proceeded to unlock the medication cart and place supplies in it. On 01/07/26 at 11:46 AM, LN I could not think of anything she did wrong, but said she understood hand washing and changing gloves needed to be done after touching any dirty surface and before touching a clean surface. LN I confirmed supplies needed to be cleaned prior to using them to cut dressings, and supplies cannot be taken out of a resident's room and returned to the cart. On 01/08/2026 2:25 PM, Administrative Nurse D stated she expected staff to use appropriate hand hygiene, which included hand hygiene after removing soiled gloves prior to putting on clean gloves during care. Administrative Nurse D stated supplies were not to be taken from a resident's room and returned to the cart, and reusable equipment was to be sanitized between uses. Administrative Nurse D said she expected excellent infection control practices for wound care and IV medication administration. The facility's policy Handwashing/Hand Hygiene, undated, documented the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene was to be performed immediately before and after touching a resident, before performing an aseptic task, after contact with blood, body fluids, or contaminated surfaces; after touching a resident's environment, between work on a soiled body part and a clean body part, and immediately after glove removal. The facility's policy Wound Care, undated, documented staff should remove gloves after removing the dressing and wash their hands. Clean reusable supplies like scissors with alcohol and return. Do not return disposable items to the drawer.

The facility reported a census of 31 residents, the sample included 12 residents. The facility failed to allow and facilitate residents to exercise dining preferences related to timing of receiving room trays and eating in the room versus the main dining area. Findings included:- Observed on 01/06/26 at 12:13 PM, Resident (R) 14 received his lunch tray in his room. R14 received chicken noodle soup. The bowel had a clear wrap and foil over it. R14 reported the soup was barely warm. During an interview on 01/06/26 at 11:15 AM, R6 reported he now goes to the dining room to eat because it would take a long time to get his food in his room, and the food would not be hot, but he preferred to eat in his room. During an interview on 01/06/26 at 12:06 PM, R14 reported he started eating in the dining room because it took a long time to get his food to his room, and the food would not be hot, and his lunch would not arrive until after 12:00 PM. R14 further stated the residents who ate in their rooms ate last, after the kitchen closed. During an interview on 01/06/26 at 12:29 PM, R9 reported he used to eat in his room, and staff told him he was not supposed to eat in his room, so he started going to the dining room. During an interview on 01/08/26 at 09:07 AM, Certified Nurse Aide (CNA) M stated the facility had made a rule stating residents who ate in their rooms were to receive their meal trays last, after everyone in the dining area was served. During an interview on 01/08/26 at 09:45 AM, Administrative Staff A stated if there was a reason for a resident to stay in their room or choose to, then they could, and there was no rule or policy related to serving meal trays last to those residents who had chosen to remain in their rooms. Administrative Staff A also stated he had told the staff it was easier to feed the dining room residents first, so it had been recommended to the staff to implement time management strategies when providing food trays to the residents. Administrative Staff A stated he expected staff to discuss the residents' preferences and acknowledge any circumstances or preferences which would indicate the resident should receive their room tray earlier, and staff should accommodate the residents' preferences. The facility policy Resident Rights, dated 10/2025, documented federal and state laws guaranteed basic rights to all residents of the facility, including the resident's right to self-determination and to be treated with respect, kindness, and dignity.

The facility reported a census of 31 residents, the sample included 12 residents. Based on interview and record review, the facility failed to inform Resident (R) 6, R2, R4, R5 and R28 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. Findings included:- Review of both Electronic Medical Record (EMR) and paper records revealed the following: 1. R6's EMR under the Orders tab revealed orders for the following:Sertraline HCL (an antidepressant medication), 150 milligrams (mg) one time a day for depression, dated 08/14/25.R8's scanned documents in the EMR did not contain consent forms for the above listed medications and lacked evidence of informed consent. 2. R2's EMR Orders tab revealed orders for the following:Bupropion oral tablet extended release 24-hour (a medication used to treat anxiety and depression), 150 mg by mouth one time a day related to generalized anxiety disorder.Lemborexant (a medication used to treat sleeplessness), 5 mg every 24 hours as needed for insomnia (inability to sleep) for 30 days each night as needed for sleep up to 30 days, dated 12/11/25.R2's scanned documents in the EMR did not contain consent forms for the above listed medications and lacked evidence of informed consent. 3. R4's EMR Orders tab revealed orders for the following:Bupropion oral tablet extended release 24-hour, 150 mg by mouth one time a day for depression, dated 09/13/24.Fluoxetine HCL (a medication used to treat depression and obsessive-compulsive disorder [OCD]), 20 mg one time a day for OCD, dated 03/12/19.Risperdal (am antipsychotic medication), 0.5 mg two times a day for OCD, dated 08/01/24.R4's scanned documents in the EMR did not contain consent forms for the above listed medications and lacked evidence of informed consent. 4. R5's EMR, under the Orders tab revealed the following orders:Ativan (antianxiety medication)0.5 mg, give 0.5 mg three times daily for anxiety and give 0.5 mg every eight hours as needed for anxiety for six months, dated 09/26/25.Zoloft (antidepressant medication) 100 mg one time daily for depression, dated 09/19/25R5's scanned documents in the EMR did not contain consent forms for the above listed medications and lacked evidence of informed consent. 5. R28's EMR, under the Orders tab revealed the following orders:Remeron (a medication used to treat depression), 15 mg, one time a day for depression, dated 8/18/24.Seroquel (an antipsychotic medication), 25 mg, 0.5 tablet by (12.5 mg), one time a day for dementia with behaviors, dated 10/10/25.Seroquel oral tablet 25 mg two times a day, for dementia with behavior, dated 10/10/25.Zoloft (a medication used to treat depression), 100 mg, one time a day for depression, dated 5/29/24.R28's scanned documents in the EMR did not contain consent forms for the above listed medications and lacked evidence of informed consent. During an interview on 01/07/26 at 04:22 PM, Social Services X stated there were no informed consents for psychotropic medications. During an interview on 01/08/26 at 10:03 AM, Administrative Nurse D stated the resident or legal representative were to be notified before any psychotropic medication was to be started and it was only required to be done before starting a psychotropic medication. Administrative Nurse D also stated every time the medication was to change then the resident or legal representative would be informed of the change. Administrative Nurse D further stated the nurse who received the order and the social services designee were to perform the notification and informed consent procedures for psychotropic medications. The facility policy Psychotropic Medication Use, dated 02/2025, documented prior to initiating the use of, increasing the dose, or switching to a different psychotropic medication, the staff and physician would review non-pharmacological alternatives, the indications and rational for the recommendation, the potential risks and benefits, and the resident's and/or representative's right to accept or decline treatment, prior to obtaining documented consent or refusal.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 2, R4, and R6, who did not receive medications as ordered. Findings included:1. R2's Electronic Medical Records (EMR) documented diagnoses which included constipation (difficulty passing stools), pain due to acute trauma, and multiple fractures, including to the face, both legs, right arm, and spine.R2's 12/17025 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R2 was dependent on the staff for care. R2 took an anticoagulant (a class of medications used to prevent the blood from clotting) medication,The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R2 was admitted from the hospital following a motor vehicle incident with multiple fractures and injuries. R2 had limited range of motion to her right arm and both legs. She needed maximum assistance with toileting, bathing, dressing, bed mobility, and transfer; standing was not attempted due to her non-weight-bearing status.R2's Care Plan dated 12/23/25, documented R2 had pain related to multiple fractures and directed staff to monitor/document side effects of pain medication, which included constipation. R2 had a self-care performance deficit related to multiple fractures with non-weight-bearing status, revised on 12/23/25. The plan lacked documentation of the anticoagulant medication.R2's Physicians Orders revealed an order for enoxaparin sodium (anticoagulant medication) injection solution, prefilled syringe 30 milligrams (mg)/per milliliter (ml) with instructions to inject the syringe two times a day related to long-term use of anticoagulants, ordered on 12/11/25.R2's Medication Administration Record, reviewed from 12/12/26 to 12/31/25 documented enoxaparin sodium was not given on 12/12/25 at 08:00 AM and 08:00 PM, 12/14/25 at 08:00 PM, 12/16/25 at 08:00 AM and 08:00 PM, 12/17/25 at 08:00 PM, 12/19/25 at 08:00 PM, 12/23/25 at 08:00 PM, 12/25/25 at 08:00 PM, 12/26/25 at 08:00 PM, 12/27/25 at 08:00 AM, 12/28/25 at 08:00 PM, 12/30/25 at 08:00 PM, and 12/31/25 at 08:00 PM.R2's Medication Administration Record, from 01/01/26 to 01/08/26, documented the enoxaparin sodium was not given on 01/02/26 at 08:00 PM, 01/03/26 at 08:00 PM, 01/05/26 at 08:00 AM, 01/05/26 at 08:00 PM, 01/08/26 at 08:00 AM.On 01/06/226 at 10:23 AM, R2 laid in her bed. She reported she could not get out of bed due to her non-weight-bearing status. 2. R4's EMR documented diagnoses which included obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R4's 12/23/25 Significant Change MDS documented R4 had a BIMS of 15, indicating intact cognition. R4 took an antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medication and an antidepressant (a class of medications used to treat mood disorders) medication.The Psychotropic Drug Use Care Area Assessment (CAA) documented R4 had a diagnosis of Alzheimer's disease, obsessive-compulsive disorder, and depression. R4 took bupropion (an antidepressant), fluoxetine (an antidepressant), and Risperdal (an antipsychotic).R4's Care Plan documented R4 had a history of verbal outbursts. She was started on Risperdal, and these behaviors have subsided, revised 07/10/25.R4's Physicians Orders revealed an order for Risperdal (risperidone) 0.5 milligrams, one tablet, two times a day, related to obsessive-compulsive disorder, ordered on 08/01/24R4's December 2025 Medication Administration Record documented Risperdal was not given on 12/15/25 at 08:00 PM, 12/21/25 at 08:00 PM, 12/23/25 at 08:00 PM, and 12/31/25 at 08:00 PM. 3. R6's EMR documented diagnoses, which included diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin),R6's 10/15/25 Quarterly MDS documented a BIMS could be completed, but it was not completed. R6 had a diagnosis of diabetes and received insulin (a hormone which lowers the level of glucose in the blood) injections.R6's Care Plan documented R6 had a history of diabetes and was dependent on insulin, dated 05/07/25. The plan directed staff to monitor for signs and symptoms of high or low blood sugar,R6's Physicians Orders revealed the following orders:Novolog FlexPen 100 units/ml (fast-acting insulin), inject 15 units after meals related to diabetes, dated 12/10/25.Lantus (slow-acting insulin), inject 28 units at bedtime for diabetes, dated 04/29/25.R6's December 2025 Medication Administration Record documented Lantus was not given at 08:00 PM on 12/03/25, 12/11/25, 12/16/25, 12/19/25, and 12/22/25. The Novolog was not given at 06:00 PM on 12/11/25 or 12/22/25. The EMR lacked information on why it was not given.R6's January 2026 Medication Administration Record, documented on 01/02/26, Lantus was not given at 08:00 PM, and Novolog was not given at 07:00 PM. The BG at 04:00 PM was 140, and the BG at 08:00 PM was 140. The EMR lacked evidence of a hold order for the insulin. On 01/08/26 at 09:29 AM, Licensed Nurse (LN) G stated all medications should be given and documented as ordered and checked prior to leaving for the shift. On 01/08/26 at 10:29 AM, Administrative Nurse D said the nurse was to give medications and complete treatments when they are ordered and chart when they are completed. The pharmacist had been working with them on correcting the problem of medications not being given. On 01/08/26 at 08:40 AM, Licensed Nurse (LN) G stated if a medication was not given, staff should notify the provider, and it should also be documented in the chart as not given with a reason. LN G said if a medication was held, there should be a hold order and a progress note. On 01/08/26 at 8:45 AM, Administrative Nurse D stated if a medication was not given, the nurse should document it as not given, and if the medication was held, the nurse was to document it as held. Administrative Nurse D stated the nurse should notify the provider if a medication was held for any reason and there should be a hold order charted; the nurse should also make a progress note. Administrative Nurse D confirmed the medication errors. On 01/08/26 at 10:29 AM, Administrative Nurse D said the nurse should give medications and complete treatments when they were ordered and chart when they were completed. Administrative Nurse D said the pharmacist had been working with the facility on correcting the problem of medications not being given as ordered. The facility's undated Administering Medications policy stated medications shall be administered in a safe and timely manner as prescribed.

The facility identified a census of 31 residents; the sample included 12 residents with six reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for Resident (R)11 when staff did not ensure the resident had a call light within reach and propelled the residents in a wheelchair without foot pedals. Findings included:- R11's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and osteoporosis (chronic arthritis without inflammation). R11's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of zero, indicating severely impaired cognition. The MDS recorded she had behaviors and wandered during the observation period. R11 required staff assistance with activities of daily living. The MDS noted she had two or more falls since the last assessment, one resulting in an injury. R11's Care Plan noted an intervention dated 02/06/25, which directed staff to ensure R11's call light was within reach and encourage her to use it as needed. The plan recorded an intervention revised on 07/31/25 recorded R11 was dependent on staff assistance for mobility in a wheelchair for distances. On 01/06/26 at 10:03 AM, R11 sat on the edge. She attempted to stand but was unable, only raising a few inches off the bed, then sat down again. She reached out her arms toward the surveyor and appeared to be asking for help. She continued to rock forward as though she were attempting to stand. Observation revealed R11's call light was coiled at the foot of the full-sized bed on the opposite side of the resident. The call button had dropped between the bed and the wall and was not within reach of the resident. At 10:14 AM, Certified Nurse Aide (CNA) M entered the room in response to the surveyor's call for assistance and stated the resident sometimes threw the call light towards the end of the bed. She said R11 had not been feeling well and had been vomiting and having loose stools the previous day. CNA M reached down between the bed and the wall and retrieved R11's call light. On 01/08/26 at 10:58 AM, Certified Medication Aide (CMA) R pushed R11 in her wheelchair. R11 wore socks, and her wheelchair did not have foot pedals. R11 pedaled her feet, which lightly touched the floor, as staff propelled her in the wheelchair. On 01/09/26 at 07:30 AM, R11 sat in the main lobby, sitting in her wheelchair with both feet resting on the wheelchair foot pedals. On 01/08/26 at 11:02 AM, CMA R stated R11 occasionally self-propelled her wheelchair, so she does not need foot pedals, but confirmed if staff propel the chair. Foot pedals should be placed on the wheelchair at that time. CMA R stated R11 needed to use the bathroom, so she assisted R11 by pushing the wheelchair even though there were no pedals on the chair. On 01/08/26 at 12:24 PM, Administrative Nurse D stated she expected staff to ensure the residents' feet were on their wheelchair foot pedals when being pushed by staff. Administrative Nurse D said there should be a bag on the back of the wheelchair for the foot pedals to be stored in, in the event they are needed. Administrative Nurse D said she expected staff to ensure R11's call light was placed within her reach. The facility's policy Falls-Clinical Protocol documented if interventions had been successful in fall prevention, the staff would continue with current approaches and would discuss periodically with the physician whether the measures were still needed.

The facility identified a census of 31 residents. The sample included five residents with five residents sampled for quality of care. Based on observation, interview, and record review, the facility failed to provide care and services for no pressure related skin issues for Resident (R) 33 when staff failed to change the dressing as ordered by the physician. Findings included:- R33's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (a mood disorder which causes a persistent feeling of sadness and loss of interest). R33's 11/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 12, indicating moderate cognitive impairment. The MDS recorded R33 had no wounds or treatments. R33's Admission/re-admission Data Collection - V 4.0 dated 01/01/26 for R33's readmission documented a wound to the bottom of R33's left foot. R33's Care Plan dated 01/01/26 documented R33 had a potential or actual skin impairment, and staff were to use caution when transferring R33. The plan lacked mention of any wounds. R33's Physician's Orders documented an order to cleanse the left foot wound with normal saline and pat dry with gauze. Apply Hydrofera Blue (a type of moist wound dressing which provides wound protection and addresses bacteria and yeast), cover with Optifoam dressing (a multi-layered, silicone-bordered foam dressing for advanced wound care, used for partial to full-thickness wounds with moderate drainage, preventing skin breakdown from friction and shear, and promoting a moist healing environment) Change the dressing every Monday, Wednesday, and Friday. Ordered on 01/01/26. The start date was 01/02/25. R33's Other Progress Note dated 11/29/25 at 02:06 PM documented R33 reported his left foot was hurting. He stated he stepped on a nail prior to moving to the facility. A photo of the foot was sent to the doctor. R33's January 2026 Medication Administration Record (MAR) documented the dressing change was not completed on 01/02/26 or 01/05/26. On 01/07/26 at 08:21 AM, R33 laid on the bed with a dressing on his foot dated 01/01/26. On 01/07/26 at 11:46 AM, Licensed Nurse (LN) I removed the dressing which was dated 01/01/26. She verified it was dated 01/01/26 and verified the order read to be changed on Monday, Wednesday, and Friday. LN I confirmed it appeared the dressing had not been changed in a week. When LN I removed the dressing, there was no Hydrofera Blue present. On 01/08/26 at 10:29 AM, Administrative Nurse D stated the nurses should complete the treatments as ordered and document. The facility's policy Wounds, Clean/Dry documented to verify the order prior to completing a dressing change and to document after it is completed.

The facility had a census of 31 residents. The sample included 12 residents with three residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide a bed hold and written notification transfer for Resident (R) 30. The facility additionally failed to notify the Office of the Long-Term Care Ombudsman (LTCO). This placed the resident at risk for impaired rights related to returning to the facility. Findings included:- R30's Electronic Medical Record (EMR) revealed diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), paroxysmal atrial fibrillation (rapid, irregular heartbeat), and the presence of a cardiac pacemaker (an implanted device to regulate the beating of the heart). R30's Discharge with Expected Return Minimum Data Set (MDS) dated 11/09/25 had not documented a Brief Interview of Mental Status (BIMS). The health conditions section documented R30 had shortness of breath or trouble breathing at rest and with exertion. R30's Care Plan documented on 10/21/25 R30 had an altered cardiovascular status related to having a pacemaker, heart failure, and coronary artery disease (CAD- an abnormal condition may affect the flow of oxygen to the heart). The care plan interventions, dated 11/06/25, included instructions for staff to monitor, document, and report, as needed, any changes in lung sounds on auscultation (listening), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and weight. The Progress Notes dated 11/09/25 at 12:34 PM, documented R30 continued to have fluid retention, shortness of breath (SOB), her oxygen saturation was 90% on room air, and she only voided once that morning. The note further documented R30's representative was there and agreed R30 needed to go back to the hospital for evaluation and treatment; R30 was taken back to the emergency room via Emergency Medical Service (EMS). The Progress Notes dated 11/09/25 at 02:47 PM documented R30 was admitted to the hospital. R30's EMR lacked evidence the facility provided written notification of the transfer and a bed hold notice to R30 and/or her representative. The facility was unable to provide evidence of notification to the LTCO for R30's transfer. During an interview on 01/07/26 at 01:02 PM, Social Services X stated a bed-hold had not been done or sent for R30's discharge, and there had been no discharge notification sent to the Ombudsman or the family. During an interview on 01/07/26 at 01:08 PM, Administrative Nurse D stated the social services designee (SSD) had been responsible for initiating the bed hold, and it should have been done within 24 hours of the discharge. Administrative Nurse D further reported she was not aware the resident and/or family were to have been notified in writing of the transfer or discharge. The facility did not provide a policy related to bed hold and notification of resident transfers or discharge.

The facility reported a census of 31 residents; the sample included 12 residents. Based on interview, observation, and record review, the facility failed to protect the dignity of resident (R) 8; when he was transferred through the facility without a dignity cover on his urine collection bag, leaving his urine visible to other residents and visitors. Findings included:- The Electronic Health Record (EHR) for R8 included the diagnoses of: benign prostatic hyperplasia with lower urinary tract symptoms (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), overactive bladder (a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips and sometimes urine leakage), and urinary retention (lack of ability to urinate and empty the bladder). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The assessment documented R8 using a wheelchair for mobility, and R8 was dependent on staff for all care and activities of daily living (ADL). The bladder and bowel section documented yes for R8 having an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Observed on 01/07/26 at 01:00 PM, R8 sat in his Broda chair (specialized chair with the ability to tilt and recline) next to the fireplace in the front lobby area, across from the entryway and the nurse's station. R8's urine collection bag was visible under the footrest. The bag did not have a dignity cover and was approximately half full of pale-yellow urine. Observed on 01/07/26 at 01:30 PM, Certified Nurse Aide (CNA) O pushed R8 in his Broda chair from the 100 Hall to the main lobby area. R8's urine collection bag hung under the footrest. The bag lacked a dignity cover, and pale-yellow urine was visible. During an interview on 01/08/26 at 08:06 AM, CNA N stated the urinary collection bag should have been placed below the bladder and should have been covered or in a dignity bag. During an interview on 01/08/26 at 08:14 AM, Administrative Nurse D stated the urinary catheter collection bag should have been placed below the level of the bladder with a cover or in a dignity bag. The facility policy Resident Rights, dated 10/2025, documented federal and state laws guaranteed certain basic rights to all residents of the facility and included the resident's right to a dignified existence.

The facility identified a census of 32 residents. The sample included 12 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to monitor bowel movements for Resident (R) 2 and follow the physician orders to administer medications for constipation after a 13 day interval with no bowel movements documented. Findings included:- R2's Electronic Medical Records (EMR) documented diagnoses, which included constipation (difficulty passing stools) and pain due to acute trauma. R2's 12/17/25 admission Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS noted R2 was frequently incontinent of bladder and bowels. R2 was dependent on the staff for care. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R2 was admitted from the hospital following a motor vehicle incident with multiple fractures. R2 had functional limited range of motion to her right arm and both legs. She needed maximum assistance with toileting, bathing, dressing, bed mobility, and transfer. She had frequent bowel and bladder incontinence. R2's Care Plan dated 12/23/25, documented R2 had pain related to multiple fractures and directed staff to monitor/document side effects of pain medication, which included constipation. R2's Physician Orders in the EMR documented a standing order for constipation- bowel protocol. Day one: prune or apple juice, or prunes in the morning and evening as needed for constipation, ordered 12/11/25.Standing orders for bowel protocol- Day two- Milk of Magnesia (laxative) 30 milliliters (ml) in the morning as needed for constipation, ordered 12/11/25. Standing orders for bowel protocol- Day three- Laxative suppository in the morning as needed for constipation, ordered 12/11/25. Review of R2's bowel movement frequency under the Tasks in the EMR dated 12/12/25 through 01/08/26 revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 12/26/25 at 08:14 PM through 01/08/26 at 05:50 AM (13 consecutive days). R2's December 2025 and January 2026 Medication Administration Record (MAR) lacked evidence the Bowel protocol medications were administered as ordered. No medication for constipation was given, and no assessment was documented. R2's EMR lacked evidence of a clinical assessment related to the lack of bowel movements for the 13-day interval. On 01/06/26 at 10:23 AM, R2 laid in her bed. She reported she could not get out of bed due to her non-weight-bearing status. R2 stated it was difficult to even reposition in bed due to the fracture of her upper right arm. On 01/08/26 at 08:34 AM, Certified Nurse Aide (CNA) O stated the CNAs documented the bowel movements, and the nurses followed up if any medications were needed. On 01/08/26 at 09:29 AM, Licensed Nurse (LN) G stated an alert comes up in the EMR if the resident does not have a documented bowel movement in two days. She said she was unsure what the bowel protocol was; if needed, she would find out. LN G said staff followed up after day three of no bowel movement, and the nurse provided prune juice, then Milk of Magnesia on the following day if no bowel movement, then a suppository on the following day. On 12/03/25 at 11:07 AM, Administrative Nurse D said the nurse monitored the residents for bowel movement and followed the standing orders for the bowel movement protocol. If there was no bowel movement, the nurse assessed the resident, provided the proper medication, and documented the assessment and medication. If the resident took themselves to the bathroom, the CNAs were to ask the resident every shift if the resident had a bowel movement or not and document it. Administrative Nurse D stated if the system alerted more than three days with no bowel movement, and the nurse was unsure it was correct due to the resident taking herself to the bathroom, the nurse was to ask the resident if she had a bowel movement prior to giving medication and if the resident had a bowel movement, the nurse should document the bowel movement in the EMR. The facility did not provide a policy for bowel monitoring.

The facility reported a census of 31 residents. Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing sheets included accurate and identifiable information to include the actual hours worked, as required. Findings included:- Observed on 01/06/26 at 08:20 AM, the posted staffing sheet lacked the actual hours worked Observed on 01/07/26 at 09:30 AM, the posted staffing sheet lacked the actual hours worked. Observed on 01/08/26 at 10:30 AM, the posted staffing sheet lacked the actual hours worked. Review of the daily staffing sheets from 12/25/25 and 01/05/25 revealed the staffing sheets lacked the actual hours worked. During an interview on 01/08/26 at 08:20 AM, Administrative Nurse D stated the posted staffing sheet should have documented an accurate census, the total number of medical staff per shift, and should also have documented the actual hours and total hours worked. The facility policy Posting Direct Care Daily Staffing Numbers, dated 08/2022, documented the staffing sheet of staff who were directly responsible for resident care would be posted in a prominent location and in a clear and readable format. The policy also documented the posted document would include the name of the facility, current date, the resident census at the beginning of the shift for which the information was posted, the 24-hour shift schedule operated by the facility, the shift for which the information was posted, type and category of nursing staff working during the shift who were paid by the facility, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.

The facility reported a census of 38 residents with five residents reviewed for Covid-19 vaccinations. Based on interview and record review, the facility failed to ensure the residents of the facility received up to date Covid vaccinations, if desired, and failed to ensure residents were given the opportunity to rescind previous year declination. Findings included: - Review of Resident (R)32's medical record immunization tab, revealed the resident received a Covid vaccination on 11/17/22 and no Covid vaccine offered in 2023. Review of R 20's medical record immunization tab revealed the resident refused the covid booster on 11/13/21 , with no opportunity to change declination in 2022 and 2023. Review of R5's medical record Immunization tab, revealed the resident received a Covid booster 11/17/22 and no Covid vaccine offered in 2023. Review of R3's medical record Immunization tab, revealed the resident received a Covid vaccination 11/17/22 , and no Covid vaccine offered in 2023. Review of R2's medical record Immunization tab, revealed the resident declined Covid vaccination 01/26/21 with no further opportunities to make informed decisions regarding change in vaccination acceptance/declination in 2022 and 2023. Interview, on 03/11/24 at 01:12 PM, with Administrative Nurse D, confirmed the medical record lacked indication the facility offered Covid vaccinations in 2023. The facility policy Coronavirus Disease (COVID-19)- Vaccination of Residents revised May 2023, instructed staff to ensure each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. This policy instructed staff the resident or resident representative could accept or refuse a COVID-19 vaccination and to change his/her decision. The facility failed ensure residents received COVID-19 vaccinations in a timely manner and were given opportunities to make informed decisions to change acceptance/declination as required.

The facility reported a census of 38 residents with three residents reviewed for Medicare Advance Beneficiary and Medicare Non-Coverage Notices. Based on interview and record review, the facility failed to ensure three Resident (R) 40, R95 and R 96 received the Center for Medicare/Medicaid Services (CMS) form 10123 (for the right of expedited review of discontinuation of services) as required when skilled services ended. In addition, the facility failed to issue CMS 10055 (the right to continue skilled services and cost of the services) to R40 as required. Findings included: - Review of Resident (R) 40's medical record revealed skilled therapy discharged the resident on 12/21/23. The facility contacted the responsible party by phone but did not issue the required CMS 10123 or CMS 10055. The resident remained in the facility and was placed on hospice services 01/02/24. Review of R95's medical record, revealed skilled services ended 10/18/23, and the facility issued CMS 10055 to the resident's responsible party by email on 10/23/23. The facility did not issue CMS 10123 as required. The resident remained in the facility and went on hospice services 10/27/23. Review of R 96's medical record revealed skilled services ended 11/19/23. The resident received CMS 10055 which was not completed to include estimated cost of continued services. The resident did not receive CMS 10123 as required. The resident discharged from the facility on 11/20/23. Interview, on 03/11/24 at 12:09 PM, with Administrative Staff B, revealed neither she or Social Service Staff X, knew to issue CMS 10123 for skilled services and did not have a policy for issuance of the forms. The facility lacked a policy for CMS 10123 or CMS 10055 at the time of the required issuance for the above residents but did develop a policy on 03/11/24. The facility failed to issue CMS 10123 and CMS 10055 to ensure residents/responsible parties were informed of expedited review for discontinuation of therapies and estimated cost of continuing therapies and desire for continuation of skilled services as required.

The facility reported a census of 38 residents with 13 residents selected for review, which included one Resident (R)20, reviewed for Pre-admission Screening and Resident Review (PASRR) Level two. Based on observation, interview, and record review, the facility failed to obtain a reassessment for R20 to determine mental health needs as required. Findings included: - Review of Resident (R)20's medical record, revealed diagnoses that included schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) with psychotic disorder (any major mental disorder characterized by a gross impairment in reality perception), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), hallucinations (sensing things while awake that appear to be real, but the mind created), and osteomyelitis (local or generalized infection of the bone and bone marrow). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive status with no behaviors or psychosis. The resident had functional limitation in range of motion on one side of his upper extremity and both lower extremities. R20 was dependent of staff for transfers and was independently mobile in his wheelchair. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/12/24, assessed the resident with schizophrenia, with recent delusions which resulted in a transfer to an inpatient psychiatric facility. The resident received antipsychotic (class of medication used to treat major mental conditions which cause a break from reality) medication paliperidone. The Care Plan, revised 01/24/24, instructed staff the resident required assistance for transfers and stand by assistance for activities of daily living, but declined staff assistance. Review of R20's medical record revealed a Pre-admission Screening and Resident Review (PASRR) determination letter, dated 03/08/2019, which indicated the level of services provided in a nursing facility/nursing facility for mental health for a temporary period for stabilization of R20's mental health condition. The letter instructed the facility to request another assessment if at the end of 12 months, the resident required more time in the facility. The medical record lacked reassessment documentation. Interview, on 03/07/24 at 11:30 AM with Social Services Staff X, confirmed the PASRR indicated a temporary 12-month period after which a reassessment was needed. Social Service Staff X confirmed the facility failed to obtain a reassessment in a timely manner after the Covid pandemic crisis ended in May 2023. Interview, on 03/07/24 at 04:00 PM with Administrative Staff A, confirmed he would expect staff to follow up with contacting the State Agency for a reassessment. The facility lacked a policy for PASRR. The facility failed to request reassessment for R20 to determine continued care needs for services in a nursing facility/nursing facility for mental health as required.

The facility reported a census of 38 residents with 13 residents selected for review, which included five residents selected for review for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)13 received reevaluation for continued use of as needed (PRN) psychotropic (medication that alters mood or thought) , and R11 related to lack of an abnormal involuntary movement scale (AIMS) to monitor for adverse effects of antipsychotic medications. Findings included: - Review of Resident (R)13's medical record, revealed diagnoses that included 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), aphasia(condition with disordered or absent language function), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident had severely impaired cognitive skills for decision making. The resident received antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), and antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) medications. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/03/24, assessed the resident admitted with hospice. The resident had dementia with agitation, mood disturbance and anxiety. The Care Plan, reviewed 12/28/23, instructed staff the resident received psychotropic medication and to monitor for side effects. Staff were to monitor for occurrence of target behavior symptoms of anxiety and document. On 12/28/23, the physician instructed staff to administer clonazepam 0.5 milligrams, twice a day, as needed for anxiety. Review of the Medication Administration Record (MAR) for January 2024, revealed the resident received seven doses. Review of the February 2024 MAR revealed the resident received 10 doses, and review of the March 2024 MAR revealed the resident received four doses. Review of the Note to Attending Physician/Prescriber for review period 02/01/24 through 02/17/24, reminded the prescriber of the recommendation to reevaluate PRN clonazepam use and indicate a length of time for it's use. The facility failed to follow up on this recommendation. Interview, on 03/11/24 at 01:00 PM, with Administrative Nurse D, revealed she would expect the charge nurse to follow up with the pharmacy recommendations, and confirmed the physician did not reevaluate clonazepam to indicate a length of time for its use. The facility policy Psychotropic Medication Use dated July 2022, instructed staff psychotropic are not prescribed on a PRN basis beyond 14 days, unless the prescriber documents the rationale for extending the use and included the duration for the PRN order. The facility failed to ensure the prescriber reassessed R13 for the continued administration of PRN clonazepam beyond the 14-day initial period as required. 34056 - Review of Resident (R)11's undated Physician Order Sheet (POS), included diagnoses of delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) and malignant neoplasm of the bladder and lung (cancerous tumors of the lung and bladder). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. He received an anti-psychotic medication (medication used to treat psychosis) during the assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 01/12/24, documented the resident received Haldol (an anti-psychotic medication) for a delusional disorder. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14, indicating intact cognition. He did not receive anti-psychotic medication during the assessment period. The care plan, revised 11/22/23, instructed staff the resident received Haldol due to a diagnosis of delusional disorder. Staff were to monitor for side effects of the medication every shift. Review of the resident's electronic medical record (EMR), revealed the following physician's order: Haloperidol 5 milligrams (mg), by mouth (po), three times a day (TID), for agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and aggression (hostile or violent behavior or attitudes toward another), ordered 03/04/24. Review of the resident's EMR lacked an Abnormal Involuntary Movement Scale (AIMS), used to aide in the early detection of tardive dyskinesia (side effect of antipsychotic medications which involves involuntary muscle movements). On 03/11/24 at 09:07 AM, Licensed Nurse (LN) G stated an AIMS assessment should be completed by the nurse on duty when the physician ordered a new antipsychotic medication, and then every three months, and with any significant change of the resident. On 03/11/24 at 12:07 PM, Administrative Nurse D stated AIMS assessments were to be completed on admission, quarterly, with a significant change, or when an antipsychotic medication was ordered. The facility policy for Psychotropic Medication Use, undated, included: Anti-psychotic medications are subject to adequate monitoring for efficacy and adverse consequences. The facility failed to monitor this dependent resident for side effects of his antipsychotic medications.

The facility reported a census of 38 residents with 13 residents sampled, including one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)19 received adequate assistive devices to maintain proper vision, by failing to have her glasses repaired in a timely manner. Findings included: - Review of Resident (R)19's electronic medical record (EMR) included a diagnosis of 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). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required glasses for her vision. The Visual Function Care Area Assessment (CAA), dated 10/27/23, did not trigger. The Quarterly MDS, dated [DATE], did not assess cognition or vision. The care plan, revised 02/01/24, lacked staff instruction on the resident's use of eyeglasses. On 03/06/24 at 10:39 AM, the resident stated her glasses were broken a long time ago and had not been repaired. She told the staff her glasses were broken and needed to be repaired but no one had taken them to be fixed. She was having to wear her old glasses and was unable to see well. On 03/07/24 at 10:04 AM, Certified Nurse Aide (CNA) N stated the resident's glasses had been broken for a long time and she was unsure why they had not been fixed yet. The resident always wears her glasses while awake and was currently needing to wear her old glasses while she waited for her new glasses to be fixed. On 03/07/24 at 10:40 AM, Social Services staff X stated she had not been aware of the resident's glasses being broken but will have them taken to the eye doctor to be repaired. On 03/07/24 at 02:35 PM, CNA M stated the resident would wear her glasses at all times, while awake. The resident had told someone that her new glasses were broken, but it had been a few weeks ago. On 03/11/24 at 12:01 PM, Licensed Nurse (LN) G stated she was unaware of the resident's glasses being broken. On 03/11/24 at 12:07 PM, Administrative Nurse D stated she was unaware the resident's glasses were broken. Administrative Nurse D stated she would have Social Services staff X get them fixed. The facility lacked a policy regarding resident eyeglasses. The facility failed to ensure this dependent resident received the assistive devices she required to maintain proper vision.

The facility reported a census of 38 residents with 13 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)19 regarding the use of eyeglasses. Findings included: - Review of Resident (R)19's electronic medical record (EMR) included a diagnosis of 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). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required glasses for her vision. The Visual Function Care Area Assessment (CAA), dated 10/27/23, did not trigger. The Quarterly MDS, dated [DATE], did not assess cognition or vision. The care plan, revised 02/01/24, lacked staff instruction on the resident's use of eyeglasses. On 03/06/24 at 10:39 AM, the resident stated her glasses were broken a long time ago and had not been repaired. She told the staff her glasses were broken and needed to be repaired but no one had taken them to be fixed. She was having to wear her old glasses and was unable to see well. On 03/07/24 at 10:04 AM, Certified Nurse Aide (CNA) N stated the resident's glasses had been broken for a long time and she was unsure why they had not been fixed yet. The resident always wears her glasses while awake and was currently needing to wear her old glasses while she waited for her new glasses to be fixed. On 03/07/24 at 02:35 PM, CNA M stated the resident would wear her glasses at all times, while awake. The resident had told someone that her new glasses were broken, but it had been a few weeks ago. On 03/11/24 at 12:01 PM, Licensed Nurse (LN) G stated eyeglasses should probably be included on a resident's care plan. On 03/11/24 at 12:07 PM, Administrative Nurse D stated staff should have included the resident's eyeglasses on her care plan. The facility policy for Care Plans, revised March/2022, included: Assessments of residents are ongoing and care plans are revised as information about the resident changes. The facility failed to review and revise this dependent resident's care plan to include her eyeglasses.

The facility reported a census of 38 residents. Based on observation, record review, and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, daily, for the 38 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, from 02/11/24 through 03/11/24, revealed the actual hours worked had not been completed on the daily staffing sheets. On 03/11/24 at 11:33 AM, Administrative Nurse D stated, she was unaware the actual hours worked were to be included on the daily staffing sheets. The facility policy for Posting Direct Care Daily Staffing Numbers, revised August/2022, included: The information recorded on the form shall include the actual time worked during the shift for each category and type of nursing staff. The facility failed to properly complete the daily staffing sheets for the residents of the facility.

The facility reported a census of 46 residents with seven selected for review and one resident reviewed for abuse. Based on observation, interview, and record review the facility failed to protect the residents from verbal abuse from Licensed Nurse (LN) G. On the morning of 08/26/23, Certified Nurse Aide (CNA) M heard LN G threaten to hit Resident (R) 2 and CNA N heard LN G threaten R2 if she hit her again, she would be sorry. CNA N failed to report the verbal abuse and CNA M reported the verbal abuse to LN H. LN H failed to notify Administrative Nurse D. LN G worked three shifts after the verbal abuse on 08/26/23, 08/27/23, and 08/28/23 until Administrative Nurse D was made aware of the occurrence on 08/31/23. Failure to report the verbal abuse to Administrative Nurse D immediately placed all residents in the facility in immediate jeopardy. Findings included: - The Medical Diagnosis tab for R2 included a diagnosis of Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder). The Admission Minimum Data Set (MDS) dated [DATE] for R2 lacked a Brief Interview of Mental Status (BIMS) assessment and lacked a staff assessment of mental status. R2 did not have any physical or verbal behaviors but had other behavioral symptoms and rejection of care one to three days of the assessment period. R2 did not walk or wander, she required extensive assistance of one to two staff for her activities of daily living (ADLs), and required staff support to maintain her balance. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 05/07/23 revealed R2's verbalizations varied, at times she would comment or answer questions and other times she would not. R2 responded only to simple and direct instructions and her cognitive impairment and communication abilities would decline as part of the Huntington's disease. The Behavioral Symptoms CAA dated 05/07/23 revealed R2's behaviors of crying and rejection of care would not be addressed in the care plan, the behavior was isolated, and there were no further behaviors noted after the assessment reference date. The behaviors occurred only one day. The Psychotropic Drug Use CAA dated 05/07/23 revealed R2 required Haldol (psychotropic medication - class of medications capable of affecting the mind, emotions, and behavior) for anxiety, restlessness, and agitation. The Quarterly MDS dated [DATE] assessed R2 with having a BIMS score of seven, indicating severe cognitive impairment, physical and verbal behavior symptoms four to six days; other behavioral symptoms, rejection of care, and wandering one to three days. R2 required limited to extensive assistance of one to two staff for ADL's including walking and she continued to require staff support to maintain her balance. The Care Plan initiated on 04/24/23 revealed R2 had impaired communication, impaired cognitive function, and used psychotropic medication for restlessness, agitation, and anxiety. The care plan lacked direction for staff when R2 had behaviors. The Progress Note dated 08/26/23 at 02:12 PM, revealed R2 had staff with her continuously during the day and she continued to display behaviors of kicking, hitting, and cussing. The Progress Note dated 08/26/23 at 09:28 PM, revealed R2 slept approximately two hours in a reclining style wheelchair at the nurse's station. She woke up combative and restless approximately at 0800 (indicating 08:00 AM). She was given Haldol at 0830 (indicating 08:30 AM) with fair results. A facility investigation dated 09/11/23, revealed while Administrative Nurse D conducted an interview with CNA M on 08/31/23, CNA M reported she arrived on shift on 08/19/23 at 06:00 AM and R2 displayed agitation and was hitting staff. LN G and CNA N were with R2 as she was up walking. CNA M heard LN G state to R2 If you hit me, I will hit you right back. CNA M stated she reported this to the charge nurse, LN H, who did not report this to Administrative Staff A or Administrative Nurse D. Administrative Nurse D asked LN H about the incident, LN H could not recall CNA M reporting what LN G stated to R2 to her. Administrative Nurse A placed LN G on suspension on 09/01/23. Administrative Nurse D and LN I spoke with R2 on 09/01/23 about the incident and she did not appear to remember the incident in question, denied if any of the staff made her feel uncomfortable, and could not answer the question if she felt safe at the facility. CNA N stated she did not remember LN G stating what CNA M reported but did hear LN G state if you hit me again, you'll be sorry. The investigation revealed due to the inconsistencies in what the CNA's reported and the fact that R2 did not remember the incident and was not affected by it, the facility found the verbal abuse allegations to be unsubstantiated, however, the facility terminated LN G on 09/07/23 for being high risk due to poor communication skills. The investigation lacked a statement from LN G. The Witness Statement dated 08/31/23 for incident on 08/19/23 by CNA M revealed she had just clocked in and R2 was being violent and hitting nurse and aide. After R2 hit LN G, CNA M heard LN G say [resident name] if you hit me, I will hit you right back. CNA M told the day shift nurse on duty, but nothing was done. The facility investigation included an interview by Social Services Staff X with R7, dated 09/01/23. When asked how he felt about the staff members at the facility and if they treated him with respect, R7 responded that most do, the night nurse has an attitude towards me and it takes a while for her to come. When asked if any staff member ever yelled, sworn, or cursed at him, R7 responded no but night nurse has been short and sharp with her response. The interview lacked the specific nurse R7 was referring to. The facility investigation included an interview by Social Service Staff X with R6, dated 09/01/23. When asked how he felt about the staff members at the facility and if they treated him with respect, R6 responded the night nurse could be hateful and not friendly. When asked if any staff member had yelled, sworn, or cursed at him, R6 responded a nurse has yelled at him. The interview lacked which specific nurse R6 was referring to. The Daily Assignment Sheet revealed LN G worked the night shift on 08/19/23, 08/20/23, 08/21/23, 08/25/23, 08/26/23, 08/27/23, and 08/28/23. The Daily Assignment Sheet lacked documentation of CNA M being scheduled on 08/19/23 at 06:00 AM and the facility failed to provide the Daily Assignment Sheet for 08/18/23, which would have shown the staff assigned on the 10:00 PM to 06:00 AM shift. On 09/11/23 at 04:15 PM, R6 stated there was a time about three months ago he fell and while he was on the floor, LN G started to lecture me and he asked her to wait until he got into bed. On 09/12/234 at 09:51 AM, Administrative Nurse D stated she did not get a statement from LN G or interview her, she had discussed the situation with Administrative Staff A which directed her to place LN G on suspension pending investigation due to the allegation. Administrative Nurse D stated the staff member R6 and R7 were referring to in the interview conducted on 09/01/23 by Social Service Staff X was LN G. On 09/12/23 at 10:14 AM, Certified Medication Aide (CMA) R stated on different days R2 would be up and going and due to Huntington's disease, R2 had a hard time sitting still and occasionally would hit at the staff. On 09/12/23 at 10:27 AM, observed R2 in her room laying on two mattresses placed together on the floor, R2 had her eyes closed and a blanket covering her and was without any abnormal movements at this time. On 09/12/23 at 10:33 AM, R7 stated one night there was a night nurse that was being smart and kind of rude and he hadn't seen her for a week. R7 stated when he put his call light on, she would say I have others I have to give medication to, you're not the only one. R7 stated he felt like R7 was being intentionally rude and they got after her about it, then she was really nice to me for a while. On 09/12/23 at 11:34 AM, CNA O stated R2 had movements and sometimes people would get her movements confused with behaviors, and the behaviors would come out if R2 did not have what the staff were trying to do explained to her and she could get aggressive. Sometimes R2 would shake her arms if staff were holding onto her when walking. CNA O stated she had not seen R2 try to hit anyone but had seen her pour out a drink she did not want in front of someone. On 09/12/23 at 11:55 AM, Administrative Nurse D stated she believed the incident happened over the weekend, on 08/26/23. Administrative Nurse D reviewed times clocked in, and CNA M did not work on 08/19/23 and CNA N could not recall the date but knew it was the weekend that her and LN G stayed over, R2 had been agitated that morning. Administrative Nurse D stated she had asked LN H when the morning that LN G and CNA N stayed over late if R2 had been agitated, she did not recall CNA M saying anything to her and did not say if she seen any behaviors between R2 and LN G and CNA N. On 09/12/23 at 12:02 PM, LN G stated there was a morning on the weekend R2 was hitting, kicking, biting, scratching, and wanting to go out to the hallway. LN G stated another nurse (did not specify) had given her Haldol injectable, given her Morphine (medication for moderate to severe pain), and everything she was supposed to have when she stayed over past her shift end that morning. LN G denied stating to R2 she would hit her and denied saying to R2 if she hit her again, you'll be sorry. On 09/12/23 at 03:33 PM, attempted to interview LN H via phone without success. On 09/12/23 at 03:42 PM, reviewed facility video footage for 08/26/23 beginning at 05:58 AM through 07:52 AM with Administrative Nurse D. During the review, observed CNA M standing in the hallway by R2's room doorway while LN G and CNA N were in the room with R2. During the review, R2 walked out of room and into another resident room, crawled in and out of the room, sat on floor in the hallway, pulled CNA M down over her in the hallway, and was there awhile before R2 released her hands from CNA M's wrists. On 09/12/23 at 04:08 PM, Administrative Nurse D stated the staff were to report allegations to her and neither CNA M nor CNA N reported to her what they heard LN G say to R2. On 09/12/23 at 04:26 PM, a telephone interview with CNA M revealed the verbal incident with LN G to R2 occurred the last weekend she worked before she quit, which was the weekend of 08/26/23 and 08/27/23. CNA M stated R2 had been very agitated, was walking and crawling out of her room, and hitting at staff. CNA M stated she was outside of R2's room in case CNA N and LN G needed help with R2 when in her room trying to calm her down and keep her in bed. CNA M stated she heard LN G say [specified name] if you hit me, I will hit you right back. CNA M stated she did not enter the room and intervene at that time as LN G intimidated her and she was scared of what LN G might say or snap back at her, as she had done that before when she tried to ask LN G something. CNA M stated she told the day shift agency charge nurse, could not recall her name, who told her she would contact Administrative Nurse D or the scheduler who worked under Administrative Nurse D. On 09/12/23 at 05:08 AM CNA N stated on 08/26/23 that R2 was trying to hit and spit at her, and LN G and LN G stated to R2 you keep it up, you will be sorry. CNA N stated she thought the comment was wrong but LN G was her supervisor, and she could not go against her supervisor. CNA N stated she did not tell any other staff what LN G stated to R2. CNA N stated LN G was known to not be very polite with the staff and residents and she had told a previous supervisor about LN G, which was no longer at the facility, and nothing was done so she quit telling. The facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 revealed if resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the law. Immediately defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Any employee who has been accused of resident abuse should be placed on leave with no resident contact until the investigation was complete. The facility staff failed to report the verbal abuse allegation immediately to the Administrator on 08/26/23 and LN G continued to work three shifts after the allegation, 08/26/23, 08/27/23, and 08/28/23. The identified noncompliance placed all residents of the facility at risk for the likelihood of verbal abuse when LN G continued to work as a Licensed Nurse responsible for all residents in the facility during her shift. On 09/13/23 at 11:17 AM Administrative Nurse D was informed the residents were in Immediate jeopardy and was provided the Immediate Jeopardy template for failure to prevent further verbal abuse when the staff failed to report the occurrence of verbal abuse to R2 by LN G to administrative staff and LN G continue to work as a charge nurse in the facility for three shifts after the allegation occurred before being place on suspension. The facility implemented correction action on 09/01/23 and completed on 09/05/23 at 10:30 AM which included: 1. On 9/01/23, the facility suspended LN G pending investigation and immediately began investigation for allegation of verbal abuse. Administrative Nurse D interviewed R2 who did not recall the incident, felt protected, felt care needs were met, and did not voice any staff that made her feel uncomfortable. Administrative Nurse D began education for all staff on the process of how to report abuse neglect and exploitation and the signs and symptoms of abuse and neglect before their next scheduled shift. This incident was submitted to KDADS Complaint Hotline. 2. On 09/01/23 Administrative Nurse D emailed all agency staff schedulers the process of how to report abuse neglect and exploitation and the signs and symptoms of abuse and neglect. 3. The Administrator, DON, or designee will ensure education with all new employees and new agency staff is completed. All new staff will review and sign Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and Identifying Types of Abuse and Recognizing signs and symptoms. 4. The activities director will continue to remind the residents at the resident council each month of the process of reporting concerns or filing a grievance. DON or designee will complete random audits with the staff to ensure they understand the process of how to report abuse neglect and exploitation and the signs and symptoms of abuse and neglect. All findings will be reported to the Administrator or designated party and then reported to Quality Assurance and Performance Improvement (QAPI). The deficient practice was deemed past non-compliance due to the implemented corrective actions and existed at a L scope and severity.

The facility reported a census of 47 residents, with three residents reviewed for abuse and neglect. The facility identified eight residents that resided in the secured unit. Based on record review and interview, the facility failed to ensure the residents that resided in the secured unit remained free from physical abuse when R1, who had a history of physical aggression, hit two separate residents, R2 and R3, and R3 sustained fractures to her right radius (one of the bones going from the wrist to the elbow) and ulna (one of the bones going from the wrist to the elbow), and to her left index finger. This failure placed R2 and R3 in immediate jeopardy and placed the other residents who resided in the secured unit at risk. Findings included: - R1's Hospital Discharge Orders, dated 06/09/23, revealed diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The 06/09/23 Entry Minimum Data Set (MDS) documented the resident admitted from an acute hospital. The Admission MDS was in progress. The 06/09/23 Baseline Care Plan revealed R1 had impaired cognitive function due to dementia and impaired thought processes related to Alzheimer's disease. Staff were to monitor, document, and report any changes in his cognitive function as needed. The revised Care Plan, dated 06/10/23, revealed R1 had the potential to be physically aggressive related to Alzheimer's disease. R1 became physically aggressive to staff and other residents since admission. The facility placed interventions as follows: On 06/10/23, staff were to administer medications as ordered and monitor/document for side effects and effectiveness. Staff were to analyze time of day, places, circumstances, triggers and what de-escalated the resident's behaviors and document. Staff were to monitor/document/report as needed (PRN) any signs and symptoms of the resident posing a danger to himself and others. The resident liked to walk and often held staff's hand while walking, per documentation from hospitalization , Resident is usually easily redirected by simply taking him by the hand and walking with him. Staff were to intervene before R1's agitation escalated, and staff were to guide him away from the source of distress. If R1's response was aggressive, staff were to walk calmly away and approach him later. On 06/12/23, staff were to utilize as needed (PRN) medication Ativan (medication used to treat anxiety) and Seroquel (antipsychotic medication used to treat psychosis and other mental emotional conditions) to help manage his behaviors. The Physician's Orders included and order for lorazepam (benzodiazepine) Oral Tablet 0.5 milligrams (mg), administer 0.5 mg by mouth, every six hours, as needed for agitation, related to Alzheimer's Disease and Parkinson (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) Disease, start date of 06/13/23. Review of the residents Electronic Medical Administration Record (EMAR) for June 2023 revealed staff administered the resident's Lorazepam on one occasion, on 06/13/23 at 05:35 AM. The Physician's Orders included an order for quetiapine fumarate (antipsychotic) tablet 25 mg, administer 25 mg by mouth every four hours as needed, for agitation related to Alzheimer's disease, start date 06/09/23. Review of the R1's June 2023 EMAR revealed quetiapine was not administered on 06/09/23 or 06/10/23. Staff administered the PRN medication on 06/11/23 at 09:33 PM. Staff administered the PRN medication on 06/12/23 at 02:44 PM and noted it was ineffective. Staff administered the PRN medication on 06/13/23 at 09:25 AM and noted was ineffective. The facility failed to administer the medication even though it was ordered by the physician to be administered every four hours, as needed. On 06/13/23, staff placed the resident on 15-minute visual checks following return from the Emergency Department (ED). Review of the resident's Progress Notes revealed the following: On 06/10/23 at 07:15 AM, R1 tried to grab a medication bottle from the medication cart. When an unidentified Certified Medication Aide (CMA) attempted to retrieve the bottle of medication, R1 grabbed the CMA's left wrist and turned her arm backwards. On 06/12/23 at 10:30 AM, R1 had a telehealth appointment. The physician reviewed R1's medications and behaviors. The physician directed staff to utilize the orders for PRN Ativan and Seroquel for behaviors. On 06/12/23 at 05:24 PM, the resident was combative and aggressive. The resident was actively violent and physically abusive towards staff and another resident. On 06/12/23 at 06:43 PM, staff reported R1 hit another resident. R1 was anxious and pacing. Staff reviewed the video and noted R1 walked with another resident and went into a room with her. R3 stood outside the door in the hallway and when R1 came out of the room he hit the other resident in the face and in the chest at 04:15 PM. Staff intervened and separated the residents. R1 had visual and auditory hallucinations prior to leaving with EMS at 05:24 PM. The resident returned to the facility on [DATE] at 12:26 AM. On 06/13/23 at 09:25 AM, the resident was very anxious and wandering. At 10:30 AM, staff observed R1 as he exited another resident's room and R1 stated we have a war going on here. The R2 reported that man just grabbed my arm and finger. Staff then placed the resident on 1:1. Staff received physician orders to send the resident to the hospital for behaviors, and EMS transported the resident from the facility at 12:20 PM. Review of the facility's investigation report, dated 06/22/23, revealed R1 admitted to the facility on [DATE] and resided on the secured dementia/ memory care unit. He was previously hospitalized for aggressive behaviors. R1 had a sitter while in the hospital due to his wandering. On 06/10/23 at 05:10 PM, R1 grabbed the CMA's arm while R1 grabbed medication at the medication cart. On 06/11/23 at 08:10 PM, R1 hit the CMA in the face, causing a small cut on her cheek and a black eye. On 06/12/23 at 04:15 PM, R1 hit R3 in the chest and face. EMS transported R1 to the Emergency Department. When the resident returned to the facility, staff placed him on 15-minute visual checks until further notice. On 06/13/23 at approximately 10:50 AM, R1 went into R3's room and grabbed her right forearm and left hand. At that time, R1 was placed on 1:1. R3 sustained fractures to her right radius and ulna, and her left index finger. EMS transferred R3 to the Emergency Department at 12:20 PM and the facility sent a discharge letter to R1's daughter/durable power of attorney. Interview on 06/22/23 at 09:45 AM, with Social Services X confirmed she did interview the hospital staff and the resident did have aggression towards himself or hospital staff during admission to the behavior health unit (BHU) toward staff or himself. Hospital staff reported that a sitter was 1:1 with the resident during his stay at the BHU. SS X clarified that she did not document her interviews with the staff members or observation of R1 during her assessment at the BHU. On 06/22/23 at 12:17 PM, Licensed Nurse H reported R1 appeared to be sundowning (condition where a person tends to become confused or disoriented toward the end of the day) later in the evening. On 06/21/23 at 03:00 PM, Administrative Nurse D confirmed the nursing staff were not utilizing the PRN medications that the physician ordered for R1. Administrative Nurse D confirmed the facility knew R1 had a history of aggression towards others to admission to the facility. On 06/21/23 at 03:05 PM, Administrative Staff A reported the hospital records revealed that R1 did have history physical behaviors at the hospital. He was admitted to the hospital for behaviors in January 2023. The facility Abuse and Neglect Policy, dated 09/2022, revealed the residents have the right to be free from abuse, neglect and to be protected from abuse and neglect from other residents. The facility failed to ensure residents that resided in the secured unit remained free from physical abuse when R1, who had a history of physical aggression, hit two separate residents, R2 and R3, and R3 sustained fractures to her right radius and ulna, and to her left index finger. On 06/27/23 at 03:05 PM, the Immediately Jeopardy (IJ) Template was provided to the facility. The facility provided an acceptable plan of removal of the immediate jeopardy on 06/27/23 at 02:30 PM after completing the following: 1. The Medical Director was notified on 06/21/23. 2. A new pre-admission checklist was implemented for screening potential new admissions when there are aggressive behavioral concerns documented in the pre-admission paperwork. The checklist would include a new process for completing a trauma informed screening prior to admission to evaluate behavior root causes and triggers. The trauma informed screening would be used to ensure an appropriate trauma informed plan of care is in place with appropriate interventions at the time of admission. The new pre-admission process will also include orienting direct care givers to the new resident's history, possible behavioral triggers, and interventions. This was completed on 06/22/23 at 05:00 PM. 3. Effective immediately (06/22/23) all resident to resident and resident to staff incidents will be reviewed by administrator, director of nursing, and social services to ensure appropriate interventions are put in place to prevent further incidents. This was completed on 06/22/23. 4. On 06/23/23 the Director of Nursing and Social Services Designee were educated on the new pre-admission checklist process. This was completed on 06/23/23 at approximately 01:00 PM. 5. On 06/22/23 at approximately 06:00 PM, employee education started on the Behavioral Health Services policy, which included recognizing changes in behavior and implementing care plan interventions that are relevant to the resident's diagnoses and appropriate to his or her needs, monitoring care plan interventions, reporting changes in condition, and checklists and guidelines related to the treatment of mental disorders psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder. This training was completed on 06/24/23 at 06:30 AM for all employees working the weekend. As of 06/27/23 at 02:30 PM, all other employees have reviewed and signed the education (other than a few employees who we have not been able to reach and who have not been in the building working). Any employee that has not yet completed the education will not be allowed to work until reviewing the education and signing for completion. The immediate jeopardy was removed on 06/27/23 at 03:33 PM, when the onsite surveyor verified implementation of the corrective actions. The deficient practice remained at a scope and severity of a G after removal of the immediate jeopardy.

The facility reported a census of 47 residents, with three residents reviewed for abuse and neglect. The facility identified eight residents that resided in the secured unit. Based on record review and interview, the facility failed to ensure the protection of the residents from abuse, when the facility did not provide adequate supervision or care planned interventions to address physically aggressive behaviors of Resident (R) 1, who had a history of physical altercations with staff and residents. On 06/10/23 R1 grabbed CMA R's arm; on 06/11/23 R1 hit CMA H in the face which caused a small cut on her cheek and a black eye; on 06/12/23 R1 hit R3 in the chest and face. On 06/13/23 at 11:30 AM Licensed Nurse (LN) G reported R1 exited R2's room and stated, There's a war going on in here. LN G entered R2's room and found R2 with visible deformity to the left forearm and hand, which were fractured, and required surgical repair. This failure placed R2 and R3 in immediate jeopardy and placed the other residents who resided in the secured unit at risk. R1 was transported to the hospital for evaluation. Findings included: - R1's Hospital Discharge Orders, dated 06/09/23, revealed diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dementia (progressive mental disorder characterized by failing memory, confusion). The 06/09/23 Entry Minimum Data Set (MDS) documented the resident admitted from an acute hospital. The Admission MDS was in progress. The 06/09/23 Baseline Care Plan revealed R1 had impaired cognitive function due to dementia and impaired thought processes related to Alzheimer's disease. Staff were to monitor, document, and report any changes in his cognitive function as needed. The revised Care Plan, dated 06/10/23, revealed R1 had the potential to be physically aggressive related to Alzheimer's disease. R1 became physically aggressive to staff and other residents since admission. The facility placed interventions as follows: On 06/10/23, staff were to administer medications as ordered and monitor/document for side effects and effectiveness. Staff were to analyze time of day, places, circumstances, triggers and what de-escalated the resident's behaviors and document. Staff were to monitor/document/report as needed (PRN) any signs and symptoms of the resident posing a danger to himself and others. The resident liked to walk and often held staff's hand while walking, per documentation from hospitalization , Resident is usually easily redirected by simply taking him by the hand and walking with him. Staff were to intervene before R1's agitation escalated, and staff were to guide him away from the source of distress. If R1's response was aggressive, staff were to walk calmly away and approach him later. On 06/12/23, staff were to utilize as needed (PRN) medication Ativan (medication used to treat anxiety) and Seroquel (antipsychotic medication used to treat psychosis and other mental emotional conditions) to help manage his behaviors. The Physician's Orders included and order for lorazepam (benzodiazepine) Oral Tablet 0.5 milligrams (mg), administer 0.5 mg by mouth, every six hours, as needed for agitation, related to Alzheimer's Disease and Parkinson (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) Disease, start date of 06/13/23. Review of the residents Electronic Medication Administration Record (EMAR) for June 2023 revealed staff administered the resident's Lorazepam on one occasion, on 06/13/23 at 05:35 AM. The Physician's Orders included an order for quetiapine fumarate (antipsychotic) tablet 25 mg, administer 25 mg by mouth every four hours as needed, for agitation related to Alzheimer's disease, start date 06/09/23. Review of the R1's June 2023 EMAR revealed quetiapine was not administered on 06/09/23 or 06/10/23. Staff administered the PRN medication on 06/11/23 at 09:33 PM. Staff administered the PRN medication on 06/12/23 at 02:44 PM and noted it was ineffective. Staff administered the PRN medication on 06/13/23 at 09:25 AM and noted was ineffective. The facility failed to administer the medication even though it was ordered by the physician to be administered every four hours, as needed. On 06/13/23, staff placed the resident on 15-minute visual checks following return from the Emergency Department (ED). Review of the resident's Progress Notes revealed the following: On 06/10/23 at 07:15 AM, R1 tried to grab a medication bottle from the medication cart. When an unidentified Certified Medication Aide (CMA) attempted to retrieve the bottle of medication, R1 grabbed the CMA's left wrist and turned her arm backwards. On 06/12/23 at 10:30 AM, R1 had a telehealth appointment. The physician reviewed R1's medications and behaviors. The physician directed staff to utilize the orders for PRN Ativan and Seroquel for behaviors. On 06/12/23 at 05:24 PM, the resident was combative and aggressive. The resident was actively violent and physically abusive towards staff and another resident. On 06/12/23 at 06:43 PM, staff reported R1 hit another resident. R1 was anxious and pacing. Staff reviewed the video and noted R1 walked with another resident and went into a room with her. R3 stood outside the door in the hallway and when R1 came out of the room he hit the other resident in the face and in the chest at 04:15 PM. Staff intervened and separated the residents. R1 had visual and auditory hallucinations prior to leaving with EMS at 05:24 PM. The resident returned to the facility on [DATE] at 12:26 AM. On 06/13/23 at 09:25 AM, the resident was very anxious and wandering. At 10:30 AM, staff observed R1 as he exited another resident's room and R1 stated we have a war going on here. The R2 reported that man just grabbed my arm and finger. Staff then placed the resident on 1:1. Staff received physician orders to send the resident to the hospital for behaviors, and EMS transported the resident from the facility at 12:20 PM. Review of the facility's investigation report, dated 06/22/23, revealed R1 admitted to the facility on [DATE] and resided on the secured dementia/ memory care unit. He was previously hospitalized for aggressive behaviors. R1 had a sitter while in the hospital due to his wandering. On 06/10/23 at 05:10 PM, R1 grabbed the CMA's arm while R1 grabbed medication at the medication cart. On 06/11/23 at 08:10 PM, R1 hit the CMA in the face, causing a small cut on her cheek and a black eye. On 06/12/23 at 04:15 PM, R1 hit R3 in the chest and face. EMS transported R1 to the Emergency Department. When the resident returned to the facility, staff placed him on 15-minute visual checks until further notice. On 06/13/23 at approximately 10:50 AM, R1 went into R3's room and grabbed her right forearm and left hand. At that time, R1 was placed on 1:1. R3 sustained fractures to her right radius and ulna, and her left index finger. EMS transferred R3 to the Emergency Department at 12:20 PM and the facility sent a discharge letter to R1's daughter/durable power of attorney. Interview on 06/22/23 at 09:45 AM, with Social Services X confirmed she did interview the hospital staff and the resident did have aggression towards himself or hospital staff during admission to the behavior health unit (BHU) toward staff or himself. Hospital staff reported that a sitter was 1:1 with the resident during his stay at the BHU. SS X clarified that she did not document her interviews with the staff members or observation of R1 during her assessment at the BHU. On 06/22/23 at 12:17 PM, Licensed Nurse H reported R1 appeared to be sundowning (condition where a person tends to become confused or disoriented toward the end of the day) later in the evening. On 06/21/23 at 03:00 PM, Administrative Nurse D confirmed the nursing staff were not utilizing the PRN medications that the physician ordered for R1. Administrative Nurse D confirmed the facility knew R1 had a history of aggression towards others prior to admission to the facility. On 06/21/23 at 03:05 PM, Administrative Staff A reported the hospital records revealed that R1 did have history physical behaviors at the hospital. He was admitted to the hospital for behaviors in January 2023. The facility Abuse and Neglect Policy, dated 09/2022, revealed the residents have the right to be free from abuse, neglect and to be protected from abuse and neglect from other residents. The facility failed to ensure the protection of the residents from abuse, when the facility did not provide adequate supervision or care planned interventions to address physically aggressive behaviors of Resident (R) 1, who had a history of physical altercations with staff and residents. On 06/27/23 at 03:05 PM, the Immediately Jeopardy (IJ) Template was provided to the facility. The facility provided an acceptable plan of removal of the immediate jeopardy on 06/27/23 at 02:30 PM after completing the following: 1. The Medical Director was notified on 06/21/23. 2. A new pre-admission checklist was implemented for screening potential new admissions when there are aggressive behavioral concerns documented in the pre-admission paperwork. The checklist would include a new process for completing a trauma informed screening prior to admission to evaluate behavior root causes and triggers. The trauma informed screening would be used to ensure an appropriate trauma informed plan of care is in place with appropriate interventions at the time of admission. The new pre-admission process will also include orienting direct care givers to the new resident's history, possible behavioral triggers, and interventions. This was completed on 06/22/23 at 05:00 PM. 3. Effective immediately (06/22/23) all resident to resident and resident to staff incidents will be reviewed by administrator, director of nursing, and social services to ensure appropriate interventions are put in place to prevent further incidents. This was completed on 06/22/23. 4. On 06/23/23 the Director of Nursing and Social Services Designee were educated on the new pre-admission checklist process. This was completed on 06/23/23 at approximately 01:00 PM. 5. On 06/22/23 at approximately 06:00 PM, employee education started on the Behavioral Health Services policy, which included recognizing changes in behavior and implementing care plan interventions that are relevant to the resident's diagnoses and appropriate to his or her needs, monitoring care plan interventions, reporting changes in condition, and checklists and guidelines related to the treatment of mental disorders psychosocial adjustment difficulties, history of trauma and post-traumatic stress disorder. This training was completed on 06/24/23 at 06:30 AM for all employees working the weekend. As of 06/27/23 at 02:30 PM, all other employees have reviewed and signed the education (other than a few employees who we have not been able to reach and who have not been in the building working). Any employee that has not yet completed the education will not be allowed to work until reviewing the education and signing for completion. The immediate jeopardy was removed on 06/27/23 at 03:33 PM, when the onsite surveyor verified implementation of the corrective actions. The deficient practice remained at a scope and severity of a G after removal of the immediate jeopardy.

The facility reported a census of 45 residents with three residents sampled for accidents. Based on record review and interview, the facility failed to follow care planned fall prevention interventions for Resident (R) 3 to prevent falls from the lift chair when Physical Therapy Consultant GG plugged in the lift chair, and then left the remote within her reach. The resident raised the lift chair to the highest position, then fell forward on her face, which resulted in a nasal fracture (broken nose). Findings included: - R3's signed Physician Orders, dated 10/6/21, documented diagnoses of cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels), [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (weakness on one side of the body) following a cerebral infarction affecting the left non-dominant side, and muscle weakness. The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with severely impaired cognitive skills for daily decision making, continuous inattention, and disorganized thinking. The resident required extensive assist of two staff members for bed mobility and transfers. The resident was totally dependent on staff for transport in her wheelchair. The resident had one major injury fall since admission. The [CONDITION(S)] Care Area Assessment (CAA), dated 09/21/21, documented the resident admitted on [DATE] to the facility from the hospital following a cerebral vascular accident and had left sided [CONDITION(S)]/[CONDITION(S)]. On 08/28/21, R3 fell out of her recliner, hit her forehead and sustained a nasal fracture. The physician visited the resident on 09/02/21 and wrote that she also had a concussion (temporary unconsciousness or confusion caused by a blow on the head). The Activities of Daily Living (ADL) CAA, dated 09/21/21, documented the resident required extensive to total assist with ADLs. The Care Plan, revised 09/01/21, advised the staff that the resident had limited physical mobility related to a stroke. Instructions to the staff included to keep her recliner unplugged at all times and to remove the battery from the room as to prevent accidental forgetfulness of the resident's need for safety. The staff deactivated the lift chair in her room to prevent falls and removed the battery pack from the room. The resident had a fall on 08/28/21 with injury. The root cause of the fall was due to the electronical controls being left by staff within reach of the resident. A Facility Bulletin Board Message, dated 08/25/21, advised staff that R3 was a new admission following a stroke. She had left sided weakness. Her lift chair was inactive and was only to be used for sitting up. (Not as a lift chair) A Nurse's Note, dated 08/28/21 at 07:20 PM, revealed Licensed Nurse (LN) G walked into R3's room and found her lying partly on her right side and partly prone in front of her chair. The electric lift recliner at that time was noted to be up in its highest position. There was obvious swelling to the left forehead with bleeding noted and blood coming from her nose. A Nurse's Note, dated 08/29/21 at 01:53 AM, LN H revealed the resident returned to the facility from the emergency roiagnom on [DATE] at 10:15 PM, with her family. The family stated R3 had a computerized tomography (CT) scan and it found a fractured nose. A Witness Statement, dated 08/26/21, revealed Physical Therapy Consultant GG completed an evaluation with Occupational Therapy services. The lift chair did not have a plug for it. Consultant Staff GG requested maintenance to get one and it was brought to her room. R3 was in bed and they assisted R3 to sit in her wheelchair. They discovered the resident could not sit up adequately in her wheelchair. After they toileted R3, staff transferred R3 to sit in her lift chair and reclined it backwards. A facility provided email correspondence, dated 08/31/21 at 06:16 PM, from Physical Therapy Consultant GG to Administrative Staff A, revealed he saw R3 on 08/26/21 for a physical therapy evaluation. The resident was not able to sit very well in the wheelchair, so he put her in the recliner. Consultant Staff GG requested that Maintenance Staff U get the plug-in for the lift chair so R3 would not have to go back to bed and she could sit up for a while. Consultant Staff GG stated he did not look in the resident's records on the computer, but had the hospital records at the nurse's station to review before he went into the resident's room. He did not know that R3 was a fall risk. He thought the cord to the lift chair was just misplaced somewhere. Interview, on 01/27/22 at 10:47 AM, with Maintenance Staff U verified his witness statement and stated Physical Therapy Consultant GG performed an assessment for physical therapy. Maintenance Staff U took out the plug and the remote from the resident's room when she admitted so she could not use the chair. He told Consultant Staff GG that R3 was not supposed to use the chair plugged in with the remote, but staff U went ahead and got the plug so Consultant Staff GG could do his assessment. Consultant Staff GG went to the nurse's station and told the staff just to keep the remote away from R3 and he put it on the floor where she could not reach it. The remote should not have been left in the resident's room. Interview, on 01/31/22 at 09:40 AM, LN G verified her witness statement and stated that the resident was unable to stand or walk due to a stroke she had before admitting to the facility. LN G stated the resident was fidgety with her hands and was always doing that to her clothes. The resident was alert and able to answer simple yes/no questions. The remote and cord was left in the room after physical therapy assessed her. The cord and remote should have been removed after the assessment. LN G did not know how the resident got a hold of the remote. Interview, on 01/31/22 at 11:05 AM, with Administrative Staff A stated that the therapists have open access to the resident's information and she expected them to review that information when a new resident admitted to the facility before their evaluation, especially for skilled therapy services. Physical Therapy Consultant GG stated to her that he only looked at the hospital paperwork at the nurse's desk, but that was not the full discharge information. The facility policy Fall Prevention Protocol, dated 04/12/19, documented .Procedure .Ensure optimal communication regarding the resident's condition and potential for fall with other care providers .include all disciplines . The facility failed to ensure this resident remained free of accident hazards when facility staff left R3's lift chair with power and the remote within reach. The resident raised the chair to the highest position and fell , sustaining a nasal fracture.

The facility census was 47 residents. Based on observation, interview, and record review the facility failed to properly screen staff and visitors for COVID-19 before entry into the facility, and assess resident temperatures daily. The facility failed to ensure that staff wore face masks while in the facility. The facility's failure to ensure all who entered the facility were properly screened for COVID-19, and that staff wore facemasks placed all residents in the facility in immediate jeopardy. Findings included: - An observation on 04/27/20 at 8:15 AM revealed Administrative Staff B answered the front entrance door and asked the surveyors their purpose for their visit. Administrative Staff B allowed the surveyors to enter the foyer, asked screening questions, but did not fully ask the questions or complete the screening forms. A review of the visitor screening forms, Screening Checklist for SNF (Skilled Nursing Facility) Visitors to Prevent COVID-19 from 04/01/20 to 04/27/20 revealed 16 of the 19 forms were not fully completed. An observation on 04/27/20 at 08:15 AM revealed while surveyors were screened by the front entrance none of the staff observed in the facility wore facemasks. During an interview on 04/27/20 at 08:41 AM Laundry Staff (LS) E stated that staff were screened when they came to work in the morning, and a nurse took her temperature. LS E stated not much else changed since the [MEDICAL CONDITION] situation started. During an interview on 04/27/20 at 08:37 AM, Certified Medication Aide (CMA) D revealed the staff wore masks only if a resident was coughing or sick. An observation on 04/27/20 at 09:01 AM revealed Licensed Nurse (LN) C screened employees coming on duty for their shift. This took place at the residents' Hall 2 nurses' station (approximately 40 feet from the entrance used by facility staff). LN C used hand sanitizer and donned gloves before she used an infrared thermometer to take the employee's temperature. The employees' temperatures were written down on the Wheat State Manor Daily Health Screen form. The employees initialed the Can Work Y/N portion of the screening form. No other screening questions were asked. During an interview 04/27/20 at 09:05 AM, LN C revealed the staff did not wear masks unless a resident was sick. LN C stated the staff were discouraged from wearing masks continuously because it caused the residents to become anxious. During an interview on 04/27/20 at o09:23 AM, Certified Nurse Aide (CNA) F revealed that staff do not wear masks unless a resident was sick. During an interview on 04/27/20 at 9:40 AM, Administrative Staff A stated he received continuous updates concerning COVID-19 from the CDC (Centers for Disease Control, CMS (Centers for Medicare and Medicaid Services), as well as from the Leading Age. During an interview on 04/27/20 at 9:46 AM, Administrative Staff B stated the protocol for determining when residents and staff should be tested for COVID-19 was if a resident had a temperature of over 100.4 F (Fahrenheit), had a productive cough, experienced shortness of breath, had difficulty breathing, or had abnormal aches and pains. During an interview on 04/27/20 at 10:10 AM, Administrative Staff B stated resident temperatures were taken routinely on a monthly basis, or as needed. Record review of five randomly picked residents in the electronic medical records revealed the residents did not have daily temperatures taken. During an interview on 04/27/20 at 10:21AM, Administrative Staff A stated all staff were required to report to the Hall 2 nurses' station to have their temperature taken. Administrative Staff A stated they did not ask questions like they did with visitors. Review of the Wheat State Manor Daily Health Screen form revealed there was no place to document asking of symptoms or other screening questions. During an interview on 04/27/20 at 10:37 AM, Administrative Staff B stated face masks were not required to be worn by staff as per CDC (Centers for Disease Control) due to there not being any active cases of COVID-19. During an interview on 04/27/20 at 10:46 AM Administrative Staff B stated the facility took staff temperatures prior to each shift, but did not ask any other screening questions. Administrative Staff B stated staff knew to tell us if they had been in contact with anyone who had or may have had COVID-19, or have been in contact with someone who had been tested . They know they need to tell somebody. Review of the COVID-19 Long-Term Care Facility Guidance letter dated April 2, 2020 provided by CMS revealed, The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations .In accordance with previous CMS guidance, every resident should be assessed for symptoms and have their temperature checked every day .For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. Review of the Novel Coronavirus (2019-nCoV) (COVID-19) policy dated 03/17/20 revealed, This facility will conduct education, surveillance and infection control and prevention strategies to reduce the risk of transmission of the novel Coronavirus (2019-nCoV). The facility will implement actions according to Centers for Disease Control (CDC), State, County and Local Health Departments, State Survey Agency, and World Health Organization recommendations. The facility failed to properly screen staff, visitors, and residents for COVID-19, and failed to ensure staff wore facemasks while in the facility. On 04/27/20 at 03:21 PM, the surveyor provided Administrative Staff A with the IJ template and notified the facility of the failure to ensure all staff were properly screened for the 2019 Novel Coronavirus (COVID-19) by not asking about symptoms of COVID-19, failure to ensure all guests were properly screened for COVID-19 by not completing all questions on the screening checklist for 16 of 19 checklists reviewed, failure to ensure all residents were routinely screened to include temperatures checked daily, and failure to ensure all long-term care facility personnel wore appropriate personal protective equipment (PPE) to include a facemask while in the facility constituted immediate jeopardy at F880. These failures had the potential to affect all residents in the facility. The facility presented an acceptable plan for removal of the immediate jeopardy on 04/27/20 at 05:18 PM, which included all visitors and staff will be screened upon entry using the Screening Checklist for SNF Visitors to Prevent COVID-19, all staff will wear masks during their shift, and residents will be screened for symptoms (consider atypical symptoms as well), O2 saturation levels, and fever daily. The survey team validated onsite the immediate jeopardy removal on 04/28/20 at 01:15 PM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of an F.

The facility reported a census of 56 residents with 7 selected for review including 3 residents reviewed for pressure ulcers. Based on observation, interviews and record review, the facility failed to implement and monitor effective interventions to prevent worsening of pressure ulcers for 1 (#2) of the 3 residents reviewed for pressure ulcers. Findings included: - Review of resident #2's physician order [REDACTED]. The annual MDS (minimum data set), dated 3-15-15, assessed the resident with intact cognitive status and independent with bed mobility, transfer, and ambulation in his/her room. The resident's balance was steady without staff assistance and had no impairment of upper or lower extremities. The resident was assessed as not at risk for pressure ulcer development, and had no pressure ulcers. This MDS documented the resident had a pressure reducing device in his/her chair, and no pressure reducing device on the resident's bed. The quarterly MDS, dated [DATE], assessed the resident with intact cognitive status, independent with transfers, ambulation, eating and personal hygiene, the resident's balance was not steady, but the resident was able to stabilize without staff assistance. The resident was assessed as not at risk for pressure ulcer development. The resident had no pressure ulcers and had 1 venous/arterial ulcer to his/her foot. The resident had a pressure reducing device in his/her chair, and none on his/her bed. The CAA (care area assessment), dated 3-15-15, lacked a pressure ulcer analysis. The five day medicare MDS (conducted after the resident returned from a hospital stay), dated 2-18-16, assessed the resident with intact cognition, required extensive assistance with bed mobility, transfer and toileting. The resident assessed as at risk for pressure ulcer development, and had 5 stage 2 pressure ulcers with 3 present upon admission, most severe tissue type described as granulation. This MDS documented the resident had a pressure relieving device in his/her chair and no pressure relieving device in his/her bed. The 14 day medicare MDS, dated [DATE], assessed the resident with intact cognition, required extensive assistance with bed mobility, transfer and toilet use. The resident was assessed as at risk for pressure ulcer development, and had a pressure reducing device in his/her chair, but not on his/her bed. The resident assessed as having 3 stage 2 pressure ulcers present upon admission and 1 stage 2 not present or present at a lesser stage on prior assessment. The care plan, dated 12-17-15, advised staff the resident was at risk for skin breakdown due to a decrease in mobility and incontinence, required moisturizing cream to bilateral feet 3 times weekly, for diabetes, was able to reposition self and staff advised to encourage the resident to reposition him/herself. Staff advised the resident was incontinent and could toilet self independently. Staff advised of the dressing to the resident's left foot 3rd toe and anterior tibia. Staff advised of the resident's habit of hanging his/her legs off their bed and staff advised to encourage the resident to put his/her feet up due to blood clots. As of 3-17-16 during review, the care plan lacked documentation of the resident's pressure ulcers upon return from the hospital on 2-9-16 or the heel pressure ulcer as of 2-16-16, or use of heel protectors/floatation devices, use of a Roho cushion in his/her chair, or use of pressure reducing device in his/her bed. The care plan also lacked a turn and reposition schedule. The resident's Norton skin assessment, dated 12-17-15, assessed the resident as moderate risk with a score of 14 (moderate risk 11-15, high risk 10 and below), on 1-19-16, the score was 11 and on 2-19-16, the score was 11. The late entry nurses' note, dated 2-9-16 at 4:59 pm, documented the wound care nurse would assess the resident's coccyx in the morning. The skin assessment, dated 2-10-16 at 10:02 am, assessed the resident's wound to his/her coccyx as a stage 2 measuring 3 by 1.5 by 0.2 cm(centimeter), a superficial (not staged) right buttock wound measured 0.5 cm in diameter, and the left buttock wound measured 1.5 by 1 by 0.1 cm, described as red in color with a small amount of serosanguinous (semi-thick reddish) drainage (not staged). The assessment lacked documentation of the condition of the resident's heels. A progress note, dated 2-16-16, assessed the resident's right heel with an intact blister, dark red in color, measuring 6 by 7 cm. This assessment, documented the blister as a stage 2. A wound assessment, dated 2-17-16, documented the right heel as a stage 2, red in color, 6 by 7 by 0.1 cm, with moderate exudate and evidenced the wound clinic debrided the skin. The skin assessment , dated 2-18-16, assessed the resident's coccyx as Stage 2 measuring 3.5 by 2.5 by 0.2 cm. The resident's left buttock cheek measured 2.5 by 2 by 0.1 cm, red in color with no tunneling or odor and a moderate amount of serosanguinous drainage. The resident was to continue with multivitamin, Arginade (a protein supplement) and the house supplement. The skin assessment lacked documentation of the right buttock wound. A progress note, dated 2-18-16, documented the blister to the resident ' s right heel popped and staff advised to cleanse with normal saline and apply triple antibiotic ointment and cover with a non-adherent dressing and wrap with gauze daily. A progress note from the wound clinic with wound care instructions, dated 2-18-16 (nine days after return from the hospital), advised staff to use off loading boots to heels for protection, use of a Roho cushion and a side to side turn schedule when in bed, and to encourage off loading of the resident's heels and bottom. The wound clinic advised the facility to apply [MEDICATION NAME](a moisture barrier) to the peri wound area of the right heel and buttock, and apply [MEDICATION NAME] silver (a dressing used for wounds with infection and drainage) to the ulcer bed, cover with [MEDICATION NAME] (a foam dressing) dressing and change every 3 days and as needed. The wound clinic advised staff to apply (to the sacral wound) Iodosorb (a dressing used for infected wounds with drainage) to gauze and place Iodosorb side down to the ulcer bed, apply [MEDICATION NAME] to the (peri wound) and cover with [MEDICATION NAME], and change every 3 days and as needed. A wound nursing progress note, dated 2-28-16, described the coccyx, left and right buttock wound , as one wound measuring 8 by 8 by 0.4 cm with a foul odor, red and gray in color, and appeared to have tunneling, and a moderate amount of drainage. The right heel was red in color, and measured 7 by 6 by 0.1 cm, with a moderate amount drainage, stage 2. A wound clinic note, dated 2-29-16 (11 days after the first recommendation of use of the Roho cushion), advised staff to order a Roho cushion for the resident as the gel cushion the resident had in his/her wheelchair was not sufficient. Staff advised to encourage side to side positions, and up for meals only for a maximum of 1 hour. The facility was advised to apply [MEDICATION NAME] silver to the ulcer on the coccyx/sacrum and cover with [MEDICATION NAME] dressing and change every 3 days and as needed. Review of the nurses' notes, from 2-9-16 through 3-1-16, revealed documentation of the wound dressing as intact or changed 6 times, and description of the wound (right heel or coccyx) only 3 times. The resident transferred to acute care 3-2-16 and had not returned to the facility as of 3-17-16. Interview, on 3-17-16 at 10:27 am, with licensed nursing staff D, revealed the resident usually sat in his/her wheelchair during the day, and he/she thought the pressure ulcers where healing. Staff D stated the resident was, at times, not cooperative with toileting measures. Interview, on 3-17-16 at 10:40 am, with direct care staff C, revealed the resident had a Roho cushion in his/her wheelchair on admission to the facility, however, staff C stated the resident wanted a different cushion, so staff C put a gel cushion in his/her wheelchair (staff C did not know the date or time). Staff changed the cushion, when the physician notified the facility that a gel cushion was not sufficient on 2-29-16. Staff C stated the resident did have a pressure relieving mattress on his/her bed and heel protectors, and thought they were available upon the resident's return from the hospital. Interview, on 3-17-16 at 11:10 am, with administrative staff A, revealed the resident admitted to the facility from the hospital with pressure ulcers, went to the wound clinic and required debridement. Interview, on 3-17-16 at 12:45 pm, with administrative nursing staff B, revealed wounds were assessed weekly, and documented in the electronic medical record. Staff B stated he/she observed the wounds just before debridement and thought they did require mechanical debridement. Staff B stated the facility wound nurse documented the wounds as stage 2. Interview, on 3-17-16 at 2:20 pm, with administrative nursing staff J, revealed he/she thought the resident had an air mattress on his/her bed but did not know the date staff applied the mattress to the resident's bed. Staff J stated he/she did not place pressure ulcer interventions on the resident's care plan after return from the hospital. Staff J confirmed the resident required extensive assistance for transfers, bed mobility and toilet use, (which on prior assessments the resident was independent) but did not complete a significant change MDS. Interview, on 3-18-16 at 10:00 am, with consulting surgical staff K, revealed the resident's pressure ulcers worsened at a rate not expected even with the resident 's comorbidities. Staff K stated the pressure ulcers required mechanical debridement, and the severity (to the bone) was discovered during the debridement. Staff K stated the pressure ulcer had eschar(necrotic tissue) on his/her coccyx and his/her right heel and was unstagable. The facility policy, undated, advises staff to assess the wound daily, measure wounds weekly, and review and update the care plan upon admission and or with the development of skin issues. The facility skin at risk assessment, advised staff to institute prevention on the bed and chair and note interventions and skin at risk score on the care plan. The National Pressure Ulcer Advisory Panel classifies a stage 4 pressure ulcer as extending into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. It also classifies wounds as unstageable with description of ulcers with full thickness skin or tissue loss with depth unknown, full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. A maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure. The facility failed to effectively monitor and assess this resident' s pressure ulcers which worsened, as indicated by the increase in size, exudate, and odor. Furthermore, the facility failed to implement appropriate interventions in a timely manner and failed to ensure the timely addition and effectiveness of pressure relieving devices. The resident readmitted to the facility with 3, stage 2 pressure ulcers which worsened and required surgical debridement. Furthermore, the resident developed 2, stage 2 pressure ulcers on one of the resident's heels.