Every finding on record at Anthony Community Care Center

The facility reported a census of 23 residents. Five Certified Nurse Aide (CNA) staff, CNA G, CNA O, CNA P, CNA Q, and Social Services Designee (SSD)/CNA K, who worked in the facility for over a year, were reviewed for required annual in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. Five CNAs lacked the required training topics, and five CNAs lacked the required 12 hours per year of in-service training. This placed the residents at risk for decreased qulaity of care. Findings included: - On 04/08/25 at 03:32 PM, a review of training records for five CNAs employed by the facility for more than one year revealed all five CNAs had less than 12 hours of documented in-service training for the previous 12 months. The records that were reviewed were from the year 2024. Additionally, on 04/09/24, Social Services Designee (SSD)/CNA K had Abuse, Neglect, and Exploitation training was the only record located for education. On 04/08/25 at 03:32 PM, a review of training records for five CNAs employed by the facility for more than one year revealed all five CNAs did not have the required topics for in-service training for the previous 12 months. During an interview on 04/08/25 at 04:10 PM, Administrative Nurse B and Administrative Nurse C reported they were aware they may not have all the required in-service hours for CNAs. They recently acquired a new program to help with this problem in the future and have just started using it. On 04/09/25 at 05:30 PM, Administrative Staff A reported that she expected the staff to have the required services and the required 12 hours completed each year. The facility's policy, Required Training and In-Service of Staff, dated 04/02/25, documented that all nurse aide personnel participate in regularly scheduled in-service training classes, which are no less than 12 hours per employment year and include training in dementia management and abuse prevention.

The facility reported a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop and implement, including an annual review, of the facility's infection control policy. Findings included: - During an interview on 04/10/25 at 12:19 PM, Administrative Nurse B reported that the facility lacked an annual review of the infection control policy that was last reviewed on 11/22/20. Additionally, she expected staff to remove the PPE correctly to prevent cross-contamination. The facility's policy Infection Control dated 11/22/2020 documented the facility would facilitate safe care for all elders and staff with known or suspected communicable diseases by establishing and maintaining an infection prevention and control program. The program would follow the accepted national standards.

The facility census totaled 25 residents with three residents sampled for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment when the facility staff allowed three residents to hold lit fireworks in their hands during an Independence Day Celebration. On 07/03/24, the facility staff allowed three residents to hold lit Roman Candle (cardboard tube filled with pyrotechnic fireworks to include exploding shells/stars) fireworks, including cognitively impaired Resident (R)1. R1 sustained a burn injury and bruising to her right hand, between her thumb and forefinger, after the last exploding shell/star from the Roman Candle firework misfired and the tube blew up in R1's right hand as she held the lit firework with the assistance of staff. This deficient practice placed the three residents who held the fireworks in immediate jeopardy and at risk for personal injury. (R1, R2, and R3) Findings included: - R1's electronic medical record (EMR) included the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident was dependent on staff for all cares. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/02/24 revealed R1 had impaired cognition due to dementia. The CAA noted she had impaired memory, was unable to recall, and required assistance with decision making. The Quarterly MDS, dated [DATE] revealed no significant changes in status from the above MDS. R1's Care Plan, revised 01/24/20, revealed R1 had memory problems, no recall, and had moderately impaired decision-making ability. On 07/03/2024 at 07:05 PM, an Incident Note revealed R1 held a roman candle firework and as the last shot blew from the firework, it blew up in her right hand. The nurse immediately assessed the area, cleansed the area, and applied ice. R1's right hand, between her thumb and forefinger was red, slightly swollen, and had some small pinpoint bruising. R1 given one dose of as needed Tylenol and the physician ordered an as needed burn cream. On 07/04/2024 at 06:04 PM, an Incident Note revealed R1 could feed herself and noted R1's mid-pointer finger had a small pink area and staff applied burn cream. On 07/06/2024 at 09:33 AM, an Incident Note revealed R1 had slight bruising to her finger webbing. During an observation on 07/08/24 at 09:10 AM, with Administrative Nurse A, revealed the resident was awake in her bed. Observation of R1's right hand revealed a slightly bruised area in the web between her finger and thumb. During an interview on 07/08/24 at 09:40 AM, Social Service Staff C reported on 07/03/24 at approximately 06:00 PM, she and Certified Medication Aide (CMA) B took a group of 12 residents outside, in front of the building, to light fireworks for them until about 07:00 PM. SS C said the last thing they had were the roman candles to shoot off. She asked if any of the residents wanted to hold them, and three residents indicated they did. CMA B helped the residents hold the candles as SS C lit them. SS C said the last ball of the roman candle backfired and the whole tube blew up in R1's hand. SS C took the resident back into the building to Licensed Nurse (LN) D to evaluate her right hand. SS C said there were reddened areas and some bruising, but did not look like burns. SS C said she then left the resident with the nurse and went to tend to the other residents outside. SS C reported she never thought about the residents holding the roman candles and did not read the label about how to shoot the fireworks off properly. SS C said the fireworks were destroyed and unable to read the label, so she went to a firework stand and looked at a roman candle just like what they had for the residents, and it was clear the roman candles were not to be held when lit. During an interview on 07/08/24 at 11:25 AM, CMA B reported on the evening of 07/03/24, there was a group of residents outside in front of the building to watch the fireworks. SS C asked the residents if they wanted to hold the roman candle and R1 shook her head she did. CMA B then took R1 further down away from the other residents and helped R1 hold it while SS C lit the candle. The last ball in the roman candle blew up and caused the tube to explode. CMA B then ripped it out of the resident's hand and SS C quickly took R1 into the nurse to be looked at. CMA B said she never thought about the residents holding them nor did she read the label about how to shoot the firework off. During an interview on 07/08/24 at 03:20 PM, LN D reported she was the charge nurse on 07/03/24, when staff took a lot of the residents outside to watch fireworks. It was about 07:00 PM when SS C brought R1 inside and reported a roman candle blew up in her hand. LN D immediately sent a staff for a cool washcloth and examined R1's right hand. LN D said there was a small area of redness and slight swelling on her index finger and what might be a bruise in the webbing between her thumb and finger. LN D put the cool cloth on the area and saw no open, blistered skin, just a pinpoint red area. LN D called the physician who gave a verbal order for burn cream to the area until healed. LN D reported she gave the resident some Tylenol in case the hand was causing any pain. LN D monitored and checked the area all through the night and by morning the redness was almost gone, and swelling had resolved. LN D said there was faint bruising on the webbing, but the resident used her hand as she did prior to incident. During an interview on 07/08/24 at 08:30 AM, Administrative Nurse A reported staff were lighting fireworks for the residents on 07/03/24 and without reading the labels, they allowed three residents to hold roman candles and then lit them. Administrative Nurse A said the first two residents' candles went off as planned but then the third one was lit by SS C while CMA B helped the resident hold her candle and it went off okay until the last ball backfired and blew up in the resident's hand. Review of the safety sheet on fireworks.com revealed fireworks such as roman candles should not be held in the hand and can burn at high temperatures; Some can reach temperatures of up to 2000 degrees Fahrenheit. The firework should never be held in the hand, and after they are lit, people should be a safe distance away of at least 100 feet. The facility policy for Accidents and Incidents- Investigation and Reporting dated 11/28/16 revealed all accidents or incidents involving residents, employees, visitors, vendor, etc., occurring on the premises shall be investigated and reported to the Administrator. The Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The facility failed to provide a safe environment for three residents in the facility identified by the facility, when the facility staff allowed three residents to hold lit fireworks in their hands during an Independence Day Celebration, that resulted in injury to one confused resident. On 07/08/24 at 01:50 PM, the surveyor provided the IJ Template to Administrative Staff A and notified the facility failure to ensure a safe environment when staff allowed three residents to hold lit fireworks, one which misfired and blew up in cognitively impaired R1's right hand. This failure placed R1, R2, and R3 in immediate jeopardy and at risk for injury. The facility identified, implemented, and completed the following corrective actions on 07/04/24: 1. On 07/04/24, staff counseled on reading all labels on any fireworks for safe lighting instructions. 2. On 07/04/24, no staff/resident were to hold fireworks while being lit. 3. The facility gave SS C and CMA B a written disciplinary warning. The surveyor verified the completed corrective actions during an onsite visit on 07/08/24 at 08:00 AM. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a G scope and severity.

The facility reported a census of 20 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for five of the five Certified Nurse Aides (CNA) reviewed, CNA MM, Q, P, O and M, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: Review of Certified Nurse Aide (CNA) P, hired 08/30/20, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) O, hired 07/21/22, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) M, hired 06/24/22, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) Q, hired 12/02/17, lacked an annual performance review in her personnel file. Review of Certified Nurse Aide (CNA) MM, hired 06/18/20, lacked an annual performance review in her personnel file. On 08/23/23 at 03:42 PM, Administrative Nurse D stated she had not completed the employee's annual evaluations. The Facility Employee Handbook, included: During your employment, your performance will be observed and reviewed. You will receive a written evaluation prior to completion of your Introductory Period and periodically thereafter. The facility failed to complete an annual performance review for these five CNAs, employed by the facility for greater than one year, to ensure adequate appropriate cares and services provided to the residents of the facility.

The facility reported a census of 20 residents. Based on observation, interview, and record review, the facility failed to properly store, prepare and distribute food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. Findings included: - During the initial tour of the kitchen on 08/22/23 at 08:29 AM, the following areas of concern were noted: 1. A large can opener had a heavy build-up of a sticky substance including on the tip which comes into contact with the food. 2. The shelves below the food preparation table contained dried food debris. 3. The shelf, which contained the multiple containers of spices, contained dried food debris. 4. The enclosed dry storage bin contained dried food debris. The inside and outside of the doors to the dry storage bin had a dried-on sticky liquid substance. 5. The sugar and flour bins had debris on the bin covers and around the bins, including a container next to the sugar bin which held clean pot lids. 6. Two drawers which held cooking utensils such as scoops, spatulas and serving spoons had dried food debris throughout the drawers. 7. Two two-cup plastic measuring cups and one four-cup plastic measuring cup had multiple cracks throughout. 8. Six reach-in freezers and reach-in refrigerators in the kitchen and in the kitchen storage building had dried food on the shelves and a heavy build-up of food debris in the rubber gaskets around the doors. 9. The outsides of the six reach-in freezers and reach-in refrigerators doors had a dried, sticky substance. 10. The white handles of three of the five freezers in the kitchen storage building had a heavy build-up of grime, causing the white handles to be dark brown in color. 11. The hand-washing sink on the south side of the kitchen contained rust behind the faucet. The pipes beneath the sink had a heavy build-up of dirt and grime. 12. The pipes beneath the three-compartment sink had a heavy build-up of dirt and grime. 13. The dry storage room had a plastic bin which contained dried pudding mix which had a build-up of dirt and grime. On 08/23/23 at 03:45 PM, Dietary Staff BB confirmed the areas of concern needs to be addressed. The facility policy for Dietary Cleaning Procedures, dated 02/24/16, included: The facility will store, prepare, distribute and serve food under sanitary conditions to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses is attained continuously. The facility failed to properly store, prepare and distribute food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. 28560 - Observation, on 08/22/23 at 08:30 AM, revealed the resident's popcorn machine in the common living area contained popcorn and a yellow substance streaming down the entire surface of the two front doors across. Observation on 08/23/23 and 08/24/23 at 08:30 AM, revealed the popcorn machine in the common living area remained in the same condition. Interview, on 08/24/23 at 12:06 PM, with Administrative Nurse E, stated staff used the popcorn machine to pop popcorn for the residents typically for movies, usually on the weekend. Administrative Nurse E confirmed staff needed to clean the popcorn machine, and expected the staff member that used the machine last should clean it. Interview, on 08/24/23 at 01:00 PM, with Administrative Nurse revealed the facility did not have a policy for cleaning the popcorn machine. The facility lacked a policy for cleaning the popcorn machine. The facility failed to ensure staff maintained the popcorn machine in a sanitary manner to prevent the spread of food borne illness.

The resident reported a census of 20 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings included: - During the initial tour of the kitchen on 08/22/23 at 08:29 AM, the following area of concern was noted: The floor throughout the kitchen had areas which contained a dried, liquid, sticky substance. The parameter of the floor had a heavy build-up of dirt and grime. On 08/23/23 at 03:45 PM, Dietary Staff BB confirmed the floors of the kitchen needed to be kept clean at all times. The facility policy for Dietary Cleaning Procedures, dated 02/24/16, included: Staff members who prepare food in the kitchen will wipe any spills on the floor immediately and keep the kitchen floor free of debris. The facility failed to provide a safe, functional, sanitary and comfortable environment for residents and staff.

The facility reported a census of 20 residents with seven residents identified that used the facility glucometer for obtaining blood glucose (the amount of sugar in the blood) to determine insulin (a medication used to control blood sugar levels) needed to maintain a normal level of blood sugar. Based on observation, interview, and record review, the facility failed to ensure staff sanitized the multi- resident use glucometer and failed to ensure staff provided catheter care for one Resident (R)15 in a sanitary manner to prevent the spread of infection. Findings included: - Observation, on 08/23/23 at 11:04 AM, revealed Certified Medication Aide (CMA) R, obtained a blood glucose level with the facility glucometer from Resident (R) 2. CMA R then used an alcohol wipe to sanitize the glucometer. Interview, at that time with CMA R, revealed she used the glucometer for several other residents to obtain their blood glucose level, and sanitized them with an alcohol wipe. CMA R thought this was the proper procedure. Interview, on 08/23/23 at 11:20 AM, with Administrative Nurse D, confirmed the glucometer manufacture recommended the use of an EPA (Environmental Protection Agency) registered disinfection wipe. The manufacturer recommended that the glucometer intended use was for a single patient use. Administrative Nurse stated staff obtained blood glucose levels for R19, R6, R5, R15, R11, R2 and R3. The facility policy Blood Glucose Monitoring, effective 02/01/2016, instructed staff to thoroughly clean all equipment per manufacturer recommendations. The facility failed to effectively sanitize the glucometer used for these seven residents to prevent the spread of infection. 34056 - Review of Resident (R)15's electronic medical record (EMR) revealed a diagnosis of retention of urine (inability to pass urine). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He required extensive assistance of one staff for toileting and had an indwelling urinary catheter (a catheter which drains urine from your bladder into a bag outside your body). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 01/09/23, documented the resident had an indwelling urinary catheter due to obstructive uropathy (a condition of excess urine accumulation in the kidneys which causes swelling of the kidneys). He required extensive assistance with emptying the catheter. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 14, indicating intact cognition. He required extensive assistance of one staff for toileting and had an indwelling urinary catheter. The care plan for Activity of Daily Living (ADL), revised 07/12/23, instructed staff the resident had an indwelling urinary catheter and required extensive assistance with toileting. Review of the resident's EMR from 07/25/23 through 08/22/23, revealed he required extensive assistance of one staff for toileting. On 08/23/22 at 08:30 AM, Certified Nurse Aide (CNA) M entered the resident's room to provide catheter care for the resident. CNA M gathered supplies and placed the graduate (a measured plastic container used to measure liquids) directly on the resident's floor, next to his bed, without a barrier. CNA M then unhooked the drainage nozzle from the catheter collection bag and drained 750 cubic centimeters (cc) of urine into the graduate. CNA M then reconnected the nozzle to the port of the collection bag without cleansing the tip of the nozzle. On 08/23/23 at 08:30 AM, CNA M confirmed she did not cleanse the tip of the nozzle before reinserting it into the port of the catheter collection bag and did not use a barrier for the graduate when she sat it onto the floor without a barrier. On 08/24/23 at 09:00 AM, Administrative Nurse D stated the staff should have a barrier between the floor and the graduate while draining urine and should cleanse the tip of the nozzle before reinserting it into the port on the catheter collection bag. The facility's policy for Indwelling Catheter Protocol, effective 02/01/17, included: Staff shall empty the catheter drainage bag every eight hours, or when the drainage bag is 2/3 full. When the drainage bag is empty, staff shall clean the nozzle with an alcohol swab before reinserting into the port on the drainage bag. The facility failed to place a barrier between the graduate and the resident's floor while draining urine and failed to cleanse the tip of the nozzle after draining urine from the catheter collection bag into the graduate before reinserting the nozzle into the port on the collection bag.

The facility reported a census of 20 residents. Based on interview and record review, the facility failed to ensure residents/responsible parties acknowledged receipt of the benefit verses risk information for COVID-19 to make informed declination decisions and failed to offer/arrange for COVID-19 vaccinations for newly admitted residents as required for five Residents (R)4, R10, R15, R16, and R8. - Review of the medical records for Residents (R) 4, R10, R15, R16, and R8 revealed lack of COVID-19 vaccination declinations. Review of R 19's medical record revealed the resident admitted to the facility on [DATE]. The resident historically received three doses of COVID-19 vaccine, with the last vaccine received on 10/21/21. Furthermore, the record lacked a COVID-19 vaccine acceptance/declination form. Review of R 17's medical record revealed the resident admitted to the facility on [DATE]. The resident historically received COVID-19 vaccinations with the last dose on 10/21/21. Interview, on 08/24/23 at 09:48 AM, with Administrative Nurse E, revealed the facility verbally obtained declinations from residents/responsible parties, but did not have documentation of the receipt of benefits/risks of the COVID-19 vaccine to make informed declination decisions. Administrative Nurse E confirmed R17 and R19 needed COVID boosters, and R 4, R10, R15, R16, and R8 lacked COVID-19 vaccination declinations. The facility policy Covid-19 Vaccination Policy, dated 03/15/21, instructed staff to retain copies of all immunization forms in the medical record and residents have the right to choose not to receive the COVID-19 immunization. Each resident's medical record will include documentation that the resident/representative was provided education related to the benefits and potential side effects. This policy instructed staff to offer and arrange for the administration to any new resident or resident that previously declined the vaccine but wished to receive the vaccine. The facility failed to ensure residents/responsible parties acknowledged receipt of the benefit verses risk information for COVID-19 to make informed declination decisions and failed to offer/arrange for COVID-19 vaccinations for newly admitted residents as required.

The facility reported a census of 20 residents with 12 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide appropriate, safe transfers for one Resident (R)17. Findings included: - Review of Resident (R)17's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). 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 required extensive assistance of one staff for transfers. The resident used a walker. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/09/23, documented the resident had moderately impaired cognition and required extensive assistance with transfers. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. He required extensive assistance of one staff for transfers and used a walker. The care plan for ADL's, revised 08/09/23, instructed staff the resident's requirements for ADL's varied from independent to extensive assistance due to cognitive impairment, weakness and poor balance at times. Review of the resident's EMR from 07/25/23 through 08/22/23, revealed he required limited to extensive assistance of one staff for transferring. On 08/22/23 at 09:54 AM, Certified Nurse Aide (CNA) N transferred the resident from his bed to his recliner for breakfast. CNA N used extensive assistance to help the resident stand up from the side of the bed to his walker and ambulate four steps to his recliner. The resident was unable to fully straighten his legs and his balance was unsteady during the transfer. CNA N did not use a gait belt during the transfer. On 08/23/23 at 10:17 AM, CNA M assisted the resident from his bed to the bathroom. CNA M used extensive assistance to help the resident stand up from the bedside to the walker. The resident then ambulated from his bed to the bathroom with an unsteady gait. The resident was unable to fully straighten his legs while ambulating. CNA M did not use a gait belt while giving cares. On 08/22/23 at 09:54 AM, CNA N stated the resident was weak at that time due to having a UTI (urinary tract infection). CNA N stated the resident usually was able to get up and ambulate much better than he was able to recently and staff did not use a gait belt for transfers with the resident. On 08/23/23 at 10:17 AM, CNA M stated the resident currently had a UTI and was much weaker than normal. CNA M confirmed she should have used a gait belt while transferring and ambulating with the resident due to his current weakness, but did not as there was not a gait belt in his room. On 08/23/23 at 02:48 PM, CNA O stated the resident required a gait belt with transfers due to his current weakness. On 08/24/23 at 09:00 AM, Administrative Nurse D stated the staff should use a gait belt for the resident's transfers as he was unusually weak due to currently having a UTI. The facility policy for Use of Transfer Belt/Gait Belt, effective 02/01/17, included: Transfer belts or gait belts will be used when transferring elders who are partially dependent or have some weight-bearing capacity. The facility failed to provide appropriate, safe transfers for this resident.

The facility had a census of 23 residents with 22 residents who received meals from the main kitchen. Based on observation and interview the facility failed to have adequate staff to carry out all functions of the dietary service and in a sanitary manner. Findings included: - Observation of the noon meal revealed only one staff (Dietary Staff (DS) L) performed all dietary functions for the meal. The plates were located on a preparation counter located approximately 20 feet behind the steam table. While serving the meal DSL walked to the plates and brought them to the steam table, one at a time, served the food onto the plate, then walked the plate over to the counter by the serving window. DS L then served a piece of cake (still in the pan and not prepped prior to the meal) and handled hot rolls by the same gloved hand that previously handled utensils and other items in the kitchen. When prompted to use tongs and not gloved hands DS L used tongs and held onto the roll with gloved hands. While serving chicken he picked it up out of the pan with his gloved hand and placed it on the counter top, while holding it down with his same gloved hand, he then cut up the chicken, picked it up and placed on the plate. He repeated this numerous times. He then handled plates with contaminated hands. DS L was the only staff working the kitchen for breakfast and dinner meals for the cooking and cleaning the dishes. During the noon meal he had to stop serving the meal to residents to wash more plates to continue serving the meal. He also made three to order plates consisting of a chef salad, pancakes, and sausage, and soup and potatoes. DS K was in the dining room serving trays and did not offer assistance to DSL at any time during the meal. The first tray was served at 11:35 AM and the last tray left the kitchen at 12:15 PM. It took 40 minutes to serve 22 resident meals from the kitchen. During an interview on 12/28/21 at 01:15 PM Dietary Staff K reported the facility only had two cooks on staff. The day cook completed the breakfast and lunch meal tasks and another cook, and one dietary aide worked in the evening. The facility did not provide a policy for kitchen staffing as requested on 12/29/21 at 1:00 PM. The facility failed to ensure adequate staff to carry out all functions of the dietary service.

The facility had a census of 23 residents with 22 residents receiving meals from one main kitchen. Based on observation, interview, and record review the facility failed to prepare, store and handle food in a sanitary manner for residents who received meals from the kitchen. Findings included: - Observation of the kitchen on 12/28/21 at 11:00 AM revealed Dietary Staff (DS) L served the noon meal. While serving the meal, DS L handled hot rolls with his gloved hand, which he already used to handle utensils and other items in the kitchen. When prompted to use tongs to serve food and not his hands he used tongs and held onto the roll with a gloved hand. The rolls were stuck in the pan, so DS L leaned over the pan and the front of his shirt touched the rolls. While serving baked chicken DS L picked it up out of the pan with his gloved hand, placed the chicken piece on the counter top, held it down with his gloved hand, cut up the chicken, picked it up, and placed on the plate. He repeated this numerous times throughout the serving of the meal. He then handled plates with his contaminated gloved hands. Further observation of DS L after a resident ordered pancakes revealed he took a pitcher of pancake batter out of a small refrigerator under the counter to make the pancakes. The pitcher had no date and DS L did not know how old it was. During an interview on 12/28/21 at 01:15 PM DS K agreed DS L did not handle the food for the meal correctly and verified he should not have been touching the food with his gloved hands after touching other items with the gloves. DS K stated gloves and handwashing should be appropriate for what he was doing at that time. Review of the facility policy named Food Preparation and Handling dated 02/24/20 revealed all food items will be prepared and served with clean tongs, scoops, forks or other suitable implements to minimize handling and avoid manual contact of food at all points during preparation and service. Gloves will be changed, and hands washed between preparation of different food items and any time the gloves have been contaminated by any potentially soiled surface. Food items will never be touched directly without clean gloves in place. All left over must be dated, labeled, and covered. The facility failed to prepare, store and handle food properly and in a sanitary manner when served to residents.

The facility had a census of 23 residents with 12 residents included in the sample. Based on observation, interview and record review the facility failed to ensure the dignity of one resident who used a urinary catheter (tube inserted into the bladder to drain urine into a collection bag) by failing to place the urinary drainage bag in a dignity cover for Resident (R)173. Findings included: - R173's Electronic Health Record (EHR) revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) was incomplete as R173 admitted five days prior to the survey. The Baseline Care Plan dated 12/22/21 revealed R173 used a urinary catheter. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 12/27/21 at 10:06 AM revealed R173 sat in his room in a wheelchair and ate breakfast and watched television. A catheter bag attached underneath his wheelchair had no dignity bag in place. Observation on 12/27/21 at 04:44 PM revealed R173 sat in his room in a wheelchair and ate supper with no dignity bag covering the urinary catheter bag. In an interview on 12/28/21 at 10:15 AM Certified Medication Aide (CMA) E stated R173's catheter bag should have a dignity bag placed over it. In an interview on 12/28/21 at 03:23 PM Certified Nurse Aide (CNA) D stated she expected R173's catheter bag to be covered with a dignity bag. In an interview on 12/28/21 at 04:15 PM Administrative Nurse A stated she expected R173's catheter bag to be placed inside a dignity bag. The Indwelling Catheter Protocol policy dated 02/01/17 documented the drainage bag will be covered with a catheter bag dignity cover and the cover will be changed daily and whenever appears soiled or stained. The facility failed to maintain dignity for R173 by not placing his urinary catheter drainage bag inside a dignity cover.

The facility census totaled 23 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to provide written notice of hospitalization to the State Ombudsman for Resident (R)19's hospitalization on [DATE] and R 174's hospitalization on [DATE]. Findings included: - Resident (R) 19's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The resident required extensive to total assistance from staff with all cares. The resident had shortness of breath and required oxygen (O2) therapy. The resident had two or more falls and received antidepressant and diuretic medications for seven days of the observation period. The Cognitive loss/dementia Care Area Assessment (CAA) dated 11/29/21 revealed the resident had a BIMS of three. She had severe cognitive impairment due to a stroke, dementia, and intracerebral hemorrhage (bleeding in the brain). She remained oriented to person only. She had impaired memory and needed assistance with decision making. She had difficulties with inattention, disorganized thinking, and an altered level of consciousness that fluctuated. The Care Plan dated 11/25/2020 revealed Admission/Advance Directive Approaches included the resident desired full resuscitation. The resident was to receive a regular diet with puree, nectar thick liquids related to dysphagia. Approaches included- Resident to eat for short meal times of 15-20 minutes to decrease meal fatigue and decrease aspiration. Keep oxygen on when eating. Resident dependent with eating and staff to watch for swallow before giving next bite and use verbal cues to swallow when needed. A 12/18/2021 at 02:00 PM Nursing Progress Note revealed the resident had been lethargic today. She denied pain or discomfort. The resident stated she was just tired. She had poor oral intake. Staff encouraged fluids. The resident took thickened liquids with a spoon. She ate only bites of breakfast and let it run out of her mouth. A 12/21/2021 at 01:11 PM Nursing Progress Note revealed the resident had increasing lethargy over the past several days. She ate poorly and was not responding well verbally. The resident received an increasing dose of [MEDICATION(S)] (anti-[CONDITION(S)] medication) with the last increase on the 12/20/21 to 100 milligrams (mg) two times a day (BID). The nurse spoke with the resident's physician and he decreased the dosage with an additional decrease if this did not help. Staff called the resident's spouse and informed of the resident's condition. A 12/22/2021 09:30 AM Nursing Progress Note revealed staff alerted the Licensed Nurse (LN) that the resident looked flushed and felt warm. The resident continued to be lethargic and had poor intake. Temperature (T) taken and was 103.5 degrees Fahrenheit (F) axillary (under arm). The resident's oxygen saturation level was (SaO2) 83% on 1.5 Liters/Nasal cannula (L/NC). Staff increased the oxygen to 2L/NC and SaO2 increased to 85%. The resident's vital signs within normal limits and respirations (R) non-labored. Tylenol suppository (medication given rectally if resident unable to swallow by mouth) given at 09:07 AM for elevated temperature. At 09:22 AM T was 102 F axillary. The resident's SaO2 was 85-89% on 2.5 L/NC. At 09:40 AM, T was 101.3 F, R 22 per minute and non-labored, and SaO2 93% on 2.5 L/NC. 12/22/2021 at 11:06 AM Nursing Progress Note revealed the LN called report to the physician extender (APRN, Advanced Practice Registered Nurse) and informed her of the resident's condition. The physician extender gave orders to send the resident to the emergency room (ER). No Observation of the resident was possible due to resident remained in the hospital during all days of the survey (12/27-12/29/21. On 12/28/21 at 4:30 PM Certified Nursing Assistant (CNA) F reported she provided care to the resident prior to going to the hospital. The resident was very sick and needed total care for everything. On 12/28/21 at 10:01 AM Administrative Staff A reported no report of discharges or transfers were sent to the State Ombudsman. The facility's Bed Hold Policy dated 11/20/19 documented: All unplanned facility-initiated discharges will be reported to the State Ombudsman Office on the day of discharge / transfer by fax. The facility failed to provide written notice of hospitalization to the State Ombudsman for Resident (R)19's hospitalization on [DATE]. - Resident (R)174's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight which indicated mildly impaired cognition. The Quarterly MDS dated [DATE] revealed a BIMS score of six which indicated severely impaired cognition. A Fax note by Licensed Nurse (LN) M under miscellaneous tab on 12/06/21 documented a note informing R174's physician of a fall that resulted in a right [CONDITION(S)] and the resident transferred to the hospital. A nursing note in the Progress Notes tab by Administrative Nurse A on 12/22/21 documented R174 readmitted to the facility on [DATE]. Observation on 12/28/21 at 10:40 AM revealed R174 sat in her recliner with oxygen on per nasal cannula at 4L/min per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Room was well lit and there were no fall hazards noted. On 12/27/21 at 10:51 AM Administrative Nurse A stated R174 fell on [DATE] and broke her right hip. The facility sent R174 to the emergency room and she admitted to the hospital for surgery. R174 returned to the facility on [DATE]. On 12/28/21 at 10:01 AM Administrative Staff C stated no reports of discharges were sent to the ombudsman when a resident went to the hospital. The facility's Bed Hold Policy dated 11/20/19 documented: All unplanned facility-initiated discharges will be reported to the State Ombudsman Office on the day of discharge / transfer by fax. The facility failed to notify the ombudsman when R174 admitted to the hospital on 12/06/21.

The facility census totaled 23 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to provide the resident or the resident's represetative a Bed Hold Policy upon the hospitalization transfer on 12/22/21 of R19 and for the hospitalitzaiton transfer of R174 on 12/06/21. Findings included: - Resident (R) 19's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. The resident required extensive to total assistance from staff with all cares. The resident had shortness of breath and required oxygen (O2) therapy. The resident had two or more falls and received antidepressant and diuretic medications for seven days of the observation period. The Cognitive loss/dementia Care Area Assessment (CAA) dated 11/29/21 revealed the resident had a BIMS of three. She had severe cognitive impairment due to a stroke, dementia, and intracerebral hemorrhage (bleeding in the brain). She remained oriented to person only. She had impaired memory and needed assistance with decision making. She had difficulties with inattention, disorganized thinking, and an altered level of consciousness that fluctuated. The Care Plan dated 11/25/2020 revealed the Admission/Advance Directive approaches included the resident desired full resuscitation. The Care Plan further noted the resident required a regular diet with puree, nectar thick liquids related to dysphagia, R19 had a swallow study performed 08/25/21 and noted the resident had difficulty swallowing with moderate oropharyngeal phase dysphagia. The resident to eat for short meal times 15-20 minutes to decrease meal fatigue and decrease aspiration. The Care Plan instructed staff to keep oxygen on the resident when eating and noted the resident as dependent with eating and staff were to watch for her swallow before giving the next bite and to usee verbal cues to swallow when needed. A 12/18/2021 at 02:00 PM Nursing Progress Note revealed the resident had been lethargic today. She denied pain or discomfort. The resident stated she was just tired. She had poor oral intake. Staff encouraged fluids. The resident took thickened liquids with a spoon. She ate only bites of breakfast and let it run out of her mouth. A 12/21/2021 at 01:11 PM Nursing Progress Note revealed the resident had increasing lethargy over the past several days. She ate poorly and was not responding well verbally. The resident received an increasing dose of [MEDICATION(S)] (anti-[CONDITION(S)] medication) with the last increase on the 12/20/21 to 100 milligrams (mg) two times a day (BID). The nurse spoke with the resident's physician and he decreased the dosage with an additional decrease if this did not help. Staff called the resident's spouse and informed of the resident's condition. A 12/22/2021 09:30 AM Nursing Progress Note revealed staff alerted the Licensed Nurse (LN) that the resident looked flushed and felt warm. The resident continued to be lethargic and had poor intake. Temperature (T) taken and was 103.5 degrees Fahrenheit (F) axillary (under arm). The resident's oxygen saturation level (SaO2) was 83% on 1.5 Liters/Nasal cannula (L/NC). Staff increased the oxygen to 2L/NC and SaO2 increased to 85%. The resident's vital signs within normal limits and respirations (R) non-labored. Tylenol suppository (medication given rectally if resident unable to swallow by mouth) given at 09:07 AM for elevated temperature. At 09:22 AM T was 102 degrees F axillary. The resident's SaO2 was 85-89% on 2.5 L/NC. At 09:40 AM, T was 101.3 degrees 0F, R 22 per minute and non-labored, and SaO2 93% on 2.5 L/NC. On 12/22/2021 at 11:06 AM Nursing Progress Note revealed the LN called report to the physician extender (APRN, Advanced Practice Registered Nurse) and informed her of the resident's condition. The physician extender gave orders to send the resident to the emergency room (ER). On 12/28/21 at 4:30 PM Certified Nursing Assistant (CNA) F reported she provided care to the resident prior to going to the hospital. The resident was very sick and needed total care for everything. On 12/28/21 at 10:01 AM Administrative Staff A reported no report of discharges or transfers were sent to the State Ombudsman. The facility's Bed Hold Policy dated 11/20/19 documented: Within 24 hours [the facility] transfers a resident to a hospital or the resident goes on therapeutic leave, this facility will provide written information to the resident and/or resident representative that specifies: the duration of the state bed-hold policy during, which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The facility failed to provide the resident or the resident's represetative a Bed Hold Policy upon the hospitalization transfer on 12/22/21 of R19. - Resident (R)174's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight which indicated mildly impaired cognition. The Quarterly MDS dated [DATE] revealed a BIMS score of six which indicated severely impaired cognition. A Fax by Licensed Nurse (LN) M under miscellaneous tab on 12/06/21 documented a note informing R174's physician of a fall that resulted in a right [CONDITION(S)] and the resident transferred to the hospital. A Nursing Note in the Progress Notes tab by Administrative Nurse A on 12/22/21 documented R174 readmitted to the facility on [DATE]. Review of the resident's EHR lacked documentation of provision of the facility's bed hold policy to the resident or her representative. Observation on 12/28/21 at 10:40 AM revealed R174 sat in her recliner with oxygen on per nasal cannula at 4L/min per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/27/21 at 10:51 AM Administrative Nurse A stated R174 fell on [DATE] and broke her right hip. The facility sent R174 to the emergency room and she admitted to the hospital for surgery. R174 readmitted back to the facility on [DATE]. On 12/28/21 at 10:01 AM Administrative Staff C stated no bed hold policies were sent with residents or their family when a resident admitted to the hospital. The facility's Bed Hold Policy dated 11/20/19 documented: Within 24 hours [the facility] transfers a resident to a hospital or the resident goes on therapeutic leave, this facility will provide written information to the resident and / or resident representative that specifies: the duration of the state bed-hold policy during, which the resident is permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; the facility's policies regarding bed-hold period, which are consistent with the law permitting the resident to return. The facility failed to provide R174 or her representative with written notice concerning the facility's bed hold policy when R174 discharged to the hospital.

The facility census totaled 23 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to revise the care plan to include coordination of the nursing care provided by the facility with the care provided by hospice. Resident (R) 13. Findings Included: - Resident (R)13's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition. The resident was totally dependent on two staff for all care. The resident received all nutrition and hydration via a gastrostomy tube (tube placed through abdomen into the stomach for nourishment) with weight stable. The resident received hospice care. Review of the Care Plan dated 01/16/20 revealed the resident would maintain adequate nutritional status as evidenced by maintaining weight within 10% of 140 pounds (lbs), no signs or symptoms of worsening malnutrition through the review date. The Care Plan lacked interventions for provision of hospice care and coordination of care with hospice staff. A 12/03/21 Progress Note by Licensed Nurse (LN) B revealed the resident had a shower that morning and was shaking and moaning uncontrollably. Staff gave [MEDICATION(S)] (opioid pain medication) and [MEDICATION(S)] (antianxiety). His temperature was 102.9 degrees Fahrenheit (F) axillary (under the arm) . An assessment revealed coarse wet crackles in all lobes of the lungs. The resident was coughing with secretions running from mouth. Staff gave Tylenol (medication to bring down fever) and [MEDICATION(S)] (cough medication). After a couple hours the resident finally relaxed and rested quietly. LN B spoke with the resident's family and they felt it was time to call hospice for evaluation. Staff would request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses Progress notes dated 12/15/21 revealed the resident was to have nothing by mouth (NPO) and received enteral feedings, fluids, and medications through gastrostomy tube. He had dysphagia due to a stroke. His weight was stable. He received hospice services for Alzheimer's. The resident had severe cognitive impairment. Observation on 12/27/21 at 03:43 PM revealed the resident slept in bed with the head of bed (HOB) elevated. The resident was on his right side with a fan on in room. The resident had no signs of discomfort. Observation on 12/28/21 at 10:41 AM revealed the resident lay on back position with HOB elevated slightly. His knees were drawn up with a pillow for support. The resident made no response when spoken to with no non-verbal signs of discomfort or distress. During an interview on 12/28/21 at 10:36 AM Certified Medication Aide E verified the resident received hospice services. She reported not knowing what the hospice aide did with the resident, or how often they came, but no matter what hospice did for the resident it was just extra because we care for him and meet his needs. The facility staff provided all the residents care. During an interview on 12/28/21 at 04:30 PM Certified Nursing Assistant F reported the resident was total care for everything. He had no behaviors but did moan and occasionally would yell. He received hospice services and staff turned him every two hours. He did not take anything by mouth, it all went through his tube. During an interview on 12/28/21 at 01:20 PM LN B reported the resident has not been on hospice for long. The hospice nurse checked with staff when she came. She did not know what schedule they were on or when they would be in to see the resident. She reported she is the one to update care plans as needed but just had not had the time to get to it. She would make sure the care plan was updated. The facility's Care Plan Revisions policy dated 02/01/17 documented: The Care Plan will be revised whenever the elder or responsible party / family make the decision to accept palliative or hospice services .The Care Plan will include detailed and comprehensive instructions to staff on which staff from which specific organization provides services and equipment for the care of the elder and support to the family. The facility failed to revise the resident care plan to include coordination of the nursing care provided by the facility with the care provided by hospice.

The facility census totaled 23 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to coordinate nursing care provided by the facility with the care provided by hospice for Resident (R) 13. Findings included: - R 13's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed the resident had severely impaired cognition. The resident was totally dependent on two staff for all care. The resident received all nutrition and hydration via a gastrostomy tube (tube placed through abdomen into the stomach for nourishment) with weight stable. The resident received hospice care. Review of the Care Plan dated 01/16/20 revealed the resident would maintain adequate nutritional status as evidenced by maintaining weight within 10% of 140 pounds (lbs), no signs or symptoms of worsening malnutrition through the review date. The Care Plan lacked interventions for provision of hospice care and coordination of care with hospice staff. A 12/03/21Progress Noteby Licensed Nurse (LN) B revealed the resident had a shower that morning and was shaking and moaning uncontrollably. Staff gave [MEDICATION(S)] (opioid pain medication) and [MEDICATION(S)] (antianxiety). His temperature was 102.9 degrees Fahrenheit (F) axillary (under the arm) . An assessment revealed coarse wet crackles in all lobes of the lungs. The resident was coughing with secretions running from mouth. Staff gave Tylenol (medication to bring down fever) and [MEDICATION(S)] (cough medication). After a couple hours the resident finally relaxed and rested quietly. LN B spoke with the resident's family and they felt it was time to call hospice for evaluation. Staff would request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses Progress notes dated 12/15/21 revealed the resident was to have nothing by mouth (NPO) and received enteral feedings, fluids, and medications through gastrostomy tube. He had dysphagia due to a stroke. His weight was stable. He received hospice services for Alzheimer's. The resident had severe cognitive impairment. Observation on 12/27/21 at 03:43 PM revealed the resident slept in bed with the head of bed (HOB) elevated. The resident was on his right side with a fan on in room. The resident had no signs of discomfort. Observation on 12/28/21 at 10:41 AM revealed the resident lay on back position with HOB elevated slightly. His knees were drawn up with a pillow for support. The resident made no response when spoken to with no non-verbal signs of discomfort or distress. During an interview on 12/28/21 at 10:36 AM Certified Medication Aide E verified the resident received hospice services. She reported not knowing what the hospice aide did with the resident, or how often they came, but no matter what hospice did for the resident it was just extra because we care for him and meet his needs. The facility staff provided all the residents care. During an interview on 12/28/21 at 04:30 PM Certified Nursing Assistant F reported the resident was total care for everything. He had no behaviors but did moan and occasionally would yell. He received hospice services and staff turned him every two hours. He did not take anything by mouth, it all went through his tube. During an interview on 12/28/21 at 01:20 PM LN B reported the resident has not been on hospice for long. The hospice nurse checked with staff when she came. She did not know what schedule they were on or when they would be in to see the resident. A request was made on 12/28/21 at0 2:30 PM for a policy for Hospice Care. No policy was provided. The facility failed to coordinate nursing care provided by the facility with the care provided by hospice.

The facility reported a census of 23 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to provide necessary services to decrease the risk of a urinary tract infection when the staff failed to ensure Resident (R)173's urinary catheter drainage bag did not come in direct contact with the floor. Findings included: - R173's Electronic Health Record (EHR) revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) was incomplete as R173 admitted five days prior to the survey. The Baseline Care Plan dated 12/22/21 revealed R173 used a urinary catheter. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 12/27/21 at 10:06 AM revealed R173 sat in his room in a wheelchair and ate breakfast and watched television. A catheter bag attached underneath his wheelchair with the tubing looped down and in contact with the floor. Observation on 12/27/21 at 04:44 PM revealed R173 sat in his room in a wheelchair and ate supper. A catheter bag attached underneath his wheelchair with the tubing looped down and in contact with the floor. In an interview on 12/28/21 at 10:15 AM Certified Medication Aide (CMA) E stated R173's catheter tubing should not drape down to the floor. In an interview on 12/28/21 at 03:23 PM Certified Nurse Aide (CNA) D stated R173's catheter tubing should not drape down to the floor. In an interview on 12/28/21 at 04:15 PM Administrative Nurse A stated she expected R173's catheter b tubing should not hang down touching the floor. Administrative Nurse A expected that while R173 was in bed his catheter bag should be hooked to the side of the bed and while he sat in his wheelchair the catheter should bag be hooked under his wheelchair in a dignity bag with the excess tubing coiled inside the bag. The Indwelling Catheter Protocol policy dated 02/01/17 documented, Never allow the bag or the tubing to touch the floor. The facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to ensure R173's urinary catheter tubing did not rest on the floor.

The facility had a census of 23 residents, with 12 residents sampled, and five reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to ensure the Consulting Pharmacist identified the lack of an end date for as needed (PRN) [CONDITION(S)] (relating to or denoting drugs that affect a person's mental state) medications administered past 14 days for Resident (R) 9. Findings included: - R9's signed Physician Orders dated 11/30/21 revealed the following diagnoses: [CONDITION(S)] (when the arteries become narrowed and hardened due to buildup of plaque or fat in the artery wall), complete traumatic amputation (Removal of a body part) of left great toe, amputation at level between knee and ankle left lower leg. The Admission Minimal Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of one staff with daily cares. Medications included insulin, antidepressants, antibiotic, diuretic, and opioid medications seven days of the observation period. The Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The resident required extensive assistance of two staff with daily cares. Medications included use of insulin, antianxiety, antidepressant, diuretic, and opioid medications 7 days of the 7-day observation period. The 12/29/21 [CONDITION(S)] Drug Use Care Area Assessment (CAA) statedR9 received [MEDICATION(S)] for depression and was on medication prior to admission. She had anxiety and was at risk for falls. Physician Orders dated 11/30/21 in included an order for lorazepam 0.5 milligrams (mg). Give 1 tablet by mouth as needed for anxiety up to three times daily with a start date of 05/12/21. The Consulting Pharmacist Monthly Medication Review dated 02/27/21 through 11/30/21 failed to identify that the lorazepam lacked the 14 day stop date. Observation on 12/27/21 at 04:13 PM revealed the resident sat in her wheelchair with a pillow under her left leg with the amputation to her knee and right foot resting on a pillow on the foot pedal. The resident denied pain or discomfort and watched a movie in her room. On 12/28/21 08:22 AM the resident sat in her wheelchair and ate breakfast in her room with the left leg supported with a pillow and a sock on the right foot watching TV. Observation on 12/28/21 10:39 AM revealed the resident sat in her wheelchair and talked on the phone with no behaviors or lethargy noted. On 12/28/21 at 12:50 PM Certified Medication Aide (CMA) E reported the resident had a lot of pain still even after her amputations. The resident received [MEDICATION(S)] PRN and did not seem to be lethargic or unable to waken. She was always alert, but she had a lot of anxiety. On 12/28/21 at 04:15 PM CMA I reported the resident had a lot of pain due to her amputations she asked for the [MEDICATION(S)] PRN for anxiety. On 12/28/21 at 04:40 PM Administrative Nurse A reported they usually put a stop date on the medication and usually it will come up with an alert to notify the staff to contact the physician for a new order. The physician will put a stop date with the psychotropics, but this one was missed. On 12/29/21 at 10:30 AM Consulting Pharmacist J revealed that she was not aware that a PRN antipsychotropic needed to have a 14 day stop date or new order from the physician, but from now on would be monitoring the medications. The facility's undated [CONDITION(S)] Medication Use policy did not address PRN's. The facility failed to ensure the Consulting Pharmacist identified the lack of an end date for PRN [CONDITION(S)] medications administered past the 14-day requirement.

The facility had a census of 23 residents with 5 residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure Resident (R)9's as needed (PRN) [CONDITION(S)] medication had the appropriate end date. Findings included: R9's signed Physician Orders dated 11/30/21 revealed the following diagnoses: [CONDITION(S)] (when the arteries become narrowed and hardened due to buildup of plaque or fat in the artery wall), complete traumatic amputation (removal of a body part) of left great toe, amputation at level between knee and ankle left lower leg. The Admission Minimal Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance of one staff with daily cares. Medications included insulin, antidepressants, antibiotic, diuretic, and opioid medications seven days of the observation period. The Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The resident required extensive assistance of two staff with daily cares. Medications included use of insulin, antianxiety, antidepressant, diuretic, and opioid medications 7 days of the 7-day observation period. The 12/29/21 [CONDITION(S)] Drug Use Care Area Assessment (CAA) stated R9 received [MEDICATION(S)] for depression and was on the medication prior to admission. She had anxiety and was at risk for falls. Physician Orders dated 11/30/21 in included an order for lorazepam 0.5 milligrams (mg). Give 1 tablet by mouth as needed for anxiety up to three times daily with a start date of 05/12/21. The Consulting Pharmacist Monthly Medication Review dated 02/27/21 through 11/30/21 failed to identify that the lorazepam lacked the 14 day stop date. Observation on 12/27/21 at 04:13 PM revealed the resident sat in her wheelchair with a pillow under her left leg with the amputation to her knee and right foot resting on a pillow on the foot pedal. The resident denied pain or discomfort and watched a movie in her room. On 12/28/21 08:22 AM the resident sat in her wheelchair and ate breakfast in her room with the left leg supported with a pillow and a sock on the right foot watching TV. Observation on 12/28/21 10:39 AM revealed the resident sat in her wheelchair and talked on the phone with no behaviors or lethargy noted. On 12/28/21 at 12:50 PM Certified Medication Aide (CMA) E reported the resident had a lot of pain still even after her amputations. The resident received [MEDICATION(S)] PRN and did not seem to be lethargic or unable to waken. She was always alert, but she had a lot of anxiety. On 12/28/21 at 04:15 PM CMA I reported the resident had a lot of pain due to her amputations and she asked for the [MEDICATION(S)] PRN for anxiety. On 12/28/21 at 04:40 PM Administrative Nurse A reported they usually put a stop date on the medication and usually it will come up with an alert to notify the staff to contact the physician for a new order. The physician will put a stop date with the psychotropics, but this one was missed. On 12/29/21 at 10:30 AM Consulting Pharmacist J revealed that she was not aware that a PRN antipsychotropic needed to have a 14 day stop date or new order from the physician, but from now on would be monitoring the medications. The facility's undated [CONDITION(S)] Medication Use policy did not address PRN medications. The facility failed to ensure R9's PRN [CONDITION(S)] medication had the appropriate end date.

The facility identified a census of 22 residents, with one kitchen which included a low temperature dishwasher and a compartment sink for manual dishwashing, in which both required the use of sanitizing solution. Based on observation, interview, and record review the facility failed to maintain sanitizer solution concentration levels when they did not document or maintain logs of the sanitizer concentration levels for the dishwasher sanitizer and the Quat (a surfactant cleaning chemical that is typically used in hospitals and food processing plants) sanitizer solutions. Findings included: - Review of the logbook and records in the kitchen lacked evidence of a log for dishwasher sanitizer of the Quat sanitizing solution. An observation on 03/04/20 at 10:35 AM of Dietary Staff (DS) I checked the sanitizer in dishwasher and used improper strips and could not determine why the color was splotchy. After obtaining proper test strips, she tested the dishwasher sanitizer solution, which resulted at less than 10 parts per million (ppm). An observation on 03/04/20 at 10:45 AM of DS I revealed she did not know how to test the Quat sanitizer solution and reported she did not test or maintain logs of the Quat sanitizer. An observation on 03/04/20 at 02:08 PM revealed Eco Lab (company that maintenance the sanitizer solutions) Representative K in the kitchen with DS I, who tested the dishwasher sanitizer which resulted at 100 ppm and the Quat sanitizer resulted at 300 ppm. An interview on 03/04/20 at 10:42 AM with DS J revealed she documented dishwasher temperatures only and did not document dishwasher sanitizer levels. An interview on 03/04/20 at 10:43 AM with Dietary Manager (DM) H revealed she did not know how to test the sanitizer solutions. She stated eco lab company went to the facility on ce per month to maintain the sanitizer. An interview on 03/04/20 at 10:45 AM with DS I stated the facility used the Quat sanitizer solution for manual dishwashing and to sanitize kitchen counter and dining room table surfaces and did not test the Quat sanitizer solution. An interview on 03/04/19 at 10:45 AM with DM H, DS I, and DS J revealed the staff did not log dishwasher or Quat sanitizer concentration levels and reported they did know what effective sanitizer concentration levels were. An interview on 03/04/20 at 11:15 AM with DM H stated she did not have expectations of the dietary staff to monitor the dishwasher and Quat sanitizer solutions in the kitchen. An interview on 03/04/20 at 11:18 AM with DM H revealed she contacted an Eco Lab representative who informed her of proper dishwasher sanitizer results were 100 ppm and requested new test strips for the sanitizer. An interview on 03/04/20 at 02:05 PM with DM H stated Eco Lab Representative K arrived at the facility and tested the dishwasher sanitizer with new strips, which resulted at 100 ppm and confirmed the old test strips were bad. An interview on 03/05/20 at 12:17 PM with Administrative Staff A stated she expected dietary staff to test and log the sanitizer results at least daily and expected dietary staff to know effective sanitizer concentration levels for both the dishwasher and Quat sanitizer solutions. The facility's policy titled, Dishwashing Protocol, dated 02/24/2016 documented, All staff members will follow accepted practices in washing dishes that will prevent food borne illnesses. The policy instructed staff to check dishwasher sanitizer levels prior to the beginning of dishwashing, ensure concentration levels of a minimum of 50 ppm, and to document the results. The policy lacked information or instructions for manual dishwashing. The policy lacked information and instructions for the use and/or maintenance of the Quat sanitizer solution. The facility's policy titled, Sanitation, revised on 07/21/14 ensured the proper dishwashing procedures would be followed and lacked information or instructions for the use of Quat sanitizer solution. The facility did not provide a policy for the Quat sanitizer solution. The facility failed to maintain sanitizer solution concentration levels when they did not document and/or maintain logs of dishwasher sanitizer and the Quat sanitizer concentration level results. This had the ability to affect all residents.

The facility reported a census of 29 residents, with 15 residents included in the sample. Based on observation, interview and record review the facility failed to identify causal factors, failed to identify and/or implement fall prevention interventions to prevent further falls for 4 of 5 residents reviewed for accidents. Resident #130 experienced 64 falls from 8/3/16-2/26/18, including multiple falls due to malfunctioning fall alarm, falls from his/her mechanical lift recliner, and a fall in which he/she acquired a 5-6 centimeter (cm) [MEDICAL CONDITION] (wound to the skin). His/her skull was exposed and required 12 staples, a large skin tear to most of the back of his/her hand, and a wrist fracture (broken bone). The facility failed to identify causal factors of falls and failed to identify/implement fall prevention interventions to prevent future falls for resident #132, who experienced 10 falls from 11/24/16-6/28/17. The facility failed to provide supervision and assistive devices, failed to identify causal factors and failed to implement timely and effective interventions for cognitively impaired resident #23 identified at risk for falls. The resident experienced more than 28 falls, which resulted in skin tears, bruising, head, back and neck pain, hospital evaluation and treatments and a [MEDICAL CONDITION]. The facility failed to ensure resident #23 did not wander, unsupervised to an unsafe place. (#130, #132, #23) Findings included: - Review of resident #130's signed medication review report dated 1/9/18 revealed the following Diagnoses: [REDACTED]. The 12/17/17 quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident required extensive assistance of one staff with bed mobility, transfers, walking in the room and the corridor, and locomotion on and off the unit. The resident was not steady and only able to stabilize with staff assistance for all balance during transitions and walking, and used a walker and a wheelchair for mobility. The resident experienced 2 or more falls since prior assessment-2 with minor injury and 2 without injury. The resident received antianxiety medications for 2 days and daily antidepressant and diuretic (medication to promote the formation and excretion of urine) medications, during the 7-day observational period. The staff used a chair alarm (an alarm used to notify staff if a resident got up from his/her chair) for the resident, daily. Review of the 1/19/18 significant change MDS revealed a BIMS of 6, indicating severe cognitive impairment. The resident required extensive assistance of one staff with bed mobility, transfers, walking in the room and corridor, and locomotion on and off of the unit. The resident was not steady and required staff assistance with stabilization for all balance during transitions and walking, and used a walker and a wheelchair for mobility. The resident had a chronic disease or condition that may result in a life expectancy of less than 6 months. The resident had 2 or more falls since prior assessment. The staff used a chair alarm for the resident daily. Review of the 1/19/18 Cognitive loss/dementia Care Area Assessment (CAA) documented the resident's BIMS score decreased to 6 from 13 on 12/17/17. The resident experienced a decline in status and admitted to hospice care on 1/5/17. The resident required extensive staff assistance with most Activities of Daily Living (ADLs) and reported trouble sleeping. The care plan would focus on minimizing risks. Review of the 1/19/18 ADL CAA documented the resident required staff assist to steady him/herself with transitions. The resident was alert and able to answer questions. The resident's last hospitalization was from 10/26/17 - 10/28/17. The resident was very weak and had [MEDICAL CONDITION], depression, and anxiety. Review of the 1/19/18 Falls CAA documented the resident had a history of [REDACTED]. The resident received [MEDICATION NAME] (antidepressant medication) for depression. Review of the fall risk assessments revealed the following: 6/13/16: high risk, score of 18 9/15/16: moderate risk, score of 12 12/30/16: high risk, score of 24 3/17/17: moderate risk, score of 14 6/15/17: moderate risk, score of 12 9/15/17: high risk, score of 19. 12/16/17: high risk, score of 21 1/17/18: high risk, score of 23. Review of the 6/18/13 care plan, last reviewed (3/26/18) revealed the resident had a high risk for falls related to poor safety awareness, [MEDICAL CONDITIONS] (damage to the nerves, which causes tingling and numbness) and previous right [MEDICAL CONDITION]. The resident often felt he/she could do more for him/herself than he/she could and when staff found the resident up, the resident stated, I can get up if I want, and needed staff assistance to stabilize. The care plan included the following interventions related to falls: 6/18/13: Monitor for fall risk. 6/19/13: Anticipate the resident's needs. 6/19/13: Ensure the call light remained in reach and encourage the resident to use it for assistance. 6/19/13: The resident needed prompt response to all requests for assistance. 12/15/14: Ensure the resident had the control to his/her chair tucked back beside the resident so he/she could not accidentally raise his/her chair (resolved 11/24/15) 8/4/16: Staff witnessed the resident fall on 8/3/16. Staff were to remember to use a gait belt to assist the resident with ambulation. 11/22/16: The resident fell on [DATE] in the bathroom. Do not leave the resident on the toilet by him/herself (resolved 6/21/17) 2/15/17: The resident fell with injury on 2/15/17. Remind staff to place a silent pressure alarm in the resident's wheelchair when the resident used it. 3/25/17: The resident fell on [DATE]. The resident got up without assistance and received a skin tear to his/her left upper arm. The resident got up to fold some blankets. Intervention: bring to the nurse's station for one-on-one. (The intervention lacked specifics on when the staff should implement the intervention) 3/29/17: The resident fell backwards getting up from his/her recliner on 3/28/17, resulting in a skin tear to his/her right lower leg 1 centimeter (cm) x 2 cm. 5/16/17: The resident fell in his/her room and staff found him/her behind his/her bedside table and under the bed. Intervention: Move things in the room to give the resident access to the things he/she wanted to prevent him/her from going to look for them. 6/25/17: Staff found the resident on the floor on his/her right side. The resident slid out of the chair looking for his/her earring. Intervention: If the resident stated he/she would not to stay in his/her chair, staff would not leave him/her unattended. 7/26/17: The resident slid out of his/her recliner attempted to pick up a bracelet off of the floor. Intervention: Give the resident a food service tray to put on his/her lap when working with jewelry and other personal items to help prevent items from falling to the floor. 8/12/17: A table was set up in the resident's room with a lot of the resident's jewelry and beads to keep the resident busy so he/she did not get bored. 9/2/17: The resident rolled out of bed. 10/1/17: The resident fell on [DATE] and stated he/she did not fall and had no injury. Interventions: Ensure the resident's fall alarm worked properly. 10/6/17: The resident scooted into the hallway to look for water--no injury. 10/18/17: The resident fell out of his/her recliner reaching for newspapers. 10/25/17: The resident fell without injury but would not tell the nurse what he/she attempted to do when he/she fell . The staff ensured the busy table was within his/her reach while the resident sat in his/her recliner. 11/15/17: The resident got onto the floor to look for something. Staff were to offer the resident time on the floor after meals or at other times, per the resident's preference. 11/16/17: The resident got down on the floor to pick something up. Encourage the resident to use his/her call light and let staff pick up items. Keep the activity table within reach of the resident at all times when the resident was not at meals or activities. Staff were to keep things picked up off the resident's floor. 11/19/17: On 11/18/17 the resident got down on the floor to pick up beads and the alarm did not function properly. The staff were to ensure the resident's alarm functioned properly. 11/20/17: The resident fell in his/her room (attempted to move to his/her other chair). The staff rearranged the resident's furniture where the other chair was out of sight of the resident to discourage him/her from wanting to move to it. 11/23/17: The resident fell in his/her room when he/she went to turn off the light and used the card table as a crutch and it tipped over. No injury. 1/1/18: The resident could not bear weight and was lowered to the floor on 1/1/18. Staff were to use a gait belt with all transfers and ambulation. 2/8/18: The resident fell getting out of bed at the inappropriate height and the resident did not have his/her call light. The resident needed facial tissues. Staff were educated on correct bed height for the resident and to ensure the resident's call light was attached to the resident's clothing. 2/16/18: On 2/15/18 the resident got him/herself down onto the floor out of the recliner without injury. The resident's pressure alarm did not go off, due to it was stuck in the cushion in the resident's chair. The staff placed a new cushion in the resident's chair. 2/20/18- The resident fell from his/her mechanical lift chair he/she had in the upright/standing position. 2/26/18: The resident slid out of his/her recliner. The pressure alarm did not work and was replaced. review of the resident's medical record revealed [REDACTED]. Review of the fall incident notes and associated fall investigations revealed the following: Fall #1: Progress note dated 8/3/16 at 7:11 p.m. revealed the resident had a witnessed fall when a direct care staff member did not use a gait belt on the resident and the staff member did not know to use a gait belt for the resident. The resident acquired a 2 cm x 1.5 cm skin tear to his/her right elbow. Review of the fall investigation noted the causal factor as new staff did not use a gait belt. Fall #2: Review of the 10/6/16 incident note revealed at 5:15 p.m. a direct care staff responded to a fall alarm and found the resident seated on the floor in front of his/her recliner. Review of the medical record lacked evidence of an assessment regarding the safe usage of the mechanical lift recliner for resident #130 and the facility failed to provide lift chair assessment documentation. Review of the 10/6/16 fall investigation revealed the witness statement from direct care staff J revealed staff J sat in the dining room assisting during supper. His/her pager went off for quite a while and he/she noticed it was the resident's fall alarm. The licensed nursing staff (unnamed) on duty sat at the nurse's desk with his/her head down so the direct care staff J responded to the resident's alarm and found the resident on the floor. The resident was very confused. The fall investigation did not identify causal factors and did not identify care plan intervention. Fall #3: Review of the 10/8/16 incident note revealed at 2:16 p.m. staff found the resident on the floor, on his/her pillow, with the recliner in the up position. No injury noted. Review of the 10/8/16 fall investigation revealed a copy of the incident note from 10/8/16 and the investigation did not identify causal factors or care plan interventions implemented to prevent future falls. Fall #4: Review of the 11/18/16 fall investigation revealed the resident fell , unwitnessed, at 6:25 p.m. The resident acquired a hematoma (collection of blood under the surface of the skin, due to trauma/injury) to the top of his/her scalp and a skin tear to his/her right elbow and left back side of his/her hand. The resident had impaired memory and gait imbalance and ambulated without assistance. Per the Fall Scene Investigation (FSI) report staff found the resident on his/her right side in front of the recliner with his/her right arm under him/her. The resident injuries included: skin tear (left hand) 2 cm x 1 cm - crescent shape; skin tear to right lower arm 2.5 cm x 1.5 cm, crescent shape; and an abrasion( scraping or rubbing away of a surface, such as skin, by friction) and hematoma to the right side of the top of the resident's head. The resident described the pain as aching and rated it a 4 out of 10 (with 10 being the worst pain). The fall occurred in the resident's bedroom, with the resident seated in his/her recliner just prior to the fall. The alarm was used and did not function properly. The staff noted the alarm was not connected/came out. The investigation identified the initial root cause as: the resident wanted to get up, and identified the initial intervention as: instruct resident to used call light and wait for help. Fall #5: Review of the 11/19/16 fall investigation revealed the resident fell , unwitnessed, at 6:19 p.m. in the resident's bedroom, when he/she attempted to self-transfer and slid out of his/her recliner, alone and unattended. The initial root cause identified included: non-safe use of chair remote; and initial interventions to prevent future falls: leave the chair remote out of reach and encourage call light use for assistance. Fall #6: Review of the 11/22/16 FSI revealed an unwitnessed fall at 3:30 p.m. when the resident's toilet riser tipped. Staff found the resident on his/her right side and his/her back towards the toilet. Injuries noted: skin tear to his/her right hand near the thumb 2.5 cm, right lower extremity 1 cm, right outer wrist 0.5 cm, bruise to right elbow around old skin tear and to forearm 9 cm x 6 cm. The resident denied pain. The facility identified the initial root cause of the fall as the resident was alone and his/her riser tipped as he/she got up. The initial care plan interventions to prevent future falls identified: resident not to be left unattended on the toilet. The investigation did not address securing the toilet riser. Fall #7: Review of the 12/17/16 at 3:09 p.m. progress note revealed (unnamed) direct care staff observed the resident seated on the edge of his/her chair and leaned to the left. As the direct care staff assisted the resident, the resident slid out of his/her chair, and landed on the pillow which propped up his/her legs. The resident insisted his/her her call light was on for an hour. The staff looked at the call log and resident's light was on for 3 minutes and answered prior to the fall. At the time of the fall the resident did not have on his/her call light. The resident was very head strong and did get confused at times. Staff encouraged the resident to use his/her call light when he/she needed help. There was no fall investigation associated with the fall. Fall #8: Review of the 1/1/17 at 10:37 p.m. incident note revealed the resident's pressure alarm sounded. Staff found the resident seated on the floor in his/her room facing the recliner chair. The resident acquired 2 skin tears ( 1) v-shaped 0.5 cm x 2 cm; 2) 1 cm slit; and a bruised area 9.5 cm x 2.5 cm). Review of the 1/1/17 FSI revealed an unwitnessed fall at 10:37 p.m. in which the resident used a chair remote to sit the lift chair in an up position and then slid onto floor. The resident had a silent pressure alarm sounding at the time of the fall. The FSI did not identify an initial root cause and did not identify an initial intervention to prevent future falls. Fall #9: Review of the incident note dated 1/9/17 at 1:58 p.m revealed the resident fell , unwitnessed, without injury from his/her lift recliner. The resident attempted to get up without assistance and elevated his/her lift chair to the full upright position and slid out onto the floor. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #10: Review of the 1/24/17 incident note at 6:45 p.m. revealed the resident fell without injury when he/she slid out of his/her chair onto a pillow. The unnamed licensed nurse assisted the resident up and kicked the pillow out of the way, but lost his/her balance and they both fell again. The nurse protected the resident's head, however, the resident acquired a skin tear to his/her right elbow which measured 4 cm x 2 cm, which required Steri-strips. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #11: Review of the 2/2/17 at 1:55 p.m. incident note revealed the resident experienced an unwitnessed, non-injury fall when staff found the resident on the floor by his/her doorway. Staff assisted the resident up to his/her recliner and the resident got upset he/she could not walk 10 feet The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #12: Review of the 2/4/17 at 11:05 a.m. incident note revealed the resident fell , unwitnessed, and unnamed direct care staff found the resident in the doorway of his/her room seated on his/her buttocks. The resident had blood on his/her left shin and right foot and ankle. The staff assessed two skin tears on the resident's left shin, with the higher skin tear laid back 2 cm and 4 cm long, skin was approximated (brought back together) and the lower skin tear measured 2 cm long. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #13: Review of the 2/6/17 incident note revealed at 8:51 p.m. direct care staff found the resident on the floor in his/her room seated on his/her buttocks in front of his/her recliner. The staff noted no injuries to the resident. Review of the 2/6/17 FSI report revealed the resident fell , unwitnessed, at 8:51 p.m. Staff found the resident on his/her buttocks in front of his/her recliner. Staff noted no injuries and the resident reported bilateral knee pain, rated a 5/10. The FSI did not identify an initial root cause of the fall and did not identify care plan interventions to prevent future falls. Fall #14: Review of the 2/16/17 at 2:28 a.m. incident note revealed the resident received and antianxiety medication at 4:00 p.m. for anxiety and restlessness. Staff noted the resident continued to look for objects over and over and got him/herself down to the foot rest of his/her chair and leaned nearly out of his/her chair. Staff redirected and brought the resident closer to the nurse's station for supervision and to do an activity. The resident experienced an unwitnessed fall from his/her wheelchair in the hallway at approximately 8:55 p.m. and acquired a new 4 cm x 5 cm bruise to right wrist. The associated FSI report revealed the resident fell on [DATE] at 8:55 p.m. when staff found the resident laying his/her back next to the wall in the south hallway and his/her wheelchair behind the resident. The resident acquired a 4 cm x 5 cm bruise to right wrist. The FSI initial root cause of the fall was blank. The initial care plan intervention to prevent future falls was to remind staff to place silent pressure alarm in the resident's wheelchair when the resident sat in it. The FSI identified the staff failed to use the care planned fall alarm for the resident at the time of the fall. Fall #15: Review of the 2/19/17 incident note revealed at 3:30 p.m. unnamed direct care staff responded to the resident's room because the fall alarm sounded and the direct care staff observed the resident on his/her buttocks scooting toward the sink. The staff noted the resident obtained no injuries. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #16: Review of the incident note dated 2/21/17 at 12:46 a.m. revealed the resident rang his/her call light for assistance and the direct care staff asked the resident to wait for him/her to get his/her walker from the shower room (as it was being cleaned). Upon return to the room with the walker the staff member observed the resident had scooted him/herself down the footrest and out of the recliner. The resident stated, yea, because I needed to go to the bathroom. The staff noted no visible injuries. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls. Fall #17: Review of the 2/24/17 incident note revealed staff observed the resident seated on the floor in front of his/her wheelchair at 5:15 p.m. Staff noted the resident's recliner had the foot rest up. The resident had opened a small abrasion 1 cm x 2 cm on his/her left knee. Review of the 2/24/17 FSI report revealed the resident fell on at 5:15 p.m. and slipped off the foot of his/her recliner. Staff found the resident sitting up sideways in front of the wheelchair. The investigation revealed the resident slid out of the recliner in his/her room while alone and unattended. When asked what he/she was doing prior to the fall, the resident stated, get to dryer. The resident had a fall alarm intervention at the time of the fall but it was not on, as the alarm box was next to the sink. The initial root cause of the fall was identified as weakness due to [MEDICAL CONDITION] and the initial interventions to prevent future falls was blank. Fall #18: Review of the 3/5/17 incident note revealed staff found the resident on the floor in front of his/her recliner, which the resident slid out of. The resident acquired an L-shaped skin tear to the back of his/her right hand which measured 1 cm x 0.5 cm. Review of the 3/5/17 fall investigation revealed the resident fell , unwitnessed, which resulted in a skin tear to his/her right hand (back). The direct care staff found the resident seated on the floor in front of his/her recliner in the up position and the pillow beside the resident. The staff noted the resident's chair alarm sounded. The investigation identified the resident did not use the call light which was attached to his/her chair. The investigation noted just prior to the fall, the resident was seated on the recliner with his/her feet up. The FSI did not identify initial root cause of the fall and did not identify initial care plan interventions to prevent future falls. Fall #19: Review of the 3/22/17 FSI report revealed the resident had a witnessed fall at 9:45 a.m. when the resident lost his/her balance and staff intercepted the fall. The resident acquired 2 skin tears to his/her right elbow, which measured 3.5 cm x 1.5 cm and 1 cm x 1 cm with no pain. The fall occurred in the resident room when staff transferred the resident. Initial root cause of the fall identified as loss of balance and the identified initial intervention to prevent future falls: use gait belt with transfers and ambulation. The fall investigation noted staff did not use a gait belt when the staff transferred the resident. Fall #20: Review of the 3/23/17 FSI report revealed the resident had an unwitnessed fall at 2:25 p.m. Staff found the resident sitting on the floor in front of his/her recliner- leaning back on the chair, on pillows. Staff noted the fall alarm in place and worked at the time of the fall. The initial root cause of the fall was the resident used the (chair) remote and raised the recliner up and slid off while reaching (out). The FSI did not identify initial care plan interventions to prevent future falls. Fall #21: Review of the 3/24/17 FSI report revealed the resident fell , unwitnessed, at 6:30 p.m. when staff found the resident on his/her left side with his/her back to the television and wheelchair in front of him/her. The resident acquired a skin tear to his/her left upper arm, which measured 4 cm x 3 cm. The fall investigation did not identify initial root cause of the fall and did not identify initial care plan interventions to prevent future falls. (The care plan was updated with one-on-one at nurse's station on 3/25/17.) Fall #22: Review of the 3/28/17 FSI report revealed the resident fell , unwitnessed, on 3/28/17 at 10:10 p.m. Staff found the resident seated on the pillow in front of the television and the resident received a skin tear to his/her right lower leg which measured 2 cm x 1 cm. The staff noted the fall alarm was in use, but the resident was seated on it so it never sounded. The FSI did not identify an initial root cause of the fall and did not identify initial care plan interventions to prevent future falls. Fall #23: Review of the 3/30/17 incident note revealed the resident fell , unwitnessed, 10 minutes after staff took the resident to his/her room. Staff found the resident seated in front of the wheelchair and the resident stated he/she just slid out. Staff noted no injury to the resident. The clinical record lacked evidence of a fall investigation to identify the causal factors of the fall and the care plan lacked evidence of an updated intervention implemented to prevent further falls Fall #24: Review of the 4/28/17 incident note revealed at 1:50 p.m. another resident reported resident #130 was on the bathroom floor. Staff noted the resident's wheelchair sat in the doorway to his/her room and observed the resident laid flat on his/her back. Staff noted the wheelchair brakes were not locked and noted no injury to the resident. Review of the 4/28/17 FSI report revealed the resident fell in his/her bathroom. Staff found the resident on his/her back with his/her feet towards toilet and the wheelchair sat in the doorway to his/her room. Staff noted the brakes on the wheelchair were unlocked and the fall alarm was in the recliner. The resident was left unattended at the sink in his/her room. The initial root cause of the fall was: The resident thought he/she could transfer him/herself. The FSI did not identify initial care plan interventions to prevent future falls. Fall #25: Review of the 5/4/17 FSI report revealed the resident fell , unwitnessed, at 12:25 p.m., from his/her wheelchair, and the brakes were not all the way engaged. The resident stated he/she retrieved his/her wheelchair from the sink area and locked the brakes him/herself. The fall alarm was in place and functioning. The FSI did not identify an initial root cause of the fall and did not identify initial care plan interventions to prevent future falls. Fall #26: Review of the 5/16/17 FSI report (signed on 3/22/18) revealed the resident fell , unwitnessed, with injury at 9:15 a.m. Staff found the resident on the floor on his/her right side, with his/her head on floor on his/her right side. The resident had a laceration to his/her right scalp and a large skin tear to most of the back of his/her right hand. The resident denied pain or discomfort. The resident required 1 staff assistance with transfers and ambulation. The resident acquired a 5-6 cm horseshoe flap (U-shaped laceration to the top of the resident's scalp on the right) and staff noted his/her skull was exposed. Staff covered the area with clean gauze and transported the resident to the emergency room (ER). The resident's room was set up to allow the resident to get behind his/her bedside table. Staff rearranged the resident's room so he/she could not get into that area and fall. Corrective action included: The resident was very impulsive and staff were instructed to look in his/her room each time he/she was up. Plan for monitoring included: Director of Nursing (DON) would monitor future fall records to ensure no further falls related to the area of the fall. The investigation noted the resident's fall pad did not alarm. Review of the radiologist report dated 5/16/17 revealed the resident had an acute minimally displace dorsal triquetral fracture (broken bone of the wrist). Review of the 5/17/17 at 11:27 a.m. nursing progress note revealed staff received a call from the hospital and were informed the resident received 12 staples to the top of his/her head. Fall #27: Review of the 5/17/17 incident note revealed the resident's pressure alarm sounded and the staff found the resident on the floor. Review of the 5/17/17 FSI report revealed the resident fell , unwitnessed, at 6:06 p.m. when the resident did not use the chair remote to lower the foot rest and climbed out of recliner with the footrest elevated. Staff noted no injury or pain to the resident. The FSI did not identify the initial root cause of the fall and did not identify the initial care plan interventions to prevent future falls. The investigation contained an additional root cause form which stated the problem was staff observed the resident on the floor of his/her room. The form asked why and staff wrote 1. self-transferred out of recliner 2. to get a blanket that was on the resident's shoulders 3. resident confused, restless. Fall #28: Review of the 6/1/17 incident note revealed staff found the resident on his/her buttocks on the floor in front of his/her recliner. The staff assisted the resident back to his/her recliner and encouraged the resident to use his/her call light for assistance and reminded the resident of the numerous falls he/she experienced from not asking for help Review of the 6/1/17 FSI report revealed the resident fell , unwitnessed, at 9:33 p.m. without injury. The FSI did not identify an initial root cause of the fall or initial care plan interventions to prevent future falls. The root cause form attached to the investigation stated the problem was the resident was on the floor trying to get to his/her sink; the form asked why: staff wrote the resident got him/herself out of the recliner; the form again asked why: staff worked to organize stuff at the sink; the form asked why: staff wrote resident restless. Fall #29: 6/23/17 FSI report revealed the resident experienced an unwitnessed fall, which resulted in a skin tear of 1.5 cm to the right knee, redness to his/her left knee, and rated pain as a 3 out of 10. Staff found the resident on the floor and the resident reported he/she slipped from his/her wheelchair when the chair moved. The FSI did not identify an initial root cause of the fall and did not identify initial care plan interventions. Fall #30: Review of the 6/24/17 fall investigation (signed 3/22/18) revealed at approximately 11:13 p.m. the resident experienced an unwitnessed fall with injury (4 cm x 2 cm hematoma to the right side of his/her forehead and a 3 cm half-moon skin tear to his/her right knee). The investigation revealed the new intervention if the resident stated he/she would get up the staff would spend some one-on-one time with the resident and not leave him/her alone until the resident was done getting up, and staff had assisted the resident with what the resident wanted to do. The summary included the resident fell frequently and had poor safety awareness. The resident informed staff if he/she wanted to get up he/she would get up. When the staff explained to the resident he/she had falls, the resident responded he/she was allowed. The resident had a pressure alarm to alert staff to know when the resident got up, so the staff could assist the resident, since the resident did not call for assistance much of the time. The resident did like to get on the floor at times

The facility census totaled 25 residents with 18 included in the sample. Two residents were reviewed for pressure ulcers. Based on interview and a closed record review, the facility failed to prevent the re-opening and worsening of multiple stage II pressure ulcers for 1 of 2 residents reviewed for pressure ulcers. The resident had pressure ulcers that developed, closed, and then redeveloped from 3/2013 through from 6/2013. (#10) Findings included: - Review of resident #10's signed physician orders [REDACTED]. The resident had been admitted to the facility on [DATE]. Review of an annual MDS (Minimum Data Set) dated 11/28/12 revealed a BIMS (Brief Interview for Mental Status) score of 8, indicating moderate cognitive impairment, and the resident did not exhibit behaviors of rejecting care. The assessment identified the resident required extensive assistance from one staff for bed mobility, independent when walking in the room/corridor, toileting, and required supervision with set up assistance from staff with personal hygiene, eating, was not at risk for the development of pressure ulcers and did not have any pressure ulcers. Review of a quarterly MDS dated [DATE] revealed a BIMS score of 5, (indicating severe cognitive impairment), and the resident did not exhibit behaviors including rejection of care. The resident required supervision with set up assistance from staff with bed mobility, walking in the room/corridor, was independent with transfers, and required supervision from one staff with toileting, and one person limited assistance with personal hygiene. The assessment identified the resident was at risk for the development of pressure ulcers, had two stage 2 pressure ulcers (Partial thickness loss of dermis-skin-presenting as a shallow open ulcer with a red-pink wound bed, without slough), received pressure ulcer care, was on a on a turning/repositioning program, and staff used a pressure relieving device on the chair and in bed. Review of the CAAs (Care Area Assessments) for Pressure Ulcers, ADL (Activities of Daily Living), and Nutritional Status dated 11/28/12 revealed staff failed to complete an analysis of findings. . Review of the resident's pressure ulcer care plan, located in a chart at the nurse's station and revised by staff on 3/5/13 revealed the resident entered the facility (on 12/8/11) with a stage I and stage II on each buttock and the resident was at increased risk for more pressure ulcers due to a [DIAGNOSES REDACTED]. Interventions directed staff to complete a wound assessment and document the assessment at least every 7 days, notify the physician if no improvement in 2 weeks or if staff noted worsening in the wound at any time, provide Resource Breeze (a dietary supplement) three times a day. It also directed staff to conduct skin inspections with showers, Braden scale (assessment for risk of development of pressure ulcers) every 3 months and PRN (as needed), follow nutritional interventions, and encourage the use of pillows under one hip to offload buttocks slightly (changing every 1/2-1 hour) from 7 a.m.-1 a.m. daily. The resident slept in a recliner, encourage and supervise the resident to stand up for 5 minutes every 1/2-1 hour from 7 a.m. until 1 a.m., and give vitamin C, Zinc, multivitamin and healthy shots (dietary supplements) as ordered twice a day. On 6/13/12, staff added an intervention that identified the treatment of [REDACTED]. Staff marked the area as resolved, but failed to date the entry onto the care plan. Staff changed the time for repositioning from every 1 and 1/2 hours to every 1/2-1 hour on 6/19/12. No further interventions had been added after 6/19/12. Review of the resident's computerized pressure ulcer care plan, dated 3/13/13, revealed the resident had a Stage 2 pressure ulcer on the right inner buttock related to a history of pressure ulcers, choosing to sleep in his/her recliner rather than bed, his/her scooting down/sliding down in his/her recliner, and refusal to change position even with staff offering assistance. The interventions for staff included to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (physician). The resident needed reminding and assistance with (or he/she will say ok and not change positions) to turn/reposition at least every 2 hours, more often as needed or requested. Monitor/document/report to MD PRN changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage. Pressure relieving roho (brand of cushion) air cushion in his/her recliner at all times. The resident preferred to sleep in his/her recliner. He/she refused to sleep in his/her bed. Attempt to encourage and offer assistance with getting into bed if willing at least for a short period of time. Try alternative methods to gain compliance with position changes and sleeping in bed. Review of a physician's note dated 12/14/11 revealed the resident "really does not have any particular problems except he/she will not sleep in a bed because it hurts his/her back and has slept in a recliner for decades, resulting in small decubitus [MEDICAL CONDITION] (decubitus ulcer is essentially a hole caused by tissue death) on the sacral (triangular-shaped bone at the bottom of the spine) area." Review of a Nursing Home Note for a physician visit on 3/13/13 revealed " PLAN: No change in treatment. He/she may have his/her nutritional supplements discontinued. The nurses did say that he/she has a pin hole size decubitus lesion on the coccyx and they would like to use [MEDICATION NAME] (Mupirocin Calcium ointment-unique topical agent recently developed for use in the treatment of [REDACTED].i.d. (three times daily) until healed. This request will be ordered." Review of the Weekly Skin Documentation form revealed notes on 1/19/13 and 1/25/13 with no open areas noted. At that time, the facility did not use electronic charting. Review of the physician's orders [REDACTED]. Review of the electronic Skin/Wound Notes revealed the following: 3/13/2013 Location: Right inner buttock Type of Wound: Stage 2 Pressure Ulcer Length (cm-centimeter) x Width (cm) x Depth (cm): 0.5cm (L) x 0.6cm (W) x superficial depth Drainage/Characteristics: Very light serosanguineous (wound drainage of a semi-thick reddish fluid) Narrative: Physician Assistant P in the building today and notified of new wound. New treatment orders received. Review of a fax sent to the physician on 3/13/13 revealed the resident had a left buttock stage 2 pressure ulcer. Nursing asked for a "trial of Mucinoprin to site" three times a day. The physician sent a fax back in agreement that same day. 3/23/2013-Skin/Wound Note: Location: Open area to buttocks has closed, dry scab-like patch of skin remains. No other open areas noted. Mupirocin treatment continues as well as [MEDICATION NAME] for prevention. 3/27/2013 Location: Right inner buttocks. Type of Wound: Stage II Pressure Length (cm) x Width (cm) x Depth (cm): Area is resolved with clear pink skin. No dryness or scaling. Drainage/Characteristics: NA Narrative: Area to buttocks is resolved. Request from Physician to stop [MEDICATION NAME] due to drying and dc (discontinue) mupirocin routinely and start PRN for wounds. Review of a fax sent to the physician on 3/27/13 revealed the area to the right buttocks had resolved and asking to discontinue the mupirocin and change it to as needed. "Also believe [MEDICATION NAME] is drying. May we try no cream and observe for changes." The physician sent back a fax in agreement on 4/5/13. 4/1/2013-Skin/Wound Note Location: Coccyx Type of Wound: Pressure ulcer stage II Length (cm) x Width (cm) x Depth (cm): 0.8 X 0.4 X 0.2 cm Drainage/Characteristics: No noted drainage. Narrative: Skin assessment completed this AM after shower. Noted new open area to coccyx, see above description. Start mupirocin to coccyx BID (twice a day) till resolved. Review of a fax sent to the physician on 4/1/13 revealed the resident had a new open area to the coccyx. "Will restart mupirocin BID till resolved." The physician sent a fax back in agreement on 4/1/13. 4/8/2013-Skin/Wound Note Location: Coccyx Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): Resolved Drainage/Characteristics: none Narrative: Area is resolved with no further problems noted at this time. Review of the physician's orders [REDACTED]. Review of a fax sent to the physician on 4/8/13 to notify the physician the area to the coccyx had resolved. "Mupirocin discontinued, May we use [MEDICATION NAME] to buttocks BID (twice a day) for prevention." The physician sent back a fax in agreement. Review of a Nursing Home Note for a physician visit on 4/10/13 revealed the resident "did have some small decubitus [MEDICAL CONDITION] that were not fully healed and medication treatment for [REDACTED]." Review of a physician order [REDACTED]. 4/25/2013-Skin/Wound Note Location: Left inner buttocks near coccyx. Type of Wound: Stage II pressure Length (cm) x Width (cm) x Depth (cm): 0.3cm x 0.3cm x 0.2cm Drainage/Characteristics: no drainage or discharge noted Narrative: Resident in shower with assist of one. Noted to have a new open area to left buttocks near coccyx. Resident has order for [MEDICATION NAME] (Skin Protectant with a high-[MEDICATION NAME] formula) ointment twice a day and PRN. Will ask for increase to QID (four times a day) and PRN. Review of a fax sent to the physician on 4/26/13 revealed the resident had a new open area to the left buttock and nursing asked for the [MEDICATION NAME] to be increased to four times a day until healed. The physician sent back a fax the same day in agreement. 5/2/2013 Skin/Wound Note Late Entry: Location: Left inner buttock Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.8 x 0.5 x 0.2 Drainage/Characteristics: none Narrative: wound is slightly more open, wound bed pink, no slough noted. 5/2/2013 Late Entry: Location: Right inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 X 0.5 X 0.2 cm Drainage/Characteristics: no noted drainage Narrative: area is slightly larger. Resident asked to lie down for a short time several times each day but will not always do so. Review of a Nursing Home Note for a physician visit on 5/8/13 revealed no mention of any skin issues. 5/9/2013 Late Entry: Location: Left inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 1 x 0.5 x 0.2 cm Drainage/Characteristics: none Narrative: resident has clean pink wound bed. No s/s (signs/symptoms) of infection. 5/9/2013 Late Entry: Location: Right inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.4 x 0.2 cm Drainage/Characteristics: none noted Narrative: very small improvement noted in size. Area remains clean and free of s/s (signs/symptoms) of infection. 5/16/2013 Late Entry: Location: Left inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 1 X 0.75 x 0.2 cm Drainage/Characteristics: none Narrative: noted larger area, continues to be free of infection and has pink granulated (healing tissue) wound bed. 5/16/2013 Late Entry: Location: left inner buttock Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 X 0.5 X 0.25 cm Drainage/Characteristics: none Narrative: noted slight increase in size, no s/s of infection. 5/16/2013 Late Entry: Location: right inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.3 x 0.2 Drainage/Characteristics: no noted drainage Narrative: slight improvement noted. Continues to have pink wound bed with granulated tissue noted 5/23/2013 Late Entry: Location: Left inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.25 x 0.2 Drainage/Characteristics: none Narrative: no changes noted to wound. No s/s of infection. Wound beds are pink and granulated. 5/23/2013 Late Entry: Location: Right inner buttocks. Type of Wound: Pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.25 x 0.2 Drainage/Characteristics: none Narrative: Area has good granulated wound bed, no s/s of infection 5/24/2013 Late Entry: Location: Right inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.25 x 0.2 cm Drainage/Characteristics: none Narrative: area remains much the same. No s/s of infection. Continue current treatment and monitoring schedule. 5/24/2013 Late Entry: Location: Left inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 1.25 x 0.75 x 0.2 cm Drainage/Characteristics: none Narrative: Area has pink granulated wound bed. No s/s of infections. Continue treatment as ordered 5/26/2013 Location: Right inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 0.5 x 0.25 x 0.2 Drainage/Characteristics: none Narrative: Area not improved increasing treatment to QID, Physician Assistant P Review of a MD/Nursing Communications form signed by the physician on 5/29/13 revealed an order to increase the [MEDICATION NAME] ointment to four times a day since there had not been any improvement in the pressure ulcer to the resident's right inner buttocks. 5/26/2013-Skin/Wound Note Location: Left inner buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 1.25 x 0.75 x 0.2 cm Drainage/Characteristics: none Narrative: Area shows no sign of improvement Physician Assistant P notified and treatments increased to QID. 5/31/2013 Location: Left buttocks Type of Wound: pressure Length (cm) x Width (cm) x Depth (cm): 1.3 x 0.5 x 0.1 cm Drainage/Characteristics: no noted drainage. Narrative: Slight improvement noted in size. Call to doctor ' s office to report to Physician Assistant P. Message left and report faxed to Physicians office. A Braden Scale for Prediction of Pressure Sores completed on 5/30/13 revealed the resident had no sensory impairment, his/her skin was occasionally moist, had no limitation in mobility and walked occasionally, "probably" had inadequate nutritional intake, and had a potential risk for friction and shear. These indicators gave the resident a score of 18 that indicated the resident had a low risk for developing a pressure ulcer. Interview with direct care staff H on 8/13/13 at 3:50 p.m. revealed the resident had interventions in place for a Roho (brand of cushion) cushion in his/her chair, staff had to convince the resident to lay in the bed for at least 15 minutes, [MEDICATION NAME] for his/her bottom, dry incontinence products, clean skin. During the day, he/she would not stay in the bed for very long. At night, he/she would sleep in the bed for an hour or so. Once the areas closed, some CNAs (Certified Nurse Aides) think they don't need to worry about it anymore, so they just stop doing the interventions, like the [MEDICATION NAME] and turning. Interview with direct care staff J on 8/14/13 at 11:19 a.m. revealed there were interventions to encourage the resident to walk more, reposition him/her, padding in the chair, [MEDICATION NAME] ointment to the area, making sure his/her incontinence products were dry, cleaning the area. The resident had been pretty independent and only occasionally incontinent. The resident spent a lot of time in his/her chair and did not like to be in the bed. He/she did slide down in his/her chair and wiggled. Interview with licensed nursing staff K on 8/14/13 at 3:17 p.m. revealed the staff tried to keep the resident's skin dry, moisture barrier [MEDICATION NAME] with every toileting, gel cushion in his/her chair. He/she was up ad lib (whenever the resident wanted) and he/she was just so thin, it was a challenge to keep them closed. When they were open, we would try [MEDICATION NAME]. I'm not really sure why the areas kept reopening. He/she ate pretty well, but he/she was just so thin and incontinent at times. He/she would allow the staff to reposition him/her most of the time, and he/she walked a lot. Interview with administrative nursing staff A on 8/15/13 at 5:15 p.m. revealed if a resident had an open area, the doctor should be notified to obtain a treatment order, changing the resident's position at least every 2 hours or more often, documenting on the status of the wound during treatments with measurements and drainage, document a skin note. If an area closed, it still needed to be monitored closely, weekly skin assessments to be sure it didn't re-open. If a resident had pressure ulcers that re-opened frequently, they should have been sent to see a wound specialist. During an interview on 8/20/13 at 4:13 p.m., physician assistant P reported that the resident had been admitted to the facility with some [MEDICAL CONDITION] on his/her buttocks. Physician assistant P confirmed the resident had multiple stage II pressure ulcers that closed and reopened many times and had not seen a wound care specialist because the pressure ulcers had been very small and managed with the skin creams and treatments the facility had been using. Physician assistant P reported that contributing factors that led to the ulcers reopening frequently were thinning skin, sedentary lifestyle, and frailty and reported the resident did walk, but spent a lot of time sitting. Physician assistant P reported the resident had a chair cushion to prevent pressure. Physician assistant P reported that he/she did not know if the reopening of the pressure ulcers had been unavoidable. Review of the facility's policy on Skin Care, dated 2/1/05, identified the staff were to determine the cause of the skin impairment. If staff identified the impairment was the result of a pressure ulcer, then: "a. Each nurse will be trained by the continuing education units and by in house in-services in the area of wound assessment and treatment. The Assistant Director of Nursing will be the lead wound nurse for any areas of clarification. The physician or the physician extender or Nurse Wound Consultant will also serve to clarify the etiology of any wound that is questionable. b. Special emphasis will be put on prevention. This will be done by risk assessment as shown by the Braden Scale and any other outstanding factors such as history of previous pressure ulcers, active dying phase, end stage system failure, para/quad/or [MEDICAL CONDITION], casts or splints. c. Any elder that is identified upon admission or upon quarterly, annual, or significant change assessment is shown to be at risk by the Braden Scale or has one of the other predisposing factors listed above will be placed on high risk precautions. 4. High Risk Precautions Any elder that is assessed by the MDS Coordinator or the Director of Nursing as being at high risk for skin break down will trigger the initiation of the high risk skin breakdown prevention protocol. a. Weekly skin assessment (shower/bath) as stated previously. b. Pressure reduction devices in wheel chair and in the bed, and any other surface the elder would be in for more than 2-hour consecutive time frame. c. If the elder is in bed for an extended amount of time heel protectors of the elder ' s choice will be used. d. Depending on the nature of the area of pressure risk that particular part of the body must be off-loaded as much as possible. Examples: O2 padding if continuous O2 use, leg strap if Foley catheter, padding around a cast." The facility failed to assess open areas weekly. The facility failed to provide continuous preventative treatments to the inner buttocks and coccyx for a resident that had multiple pressure ulcers develop, heal, then re-open from 3/2013 until 5/2013.

The facility census included 25 residents with 18 included in the sample. Based on observation, record review, and interview, the facility failed to follow the incontinence program and maintain, prevent decline, or improve urinary continence for 2 of 4 sampled residents reviewed for urinary incontinence (#34 and #13). Resident #34's urinary continence declined over a 3 1/2 month period. Findings included: - Review of resident #34's signed physician orders dated 8/10/13 revealed a [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE]. Review of the admission MDS (minimum data set) dated 5/2/13 revealed a BIMS (brief interview for mental status) score of 2, indicating severe cognitive impairment. The resident required setup assistance for transfers, was independent with setup assistance for toileting, and required supervision with setup assistance for walking in the room and corridor. The resident had not had any falls. The MDS identified the resident as always continent. Review of the quarterly MDS dated [DATE] revealed the resident had problems with short and long term memory recall, continuous inattention, moderately impaired decision making, and continuous disorganized thinking. The resident required extensive assistance of one person for transfers, walking in the room and corridor, dressing, and toileting. The resident had been on a toileting program and was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding during the 7 day lookback period). Review of the Cognitive Loss/Dementia CAA (care area assessments) dated 5/7/13 revealed an analysis of findings of: "Resident very confused and has more difficulty during late afternoon and evening." Review of the resident's CAAs dated 5/7/13 revealed the Urinary Incontinence and the ADL (activities of daily living) Functional/Rehabilitation Potential CAAs did not trigger. Review of the resident's care plan for ADL assistance with a revision date of 5/29/13 revealed the resident required assistance of cueing with short, simple instructions, such as "hold your brush", "wash your hands" for personal hygiene care. The care plan lacked anything indicating the resident had incontinent episodes or required assistance with toileting. Review of a "Bowel and Bladder Program Screener" dated 5/2/13 revealed the resident toileted Independently, with reasonable speed, was always aware of the need to toilet, and not always, but at least daily voided appropriately without incontinence. The resident had a score of 19, which identified the resident as a good candidate for bladder retraining. Review of a "Bowel and Bladder Program Screener" dated 6/20/13 revealed the resident required assistance of one staff, was sometimes aware of need to toilet, and not always, but at least daily voided appropriately without incontinence. The resident had a score of 14, which identified the resident as a candidate for scheduled toileting. Review of a "Bowel and Bladder Program Screener" dated 8/2/13 revealed the resident required assistance of one staff, was sometimes aware of need to toilet, and less than daily voided appropriately without incontinence. The resident had a score of 12, which identified the resident as a candidate for scheduled toileting. Review of the nurses notes from 4/ 25/13 - 8/15/13 revealed no mention of increasing incontinence or possible contributing factors. Review of the resident's chart revealed it lacked documentation of a toileting program. Observation on 8/13/13 at 8:05 a.m. revealed direct care staff D went into the resident's room where the resident lay in bed and offered to get him/her up for a shower, and the resident declined. Staff C then asked the resident if he/she needed to go to the bathroom and the resident declined. Observation on 8/13/13 at 8:42 a.m. revealed direct care staff members C and D went into the resident's room where the resident lay in bed and offered to get him/her up for a shower, and the resident declined. Staff C then asked the resident if he/she needed to go to the bathroom and the resident declined. Observation on 8/13/13 at 9:55 a.m. revealed administrative nursing staff B and direct care staff D assisted the resident to sit on the side of the bed and then ambulate to the bathroom. The resident wore a wet incontinence brief and urinated in the toilet. Observation on 8/13/13 at 12:19 p.m. revealed direct care staff D went into the resident's room and offered to take him/her to the bathroom, and the resident declined. Staff D forgot his/her gait belt, then went to retreive it, came back and offered to take the resident to the bathroom again, and the resident again declined. Staff D then assisted the resident to walk to the dining room. Interview with direct care staff D on 8/13/13 at 10:04 a.m. revealed the resident could tell staff he/she needed to go to the bathroom if staff offered to take the resident, but the resident did not ask to go to the bathroom. Staff D identified the resident as usually continent. Interview with direct care staff H on 8/13/13 at 3:50 p.m. revealed when the resident first came in, he/she had urinary continence and toileted him/herself, but had more incontinence when the resident slept. Staff H identified the resident as incontinent now and needed assistance of one to two staff for toileting, depending on how the resident felt and his/her mood. Interview with direct care staff J on 8/14/13 at 11:19 a.m. revealed the resident had been continent for the most part when he/she first came in to the facility, but now had much more frequent incontinence. Staff J reported the resident did not have a toileting program in place but staff offered to take the resident to the bathroom every few hours and the resident could tell staff when he/she thought he/she needed to urinate. Staff J reported the resident's health had been going downhill and that could be why the resident's continence had gotten a little worse. Interview with licensed nursing staff K on 8/14/13 at 3:31 p.m. revealed the resident required assistance of one for toileting and was mostly incontinent, but it his/her continence fluctuated based on how the resident felt. Staff K confirmed that if the staff asked the resident, he/she could tell the the staff if he/she needed to go to the bathroom. Staff K reported the staff toileted the resident at least every two hours. Staff K confirmed when the resident first came to the facility, he/she had required less assistance with toileting. Staff K reported the resident had a health decline and his/her dementia had gotten worse and attributed that to why the resident required more assistance and had a decline in continence. Interview with administrative nursing staff A on 8/15/13 at 5:15 p.m. revealed he/she expected the care plan to include how much assistance the resident required with toileting, when to toilet, toileting at least every 2 hours, and if the resident had a voiding pattern. Staff A reported he/she did not know what kind of assessments were done during admission, but a continence assessment would be helpful that included when the resident voided, how frequently, and how much assistance the resident needed. During an interview on 8/20/13 at 3:10 p.m. with physician O revealed he/she was unsure of why the resident had become increasingly incontinent and did not know enough about the resident's voiding patterns to know if the resident had frequency, urgency, or what the issue may be. Physician O confirmed the resident may have benefitted from a toileting program. Review of the facility policy for Toileting and Perineal Care, last revised 5/29/09, revealed, "The goal is to prevent incontinence for as long as possible. ... 1. Upon admission continence, type of incontinence, and risk for skin breakdown will be done. Throughout assessment week, continence will be evaluated and assessed ... If functional incontinence of bowel and bladder is identified, absorbent products will be provided and a check and change program may be initiated. A basic check and change program would be at rising in the AM, after meals, and at bed time as well as PRN (as needed), but no more than two hours between checks ... If the incontinence is due to frequency or urgency, then the physician will be notified to check to see if a medication may be appropriate ... If the incontinence is due to a physical disability, a toileting plan may be initiated." The facility failed to determine causal factors and develop and implement interventions to prevent decline in resident #34's urinary continence. - Review of resident #13's electronic record revealed the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. to filter waste from the blood), not acute (sudden onset) or chronic (occurs long-term) [MEDICAL CONDITION] (inflammation of one or both kidneys) and [MEDICAL CONDITION] (kidney disorder), and personal history of urinary tract infections. Review of the annual MDS (Minimum Data Set-a required assessment) dated 1/9/13, identified the resident with a BIMS (Brief Interview for Mental Status) score of 15/15 (indicated the resident had little to no cognitive impairment), exhibited behaviors that affected others 1-3 days out of the last 7, and behaviors that did not affect others 4-6 days out of the last 7. The assessment identified the behaviors impacted the resident's care, and identified the resident rejected assistance with care 1-3 days out of the last 7. The assessment identified the resident as dependent on 2 staff for bed mobility, transfers, toileting, and personal hygiene, always incontinent of bladder and not on a toileting program. Review of the quarterly MDS dated [DATE], identified the resident with a BIMS of 15, rejected care 1-3 days out of the last 7, required the extensive assistance from 2 staff with bed mobility, transfers, toileting, personal hygiene, always incontinent of urine and not on a toileting program. This assessment identified an improvement in the resident's behaviors and physical abilities to assist with ADLs (Activities of Daily Living). Review of the Urinary Incontinence CAA (Care Area Assessment-a further assessment) worksheet, dated 1/9/13, identified the following: "Resident refuses to allow routine check and changes. Resident refuses to sit on the bedside commode or toilet for urination or on a daily basis to assist with bowel movements. Resident has had long term institutionalization and uses areas of care such as toileting as a form of control despite his/her choices being poor and leading to other health problems such as UTIs (Urinary Tract Infections) and pressure ulcers. Resident will be incontinent of urine and refuse to have proper peri-care. He/she will also be incontinent of urine and refuse to have his/her position changed or moved to the bed so that urine absorbing products can be changed and peri-care provided. Resident previously had long term use of Foley catheter. Refused the replacement of the Foley catheter for a reason he/she will not discuss. He/she denies the ability to recognize the need to urinate. Resident takes in large amounts of fluid daily and has been known to cause him/her to be fluid overloaded. Dependent on staff for cares but is cognitive and refuses the care he/she needs for proper urinary incontinence interventions. Resident had no input and denied his/her refusal to accept cares. The resident stated he/she rang for assistance when he/she was wet and that staff refused to provide him/her care which is not accurate. Resident refuses appropriate interventions to prevent complications such as UTIs, yeast infections, skin breakdown, and pressure ulcers. Staff can only provide interventions that he/she is agreeable to when he/she chooses them which makes avoiding complications and minimizing risks very difficult. Resident has been educated numerous times on the potential complications including infections and possible death." Review of the care plan, dated 10/18/12 and last reviewed 7/11/13, identified the resident required extensive to total assistance for all ADL's except eating, a history of chronic occurrence of UTI's and [MEDICAL CONDITION], had a Foley catheter in place for over two years and recently asked to have the catheter changed due to urinary leakage and then refused to have the catheter put back in. The care plan indicated the resident was incontinent of urine and due to his/her refusal to use the bed side commode except for rare instances. The care plan directed the staff to encourage the resident to use the bed side commode at least once per day and when feeling the urge to have a bowel movement. The care plan indicated the resident did not want routine check and changes, and identified he/she would call for assistance when he/she was wet with urine and wanted to be changed. Review of the electronic record revealed it lacked an assessment of the resident's type of urinary incontinence or habits/patterns. Observation on 8/13/13 at 9:15 a.m. revealed the resident asked Direct care staff E if he/she would change the resident. Staff member E reported to the resident he/she would find someone to help him/her. On 8/13/13 at 9:20 a.m., observation of Direct care staff E and Direct care staff C revealed the staff changed the resident's brief as the resident lay in bed. Observation at that time revealed the resident's left inner thigh red, perineal area slightly red, and buttocks red. Staff C reported at that time the resident's brief was saturated with urine. Staff C applied Vaseline gauze to the resident's left inner thigh, applied "bag balm" to the resident's bottom, and then applied a new brief under the resident. Staff E and C did not tape the brief shut but left the brief lay loosely on the resident's stomach. Staff E reported at that time the staff applied the brief loosely to prevent rubbing to the left inner thigh, and that the redness located to the left inner thigh was from the brief rubbing. On 8/13/13 at 7:30 a.m. the resident revealed he/she had not been changed yet that morning. The resident stated he/she asked to be changed around 7:00 am and asked staff C to change him/her. Staff failed to change the resident until 9:15 a.m., over 2 hours later. On 8/13/13 at 3:42 p.m., interview with direct care staff G revealed he/she checked the resident every two hours and in between if the resident rang to be changed. Staff G reported the resident was "pretty good" about ringing and letting staff know when he/she was wet. Review of a log, identified as a "Two Hour Check and Change" log, revealed on 8/13/13 staff documented they had changed the resident at 3:45 a.m., then again at 7:15 a.m., 3 and 1/2 hours later. Further documentation on the same day revealed staff changed the resident at 9:00 a.m., 10:00 a.m. and 11:30 a.m. The documentation showed the next time staff changed the resident's incontinent brief was at 9:00 p.m., or 9 and 1/2 hours later. Review of the log dated 8/14/13, revealed the first time staff changed the resident was at 4:45 a.m., almost 8 hours after the last change, then again at 8:00 a.m., or over 3 hours later. On 8/14/13 at 8:39 a.m. interview with direct care staff J reported staff checked all residents identified with urinary incontinence about every 2 hours and applied barrier cream to their bottoms with peri care. Staff J identified that for resident #13, staff checked him/her every two hours and sometimes more often. Staff J said the resident very rarely refused to be changed. Staff J stated the resident was able to voice when he/she needed to be changed and it usually took 5-10 minutes to get back in to the resident once he/she requested to be changed. Staff J said the facility had started to document on a log when they changed him/her. Staff J said the staff documented the care as soon as they finished. Staff J identified the log was "a new thing" in the past 2-3 weeks because the resident had accused staff of not changing him/her or taking care of him/her. Staff J stated the staff were still getting used to filling out the log. On 8/14/13 at 11:57 a.m., Licensed Nurse K reported the resident was incontinent of urine and staff kept a log to show when staff checked and changed the resident. Nurse K said the resident had told the physician that the facility was not changing him/her, so the physician came and looked at the spot, noticed a red spot-probably from shearing-about the size of a quarter and ordered the Vaseline gauze to be applied. After the physician came to the facility, the staff started keeping a log of when staff changed him/her. Also the resident refused sometimes to be changed if he/she gets mad. Nurse K looked at the log and confirmed on 8/13/13 that from 1:30-9:00 pm staff had failed to document they changed the resident's brief. On 8/15/13 at 5:35 p.m. Administrative Nurse A reported the resident complained staff were not checking or changing him/her every 2 hours. Administrative Nurse A said he/she asked the staff if they were checking the resident every two hours and they confirmed they were. So, in order to help prove that they were checking and changing the resident, Administrative Nurse A started a 2 hour check list for the staff to document the occurrences. Nurse A said that he/she thought staff had forgotten to document when they had cared for the resident, so nurse A reported that now the charge nurse would be responsible for making sure the staff documented on the checklist. Nurse A confirmed staff had not documented they had provided incontinent care every 2 hours. Review of the facility policy for Toileting and Perineal Care, last revised 5/29/09, revealed, "The goal is to prevent incontinence for as long as possible. ... 1. Upon admission continence, type of incontinence, and risk for skin breakdown will be done. Throughout assessment week, continence will be evaluated and assessed ... If functional incontinence of bowel and bladder is identified, absorbent products will be provided and a check and change program may be initiated. A basic check and change program would be at rising in the AM, after meals, and at bed time as well as PRN (as needed), but no more than two hours between checks ... If the incontinence is due to frequency or urgency, then the physician will be notified to check to see if a medication may be appropriate ... If the incontinence is due to a physical disability, a toileting plan may be initiated." The facility failed to ensure staff followed the planned incontinence program of check and change every 2 hours for this dependent, incontinent resident.

The facility census totaled 25 residents, with 18 included in the sample. Four residents were reviewed for accidents. Based on interview, record review, and observation, the facility failed to thoroughly investigate all falls and implement appropriate fall interventions to prevent accidents for 2 of 4 residents (#34, #26), resulting in a fractured thumb for resident #34. The facility also failed to prevent accidents due to unsecured chemical storage for 6 cognitively impaired, independently mobile residents. Findings included: - Review of resident #34's signed physician orders dated 8/10/13 revealed the following Diagnoses: [REDACTED]. The resident admitted to the facility on [DATE]. Review of the admission MDS (minimum data set) dated 5/2/13 revealed a BIMS (brief interview for mental status) score of 2, indicating severe cognitive impairment. The resident had minimal hearing loss, wore hearing aides, usually made him/herself understood, understood others, and had adequate vision. The resident required setup assistance for transfers, was independent with setup assistance for toileting, and required supervision with setup assistance for walking in the room and corridor and eating. The resident had not had any falls. Review of the quarterly MDS dated [DATE] revealed the resident had problems with short and long term memory recall, continuous inattention, moderately impaired decision making, and continuous disorganized thinking. The resident had highly impaired hearing, wore hearing aides, impaired vision, wore glasses, usually made him/herself understood, and understood others. The resident required extensive assistance of one person for transfers, walking in the room and corridor, dressing, and toileting. The resident had occasional moderate pain, had two or more minor injury falls since the previous assessment, and one fall with major injury. Review of the Cognitive Loss/Dementia CAA (care area assessments) dated 5/7/13 revealed an analysis of findings of: "Resident very confused and has more difficulty during late afternoon and evening." Review of the Falls CAA dated 5/7/13 revealed an analysis of findings of: "Resident wanders throughout the facility with and without walker or cane. Fall potential is high due to unsteadiness." Review of the fall risk assessment dated [DATE] revealed the resident had a fall risk score of 7, indicating moderate risk. Review of the fall risk assessment dated [DATE] revealed the resident had a fall risk score of 16, indicating high fall risk. Review of the resident's care plan for impaired cognitive function with a date of revision of 5/29/13 revealed interventions directing staff to reduce any distractions (turn off TV, radio, close door), use consistent, simple, directive sentences, provide the resident with necessary cues, stop and return later if the resident became agitated, engage the resident in simple, structured activities that avoid overly demanding tasks, keep the resident's routine consistent, try to provide consistent care givers as much as possible in order to decrease confusion, and monitor/document/report to the physician any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, or mental status. Review of the resident's care plan for fall risk with a revision date of 5/29/13 revealed interventions directing staff to ensure that the resident wore appropriate footwear (his/her black shoes or tan slippers) when ambulating, provide activities that minimize the potential for falls while providing diversion and distraction (like one on one conversations and small groups), use a personal tab alarm in bed and while up to alert staff when the resident may need assistance (added 7/29/2013), and provide 30-minute visual checks (added 6/10/13). Review of the resident's care plan for limited physical mobility last revised 6/6/13 revealed it directed staff to remind the resident to get his/her walker if the resident forgot it or to get it for the resident if he/she moved too far away from it. Review of a Fall Investigation Form dated 5/9/13 revealed the resident had ambulated in the hall by the dining room, dragging a chair, lost his/her balance, and fell . The resident hit his/her head (right cheek) on the hand rail and the back of his/her hand on the floor. The resident complained of right knee and hip pain and was transported by EMS (emergency medical services) to the ER (emergency room ) for evaluation and treatment. The staff obtained vital signs, initiated neurological checks (a system for checking changes in brain function). Potential contributing factors included dementia and the resident took antianxiety and blood pressure medications. The charge nurse notified the physician, family, DON (director of nursing), and the administrator. Staff identified the resident toileted him/herself, attempted to move a chair and did not say why, and used a cane. The form indicated staff reviewed the care plan, but did not revise it. Statements had not been obtained by any witnesses or the staff member that found the resident after the fall. Review of a Nursing Progress Note dated 5/9/13 at 7:10 p.m. revealed the resident fell in the hall and hit his/her head and complained of right hip and right knee pain. Staff sent the resident to the ER for evaluation and treatment. Review of a Nursing Progress Note dated 5/9/13 at 9:00 p.m. revealed the resident returned from the ER with new orders for Lortab (a narcotic pain medication) and a new [DIAGNOSES REDACTED]. Review of a Nursing Progress Note dated 5/9/13 at 9:12 p.m. revealed staff received no new orders for the resident's knee and the resident stated his/her knee hurt and the resident knew he/she should stay off of it and elevate it. Review of a Nursing Progress Note dated 5/12/13 at 4:00 p.m. revealed the resident received a dose of Lortab for complaints of right knee pain. Review of a Nursing Progress Note dated 5/24/13 at 10:15 a.m. revealed the resident had gone to the clinic for an appointment regarding his/her right knee, as it had been swollen, red, warm to the touch, and tender to palpation (touch). Review of an Incident Investigation form dated 6/10/13 revealed staff found the resident on the floor in the bathroom. The resident complained of back pain, had a bruise to the buttock, and went to the ER at the family's request. Staff completed vital signs and neurological checks. The form identified the resident had been trying to go to the bathroom, and the resident could not use a call light appropriately. The resident took diuretic, cardiovascular, and antidepressant medications that may have contributed to the incident. Staff initiated 15 minute visual checks (staff failed to update the care plan which directed staff to provide 30 minute visual checks), and the physician and family were notified. A note on the form indicated, "Need tabs alarm for resident." No statement was obtained from the staff member that found the resident. Review of an Incident Investigation form dated 6/22/13 at 5:45 p.m. revealed staff found the resident sitting on the floor in the living room on his/her wheelchair pedals and the wheelchair tilted forward with the chair cushion 25% forward in the seat. The nurse saw the resident 5 minutes prior to staff finding the resident on the floor. Staff obtained vital signs. Potential contributing factors included vascular dementia, a hospitalization within 30 days prior, a room change in the past 72 hours, and the resident received diuretic, narcotic, and antipsychotic medications that may have contributed. Staff toileted the resident before the evening meal and found no injuries after the fall. Staff reviewed the care plan, but had not updated it. Staff notified the family, physician, and DON. A note written on the form included, "Need to assess need for personal alarm when up in w/c (wheelchair)". A witness statement had been obtained by the staff member that found the resident. Review of the resident's 15 minute visual check log for 6/22/13 revealed staff completed no visual checks between 2:15 p.m.-5:45 p.m., during the time when the resident fell . Review of an Incident Investigation form dated 7/28/13 at 1:50 p.m. revealed staff found the resident on the living room floor on his/her buttocks. The resident sustained [REDACTED]. Staff completed vital signs, neurological checks, and notified the family and physician. Potential contributing factors were weakness, resident had been in an unsupervised area, and received diuretic, narcotic, and antipsychotic medications that may have contributed. Staff had toileted the resident at 12:00 p.m., the resident's walker was within reach, and the resident had attempted to walk without assistance. Staff reviewed and updated the care plan, and 30 minute visual checks had been in place. Staff failed to update the care plan to include the increased visual checks to 15 minutes. No statements were obtained from any possible witnesses. A note on the form indicated, "Adding personal pull tab alarm to alert staff to aide resident." Review of the resident's visual check log for 7/28/13 revealed the first visual check of the day had been completed at 2:00 p.m., after the resident fell . Review of a Nursing Progress Note dated 7/28/13 at 11:30 p.m. revealed the resident had no complaints voiced from fall. His/her left thumb had a bruise but the resident could move it. Review of a Nursing Progress Note dated 7/30/13 at 9:00 a.m. revealed the resident ambulated with a walker and required the assistance of one staff member to go to the dining room for breakfast, had a stable/slow gait, and had been alert and confused. The resident's left thumb had edema (swelling), ecchymosis (bruising), pain with range of motion, and tenderness to palpation (touch). Review of a Nursing Progress Note dated 7/30/13 at 3:00 p.m. revealed the resident went to the hospital for an X-ray of the left thumb and hand. Review of a Nursing Progress Note dated 7/30/13 at 5:00 p.m. revealed that the nurse had been notified by hospital staff that the resident's X-ray showed a fracture of resident's left thumb. Staff took the resident to the hospital to be fitted for and outfitted with a left wrist splint. Review of a Nursing Progress Note dated 8/1/13 at 12:44 p.m. revealed the resident had complained of left thumb pain, and the staff gave prn (as needed) Lortab (a narcotic pain medication) as ordered. Review of a physician order for [REDACTED]. Review of the visual checks log for the resident from 6/10/13-8/15/13 revealed the failure of staff to consistently complete the logs, even though the care plan revised on 6/10/13 identified it as an intervention to prevent falls. Observation on 8/12/13 at 2:01 p.m. revealed the resident sat with his/her eyes closed, in a recliner in his/her room with the foot rest up,and the call light and a pull alarm clipped to his/her clothing and left wrist splint in place. Observation on 8/13/13 at 7:23 a.m. revealed the resident lay in bed with his/her eyes closed, the door to the resident's room open, and no call light within reach. All of the call lights in the room were looped over the call light box on the wall. Observation on 8/13/13 at 7:47 a.m. revealed the resident lay in bed with his/her eyes closed with his/her knees bent and laying half off of the bed. The call light remained looped over the call light box on the wall and out of the resident's reach. During an interview on 8/15/13 at 12:54 p.m. the resident reported he/she had fallen and injured his/her left hand (left thumb fracture). The resident reported it "hurt quite a bit" of the time. Interview with the resident's family member on 8/19/13 at 8:10 a.m. revealed they had visited the resident several times and the resident frequently did not have a drink or call light within reach, and the tab alarm was not on. The family member reported the staff had started using the tab alarm after the fall when the resident broke his/her thumb. Interview with direct care staff H on 8/13/13 at 3:50 p.m. revealed the resident was at high risk for falls, staff had the resident on 15 minute visual checks, and used a pull tab alarm. Staff H reported the resident did not know what his/her call light was for and played with it and that staff H thought the resident fell not too long ago, about 2 or 3 weeks ago, when the resident broke his/her thumb. Interview with direct care staff J on 8/14/13 at 11:19 a.m. revealed the resident did have an increased fall risk, and interventions for a pull tab alarm, every 30 minute visual checks (identified a different time frame than direct care staff H), and to assist the resident with all ADLs (activities of daily living). Staff J reported the resident had not had any falls with major injuries, but a pull tab alarm and the visual checks had been recently implemented due to the resident's falls. Interview with administrative nursing staff B on 8/13/13 at 9:57 a.m. revealed the resident had been wearing a pull tab alarm while in bed and he/she wore it all the time. Interview with licensed nursing staff K on 8/14/13 at 9:26 a.m. revealed the physician usually wrote an order to make a resident a fall risk if a resident had an increased risk of falls, or if a resident became more unsteady on his/her feet, needed more assistance, had fallen, nursing staff made the resident a fall risk. Staff K reported if a resident fell , the nurse called administrative nursing staff A and B, and the physician, then they made suggestions about what to do or what new interventions to put in place. Staff K confirmed nursing staff could initiate fall interventions. Interview with licensed nursing staff K on 8/14/13 at 3:31 p.m. revealed if a resident fell , the nurse should do a head-to-toe assessment to determine any injuries, check vital signs, orientation, and level of consciousness, and try to determine why the resident fell . Staff K reported the charge nurse would then complete an incident investigation with witness statements and then notify the resident's family, physician, and administrative nursing staff A in as timely a manner as possible. Staff K reported staff would then initiate any new interventions depending on what the cause of the fall had been; maybe start visual checks, check to see if the environment needed to be changed, maybe a personal alarm. Staff K reported every time a resident fell , staff tried to implement a new intervention to prevent falls from happening again and then to let staff know about new interventions, the charge nurse updated the care plan and also in the 24-hour report book to reinforce the change. Staff K confirmed the resident fractured his/her thumb during his/her last fall and the resident now wore a brace to try and keep him/her from moving the thumb. Interview with administrative nursing staff A on 8/15/13 at 5:15 p.m. revealed he/she expected a fall investigation to include the cause of the fall, medications the resident took, add interventions to prevent further falls, if there may have been possible neglect by failure to follow interventions, and witness statements. Staff A confirmed for each fall, he/she expected there to be a new intervention added to the care plan. Staff A reported that after an incident report had been completed, it went to administrative nursing staff B, who reviewed it and then added any interventions needed. Staff A reported he/she did not know why the tabs alarm did not get put in place sooner as mentioned in the fall investigations prior to the resident's injury and confirmed there could have been more interventions put in place to have prevented the resident from falling and breaking his/her thumb. Staff A confirmed the 30 minute visual checks had not been getting completed like they should have been and the charge nurses were responsible for ensuring they were completed. Interview with physician O on 8/20/13 at 3:10 p.m. revealed the resident struggled with orthostatic hypotension (low blood pressure occurring in some people when they stand up) and the physician had a difficult time maintaining the resident's blood pressure as it tended to fluctuate quite greatly, and he/she believed it to be the main cause of the resident's falls, though the resident also had a decline in mental status. Physician O reported he/she saw the resident in the facility on 8/16/13 and did not know the resident had a fractured thumb as the facility staff had not brought it to his/her attention. Review of the facility policy for Accidents and Incidents, last revised 2/1/05, revealed "The nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. b. The following data as it may apply, must be included on the Accident Investigation Report Form: 1. The date and time the accident or incident took place; 2. The nature of the injury/illness; 3. Where the accident or incident took place; 4. The injured person's account of the accident or incident if possible; 5. The time the injured person's attending physician was notified; 6. The date/time the injured person's family or DPOA (Durable Power of Attorney) was notified and by whom; 7. The disposition of the injured (...transferred to hospital, put to bed, sent home, returned to work,..); 8. Other pertinent data as necessary or required; and 9. The signature and title of the person completing the report. c. A completed Accident Investigation Report For must be submitted to the director of nursing services no later than twelve (12) hours after the occurrence of the accident or incident." The facility failed to implement timely, appropriate and effective fall interventions for this cognitively impaired resident to prevent further falls, resulting in a broken thumb. - On 8/8/13 at 8:45 a.m., observation revealed an unlocked, unattended maintenance office on the north hall with Terro ant killer spray on a desktop with a warning that identified the chemical as hazardous to humans and animals. Also, a firebreak fire resistant sealer spray can sat on a low shelf just inside the door that contained a warning to keep out of reach of children. Direct care staff C and D confirmed the door was unlocked at the time and usually unlocked when staff were present, but it got locked at night. Staff C reported he/she did not think the door needed to be locked. Staff C confirmed the ant killer spray and sealer spray were available to residents and should not be. On 8/8/13 at 8:52 a.m., observation revealed an unlocked, unattended north public bathroom with Lysol disinfectant aerosol spray also with a warning to keep out of reach of children The key to the bathroom door lay on a cabinet inside. Interview on 8/8/13 at 8:55 a.m. with administrative nursing staff B confirmed the door should be locked. Observation on 8/8/13 at 8:10 a.m. revealed the north hall shower room was unlocked and unattended. There were 4 jugs of Whirlbath lemon clean liquid in an unlocked cabinet with a warning to keep out of reach of children. Also, a spray can of Lysol sat in unlocked open cabinet with a warning to keep out of reach of children and a bottle of Comet spray cleaner with bleach hung in shower. Interview with administrative nursing staff A on 8/15/13 at 5:15 p.m. revealed chemicals should be stored as recommended by the MSDS (Material Safety Data Sheet) and confirmed the residents should not have access to the chemicals. Staff A confirmed chemicals should be behind lock and key. Review of the facility's policy for Storage Areas, with no revision date, revealed, "Cleaning supplies ... shall be stored as instructed on the labels of such products." The facility failed to store chemicals in a manner to prevent accidents to the cognitively impaired, independently mobile residents. - Review of resident #26's physician's orders sheet signed 7/12/13 revealed the resident with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS (Minimum Data Set-a required assessment) dated 4/26/13 identified the resident with a BIMS (Brief Interview for Mental Status) score of 3 (indicated severely impaired cognition), required limited assistance from 1 staff for bed mobility, transfers, walking in room, supervision of one for walking in the corridor, and locomotion on the unit only occurred once or twice with one person assist. The assessment identified the resident had no fall any time in last six months prior to admission, or since admission into the facility. Review of the resident's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS of 6 (indicated severely impaired cognition), no changes in ADL (Activities of Daily Living), and had experienced 2 or more falls with injury (except major injury) since prior assessment. Review of the Fall CAA (Care Area Assessment) for the 4/26/13 MDS revealed, "Resident ambulates with walker and is not always steady. Has been ambulating without direct assist at this time. Does use a walker." "Family aware of resident's lack of steadiness. Would like him/her to continue to ambulate as able." "Care plan will focus on resident maintaining his/her current ability to ambulate with walker and no stand by assist." Review of the resident's care plan dated 5/14/13 revealed the resident was at high risk for falls related to a history of falls and directed staff to be sure to place the call light within reach of the resident and encourage to use for assistance as needed, have a fall mat next to the bed at night to reduce injury should the resident fall from bed, have a pull tab alarm attached to the resident to alert staff when up, identified the resident needed a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, bed in low position at night, handrails on walls, and personal items within reach, required one person assist for ambulation and toileting, used a pressure sensor that was attached to the call light system, ensure device is in place as needed, please check on the resident every 15 minutes to ensure the resident did not try to get up without help. Review of the resident's Resident Incident Investigations revealed the following: On 5/15/13 at 9:45 p.m. the resident had a fall - "Heard resident holler 'help'. Into residents room and observed resident on floor. Res (resident) stated he/she was trying to go to the restroom and states he/she hit his/her head. Resident was laying on right side. Hematoma (bump) to right side of head and scratch to middle of back with bruising. Called on-call doctor gave order to send to ER (emergency room ). Notified DPOA (Durable Power of Attorney)." On the form, staff circled "Go to the bathroom" and documented "attempting to go to restroom." The staff failed to document if the previous interventions of visual checks, call light within reach, bed (not high or low), or fall mat beside bed had been in place. The assessment identified staff sent the resident to the ER. On 6/9/13 at 1:55 p.m. the resident had an un-witnessed fall - "This nurse was called to resident's room and observed the resident on the floor. Alarm was attached to resident. CNA (Certified Nurse Aide) states that resident had just turned his/her light on and CNA was going to room to answer call light and states before staff got to the room he/she observed the resident on the floor. Resident denies hitting head. Neuro (neurological-having to do with brain function) checks in place. Resident complains of side pain on right side. PRN (as needed) Tylenol given. No other injuries noted at this time. (Did not identify if alarm was sounding). Identified "the resident was attempting to walk, and to go to the bathroom. Did not indicate when was last toileted " Time last toileted" blank. 15-minute visual checks initiated (added to care plan 6/10/13), bed/chair alarm in place but did not indicate if was sounding, call light within reach, and cognitive to use appropriately, bed in between (not high or low). Skin tear to right forearm. "Needing frequent toileting" on diuretic. Statement from staff "I was walking to the resident's room to answer a call light. He/she had rang several times because his/her hearing aid kept falling out. As I was heading there I heard him/her pull alarm go off so I ran to his/her room and found him/her on the floor by his/her bed. I yelled that I needed the nurse and I waited with him/her while the nurse did the assessment. He/she did not complain of any pain or soreness." Review of the Physician order for [REDACTED]. Low bed, fall precautions. Soft mat by bed." On 7/22/13 at 04:05 a.m., the resident had an un-witnessed fall with injury - "Heard resident call out for help when CNA (Certified Nurse Aide) answered the call staff found resident lying on the floor on his/her right side. Resident stated he/she wanted to go to the bathroom by himself/herself and when he/she went to sit down on bedside commode it tipped and caused him/her to lose his/her balance causing him/her to fall, resulting in a skin tear to his/her right elbow, 2 cm (centimeters) in in size. Staff applied steri strips (type of dressing) and gauze. Bed alarm was on and call light was attached to resident prior to fall. ROM (Range of Motion) performed - no complaints voiced of any discomfort from fall. Identified a transfer, last toileted at 03:00 a.m. 'He/she was wanting to start doing more for himself/herself". Body alarm care planned, but body alarm sounding not marked, bed/chair alarm in place, 30 minute visual checks (time of visual checks prior to fall), call light in reach prior to fall, cognitive to use appropriately, skin tear obtained. "Resident has 30 minute visual-checks (inaccurate-care plan identified 15 minutes checks), personal alarm. Will encourage res to use call light. Bed in low position." Confidential Interview form "I found resident on the floor in his/her room with his/her commode on top of him/her. He/she called out 'help me' so I went down to see what he/she needed. He/she said he/she thought he/she could get up himself/herself." On 7/27/13 at 9:50 p.m. the resident had a fall - "Resident was found sitting in front of his/her bedside commode by CNA (Certified Nurse Aide). Resident stated he/she was going to go to the bathroom and missed the commode. ROM (Range of Motion) performed and resident was placed on commode. No complaints other than his/her back and he/she said it was hurting prior to incident." Attempting to go to bathroom "he/she thought he/she could do it himself/herself" Body alarm care planned, on 30 minute visual checks (inaccurate-care plan identified 15 minute checks), bed/chair alarm in place, but did not identify if "Body Alarm sounding" call light within reach, and cognitive to use appropriately at times. Bed in low position. Resident in unsupervised area. It identified staff did not update the care plan but reviewed the care plan without developing changes. Last time toileted was blank. "Resident wants to do more for himself/herself. If there is an alarm on him/her, he/she takes it off sometimes. Need to place alarm further back and have a bed alarm on while in bed. Encourage resident to use call light. Already on visual checks." No staff interviews noted. Review of the "15 Minute" checks for the resident from 8/7/13-8/14/13 revealed staff failed to document multiple times, resulting in hours where the documentation revealed staff failed to check on the resident every 15 minutes as planned. Observation at 8:15 A.M. on 8/13/13 revealed the resident sat in a recliner with his/her feet elevated, covered with a blanket, call light within reach and a tab alarm attached to the back of the resident's shirt. On 8/13/13 at 10:02 A.M. observation revealed Direct care staff C applied a gait belt and assisted the resident to ambulate the bathroom. Staff C reported he/she checked on the resident every 2 hours. Staff C helped the resident to stand and walk back to the resident's chair. Resident turned and started to sit too early, staff C cued the resident to turn more. At 10:10 A.M., staff C left the room and failed to reapply the string on the pull tab alarm to the resident. At 10:20 A.M. no one re-entered the room to apply the pull tab alarm. Observation at 10:33 A.M. on 8/13/13 Medical Records staff R walked down the hall, delivering mail. Staff R looked into the resident's room, but did not go into the resident's room or fix the pull alarm. Observation at 10:37 A.M. on 8/13/13 revealed Social Services S walked down, then up hall past room without fixing the resident's pull cord. Observation at 10:46 A.M. on 8/13/13 revealed Dietary Manager M walked past room twice and failed to reattach the pull alarm. At 11:01 A.M., Direct care staff C walked into the resident's room for just a moment then turned around and walked out. Staff C failed to apply the alarm to the resident. Observation on 8/13/13 at 11:03 a.m. revealed direct care staff C again went into the resident's room, this time to assist the resident to the bathroom. Another resident occupied the bathroom at that time, so staff C waited. At 11:04 a.m., staff C put a gait belt on the resident, assisted the resident to stand, and then walked with the resident to the bathroom. The resident had not had a personal alarm in place. The resident went to the bathroom, then staff C assisted the resident back to his/her chair, put the resident's call light in his/her lap, raised the resident's foot rest, and left the room. Staff C did not clip the string on the personal alarm onto the resident before leaving the room. Staff C returned to the room at 11:13 p.m. and filled the resident's water pitcher and did not put the resident's personal alarm in place. Observation at 11:23 A.M. on 8/13/13 revealed Administrative Nurse B walked down hallway, looked in resident room, and without stopping to attach the alarm, continued to walk down hallway. On 8/13/13 at 11:37 A.M. Direct care staff C stated he/she remembered putting the alarm on the resident "the last time." Staff C reported resident took it off at times. Immediately after visiting with the staff, observation of the resident revealed he/she sat in a recliner in his/her room, with the foot rest elevated. The string on the personal alarm remained connected to the alarm on the chair. The end of the string (intended to be attached to the resident) hung down the chair, not attached to the resident, but connected by a magnet to the alarm. Observation at 11:25 A.M. on 8/15/13 in resident's room revealed Activity staff I, who also worked as a direct care staff at times, reported he/she had not seen any floor mat next to the resident's bed or in the room, and reported maybe the mat addressed in the care plan was the pressure alarm mat used when the resident laid in bed. Staff I was able to point out the pressure alarm pad on the bed, but reported there was no other mat in the resident's room. On 8/14/13 at 3:16 P.M., Direct care staff G stated the resident had a bed alarm and personal pull alarm, and staff applied both even when the resident laid in bed. Staff G stated staff were to clip the call light onto the resident's shirt. Staff G did not think the resident had a floor mat and reported the resident used the call light. Staff G said he/she knows when he/she needs to go to the bathroom, but stated the resident would ring and tell the staff a lot of times it would be too late. Staf

The facility census totaled 25 residents with 18 included in the sample. Four residents were sampled for nutrition. Based on interview, observation, and record review, the facility failed to identify and provide interventions for severe weight loss in 2 of 4 residents reviewed for nutrition (#34, #8). Resident #34 lost 39.4 pounds from 6/4/13 until 7/29/13, or 18% of his/her weight. Resident #8 lost 8.2 pounds from 6/25/13 until 7/29/13, for a 6.1% weight loss. Findings included: - Review of resident #34's signed physician orders dated 8/10/13 revealed the following Diagnoses: [REDACTED]. The resident had been admitted to the facility on [DATE]. Review of the admission MDS (minimum data set) dated 5/2/13 revealed a BIMS (brief interview for mental status) score of 2, indicating severe cognitive impairment. The resident had minimal hearing loss, wore hearing aids, usually made him/herself understood, understood others, and had adequate vision. The resident required setup assistance for transfers, was independent with setup assistance for toileting, and required supervision with setup assistance for walking in the room and corridor and eating. The resident did not have any special dietary considerations and no identified significant weight loss. The resident did not have teeth, but did not have problems with his/her dentures. Review of the quarterly MDS dated [DATE] revealed a BIMS had not been completed. The resident had problems with short and long term memory recall, continuously had inattention, had moderately impaired decision making, and continuously had disorganized thinking. The resident had highly impaired hearing, wore hearing aids, impaired vision, wore glasses, usually made him/herself understood, and understood others. The resident required extensive assistance of one person for transfers, walking in the room and corridor, dressing, eating, and toileting. The resident had trouble with residual food in his/her mouth after eating, loss of fluids/solids from his/her mouth while eating or drinking, no difficulty swallowing, weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months, and not on a planned weight loss program. The resident did not receive any special nutritional approaches. The resident did not have any dental issues, including broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose). Review of the Cognitive Loss/Dementia CAA (care area assessments) dated 5/7/13 revealed an analysis of findings of: "Resident very confused and has more difficulty during late afternoon and evening." No further information had been included. Review of the Nutrition CAA dated 5/7/13 revealed "Resident eats well, potential for weight gain." No further information had been included. Review of the Dental CAA dated 5/7/13 revealed, "Resident has upper and lower dentures." No further information had been included. Review of a Nutritional Risk assessment dated [DATE] revealed the resident had a moderate risk for nutritional impairment. Review of a Nutritional Risk assessment dated [DATE] revealed the resident had a moderate risk for nutritional impairment. No further Nutritional Risk Assessments had been completed. Review of the resident's care plan for unexpected weight loss/poor nutrition with a date of revision of 8/8/13 revealed interventions that directed staff to encourage the resident to eat and drink fluids, weigh the resident weekly until his/her weight was stable, notify the resident's physician and DPOA for any significant weight loss or gain, provide Boost nutritional supplement drinks three times a day (added 8/11/13), offer substitutes as requested or indicated (prefers breakfast foods and soft things), give the resident supplements as ordered, alert nurse/dietitian if not consuming the supplements on a routine basis, and monitor and record food intake at each meal. Review of the resident's care plan for dental health dated 8/6/13 revealed one intervention that directed staff to provide mouth care for personal hygiene. The care plan lacked any mention of dentures, denture care, or that the resident had thrown his/her dentures away. Review of a Dietary Progress Note written by the dietary manager on 5/14/13 at 12:49 p.m. revealed "Resident is adjusting to facility, appetite is good, comes to dining room for meals, family comes and eats with him/her often. [MEDICATION NAME] within normal limits. Diet is regular with texture as tolerated." Review of a Nursing Progress Note dated 6/6/13 revealed a family member had eaten breakfast with the resident and the resident stated "I threw my damned teeth away; they were not worth a[***]" Nursing staff notified the social services director (SSD) and an appointment was made with the dentist for July 16th. Review of a Nursing Progress Note dated 6/23/13 revealed the resident had been up for the noon meal. "Observed res (resident) having increase difficulty with eating task. Holding food in (gender) mouth." Review of a physician order for [REDACTED]. Review of a physician order for [REDACTED]. Review of a Dietary Progress Note written by the dietary manager on 7/24/13 at 11:28 p.m. revealed the resident "sits at assisted bar in dining room and is not eating well. (Gender) sits and stacks (gender) food and then pours (gender) drinks all over the food ... stacked and then proceeds to clean up the mess. When you cue (gender) to eat, (gender) is pocketing the food ... in (gender) mouth and then when you tell (gender) to chew it and swallow it, (gender) will either scoop it out ... and give it to you or ... simply spit it out ... Nursing is aware of this." Review of a Dietary Progress Note written by the dietary manager on 8/6/13 at 1:57 p.m. revealed the resident "comes to dining room for meals. Sits at assisted bar unless family is here to sit with him/her. He/she is not eating well, plays in foods and spends most of meal time wiping down the counter over and over until leaving dining room." Review of the resident's dietary progress notes from 4/23/13- 8/15/13 revealed the dietician had not made a progress note. A fax to the physician on 7/2/13 notified the physician the resident had weight loss and the resident had been moved to the bar in the dining room to receive assistance. A fax to the physician on 7/2/13 revealed the resident had been taking [MEDICATION NAME] and had been losing weight and sleeping more. The nurse asked for a decrease in the medication, and the physician agreed. Review of a fax signed by the physician on 7/5/13 revealed the resident had a weight of 178.8 lbs. on 7/2/13 which the fax indicated was a -14.5% 30.4 lb. change over 30 days and an 11.1% 22.4 lb. change over 90 days. The physician replied, "Weight loss not unreasonable in light of pt's (patient's) deteriorated mental status. Continue to monitor." Review of a fax signed by the physician on 7/26/13 revealed the resident had a weight of 172.2 lbs. on 7/22/13 which the fax indicated was a -5.7% 10.4 lb. change over 30 days and a 14.4% 29.0 lb. change over 90 days. The physician replied, "Weight loss noted. Continue to monitor." Review of the physician signed order summary report dated 7/19/13 revealed the resident had a regular diet ordered with as tolerated texture and thin consistency. Review of the resident's weights revealed: 4/30/13 at 201.2 lbs. (pounds) 5/6/13 at 199.6 lbs. 5/13/13 at 203.2 lbs. 5/20/13 at 202 lbs. 5/27/13 at 208.8 lbs. 6/4/13 at 209.2 lbs. 6/10/13 at 203.6 lbs. 6/24/13 at 182.6 lbs. 7/2/13 at 178.8 lbs. 7/8/13 at 178 lbs. 7/15/13 at 177.4 lbs. 7/22/13 at 172.2 lbs. 7/29/13 at 169.8 lbs. 8/6/13 at 169.8 lbs. 8/10/13 at 180.8 lbs. 8/12/13 at 178.2 lbs. Observation on 8/15/13 at 3:14 p.m. revealed direct care staff H weighed the resident to be 181.0 lbs. The weight loss between 4/30/13 and 8/15/13 totaled 20.2 lbs. or 9.9% in 3 1/2 months, indicating severe loss. Review of the May, June, and July 2013 MARs (medication administration record) revealed the resident had not received health shakes or any other dietary supplementation. Review of a Social Services Progress Note dated 8/8/13 revealed the resident's family member spoke with the SSD about the resident's diet and care. The family member had voiced concerns about the resident's diet, lack of assistance in the dining room, not sitting at the "feeders table," and weight loss. SSD reported to the family member that the aides had been sitting the resident at the "feeders table" and were needing to cue him/her more. The family member discussed the need for the resident to eat more vegetables and fruit for nutrition, and not "so much junk". The family member requested a daily supplemental drink, such as Ensure. SSD advised the family member that the resident had been having a hard time eating due to not having his/her teeth and the increase in dementia. and that staff were "not allowed to force feed resident." SSD assured the family member that he/she would speak with dietary staff M about the resident's diet, possibly changing it to pureed or ground and also to nursing about starting supplemental shakes. Review of a physician order dated 8/11/13 revealed an order for [REDACTED]. Observation on 8/13/13 at 9:53 a.m. revealed the resident drank a serving of Boost Breeze (240 calorie per serving supplement). Observation on 8//13/13 at 10:29 a.m. revealed the resident fed him/herself a waffle with syrup, a honey bun, and a serving of ground sausage, and drank a half a cup of coffee, a large glass of grape juice, and a glass of ice water. The resident ate and drank 100% of everything. Administrative nursing staff B offered the resident more to eat and he/she declined. Observation on 8/13/13 at 12:30 p.m. revealed the resident sat in the dining room and fed him/herself shredded pork, cottage cheese, cake, strawberries, and drank a Boost Breeze and a large glass of water. Observation on 8/14/13 at 3:42 p.m. revealed the resident had just returned from the dentist with new dentures in place. Interview with the resident's family member on 8/19/13 at 8:10 a.m. revealed the resident had lost about 30 lbs. The family member reported that there had been several discussions with the facility about the resident's weight loss, and the facility seemed shocked that the family had so much concern. The family member reported the facility had lost the resident's dentures the first week he/she had lived in the facility, so that had made it difficult for the resident to chew. The family member reported the facility had been feeding the resident food that he/she could not chew and "we told the staff that they were starving (gender) to death." The family member reported that administrative nursing staff A's response to a lot of the concerns had been, "They just don't train the CNAs (certified nurse aides) like they used to." Interview with direct care staff H on 8/13/13 at 3:50 p.m. revealed the resident had a poor appetite at supper usually, but otherwise ate well. Staff H reported that staff had been talking about changing the resident's diet to pureed to see if he/she ate better, and if the resident did not eat, staff offered the resident snacks when completing visual checks. Staff H reported that the dining aide or the CNAs always charted the resident's percentage of intake at the meals, but it varied as to who charted it. Staff H reported the CNAs knew that if it had been done, it showed up green in the resident's computer chart at the end of the shift and usually, the staff just knew who to keep an eye on for charting meal intake, or asked the dining aide to chart it before he/she left. Interview with direct care staff J on 8/14/13 at 11:19 a.m. revealed the resident had lost weight, had thrown his/her dentures away, had been to the dentist, and his/her new dentures should be here soon. Staff J reported the resident received health shakes and Boost drinks to help prevent further weight loss. Interview with licensed nursing staff K on 8/14/13 at 3:31 p.m. revealed the resident needed prompting to eat during meals, and when the resident threw his/her dentures away, staff had started the resident on a pureed diet and that helped with his/her intake. Staff K reported the resident had lost weight and had recently been started on health shake supplements. Staff K reported the resident had a significant weight loss of about 20 lbs. of weight loss in about 4 months. Interview with administrative nursing staff A on 8/15/13 at 5:15 p.m. revealed weight loss had been discussed during the care plan meetings. Staff A reported staff had been giving nutritional supplements, but it had not been documented and staff A thought the dietary staff had been documenting the supplements given during meals, but they were not. Staff A did not know if there had been a person designated to identify weight loss. Staff A reported that as soon as weight loss had been identified, staff should move the resident to the assisted feeding table, offer nutritional supplements, ask the physician for an order for [REDACTED]. Staff A reported the resident had been eating better and would have expected interventions to be in place much sooner to prevent further weight loss. Interview with dietary staff M on 8/15/13 at 2:11 p.m. revealed the resident had lost about 30 pounds and the resident's family had given the dietary staff a list of things the resident would not eat, but sometimes he/she would eat them. Staff M reported staff would put extra sugar in the resident's super cereal (nutritionally fortified cereal), and added sweetener to the resident's juice. Staff M reported staff had to sit with the resident when he/she ate or drank to remind the resident to eat. Staff M confirmed Boost had just been started that week, but staff had been offering it to the resident experimentally before then and confirmed it had not been documented anywhere. Staff M identified the resident as "way above" his/her ideal body weight, so "we didn't really see a concern." Staff M reported that when the resident started eating less, staff started really trying to figure out why the resident had started losing so much weight and staff M thought the dietician was aware of the resident's weight loss and would have made a note in the computer if he/she had seen the resident. Staff M reported it his/her responsibility to identify weight loss, notify the dietician, and notify the physician if needed, and would expect 5% weight loss in 30 days to be reported to the physician and at that point, something needed to be done. Staff M reported that if a resident did not eat their whole meal, sometimes, staff offered them a shake. Interview on 8/20/13 at 1:49 p.m. with consultant staff N revealed he/she had not been notified of the resident's weight loss and expected to be notified as soon as staff identified weight loss. Staff N reported that he/she made monthly visits to the facility reviewed a referral list from the dietary staff M, talked with staff M and administrative nursing staff A to identify issues, if needed discussed concerns with family members and health care providers, and occasionally attended care plan meetings. Staff N reported his/her definitions of significant weight loss were concurrent with the state regulations and if a resident had significant weight loss, depending on the resident's [DIAGNOSES REDACTED]. During an interview on 8/20/13 at 3:10 p.m., physician O reported he/she knew of the resident's significant weight loss and the resident had a spell where he/she had not been eating well, actually losing between "40-50 lbs. in the last several months". Physician O confirmed that amount of weight loss was "a lot of weight in a hurry" and he/she believed it to be of dietary cause from poor nutrition, but it had some benefit as the resident had been "quite portly" before. Physician O reported he/she did not think dietary supplements had been ordered yet. Review of the facility policy for Interdepartmental Notifications of Diet (Including Changes and Reports) revealed, "Nursing services shall notify the physician and the clinical dietician when a nutritional problem (... weight loss, pressure ulcer, eating problems...) has been identified and shall collaborate with the dietician and physician to initiate an appropriated process of clinical review for causes of the nutritional problem." The facility failed to implement interventions to prevent severe weight loss for resident #34. - Review of resident's #8 electronic Order Summary Report, signed by the physician on 7/29/13 revealed it identified the resident with the following Diagnoses: [REDACTED]. Review of the resident's annual MDS (Minimum Data Set-a required assessment) dated 10/31/12 revealed it identified the resident with a BIMS (Brief Interview for Mental Status) score of 15 (indicative of little to no cognitive impairment). The assessmnet identified the resident required supervision and set-up assistance with eating, had no swallowing problems, a steady weight of 142 pounds, and did not receive a therapeutic or mechanically altered diet. Review of the resident's quarterly MDS assessment dated [DATE] revealed it identified the resident with a BIMS of 15, needed supervision and set up assistance with eating, had no loss of liquids or solids from mouth when eating or drinking, holding food in mouth, couging or choking, or complaints of difficulty or pain when swallowing. It identified the resident had experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, a weight of 125 pounds, and did not receive a therapeutic or mechanically altered diet. Review of the Nutritional Status CAA (Care Area Assessment) for the 10/31/12 MDS assessment revealed staff failed to complete the assessment. Review of a Nutrition Progress note completed with a plan of care revision and dated 11/6/12 identified the resident's usual body weight as 131.4 pounds, the resident had a good appetite, received a regular diet with a texture as tolerated, a current weight of 142.2 pounds. The note identified the resident's weight was above the resident's ideal body weight of 110 pounds, the resident ate approximately 100% of meals and had no concerns or changes at that time. Review of the care plan revealed it lacked anything regarding weight loss. Review of the resident's Care Plan Conference Sumary dated 2/5/13 identified staff documented "the resident came to dining room for meals- appetite good." Review of Nutritional Risk assessment dated [DATE] revealed it identified the resident had "no weight change", intake met 76-100% of the resident's dietary needs. The assessment also identified the resident as ambulatory, alert, able to feed self, no chewing or swallowing problems, [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood and is used in part to determine a person ' s nutritional status) and other nutrition-related lab values WNL (within normal limits), and intact skin. Review of an Admit/Readmit assessment dated [DATE] revealed the resident had no teeth, full upper and full lower denture, noted dentures fit, then "if not, worn only when eating." It identified no chewing or swallowing problem, no pain. The assessment also identified the resident had a weight of 133.4 pounds. Review of the physician's orders sheet, signed on 7/29/13 revealed on 6/13/13 the physician gave the staff an order for [REDACTED]. Review of the resident's weights revealed the following: 6/25/13--133.4 pounds 7/2/13--130.2 7/8/13--131.4 7/15/13--128.2 7/22/13--128 7/29/13--125.2 Review of the MAR (Medication Administration Record) for August 2013 revealed "Health Shakes". All days with an "x" in the box-no initials. Review of a Nutritional Risk assessment dated [DATE] identified the resident had no weight change, the resident's intake met 76-100% of the dietary intake needs. It further identified teh resident as ambulatory, alert, able to feed self, no chewing or swallowing problems, [MEDICATION NAME] 30-34 g/L (grams per liter), and 1-2 other nutrition related labs abnormal (but failed to identify which ones). Review of a care plan note by Dietary staff M and dated 8/6/2013 identified the resident no longer came out to the dining room for meals as often as used to- not eating well- takes a bite or two and then states that he/she feels ill. Weight is down 17.2# in last 6 months. Nursing aware of lower appetite and weight change. Observation at 2:09 P.M. on 8/12/13 revealed snacks on a rolling drawer cart next to the resident's bed and bed side table. Observation at 10:29 A.M. on 8/13/13, revealed the resident rested in bed. reported he/she ate two 1/2 triangles of toast, and drank most of his/her tea. The resident reported he/she just did not feel well, and was not hungry. Observation at 12:10 P.M. on 8/13/13 revealed staff entered the resident's room and provided the resident with a room tray of green beans, spotted cake, macaroni and cheese and pork. Direct care staff C reported they thought the resident had maybe experienced some weight loss. Staff C thought it was due to difficulty with swallowing but not related to teeth. Staff C remembered the resident used to get milkshakes and milk and other kinds of things, but thought that made him/her sick. Staff C identified the resident did not like a lot of milk, and reported he/she thought the food was good, and the resident got enough of it. Observation at 12:40 P.M. revealed the resident ate 25% of the cake, ate between 25-50% of meat and sides. The resident reported it was all delicious and the meat tender, but did not want anymore. Observation at 2:35 P.M. on 8/15/13 revealed Direct care staff H assisted the resident to therapy room to weigh the resident. The residents weight totaled 123.4 pounds. Direct care staff Q at 11:01 A.M. on 8/14/13 reported he/she could not tell if the resident had weight loss or not. Staff Q identified that he/she weighed everyone every Monday. Staff Q did not know of any supplements or special snacks that the resident recieved, no specialized diet at meals. Staff Q said the resident had upper dentures and their own teeth on bottom. Top ones are only ones that staff Q had seen or cleaned for him/her. Staff Q said the resident has not ever complained about his/her mouth or teeth, if he/she did staff Q would report it to the nurse and they could come check it out. The resident does oral care for himself/herself, he/she can set it up all on his/her own. During an interview at 255 P.M. on 8/15/13, Direct Care staff H reported did not know if the resident had any weight loss. Reported did not ever give the resident shakes, did not know if the resident ever needed or received shakes, but thought the medication aide or kitchen staff provided them. Licensed Nurse K at 12:53 P.M. on 8/14/13 reported the resident had been really sick a couple months ago-had major GI (gastrointestinal) bleed. Nurse K thought the resident had done real well, when asked about weight loss, reported thought the resident might have actually gained a little bit back. Administrative Nurse B would let know the nursing staff know if the resident had lost weight. Nurse K reported he/she had not been notified of the resident's 10 pound loss since 6/25/13 and stated "this surprises me." Nurse K identified Direct care staff Q weighed the residents every week on Monday, then entered the weights into the computer. Administrative Nurse B is responsible for identifying loss notifying physician. During an interview at 1:11 P.M. with Administrative Nurse B on 8/15/13 revealed the facility's program was computerized and identified if they have had weight loss or gain. When a resident has lost 5% I notify the physician. Administrative Nurse B stated he/she faxed the physicians a sheet that has what the weight loss is, documentation that includes what the residents are eating, supplements they get, and the physicians review the fax and sign. If they want to add any new orders, they will do that, then the staff put the fax in the chart. Nurse B identified Consultant N came in monthly. Nurse B stated he/she believed the resident had a weight loss. Reported to the physician on 8/6/13 that the resident had a weight loss of 17.2 lbs in the last 6 months. New interventions include staff to encourage the resident to eat-this is a big one. Staff are to offer him/her supplements. The resident just does not want to eat. Nurse B stated he/she did not know what the doctor's response was to the weight loss. Nurse B reported he/she did not think staff documented anywhere whether staff offered a supplement or if the resident consumed a supplement. Nurse B stated he/she did not know if the supplement was effective since he/she did not if the resident had been taking them or not. Then walked up to the front desk and showed a 7/24/13 Physician communication Note - Weight warning value 128 lbs -7.5% change over 90 days Signed - Response from physician revealed no change in care plan. Administrative Nurse B reported did not know why they wrote no change in care plan. Dietary staff M looks at them as well. Nurse B did not know how often dietary staff M looked at the weights, but knows he/she has the capability. Thinks at least looks at them at care plans. Nurse B stated he/she did not notify dietary staff M or the consultant N of weight changes. Not sure if dietary staff M notifies consultant N. Administrative Nurse B stated I have orders on everybody, but typically I will not make a nutrition care plan unless they need one. Did not see one related to nutrition for the resident. During an interview on 8/15/13 at 2:00 P.M. Dietary staff M reported I am assuming that it is me that is responsible to review weights. I go over them every week in care plan meetings. I take who I see has lost in the computer every Monday. Usually Direct care staff Q has all the weights in the computer by noon. If it is anything over about 5 pounds, wether it is a loss or a gain, I holler at them. We try to figure out what to do to solve the problem - nursing checks to see if medication is causing something, or if something with staff in the dining room. Consultant N comes in once a month and I tell him/her about any problems we have. We will call him/her if weight loss is identified, and Consultant N will come in or will talk over the phone. I believe the resident had a significant loss, but the resident had quit coming to the dining room, started to eat in his/her room, and began to not eat as much. The resident would take 2 or 3 bites, and then say he/she was sick. Dietary staff M identified the resident as a hoarder, when the snack tray comes around the resident would take 2-3 things off of it. I think staff offer the supplements, we have some that are not milk based, but I do not know if the resident would drink them. Staff do not really document the supplements. I think it is on everyone's orders there is a standing order for shakes. Staff are supposed to offer if a resident is not eating or had drastic weight loss. Staff M stated the resident has not had anything changed with his/her diet, he/she is offered just what is available. Staff probably did not document the supplements. I dont think he/she drank them so staff quit offering them. I know I did not document that. On 8/15/13 at 3:49 P.M. Administrative Nurse A reported he/she was not aware of the resident having any weight loss. Staff A stated weight loss was discussed during care plans, the team talks about weight loss, do weights, what supplements had been given, but Staff A stated he/she was not aware that staff failed to document the supplements. When staff chart the meals, Staff A thought the staff charted the supplements, also. Staff A identified the staff were putting the supplements on the TAR (Treatment Administration Record), that way the charge nurse has to supervise and ensure the resident is getting them. And if the resident refuses, this needs to be charted. I do not know if there is a "designated person" for identifying weight loss. Once someone has been identified with a weight loss, staff should put the resident at the assisted feeding table, provide supplements, provide an appetite stimulator, and if that did not work, get them in for tests. Dietary staff M should be monitoring and bring the concerns to care plan, notify Consultant N and the doctor right away. Consultant N should see them and make recommendations. Interview on 8/20/13 at 1:49 p.m. with Consultant N revealed he/she had not been notified of the resident's weight loss and expected to be notified as soon as staff identified weight loss. Staff N reported that he/she made monthly visits to the facility, reviewed a referral list from Dietary staff M, talked with staff M and administrative nursing staff A to identify issues, if needed discussed concerns with family members and health care providers, and occasionally attended care plan meetings. Staff N reported his/her definitions of significant weight loss were concurrent with the state regulations and if a resident had significant weight loss, depending on the resident's [DIAGNOSES REDACTED]. Review of the facility's undated policy for Interdepartmental Notifications of Diet (Including Changes and Reports) revealed, "Nursing services shall notify the physician and the clinical dietician when a nutritional problem (... weight loss, pressure ulcer, eating problems...) has been identified and shall collaborate with the dieticiain and physician to initiate an appropriated process of clinical review for causes of the nutritional problem." The facility failed to have a system that identified, developed, implemented and reviewed interventions when a resident started to lose weight to prevent a significant weight loss. The resident lost 6.14% of weight between 6/25 and 7/29, or 8.2 pounds.

The facility census totaled 31 residents with 6 included in the sample. The sample included the review of the medication regimen for 3 residents. Based on observation, interview, and record review, the facility failed to provide adequate monitoring of medications for 2 of 3 residents. (#4 and #5). Both residents were on medications with narrow therapeutic ranges. The facility failed to conduct a laboratory blood test as ordered for resident #5, failed to identify, assess and monitor side effects of bruising for resident #5. The resident's blood became too thin and the resident required hospitalization . The facility failed to consult with the physician regarding a low laboratory result for an anti-[MEDICAL CONDITION] medication for resident #4. The staff failed to administer the anti-[MEDICAL CONDITION] medication as ordered, and the resident experienced a [MEDICAL CONDITION] and a hospitalization . Findings included: - Review of an Admission MDS (Minimum Data Set 3.0-a required assessment) dated 8/30/12 identified resident #5 with a BIMS (Brief Interview for Mental Status) score of 15/15 (indicated little to no cognitive impairment), rejected care 4-6 days of the 7 day assessment, required extensive assistance from 2 staff with bed mobility, transfers, dependent on staff for locomotion on/off the unit, and dependent on two staff for toilet use. It also identified the resident took an anticoagulant medication 2 days of the 7 day assessment period. Review of the care plan, dated 8/31/12, identified resident took [MEDICAL CONDITION] medications and provided guidance to staff on what side effects/adverse effects to monitor the resident for. The care plan directed staff to administer medications as ordered. The care plan failed to identify the resident received an anticoagulant medication and failed to provide guidance to staff what side effects or adverse effects to monitor for. Review of the resident's orders, signed by Consultant A on 8/21/12, revealed Consultant A ordered staff to administer the anticoagulant medication [MEDICATION NAME] 4mg (milligrams) daily on Monday and Thursdays, and to administer 2mg daily on the other days. Consultant A also gave the order for staff to obtain a PT/INR (a laboratory blood test to monitor how thin the resident's blood had become) in one week, or 8/28/12. Review of the record revealed that the staff failed to obtain the laboratory test as ordered to monitor the effectiveness of the [MEDICATION NAME]. Review of the nurse's notes revealed the following: On 8/25/12 at 8:00 a.m., staff documented the resident's fourth toe on the right foot was bruised. The resident told the staff he/she had hit it on something, but did not realize that it was bruised. The staff faxed the physician and placed a call to the family. The record lacked any measurement of the bruise or any further monitoring of the area. On 9/3/12 at 9:00 p.m., staff documented the resident had multiple bruises to the body. The resident stated the bruises were from bumping into things. Staff documented the resident received [MEDICATION NAME] and a side effect was bruising, and there was a black box warning and staff were monitoring by conducting routine laboratory tests and continued resident assessments. Review of the record revealed staff had not conducted any laboratory tests and the record lacked any assessments or monitoring of the "multiple bruises." On 9/17/12 at 2:58 p.m., staff identified the resident complained of not feeling well at 2:30 p.m. The staff assessed the resident as pale, and with respirations of 36 per minute. The staff sent the resident to the local emergency room . At 7:00 p.m., the resident returned to the facility. The resident told the staff the doctor had stated the resident was anemic (had a low blood count), and ordered staff to obtain a CBC (a laboratory test to check for [MEDICAL CONDITION]) in one week. The physician also ordered staff to administer iron to the resident and to administer oxygen to keep the oxygen saturation levels (how much oxygen in the blood) above 90%. On 9/18/12 at 3:00 p.m., staff documented the resident's skin as pale, and at times the resident had a small drop of blood that came from the resident's nose. At 7:30 p.m. that night, the staff sent the resident to the emergency room because the resident had a bright red nose bleed. Staff assessed the resident as pale and with cool skin that appeared more pale that the previous night. The resident returned to the facility at 10:00 p.m. with orders to see Consultant A in the morning. The emergency room attempted four times to conduct a laboratory test to monitor how thin the resident's blood was, but was unable to conduct the test. On 9/19/12 at 12:00 noon, staff documented the resident was out to see Consultant A and the resident continued to be extremely bruised. The record lacked an assessment of the bruising or ongoing monitoring of the bruises. Review of the nurse's notes revealed the resident continued to have bleeding from the nose, increased bruising to the arms, torso, legs and feet which got larger, as well as visits from Consultant A until 9/21 at 12:10 p.m., when the resident became incoherent and the facility sent the resident into the emergency room . The resident's [MEDICATION NAME] (monitors the effectiveness of the [MEDICATION NAME]) was >200 seconds (normal is 9-11.5 seconds) and the INR (International Normalized Ratio--works in conjunction with [MEDICATION NAME] to monitor blood clotting time) was >18. The resident's DPOA (Durable Power of Attorney) called the facility on 9/23/12 at 1:00 p.m. and told the staff the resident had 3 units of blood and the resident's PT/INR was more stabilized. On 10/19/12 at 1:30 p.m. Administrative staff C and Administrative Nurse G stated that the staff missed getting the order for the PT/INR on 8/28/12 as ordered because the resident's admission did not follow the normal manner in which resident admissions occurred. Staff G stated he/she had provided training to staff on how to assessment, investigate and monitor bruising on residents. Staff G provided a sheet addressed to the licensed nursing staff that gave examples of the facility's policy on assessment, investigation and documentation of skin issues, including bruising. Staff C and G confirmed the facility staff failed to follow the policy to monitor bruising on this resident. When asked if the staff had contacted the Consultant Pharmacist to review the resident's medication regimen to determine if it contained any irregularities, staff C stated that he/she had not thought to contact the Consultant Pharmacist. On 10/22/12 at 1:15 p.m., Consultant A stated he/she did not feel like the staff had failed to notify the medical staff in a timely manner of the resident's bruising. Consultant A stated the resident went from being independent to requiring extensive assistance, and Consultant A said that could cause the bruising, as well as other disease processes, including those that caused the resident to swell, or become [MEDICAL CONDITION], some psychiatric issues, and then just generally the age of the resident's skin. The facility failed to monitor the use of an anticoagulant medication for a resident by obtaining ordered laboratory testing in a timely manner and failing to assess and monitor for side effects, including bruising. The resident required a hospitalization and 3 units of blood. - Review of the recapitulation of orders, signed on 9/18/12, identified resident #4 with a [DIAGNOSES REDACTED]. Review of the annual MDS (Minimum Data Set 3.0-a required assessment) dated 10/3/12 identified the resident with severely impaired cognition, dependent on two staff for bed mobility, transfers, and bathing. Review of the care plan, last dated on 10/9/12 revealed the resident had a history of [REDACTED]. The care plan directed staff to obtain the necessary laboratory testing as ordered by the physician to monitor the [MEDICATION NAME] level in the resident's blood. Review of the resident's record revealed staff obtained a [MEDICATION NAME] level on 12/7/11. The result was 4.1 micrograms per milliliter, or ug/mL. Normal therapeutic range is 10-20 ug/mL. According to the faxed laboratory result, the staff faxed the result of the [MEDICATION NAME] level to Consultant B. The staff never called Consultant B to ensure that he/she received the abnormal results of the laboratory test. Review of February 2012 MAR (Medication Administration Record) revealed that the physician had ordered staff to administer [MEDICATION NAME] 300mg (milligrams) by mouth three times a day since March 2010. Staff assigned the times of AM, Lunch, and PM for the administration times of the [MEDICATION NAME]. According to the MAR, staff administered the medication as ordered except for 2/15 and 2/16. On those two days, staff failed to sign they administered the AM dose of the [MEDICATION NAME]. Review of a nurse's note, dated 2/17/12, identified staff were assisting the resident with a shower between 6:30 and 7:00 a.m. when the resident had a [MEDICAL CONDITION]. Staff called the licensed staff on duty, Administrative staff C, who stayed with the resident and directed the direct care staff to go call EMS. The resident then went to the emergency room . While in the emergency room , the hospital personnel obtained another [MEDICATION NAME] level and determined that it was low at 4.6 ug/mL. The hospital staff stopped the [MEDICAL CONDITION], changed the resident's [MEDICATION NAME] level, and sent the resident back to the facility with an order to obtain a [MEDICATION NAME] level in 2 weeks. The staff obtained the [MEDICATION NAME] level on 2/29/12 and the resident's [MEDICATION NAME] level at that time was within therapeutic range, 14.3 ug/mL. The record revealed the staff had not obtained another [MEDICATION NAME] level since that time, over 7 months. Observation on 10/18/12 at 4:15 p.m. revealed direct care staff D and direct care staff E used a mechanical lift and sling to assist the resident from the bed into a wheelchair. The staff changed the resident ' s incontinent brief that was wet, provided perineal care, then replaced the brief. Both staff then transferred the resident with a mechanical lift from the bed into a Geri-chair (a reclining chair), then assisted the resident out of the room to the dining room. Observation on 10/19/12 at 8:10 a.m., revealed direct care staff E and F assisted the resident from the wheelchair into bed with the use of a mechanical lift. Both staff used good technique and made sure they situated the resident in the middle of the bed. Both staff stated they had heard the resident had [MEDICAL CONDITION], but neither staff had witnessed the resident having a [MEDICAL CONDITION]. On 10/19/12 at 1:18 p.m., Administrative staff C stated he/she remembered resident #4 having a [MEDICAL CONDITION] as that was staff C's first day at work. Staff C and Administrative Nurse G both stated they did not think the staff had called Consultant B to make sure he/she received the faxed results of the resident's laboratory results. Both staff C and G were unaware that the staff had failed to administer the morning dose of the anti-[MEDICAL CONDITION] medication to the resident 2 days before the resident's [MEDICAL CONDITION]. On 10/22/12 at 2:30 p.m., Consultant B stated he/she could not remember if the staff had notified him/her about the resident's low [MEDICATION NAME] blood level in December 2011, but that he/she normally tried to keep the resident's blood level in the therapeutic range of 10-20 ug/mL. He/she also said he/she relied upon the facility to obtain the ordered laboratory testing and then report the results to him/her. The facility failed to provide adequate monitoring of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] through a failure to consult with Consultant B regarding a low [MEDICATION NAME] blood level. The facility also failed to follow the order and administer the [MEDICATION NAME] as ordered. The resident experienced a [MEDICAL CONDITION] and required a trip to the emergency room for further treatment.

The facility census totaled 32 residents, with 3 sampled. Based on observation, interview and record review the facility failed to ensure the provision of adequate supervision and assistive devices to prevent accidents for 2 of 3 sampled residents (#1 and #3). Resident #3 sustained a fracture while unsupervised in an outdoor courtyard area. Findings included: - Resident #3's Admission MDS (Minimum Data Set) dated 8-15-11 identified the resident with a BIMS (Brief Interview of Mental Status) of 6, which indicated severe impairment of the resident's cognitive status, feeling down or depressed and bad about him/herself. The MDS identified no behavioral symptoms over the two weeks previous to the completion of the MDS. The MDS identified the resident required supervision of one staff for all activities of daily living (ADL ' s) with the exception of walking in the room for which the resident required no assistance. The MDS identified the resident was not steady but able to stabilize self when moving from a seated to standing position, turning around and moving on and off the toilet. The MDS identified the resident had pain, but not within the five days previous to completion of the MDS. The MDS identified no fall for the resident. The quarterly MDS dated [DATE] identified the resident with a BIMS of 4, or severely cognitively impaired. The MDS identified the resident with fluctuating periods of disorganized thinking. The MDS also identified the resident with delusions 4 to 6 days of the look back period (the 7 days previous to completion of the MDS data collection), but not daily. The MDS identified the resident with wandering behavior 4 to 6 days of the look back period. The MDS identified the resident was independent with all ADL's except for dressing and personal hygiene for which the resident required the supervision of one person. The MDS showed the resident required physical help for bathing. The MDS identified the resident was not steady, but able to stabilize without human assist when moving from a seated to standing position and turning around and moving on and off the toilet. The MDS identified the resident with the presence of pain, but not in the previous 5 days. The MDS showed the resident had not had any falls. The CAA (Care Area Assessment) for falls, dated 8-15-11, identified the resident with a potential for falls related to balance problems, medications, postural hypotension, anemia, cognitive loss, dementia, signs and symptoms of depression and a history of impulsivity and poor safety awareness. Review of the care plan last reviewed on 2-12-12 lacked any intervention related to the use of a wanderguard to alert staff if the resident left the building. Administrative Staff E confirmed the lack of such on 6-5-12 at 1:25 p.m. The care plan review also revealed the lack of any care plan intervention indicating the resident required supervision while on the outdoor patio. Staff E also confirmed the lack of an intervention on the care plan that would require staff to supervise the resident while on the outdoor patio. Review of nursing notes dated 4-10-12 at 10:00 a.m. noted a late entry for 4-7-12. The entry noted the resident had some "abnormal behaviors" and had repeated over and over that he/she had gone to the store the previous evening and someone stole his/her car and now the cops were after him/her. On 4-10-12 at 1:00 p.m. nursing notes showed staff placed a wanderguard on the resident's left ankle, for safety. On 4-18-12 at 1:00 p.m. the nurse noted the resident was in another resident's room and refused to move. The nurse noted the resident was confused and seemed distrusting of the staff, feeling staff had called him/her a liar and blamed him/her for hurting someone. A nursing note on 4-25-12 at 1:45 p.m. noted the resident had increased behaviors, had gotten into the roommates things, which upset the roommate and then angered resident #3. This same note indicated the resident had headaches recently and had delusions and hallucinations and felt someone he/she did not know was in his/her room. The note also stated the resident wandered about the facility more and looked for support from staff. The nurse obtained a physician's orders [REDACTED]. The staff gave the Valium at 4:40 p.m. and at 5:10 p.m. the resident went to the front door opened it and walked out. Staff noted the resident had an unsteady gait and held on to the walls for support. The staff also noted the resident had displayed unsteadiness prior to receiving the Valium. A nursing note on 5-1-12 at 8:50 a.m. revealed the resident was admitted to a behavioral health unit. The next nursing note was 5/10/12 at 7:00 p.m. and noted the resident had ambulated up and down the hall visiting with other residents, and was cooperative with staff. A nursing note dated 5-1-12 at 4:00 p.m. documented the resident went to the nursing desk at 10:40 a.m. and was crying. The resident reported he/she was on the back patio and tried to jump the fence to get to music lessons and thought he/she broke his/her arm and shoulder. The nurse assessed the resident's injuries and sent the resident to the emergency department at the hospital. The note continued that the resident returned to the facility at 3:00 p.m. Family reported to the staff that the resident had a crack in his/her right wrist. Interview on 6-5-12 at 1:30 p.m. with direct care staff A revealed he/she was not here at the time resident #3 attempted to jump the fence. Staff A said resident #3 was free to come and go onto the patio whenever he/she wanted. Staff A said resident #3 did not need anyone to go out onto the patio with him/her. Staff A said someone checked on the residents on the patio every thirty minutes or so. The staff said everyone just looked out on the patio when they went by to go to the dining room or kitchen area. Staff A said the direct care staff also told each other someone was out on the patio, however no staff were assigned to supervise the patio. Staff A said care plans for the direct care staff were kept on the back of the door to each resident's bathroom. Staff A said he/she was not aware of any changes to resident #3's care after the accident on the patio. Interview with direct care staff B on 6-5-12 at 3:00 p.m. revealed resident #3 was "just out there" and sometimes said things that were not true. Staff B said he/she was in the area of the patio door when resident #3 came in on 5-11-12 and said he/she had hurt him/herself when climbing the fence to get to the bus load of kids. Staff B said the resident also told a resident's visitor he/she was hurt before going on to the nurses desk and telling Licensed Staff D he/she was hurt. Interview with Licensed Staff D on 6-5-12 at 1:48 p.m. revealed he/she put a wanderguard on resident #3 for safety reasons because he/she was having more delusions and was more restless. Staff D expressed concern that there was a highway so close to the facility. Interview with Licensed Staff C on 6-5-12 at 1:50 p.m. revealed the patio, " fenced courtyard " was considered a safe area for residents prior to resident #3's incident. Staff C identified the patio as a place residents were allowed without supervision, except for a select few who were care planned as such and required supervision to go out. Interview with Licensed Staff D on 6-5-12 at 2:45 p.m. revealed the resident did present to the desk on 5-11-12 and report he/she had tried to jump the fence to get to his/her music lessons and he/she had broken his/her arm. Interview with Administrative Staff E on 6-5-12 at 1:26 p.m. revealed resident #3 had a wanderguard but he/she was not sure why. Staff E said the residents with a wanderguard could go out onto the patio because the area was fenced. Staff E said at the time of the incident there were no staff on the outdoor patio, so no one was really sure what happened. Staff E said the resident told different staff that he/she was going to music lessons, he/she was going to get a bus load of kids, and he/she was going to get his/her car. Interview with Administrative Staff E on 6-5-12 at 1:45 p.m. revealed the facility lacked a policy related to wanderguards. Further interview with staff E revealed he/she would not consider the resident at risk in the courtyard when he/she displayed an increase in delusions and hallucinations, Staff E said the resident had just returned to the facility the day before the accident occurred. Staff E said the resident had gone to a behavioral health unit for treatment of [REDACTED]. Interview with Consultant Staff F on 6-6-12 at 4:10 p.m. revealed he/she did not see the resident in the emergency department when this fall happened but it was his/her understanding the resident had a "psychotic break" and attempted to go over the fence at the facility and fell . Staff F said he/she was of the understanding the fracture occurred as a result of the fall. Staff F confirmed the resident did not have any disease process that would cause a spontaneous fracture. Staff F said the resident sustained [REDACTED]. Policies related to the use of wanderguards and monitoring of residents wearing wanderguards and criteria for residents to go on the patio unsupervised were requested from Administrative Staff E on 6-5-12 at 1:45 p.m. Staff E looked, but said he/she found no policy for either. The facility failed to ensure supervision of a resident staff had identified with increased delusions and hallucinations and an increase in wandering. The resident sustained [REDACTED]. - Review of resident #1's Admission MDS (Minimum Data Set) dated 12-21-11 revealed the resident had a BIMS (Brief Interview of Mental Status) of 2, indicating severe cognitive impairment. The MDS identified the resident had inattention that came and went, with changes in severity. The resident also displayed disorganized thinking, with changes in the severity of the disorganized thinking. The MDS identified the resident to have hallucinations and delusions. The MDS also noted the resident had behavioral symptoms that significantly interfered with the resident's care and put others at significant risk for physical injury. The MDS identified the resident required extensive assistance of two persons for all ADL's (Activities of Daily Living) except eating, and personal hygiene which required extensive assistance of one person. The MDS identified the resident with unsteadiness and the inability to stabilize without human assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfers. The MDS identified the resident was frequently incontinent of urine. The MDS identified the resident with an anxiety disorder and mild occasional pain. The MDS showed the resident had a fall since admission with no injury. Review of the quarterly MDS dated [DATE] revealed the resident with a BIMS of 0, or severe cognitive impairment. The resident's inattention and disorganized thinking remained the same as the admission assessment. The resident continued to have hallucinations and delusions. The MDS noted an increased need for assistance for ADL's. The MDS identified the resident required extensive assistance of 2 persons for bed mobility, transfers, walking in room and corridor, dressing, toilet use, personal hygiene and was totally dependent on staff for locomotion on and off the unit and required limited assist of 1 for eating. The Cognitive CAA (Care Area Assessment) dated 12-9-11 identified the resident had Alzheimer's Dementia with behavioral disturbances, a short attention span, confusion with forgetfulness, disorientation and lived in the past at times through hallucinations and delusion. The Fall CAA dated 12-9-11 identified the resident with a history of falls, poor coordination, poor balance, unsteady gait, awkward crisscrossing steps at times, incontinent, cognitive loss and hallucinations/delusions. The facility last reviewed the care plan on 3-27-12. Care plan interventions related to prevention of falls included: 1-2 staff to provide weight bearing assistance for transfers, 1-2 staff to provide weight bearing assistance for ambulation with a gait belt and walker at times or 2 hand held assist as sometimes he/she does better that way, anticipate resident's needs, resident does not use call light, make frequent visual checks for safety, do not close the door to his/her room. Additions to the care plan included: on 4-23-12, lock wheelchair brakes and initiation of the use of a body alarm when up in the wheelchair, body alarm on when in room alone, check to ensure it is in working order before leaving the room, an addition on 4-25-12 to educate staff on mental status, assist resident to toilet per schedule and when attempting to climb out of his/her chair, do not ask if he/she needs to toilet due to diminished mental capacity and perception of needing to void/have stools. The nurse Assistant Flowsheet identified as the care plan for the nurses aides noted the following: the resident had a toileting schedule, body alarm on when in his/her room alone and check to ensure it is in working order before leaving his/her room, make sure non skid socks or shoes are worn for all transfers and ambulation, and walk to dine for each meal. Review of the nursing notes dated 4-19-12 at 4:40 p.m. identified staff found the resident on the floor between the pedals of the wheelchair. The notes identified the resident had an approximate 1.5 cm (centimeter) laceration to the right upper lip and a less than ? cm skin tear to the back of the right forearm, which staff treated at the facility. Review of the care plan found no revisions related to this fall. Interview with Administrative Staff E on 6-6-12 at 10:23 a.m. revealed the resident was getting up out of the recliner in his/her room and the wheelchair was next to the recliner and the resident fell between the wheelchair pedals. Staff E confirmed the lack of any investigation of cause of the fall and identification of interventions to try and prevent further falls of this nature. Nursing notes dated 4-23-12 at 6:15 p.m. documented the staff found the resident on the living room floor on his/her back. Review of the fall investigation dated 4-23-12 identified the resident attempted to stand without assist and fell . The investigation also noted Direct Care Staff L identified the wheelchair brakes were weak. Interview with Administrative Staff E on 6-6-12 at 10:40 a.m. revealed they did replace the resident's entire wheelchair. Review of the care plan revealed staff initiated the use of a body alarm after the fall. Review of nursing notes dated 5-5-12 at 1:30 p.m. revealed the resident fell at 12:20 p.m. in the dining room. Two nurse aides were noted to have witnessed the fall and attempted to reach the resident before he/she fell , but could not. The resident's body alarm did sound when the resident stood. The resident received a laceration above the right eye and was taken to the emergency department. The resident received 7 stitches to close the laceration above his/her eye. Review of the care plan revealed staff made no revision related to attempts to prevent further falls of this nature. Interview with Administrative Staff E on 6-6-12 at 10:42 am. revealed the resident was no longer allowed to sit at the table alone. Staff E said otherwise the staff sat the resident at the bar where the staff were closer and could supervise the resident more closely. Review of the nursing notes dated 5-25-12 at 6:05 p.m. revealed staff found the resident on the floor next to the recliner in his/her room at 5:05 p.m. The staff assessed the resident with a small abrasion to his/her right shoulder. Review of the fall investigation dated 5-25-12 revealed the staff found the resident lying between his/her recliner and the window wall. Staff noted the lack of a body alarm in place at the time of the resident's fall. Interview on 6-6-12 at 10:55 a.m. with Licensed Staff C revealed there was no body alarm even in the resident's room at the time of the fall. Staff C said he/she immediately educated the direct care staff that they must check the alarm at shift change to ensure it functioned properly and also check the functioning at the time of placement of the alarm. Nursing notes on 5-29-12 at 10:00 a.m. revealed the housekeeper heard an alarm sounding in the living room and summoned a licensed nurse. Staff found the resident lying on his/her left side. The alarm was sounding and his wheelchair had the front right wheel on top of another chair in his/her room and the resident was under the wheelchair. The resident complained of pain to his/her left shoulder and was sent to the emergency department, however he/she needed no treatment. Interview with Administrative Staff E on 6-6-12 at 10:38 a.m. revealed the staff had brought the resident to the living room to wait for breakfast and he/she attempted to get out of the wheelchair. Staff E said the direct care staff woke the resident early and brought the resident to the living room and left the resident sitting in the living room waiting for breakfast. Staff E said he/she had instructed staff not to wake the resident if still sleeping. Staff E confirmed the staff had not revised the care plan with this intervention as of the 6-6-12 interview. Interview with Administrative Staff E on 6-6-12 at 10:53 a.m. revealed he/she recognized the fall investigations did not include the immediate environmental factors possibly related to the cause of the fall, or interventions to try and prevent similar falls. Observation on 6-6-12 at 11:52 a.m. revealed Direct Care Staff H and Direct Care Staff I assisted the resident with toileting then walked the resident to the dining room. The direct care staff sat the resident at a table across from the bar. No one else sat at the table. Interview with Administrative Staff E on 6-6-12 at 12:00 p.m. confirmed the staff were to sit the resident at the bar for closer supervision and not at the table away from staff's immediate supervision. Interview with Direct Care Staff H on 6-5-12 at 10:20 a.m. revealed the staff should check on the resident frequently. Staff H said the resident can move really fast and even though staff place a body alarm on him/her, it is usually already going off and the staff cannot get to the resident before he/she falls. Interview with Direct Care Staff J on 6-6-12 at 3:55 p.m. revealed the staff try to let this resident sleep in later in the morning, because staff think maybe the resident just got tired, fell asleep and fell out of his/her chair. Staff J said the staff try to "entertain" the resident more by visiting with the resident about particular interests. Staff J said they also try to toilet the resident every two hours. Interview with Administrative Staff E on 6-6-12 at 11:00 a.m. revealed he/she sees the resident trying to do more on his/her own, and staff just need to be educated more about what to do when the resident is more active and what to do when the resident is more sleepy to prevent falls. The facility failed to consistently identify causal factors of resdient #1's falls, then develop and implement interventions in an effort to prevent falls. This resident did sustain multiple falls with one fall resulting in a laceration of the forehead that required seven sutures to close it.