Every finding on record at Arkansas City Presbyterian Manor

The facility reported a census of 46 residents with one kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to prevent the potential for food borne illness and decreased palatability. This puts the residents at risk for illness and weight loss. Findings included: During an initial tour of the resident kitchen on 08/11/25 at 09:05 AM, the following areas of concern were noted in the freezer:Two Ziplock bags of hamburger patties were unsealed, and the bag was wide open, exposing the contents to air.A Ziplock bag of chicken strips was unsealed, and the bag was wide open, exposing the contents to air.A Ziplock bag of potato wedges was unsealed, and the bag was wide open, exposing the contents to air.During the subsequent tour of the kitchen on 08/12/25 at 09:30 AM, two of the four cutting boards had deep grooves and scratches. The other two had multiple scratches.On 08/11/25 at 09:05 AM, Dietary Staff BB stated he was aware that items in the freezer should be sealed to avoid freezer burn. He immediately sealed the Ziplock bags.On 08/12/25 at 09:30 AM, Dietary Staff BB stated the cutting boards needed to be free from scratches and grooves. Dietary Staff BB stated he has ordered new cutting boards.

The facility reported a census of 46 residents. The sample included 16 residents, which included seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards when Certified Nurse Aide (CNA) M assisted a cognitively impaired resident, Resident (R) 46, with locomotion in the hallway without the use of wheelchair pedals. This deficient practice placed R46 at risk for accidents.Findings included:- Review of the Electronic Health Record (EHR) documented R46 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), long-term use of anticoagulants (a class of medications used to prevent the blood from clotting), and generalized muscle weakness.R46's 02/14/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The assessment documented R46 utilized a wheelchair and/or walker for locomotion and required setup assistance to wheel 50 feet with two turns and supervision assistance to wheel 150 feet in the corridors. The 02/14/25 Cognitive Loss / Dementia Care Area Assessment (CAA) documented R46 had a diagnosis of dementia and required staff to reorient R46 as needed, but with short-term success. The 02/14/25 Falls CAA documented R46 had a history of falls and included falls with fractures (broken bones) prior to admission. R46 utilized a wheelchair for most of her locomotion and was able to self-propel at times, and required staff assistance at times for locomotion.R46's 07/25/25 Quarterly MDS documented a BIMS score of three, which indicated severely impaired cognition. The assessment documented R46 utilized a wheelchair and/or walker for locomotion and required setup assistance to wheel 50 feet with two turns and supervision assistance to wheel 150 feet in the corridors. R46's 06/27/24 Care Plan, reviewed 08/12/25, documented the resident had impaired mobility with impaired physical function. The plan documented R46 required substantial/maximal assistance with transfers and wheelchair locomotion. R46 would sometimes propel herself in her wheelchair for short distances with her feet, dated 06/27/24 and revised on 02/28/25. R46's Care Plan instructed staff to lock R46's wheelchair for all transfers and position R46's feet on the foot pedals for all assisted wheelchair locomotion.During an observation on 08/12/25 at 02:20 PM, CNA M assisted R46 from the common area down a corridor to R46's room, and the wheelchair did not have foot pedals. R46 held her feet off the floor during assisted wheelchair locomotion.On 08/12/25 at 02:25 PM, CNA M revealed she assisted R46 to her room via R46's wheelchair. CNA M confirmed the wheelchair did not have pedals installed. CNA M stated the wheelchair pedals should have been installed prior to assisted wheelchair locomotion.On 08/12/25 at 02:35 PM, Licensed Nurse (LN) G reported that all residents being assisted with wheelchair locomotion should have their feet set on the foot pedals prior to the wheelchair going into motion.On 08/12/25 at 02:45 PM, Administrative Nurse D said that all residents should have foot pedals installed on the wheelchair with their feet set on the foot pedals prior to assisted wheelchair locomotion. Administrative Nurse D said that the wheelchairs have bags attached to the back of the wheelchairs so residents who prefer to self-propel can have the pedals stowed in the bag for easy access by staff when assisted wheelchair locomotion is required. Administrative Staff D revealed the facility's expectation was for staff to place foot pedals on the wheelchair and for staff to ensure the resident's feet are safely on the pedals prior to assisted wheelchair locomotion.On 08/13/25 at 08:10 AM, Administrative Nurse D revealed the facility did not have a policy related to the use of wheelchair pedals and that the facility expected staff to follow the standard of practice.The facility did not provide a policy.

The facility reported a census of 46 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the delivery of laundry to the residents' rooms. This deficient practice had the potential to lead to the cross-contamination and spread of communicable diseases to the residents of the facility.Findings included:On 08/11/25 at 10:35 AM, Laundry V and Laundry W were observed delivering laundry to three resident rooms. Laundry V and Laundry W did not perform hand hygiene before they entered the residents' rooms or after they exited the residents' rooms. On 08/11/25 at 10:37 AM, Laundry V and Laundry W stated they were informed by a former supervisor that hand hygiene between resident rooms stopped when the COVID-19 (highly contagious respiratory virus) pandemic ended. On 08/11/25 at 10:40 AM, Housekeeping U revealed the facility's expectation was that hand hygiene should be performed with alcohol based hand rub (ABHR - isopropyl alcohol hand sanitizer) when going from one resident's room to another, and actual hand washing with soap and water after every fourth or fifth time of using ABHR.On 08/11/25 at 11:25 AM, Administrative Nurse E stated hand hygiene should be performed by all staff when entering and/or exiting residents' rooms. On 08/11/25 at 11:27 AM, Administrative Nurse D revealed the facility's expectation was for staff to perform hand hygiene with ABHR if hands are not visibly soiled and with actual soap and water after the fourth use of ABHR. Administrative Nurse D and Administrative Nurse E confirmed staff should have performed hand hygiene after leaving one resident room prior to going into a different resident's room. The facility's Hand Hygiene policy, revised 02/03/25, documented all staff would comply with hand hygiene guidelines and gave indications for hand-washing that included before and after direct contact with residents and before and after contact with inanimate objects in the vicinity of residents.

The facility reported a census of 46 residents. Based on record review and interview, the facility failed to display accurate and identifiable staffing information, which contained the actual nursing hours worked, for the 46 residents who resided in the facility. Findings included:- Review of the facility's Daily Nurse Staffing Report from 07/10/25 through 08/10/25 revealed the actual hours worked had not been completed on the daily nurse staffing report.On 08/13/25 at 10:00 AM, Administrative Nurse D confirmed the actual hours worked were not completed on the daily staffing sheets, as required. The facility policy for Daily Nurse Staffing Report, revised 02/03/25, included: At the beginning of each shift, the form shall identify the actual shift hours expected to be worked by licensed and unlicensed staff directly responsible for resident care.

The facility reported a census of 37 residents. Based on observation, interview, and record review, the facility failed to store foods safely and in sanitary conditions due to the staff failure to date and properly seal food items and removal of undated bread items to prevent the possible spread of food borne illness. Findings included: - On 03/04/24 at 08:20 AM during the initial tour of the kitchen, and follow-up tour on 03/05 at 12:35 PM with dietary staff D, revealed the following areas of concern: The Kitchen refrigerator: There were 17 facility made Sugar free health shakes that lacked a prepared date. There were 19 facility made thawed health shakes that lacked dates when pulled from the freezer. One hamburger patty in the freezer in an open bag that lacked a date. One bag of opened chicken bites that lacked an opened date. One bag of opened broccoli that lacked an opened date. One bag of opened carrots that lacked an opened date. In addition, the tour of the facility revealed a loaf of bread with no use by date on the rolls, and one bag with mold on the rolls. One bag of Hawaiian sweet rolls, with no open date or use by date. One dented can of Artichoke hearts. One dented can of dark kidney beans. The small upright freezer in the kitchen had food particles toward the back of the freezer/shelves that had a gummy film on them. On 03/04/24 at 10:29 AM, observed dietary staff D and dietary staff E, in the food preparation area and lacked a covering/beard guard over their beards. On 03/06/24 at 12:25 PM, observed dietary staff D in the kitchen preparation area and continued to lack a covering/beard guard on his beard. On 03/06/24 at 12:25 PM, dietary staff D verified the above concerns. Items should be dated, and dietary staff should pull food items after seven days. Dietary staff D reported that working as a chef, not wearing the beard guard was not an issue. The facility failed to provide a policy regarding marking of open items and the use of beard guards while in the food preparation area. The facility failed to store food safely and in sanitary condition due to the staff's failure to dated food items, wear beard guards when in the food preparation area, and removal of outdated food items to prevent the spread of possible food borne illnesses to the resident in the facility.

The facility census totaled 37 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide a safe sanitary environment for two Residents (R)13 and R19, related to incontinent cares, to prevent spread possible infections in the facility. Findings include: - Observation on 03/05/24 at 01:20 PM, revealed Certified Nursing Assistant (CNA) C and CNA F ambulated R13 to her room and took her into the bathroom. The resident stood in front of the toilet and held onto CNA F's arms while CNA C donned gloves and took R13's pants down and removed the resident's brief. After R13 finished toileting, CNA C touched the container of disposable wet wipes from the back of the toilet, obtained some disposable wipes, and provided perineal care to the resident. CNA C placed a dry brief on the resident. CNA F stood the resident up, pulled her clean brief and pants back up. Both staff removed their gloves and ambulated the resident back to the TV commons area. Staff failed to perform hand hygiene or glove change after the removal of soiled clothing, after perineal care, and before taking the resident back to the TV commons area. Interview on 03/05/24 at 01:30 PM, CNA C reported R13's brief was not visibly soiled, so she did not think to change her gloves. Observation on 03/06/24 at 01:49 PM revealed CNA F propelled R19 to her room by a wheelchair. CNA F and CNA G donned gloves to assist her to the toilet and placed the sling of a sit to stand mechanical lift behind the resident's back, and staff propelled the mechanical lift to the doorway. CNA F removed the legs of the resident's wheelchair and placed R19's feet on the foot pads of the lift. Staff attached the mechanical lift sling to the lift and transferred the resident onto the toilet after CNA F pulled down R19's pants and removed the brief. CNAs F and G then removed their gloves to allow the resident time to sit on the toilet. After R19 provided toileting opportunity, CNA G used the mechanical lift controls and CNA F, with gloved hands, reached to the back of the toilet, opened the package of wet wipes, and provided perineal care to R19. CNA F failed to remove soiled gloves, and pulled R19's brief and pants up, and touched the mechanical lift with soiled gloves. No hand hygiene was done after either gloves were removed. Interview on 03/06/24 at 02:15 PM, CNA F reported staff should change gloves from dirty to clean surfaces and verified he failed to change his gloves. On 03/07/24 at 10:06 AM, Administrative Nurse B reported staff need additional education regarding incontinent care and proper hand hygiene. On 03/07/24 at 10:00 AM, a policy on incontinent care and hand hygiene was requested. No policy was provided. The facility failed to ensure a clean, sanitary environment for residents in the facility by the failure to change gloves and perform hand hygiene when going from dirty to clean, while assisting two incontinent residents with toileting and changing disposable briefs.

The facility reported a census of 42 residents with twelve selected for review including two residents reviewed for bowel and bladder incontinence. Based on observation, interview, and record review, the facility failed to provide perineal cares after urinary incontinence in a sanitary manner and toilet one of the residents, Resident (R)33, who required antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: - The electronic medical record (EMR) under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R33 with a Brief Interview of Mental Status score of four, indicating severe cognitive impairment. She rejected care one to three days of the seven-day assessment period. She required extensive assist of one staff for toileting. R33 had a trial of a toileting program attempted and was on a current toileting program or trial for her urinary function. She was occasionally incontinent of bladder. The Significant Change MDS, dated [DATE], had no changes from the prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/31/22, revealed R33 was able to make her needs known and her current BIMS score indicated she had severely impaired cognition. The Urinary Incontinence and Indwelling Catheter CAA, dated 05/31/22, revealed R33 was frequently incontinent of bladder, required extensive assistance with toileting task, was on a scheduled toileting plan, but could also use her call light to request assistance from staff as she needed. R33 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff encourage and remind her of the importance of adequate perineal hygiene while assisting her as needed. The Behavioral Symptom CAA, dated 05/31/22 revealed her rejection of care was not related to toileting cares. The Care Plan, dated 05/27/22, revealed R33 required extensive assistance from staff for toilet use. She required assistance with perineal care and changing her incontinent products and she was on a scheduled toileting program. Staff were to See profile for specific times. There were times when R33 would not want her incontinent product changed and staff were to approach her in a few minutes to talk to her about it again until she agreed for the staff to assist her. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Point of Care charting, located in the EMR, revealed the toileting program. Staff should toilet R33 at 07:00 AM, 10:00 AM, and 01:00 PM (every three hours) during the day shift within 30 minutes of the suggested time. On 06/27/22 at 11:15 AM, R33 sat in a wheelchair at a dining room table with a cup of fluids on the table. Her denim pants had wetness to both groin areas. On 06/27/22 at 11:16 AM, R33 stated she was drinking a Coke and she Peed my pants and that she was going to eat her lunch first then go change. On 06/27/22 at 12:02 PM, an unidentified staff member removed R33 from the dining room table to take her to go get changed. On 06/28/22 at 09:37 AM, R33 participated in an exercise activity. She had a napkin laying over her pants. On 06/28/22 at 10:30 AM, R33 sitting in wheelchair outside on the patio, with the same clothing on, napkin not in place. Staff had not taken R33 to the toilet. On 06/28/22 at 10:55 AM, R33 continued to sit outside in her wheelchair. On 06/28/22 at 10:58 AM, R33 went to the patio door, and Certified Nurse Aide (CNA) P opened the door for her and cued her to go to the table for lunch. On 06/28/22 at 12:12 PM, CNA M approached R33 and assisted to propel her to her room, then to the bathroom. CNA M applied gloves without performing hand hygiene first, guided R33 to stand and sit on the toilet. While the resident stood, her incontinence product, her pants, and the cushion of her wheelchair were visibly soiled. CNA M removed the incontinent product and placed the soiled product in the trash can and placed the wet pants directly on the floor next to the trash can, then removed her gloves. R33 stated I am wet, wet, wet. CNA M then applied a new pair of gloves without performing hand hygiene and applied a dry incontinent product and a clean pair of pants on R33 and told her she would be right back; she was going to get some wipes for the wheelchair. On 06/28/22 at 12:20 PM, R33 was unable to recall the last time she had been toileted and stated, I can't remember anything. On 06/28/22 at 12:21 PM, CNA M returned to the resident's bathroom, applied her gloves, wiped the cushion of the wheelchair with sanitation wipes, removed her gloves, then applied another pair of gloves without performing hand hygiene. CNA M moved the wheelchair closer to R33, locked the brakes, removed the perineal care wipes and draped the wipes on the edge of the sink of a shared bathroom. After having R33 stand, CNA M used one of the wipes that were on the sink edge and wiped the resident several times with the same area of the wipe front to back, then disposed the wipe in the trash and repeated the same procedure a few more times. CNA M then guided R33 to stand back up, pulled up her incontinent product and her pants with the same soiled gloved hands, and assisted R33 to sit in the wheelchair. CNA M then removed her gloves, tied up the trash bag, took the trash down the hallway and disposed the trash in appropriate container, then assisted R33 by propelling her wheelchair to the family room, without hand hygiene. After the resident was in the family room, CNA M washed her hands. On 06/28/22 at 12:30 PM, CNA M stated R33 does not let the staff know when she needs to go to the bathroom. R33 was on a scheduled toileting program in the morning at 06:00 AM, 10:00 AM, 12:00 PM, then at 02:00 PM (every four hours) on her shift. CNA M stated she did not assist R33 with her 10:00 AM toileting time, but one of the other two CNAs' would have helped her. CNA M stated R33 was wet very often on her shift and her pants would get wet too as she was a Heavy wetter. CNA M stated the wipes should not be used more than once when wiping during perineal care and verified her hands should be washed before and after and assumed, she should wash her hands or use hand sanitizer after removing her gloves. CNA M stated she did not know where else to put the wipes used for perineal care, but staff should clean the sink daily. On 06/28/22 at 12:38 PM, CNA N stated R33 does not normally let staff know when she needs to go to the bathroom and if she does it is Too late. CNA N stated R33 was on a scheduled toileting program and believed it was every three hours at 07:00 AM, 10:00 AM, and 01:00 PM. CNA N stated she assisted R33 with toileting around breakfast after she ate between 07:30 AM-08:00 AM. CNA N stated sometimes when they asked R33 if she needed to go to the bathroom she will say no, and then 20 minutes later she would be wet. CNA N stated she did not toilet R33 at the 10:00 AM toileting time today and was unaware if other staff toileted the resident. On 06/28/22 at 12:45 PM, CNA O stated she had not toileted R33 so far today on her 06:00 AM to 02:00 PM shift. The staff failed to toilet R33 between 08:00 AM and 12:12 PM, missing the 10:00 AM toileting time. On 06/29/22 at 09:10 AM, Administrative Nurse D confirmed staff should toilet the resident on her scheduled toileting times that were 07:00 AM, 10:00 AM, and 01:00 PM, within thirty minutes of the scheduled time. On 06/29/22 at 09:20 AM, Licensed Nurse (LN) G stated R33 will refuse toileting at times if she was busy in an activity. She likes to go to all of the activities. LN G had not known her to be incontinent to the degree her pants would be wet and expected the staff to toilet her per the toileting schedule. On 06/29/22 at 09:41 AM, Administrative Nurse D stated she expected staff to toilet R33 per schedule in the time frames as long as she did not refuse. Staff should not place perineal cleansing wipes on the sink. Staff should use one wipe per swipe when providing perineal cares. The facility policy Incontinence dated 10/11/2021, revealed it was the policy the residents' would be assessed to provide appropriate treatment and services to achieve or maintain normal continence function, and if the underlying condition was not reversible, it was important to treat or manage the incontinence to reduce complications. Incontinence programs must be specific to the type of incontinence and should be modified as necessary for each resident to encourage the highest level of continence. Scheduled toileting programs should be at regular intervals to match the usual voiding habits and timed voiding based on a resident's usual voiding schedule/pattern. The facility policy Giving Female Perineal Care, undated, included instructions for providing perineal care using washcloths and soap and water rather than pre-packaged wipes. The instructions included prior to performing perineal care to decontaminate hands and apply gloves, use a clean part of the washcloth for each stroke front to back, use more than one wash cloth if needed and following procedure to remove the gloves and decontaminate hands. The facility policy Hand Hygiene dated 10/12/21 revealed gloves reduce hand contamination by 70-80 percent, prevent cross-contamination and protect elders and health care personnel form infection, however, the use of gloves does not eliminate the need for hand hygiene. Gloves should be worn with contact of body fluids and removed promptly after use before touching non-contaminated items and environmental surfaces. Decontaminate hands after removing gloves by appropriate hand hygiene. The facility failed to ensure the staff toileted R33 per toileting to decrease episodes of incontinence, provide appropriate perineal care and hand hygiene to decrease occurrence of urinary tract infections.

The facility reported a census of 42 residents with five residents selected for review for adequate assistance to keep them free from accident hazards. Based on observation, interview, and record review, the facility failed to ensure staff transferred two residents appropriately with a mechanical lift (a device used to assist with transfers for a person who is unable to stand on their own, or can bear minimal weight when standing) for Resident (R)1, which resulted in a skin tear (a wound that occurs when the layers of skin separate or peel back), and for R4, placing her at risk for injury. Findings included: - The Physician Orders, dated 11/09/21, for Resident (R)1, included diagnoses of [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) with [CONDITION(S)] (type of progressive neurodegenerative dementia closely associated with [CONDITION(S)] disease primarily affecting older adults.), and [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain) of knees. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R1 with a short and long term memory problem and severely impaired decision making. She was totally dependent on two or more staff for transfers and bathing and had impaired range of motion to her upper and lower extremities. The Annual MDS, dated [DATE], revealed no changes from the prior assessment. The Pressure Ulcer/Injury Care Area Assessment, dated 09/13/21, indicated that R1required two persons to assist her with repositioning and transfers and required total assistance for most activities of daily living (ADL's). The Care Plan, dated 09/10/21, indicated R1 required two staff to assist her with transfers with the Hoyer (type of mechanical lift) lift and required two staff to assist her in/out of the whirlpool. The Witness Statement, dated 10/20/21, by CNA M, revealed that she had asked for help getting R1 into the chair to give her a bath and after she got done, she pulled R1 out of the tub and hooked her up and thought she Could do it without hurting her but as she was going sideways she was holding up both resident legs, one slipped from her arm, and R1's foot went in between the two vinyl straps of the chair. The Witness Statement, dated 10/20/21, Licensed Nurse (LN) G, revealed that a CNA stated she transferred the resident out of the whirlpool by herself, into her Broda chair (a brand of wheelchairs that can be tilted, reclined, and the leg rests adjusted) via the Hoyer lift, and the CNA caught R1's left foot in the straps of the Broda chair that are above the footrest. A skin tear was on the top of her left foot. The Interdisciplinary Note (IDT), dated 10/20/21 at 09:30 AM, indicated that a Certified Nurse Aide (CNA) called for the nurse to come to the bathhouse. R1 had a skin tear to the top of her left foot, the nurse measured the area, cleansed the area, and applied a dressing. The Skin Evaluation Record, dated 10/20/21 at 08:54 AM, revealed R1 had a skin tear to the top of her left foot that measured 5.0 centimeters (cm) long by 5.5 cm wide and was 0.4 cm deep. The wound edge was irregular and flat, and the surrounding skin was thin and fragile. The wound had a moderate amount of bloody drainage present. The facility investigation, completed on 10/25/21, revealed CNA M failed to follow R1's care plan as well as the facility's policy for mechanical lifts when she transferred R1 unassisted with a Hoyer lift. That failure resulted in a skin injury to R1 believed to be acquired as R1 was being lowered into her chair and the distal (located away from the center of the body) one third of her foot slid between the vinyl supports. On 11/16/21 at 08:49 AM, CNA N and Certified Medication Aide (CMA) R observed transferring R1 from her Broda chair to her bed using the Hoyer lift. On 11/16/21 at 12:45 PM, CMA R stated at least two staff should assist with transfers with the Hoyer lift, that included transfers in and out of the shower chair. CMA R stated she was aware that information on how to transfer residents was in the care plan. On 11/16/21 at 12:54 PM, CNA S stated two staff required for R1's transfers with the Hoyer lift. CNA S reported guidance how to transfer the resident should be in the care plan. On 11/16/21 at 01:00 PM, CNA O reported staff should use two staff to transfer with the Hoyer lift. CNA O reported guidance how to transfer the resident should be in the care plan. On 11/16/21 at 01:54 PM, CNA M stated that upon hire almost three months ago, the facility went over transfers with the Hoyer lift and should have two staff members assisting with the transfer. CNA M stated that on 10/20/21, she thought she could transfer R1 without doing any harm and once she realized what she had done she called for a nurse. CNA M stated the care plan had information on how to transfer a resident and the facility staff trained her during orientation on transfers with the lift. On 11/16/21 at 02:57 PM, Administrative Nurse D stated the requirements for transfers with the lifts are gone over during the interview before hire and reiterated daily. The orientation checklist sheet goes over transfers with the stand lift and the Hoyer lift. The information on how to transfer a resident was available in the computerized charting. Administrative Nurse D stated she expected the staff to use two to assist for all lift transfers. On 11/16/21 at 03:17 PM, CNA P stated two staff were to assist with resident transfers with the Hoyer lift and information on how to transfer a resident was in the care plan. On 11/16/21 at 03:22 PM, CNA T stated two staff should assist with transfers using the Hoyer lift and the facility had always made that known. The facility policy Lifting and Transferring Residents, dated 05/02/2019, included nurses were to assess and determine lifting and transfer requirements and the procedure used for each resident. All residents must be lifted or transferred according to the determined procedure. The appropriated procedure for each resident appears in the resident care plan. All lifts performed with a mechanical lift must be performed with two staff members present. The facility failed to ensure staff transferred the resident appropriately with the lift which resulted with the resident receiving a skin tear. - The Physician Orders, dated 11/02/21, for Resident (R)4, included a diagnosis of [CONDITION(S)] joint disease (a type of arthritis [inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement] that occurs when flexible tissue at the ends of bones wears down gradually and worsens over time). The Annual Minimum Data Set (MDS), dated [DATE], assessed R4 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required assistance of two or more staff for transfers, assist of one in part of the bathing activity, and had limited range of motion to one side of her lower extremities. The ADL (Activities of Daily Living Care Area Assessment (CAA), dated 07/29/21, indicated R4 required extensive assistance with transfers and bathing, and required a sit to stand mechanical lift (a device used to assist with transfers for a person who can bear minimal weight when standing) for her safety due to her knees giving out without notice. The Quarterly MDS, dated [DATE], assessed R4 with the same BIMS score, no changes to her transfer assistance, and was totally dependent of one staff for bathing. The Care Plan, dated 11/08/21, indicated the resident required extensive assist for transfers and staff should use a sit to stand lift for all transfers with contact guard assistance of two staff members. The Mechanical Lift Competency Checklist, dated 10/29/21, for Certified Nurse Aide (CNA) M, had a check mark in the line that read ask another staff member to assist you. On 11/16/21 at 11:44 AM, R4 stated she required assistance for transfers with the sit to stand lift and that one staff assists with her transfers. On 11/16/21 at 12:45 PM, CMA R stated at least two staff should assist with transfers with the sit to stand lift, and she was aware that information on how to transfer residents was in the care plan. On 11/16/21 at 12:54 PM, CNA S stated two staff required for R1's transfers with the sit to stand lift. CNA S reported guidance how to transfer the resident should be in the care plan. On 11/16/21 at 01:00 PM, CNA O reported staff should use two staff to transfer with the sit to stand lift. CNA O reported guidance how to transfer the resident should be in the care plan. On 11/16/21 at 01:54 PM, CNA M stated that upon hire almost three months ago, the facility went over transfers with the mechanical lift and should have two staff members assisting with the transfer. CNA M stated the care plan had information on how to transfer a resident and the facility staff trained her during orientation on transfers with the lift. CNA M verified she has transferred R4 to the shower using the sit to stand lift by herself. On 11/16/21 at 02:57 PM, Administrative Nurse D stated the requirements for transfers with the lifts are gone over during the interview before hire and reiterated daily. The orientation checklist sheet goes over transfers with the stand lift. The information on how to transfer a resident was available in the computerized charting. Administrative Nurse D stated she expected the staff to use two to assist for all lift transfers. On 11/16/21 at 03:17 PM, CNA P stated two staff are to assist with transfers with the sit to stand lift and information was available on the resident care guide in the computer. On 11/16/21 at 04:08 PM, R4 stated that whenever she gets a bath, whoever is assisting with the bath transfers her to the whirlpool chair and then assists with the transfer out of the whirlpool chair without assistance of a second staff member. On 11/17/21 at 07:37 AM, Administrative Nurse D observed to exit the bath house pushing the sit to stand lift and Certified Medication Aide (CMA) R observed propelling R4's wheelchair out of the bath house. On 11/17/21 at 09:30 AM, R4 activated call light and CNA Q responded, who then requested another staff to assist her, and the sit to stand lift was moved to R4's room. The facility policy Lifting and Transferring Residents, dated 05/02/2019, included nurses were to assess and determine lifting and transfer requirements and the procedure used for each resident. All residents must be lifted or transferred according to the determined procedure. The appropriated procedure for each resident appears in the resident care plan. All lifts performed with a mechanical lift must be performed with two staff members present. The facility failed to ensure staff transferred the resident appropriately with the lift placing R4 at risk for injury.

The facility reported a census of 39 residents, with three residents selected for review for elopement (an incident in which a cognitively impaired resident with poor or impaired decision- making ability/safety awareness leaves the facility without the knowledge of the staff). Based on record review, observation, and interview, the facility failed to monitor and provide adequate supervision for one Resident (R) 1, who had a high risk for elopement and a history of wandering. Findings Included: - The signed Physician Order Sheet (POS) for Resident (R1), dated 08/05/21, revealed the following diagnoses; Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue ), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear ), and major depressive disorder (major mood disorder). The quarterly Minimum Data Set, dated dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of 99. The resident was moderately impaired with decision making, with poor decisions and required cues/supervision. She required two-person extensive assist with transfers and ambulation. The resident used a wheelchair as a mobility device. The annual Minimum Data Set, dated dated [DATE], revealed the resident had a BIMS score of two, indicating severely impaired cognition. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/16/21, documented the resident was unable to complete the BIMS interview. The resident had problems with short-term and long-term memory. The resident had disorganized thinking and unable to complete most of her tasks. The Activities of Daily Living/Functional Care Area Assessment (CAA), dated 02/16/21, documented the resident required extensive assistance with ambulation and transfers. The behavioral care plan dated 08/02/21, guided staff to redirect the resident when wandering in the halls. Review of the nursing progress notes from 10/25/21 to 09/01/21, revealed the resident had a history of exit seeking and had a Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) from 10/27/21 until staff discontinued the Wander Guard on 01/03/21. On 08/01/21 at 08:58 AM, the resident exited the facility's health care unit (where the resident resided) through the south exit door into the facilities assisted living unit, without staff knowledge. After the resident eloped, staff re-applied a Wander Guard. On 08/31/21, review of the facility's surveillance video, revealed on 08/01/21 at 08:58 AM, the resident exited the unlatched door when Certified Nurse Aide (CNA) G exited the south exit door of the facility's health care unit. The resident was behind her and exited the south exit door, without staff knowledge, and entered the adjoined facility's assisted living. At 08:59 AM, Administrative staff for facility's assisted living AA entered the assisted living front entrance and observed R1 self-propelling into the lobby, unattended and without staff knowledge. Observation, on 08/31/21 at 09:29 AM, revealed R1 was in the family room during an activity with staff member reading a book to the residents. R1 sat in a straight back chair. The resident had a Wander Guard on her right ankle. On 08/31/21 at 10:48 AM, revealed R1, in her wheelchair, self-propelling herself in the hallway. On 08/31/21 at 01:33 PM revealed R1 lying in her bed resting in bed with eyes closed. On 08/31/21 at 09:38 AM, Licensed Nurse D advised when staff exit the doors, staff should look around to ensure residents are not near exit doors prior to exiting the doors. After the resident eloped, staff applied a Wander Guard to alert staff if the resident attempted to elope. On 08/31/21 at 11:33 AM, Administrative staff for facility's assisted living AA advised when she entered the front entrance of the Assisted Living Unit, she observed R1 sitting in her wheelchair in the lobby, without staff. On 08/31/21 at 11:55 AM, Certified Medication Aide R advised the resident followed staff members into other resident's room and required redirection. The resident would wander, and the resident would self- propel herself into other residents room and would lay down on other residents' bed and would be found by staff asleep in their beds. On 08/31/21 at 03:04 PM, Certified Nurse Aide M advised she was unaware the resident had followed her out the exit door. She reported she did not look around to see if any residents were around the door. She verified she should have slowed down, turned around, and ensure there was not a resident behind her before exiting the health care unit. On 08/31/21 at 02:55 PM, Licensed Nurse H advised staff should ensure the safety of the residents. Staff should stop and redirect the resident if the resident attempted to leave the unit. On 08/31/21 at 04:12 PM, Certified Nurse Aide N advised R1 had been an elopement risk for a very long time. R1 wanders aimlessly daily because of her confusion. The resident had a potential to exit seek because of her confusion. The resident had a Wander Guard earlier this year, but the Wander Guard was discontinued. Staff should always look prior to exiting any of the exit doors and to ensure any resident was not present at that time. On 08/31/21 at 04:33 PM, Administrative Nurse D, advised that the charge nurses should complete an elopement evaluation on admission and quarterly. The care plan team would discuss the elopement evaluation, and a score greater than ten would place the resident at a high risk for elopement. If a resident had no signs of exit seeking, staff did not necessarily care plan the resident for an elopement risk. R1 would roam the halls. Staff discontinued the resident's Wander Guard on 01/03/21. The resident did self- propel herself into her previous room, however she was unaware the resident wandered into other resident's rooms. The facility's policy for Hazardous Wandering and Elopement (Unwitnessed Exit) revised June 2001, revealed the resident will be monitored by assessment-based observation with Elopement Risk Screen on the Matrix on admission, quarterly and with any significant change of condition. These behavioral patterns will be reflected in the care plan for residents with known history of wandering and the potential for unwitnessed exits. The facility failed to monitor and provide adequate supervision for this confused, mobile resident, when the resident left the facility health care and entered the facility's adjoining assisted living, thru exit doors, without staff knowledge.

The facility reported a census of 38 residents, with three residents sampled for medication administration. Based on observation, interview, and record review the facility failed to ensure the medication regimen was free of significant medication errors for one of the residents sampled. Staff administered anti-hypertensive medications without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: - Review of Resident (R)4 's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry Minimum Data Set (MDS) dated [DATE] revealed the resident admitted to the facility on [DATE]. The Baseline Care Plan dated 07/15/21 directed the staff the resident was able to verbalize her needs. The facility reviewed the resident's medication list provided by the resident on admission and she wanted staff to administer her medications. The resident's Physician Orders, dated 07/15/21, included the following orders: 1. [MEDICATION(S)] 50 milligrams (mg) tablet by mouth every 6 hours as needed (prn) for arthritis, ordered 07/15/21. 2. [MEDICATION(S)] (vitamin D3) 1,250 micrograms (mcg)/(50,000units) once a week by mouth for [CONDITION(S)], ordered 07/15/21. 3. Calcium 500 mg twice daily by mouth, ordered 07/15/21. 4. [MEDICATION(S)] 40 mg by mouth for [CONDITION(S)] (medication used to treat high cholesterol accumulation in the body) at bedtime, ordered 07/15/21. 5. [MEDICATION(S)] 70 mg tablet by mouth weekly for [CONDITION(S)] (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), ordered 07/15/21. Her physician prescribed medications lacked orders for medications to treat hyper/[CONDITION(S)]. The Interdisciplinary Nurses' Notes (IDTNN) dated 07/20/21 at 07:13 PM included at approximately 05:00 PM, the Certified Medication Aide (CMA) notified the nurse the following meds were administered to this resident in error: 1. [MEDICATION(S)] 0.1 mg (antihypertensive medication used to lower blood pressure). 2. [MEDICATION(S)] 20 mg (antihypertensive medication used to lower blood pressure). 3. [MEDICATION(S)] 100 mg (a medication used to soften stool). Staff called and had the on-call physician paged to notify him staff administered the wrong medication to the resident. On 7/20/21 at 05:26 PM the physician returned the call and the nurse informed him of the medication error. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the IDTNN dated 07/20/21 at 09:19 PM included the following documentation: 1. On 07/20/21 at 05:30 PM, the resident's B/P was 95/42 millimeters of mercury (mmHg) and staff paged for the on-call physician. 2. On 07/20/21 at 06:00 PM the resident's B/P was 65/40 mm/Hg. 3. On 07/20/21 at 06:30 the resident's B/P was 80/40 mm/Hg. 4. On 07/20/21 at 07:00 PM the resident's B/P was 68/35 mm/Hg. The on-call physician returned the call and gave orders to send the resident to the emergency room (ER) via ambulance. 5. On 07/20/21 at 07:30 PM the resident's B/P was 63/42 mm/Hg. 6. On 07/20/21 at 07:40 PM the resident transported to the hospital via ambulance . On 07/20/21 at 10:03 PM the IDTNN documentation included the Durable Power of Attorney (DPOA) called the facility and stated the resident would be kept overnight for observation and to monitor the resident's B/P. Review of the Emergency Department records from 07/20/21 to 07/21/21 revealed the resident received [MEDICATION(S)] (medication used to treat life-threatening conditions such as shock and low blood pressure) and Normal Saline infusions intravenous (IV). On 07/21/21 at10:39 AM an IDTNN documented the resident returned to the facility at 10:13 AM. The resident's vital signs on reentry to the facility included a B/P of 90/50 mm/Hg. On 07/22/21 at 01:58 PM the resident was in the bed resting. On inquiry, she reported she did not feel dizzy nor experienced any chest pain and she answered questions appropriately . On 07/22/21 at 02:05 PM Certified Medication Aide (CMA) T verified on 07/20/21 at approximately 04:15 PM to 04:30 PM, she administered medications to the wrong resident when she administered another resident's medications to R4. She was aware of the medication error after she administered R5's medication to R4, only after R5 inquired about her medication. CMA T verified she administered medications in the dining room, and she failed to correctly identify R5. CMA T reported she should have reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/22/2021 at 02:46 PM CMA S stated staff should identify residents by looking at their picture in the MAR prior to giving them their medications. Staff should ask the resident their names and/or ask someone else on staff to verify the resident's identity if there are any questions regarding the resident's identity. On 07/22/21 at 01:25 PM Licensed Nurse (LN) G reported staff should compare the pictures of the resident on the MAR before giving medications to a resident to ensure the medications administered to the right resident. She reported if the resident was a new admission, she was not familiar with the resident she would ask other staff to confirm the resident's identity. On 07/22/21 at 12:19 PM Administrative Nurse D and Administrative Nurse E confirmed staff administered the incorrect medications to R4 that included two antihypertensive medications ordered for R 5, due to mistaken identity. Administrative Nurses D and E agreed the staff should administer medications to residents as ordered by the physician after verifying the resident's identity. The facility's policy for Medication Administration, dated 04/27/21, documentation included to identify the resident. If necessary, verify the resident with other staff personnel. The facility failed to ensure the medication regimen was free of significant medication errors for this newly admitted resident, when staff administered the wrong medications, that included anti-hypertensive medications, and the resident required hospitalization intervention for decreased blood pressure.

The facility reported a census of 45 residents with 13 selected for review including two residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to ensure adequate parameters of nutritional status for one of the two residents reviewed. The facility failed to implement interventions and follow recommendations by the registered dietitian, to prevent significant weight loss for Resident (R)36, who experienced a significant weight loss three different months. This included a 9.66 percent loss in three months, from 04/06/20 to 07/06/20, an 8.7 percent loss in three months from 05/05/20 to 08/04/20, and a 10.8 percent loss in six months, from 04/06/20 to 10/06/20. Findings included: - The Physician Orders, dated 10/17/20, for Resident (R)36, included [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], assessed R36 as having short and long term memory problems, moderately impaired decision making skills, and with inattention that fluctuated. He required extensive assistance of one staff for eating, was not on a physician-prescribed weight-loss regimen and received no nutritional approaches. He had a weight loss of five percent or more in the last 30 days and/or 10 percent or more in the last 180 days. He received a restorative nursing program on seven days for eating and/or swallowing. The Nutritional Status Care Area Assessment (CAA), dated 04/10/20, indicated that R36 received skilled speech therapy and received a level six diet (soft and bite sized) upon the assessment shortly after admission on 03/31/20. His physician ordered a regular textured diet and the goal was for him to return to that diet after therapy. His weight at the time of admission was 176 pounds and documentation indicated a fair appetite at most meals. The ideal body weight for men his height was 148 to 184 pounds. His body mass index (BMI-a measure of body fat) was 23.5 percent and placed him in the healthy category. He required extensive assistance of staff with eating and drinking. Staff offered finger foods to him, as he was able to feed himself more independently with them. He received Med Pass (a nutritional calorie and protein supplement) four ounces three times a day due to weight loss. His weight at the time of the assessment was 174 pounds. Furthermore, he voiced no complaints of pain or difficulty with chewing. He was to be weighed weekly for the first four weeks, then if his weight was stable, he would be weighed monthly. The Quarterly MDS, dated [DATE], assessed R36 as having a short and long term memory problem, moderately impaired decision making skills, and inattention that fluctuated. He required extensive assist of one for eating, had no significant weight loss, and received no nutritional approaches. He received a restorative nursing program on seven days for eating and/or swallowing. The Care Plan, dated 10/02/20, indicated that R36 was at risk for alterations in nutrition related to dementia, acute confusion, depression, B-12 deficiency, and [MEDICAL CONDITION]. The care plan included these interventions: 1. Undated: regular diet, staff to encourage finger food items as needed. 2. Undated: encourage him not to consume food high in sodium like deli meat, chips, and soups. 3. 04/13/20: Med Pass four ounces three times a day for supplement 4. 04/13/20: weigh weekly, changed to monthly on 06/16/20. 5. 04/13/20: likes hamburgers, French fries, grilled chicken, and grilled vegetables. 6. 04/13/20: encourage extra protein at breakfast 7. 04/13/20: encourage and offer him snacks in between meals as he allows. 8. 04/13/20: At times R36 was very confused and restless during the day so staff should encourage and offer snack items as he allowed for extra calories. 9. Undated: He required assistance with dining for all meals and the staff were to take his order and offer other menu items if he chose not to take the special of the day. 10. The care plan, dated 07/16/20, included this intervention, that was undated, that was not on the care plan dated 04/16/20: Staff should encourage and cue him throughout the whole meal as he tended to get sidetracked. Review of the electronic medical record (EMR), under the Vital Stats tab, revealed the following resident's weights: On 03/31/20--176 pounds On 04/06/20--176 pounds On 05/05/20--167.5 pounds (down 8.5 pounds in one month, a loss of 4.83 percent) On 06/01/20--162.5 pounds On 06/08/20--163.5 pounds On 06/16/20--163.5 pounds On 07/06/20--159 pounds (down 17 pounds in three months, a 9.66 percent significant loss in three months) On 08/04/20--154 pounds (down 13.5 pounds in three months, a significant loss of 8.7 percent, which was also down 22 pounds in four months, a 12.5 percent loss, this was his lowest weight since admission on 03/31/20.) On 09/01/20--156 pounds On 10/06/20--157 pounds (down 19 pounds in six months, a significant loss of 10.8 percent) The Dining Profile, dated 03/31/20, indicated the diet order for R36 was regular and to offer finger foods, his usual or goal weight was 200 pounds. His meal consumption reported or observed was 75% of breakfast and lunch, and 50-75% of dinner. The snack portion of the profile lacked an answer. His dining needs included supervised dining, and the changes since the last screen included to offer finger foods, experienced weight loss, and required assistance with dining. The RD (registered dietician) assessment, dated 04/10/20, indicated R36 had risk factors of poor intake, history of weight loss, dementia, and depression. He had a recent weight loss due to a decrease in oral intake related to his dementia as evidenced by a 32.8 pound weight loss, which was a 15.8 percent loss in two months. R36 was recently in a Behavioral Unit, and his appetite was poor during that stay. The assessment also indicated that according to the Certified Dietary Manager (CDM) dietary profile, he consumed 75 percent of breakfast and lunch, and 50-75 percent of his dinner. He had orders for finger foods with protein encouraged at mealtimes, and the nurse's notes reflected he received assistance with meals. The RD's recommendation included the staff were to provide fortified foods, encourage snacks when he was moving around the facility, and to refer the resident to the RD as needed. Review of the Physician Orders, dated 10/17/20, included an order dated 03/31/20, for regular diet, and an order dated 04/10/20 for Med Pass, four ounces, three times a day, for protein supplement. The Dietary Quarterly Note, dated 04/13/20, indicated R36 had a weight loss of 14 percent in 30 days. He readmitted on [DATE] from the hospital, with a weight of 176 pounds, a loss of 14 percent in 30 days. His diet was regular and staff were to encourage finger foods. He required assistance with dining for encouragement and cues, and weekly weights for monitoring. The care plan, dated 04/16/20, indicated weekly weights were changed to monthly on 06/16/20. The Dietary Quarterly Note, dated 07/09/20, indicated a weight loss of eight percent in 90 days. His diet was regular, offer finger foods as needed, and Med Pass four ounces three times a day for extra calories and protein. R36's current weight was 159 pounds, a loss of eight percent in 90 days. He required assistance, encouragement, and cues during meals. The Care Plan, dated 07/16/20, included a new intervention to encourage and cue him throughout the whole meal as he tended to get sidetracked. This intervention was put in place 10 days after his weight of 159 pounds on 07/06/20, which was a continued decrease in his weight from admission on 03/31/20 of 176 pounds. The Dietary Quarterly Note, dated 10/05/20, indicated R36 had no significant weight change. He received a regular diet and to offer finger foods as needed. He was always on the go so finger food items helped if he was going up and down the halls in between meals. R36 received Med Pass four ounces three times a day and required assistance with dining for all meals. The EMR lacked any further RD assessment for follow up after the recommendations provided on 04/10/20. The Care Plan, dated 10/02/20, lacked any further interventions to prevent further weight loss for R36 after the significant loss on 05/10/20, and his continued loss that occurred through 08/04/20. On 10/21/20 at 10:58 AM, Certified Nurse Aide (CNA) P confirmed that staff served R36 a bowl of mashed potatoes, meat, and gravy, which was one of his favorites. On 10/21/20 at 11:02 AM, R36 took several bites, then dipped his spoon into his glass of cola after CNA P cued him to take a bite. CNA P got a different spoon for him for his food, but he propelled himself away from the table with his glass of cola in his hand and left the dining room. The staff did not attempt to redirect him back to the table or offer him finger foods or snacks. On 10/21/20 at 04:56 PM, the dietary staff served R36 a bowl of ham bake and a glass of cola. He fed himself some bites and accepted a few bites from the staff before pushing himself away from the table and propelled self to the exit door in the dining room, then staff assisted him and stayed with him outside in the patio area. On 10/21/20 at 05:11 PM, the dietary staffed removed his food from the table. On 10/28/20 at 10:37 AM, CNA M revealed R36 had not had a significant weight loss and that he usually eats very well. If a resident had a significant weight loss, she would be informed so the resident could be encouraged more. R36 ate snacks periodically that he could eat on the run, like a cookie. He was not served finger foods at meals, his meals were served in a bowl with a spoon, and he could feed himself very well that way. He would have ice cream sometimes when he was up in the main lobby. 10/28/20 at 03:27 PM, CNA N revealed that if a resident lost weight, the charge nurse and the dining room staff would let her know, and usually the resident would get a milkshake or something added to the menu, or an extra food item. R36 was usually either hungry or restless and wanted to go up and down the hall. He liked ice cream and fish. He received a fortified diet, staff served his meals in a bowl, and we have a hard time getting him to stay at the table. On 10/29/20 at 08:41 AM, Licensed Nurse (LN) G revealed that staff weighed new admissions and those losing weight weekly, then if stable the staff weighed them monthly. The staff discussed weights every Wednesday in risk meeting, interventions, and a list was given to the charge nurse of those that may need Med Pass or other supplements, or a fortified diet, and we would activate the standing order. The staff would notify the doctor for an order for [REDACTED]. On 10/29/20 at 11:43 AM, Dietary staff BB revealed staff weighed the residents monthly, but if they were a new admit, readmit, had a significant change, had a pressure ulcer, a significant weight loss, or the staff say that a resident had not been eating well for a while, then the staff weighed the residents weekly. Staff discussed the weekly weights in a weekly risk meeting, and if a resident needed an intervention such as fortified food, or a supplement drink with a lot of calories put in it. If a resident had a significant weight loss, staff notified the physician and the family, and a Dining Profile would be completed to include what changes were significant. Furthermore, Dietary staff BB revealed that R36 was not an identified current significant weight loss resident, until after calculating his weights, then staff BB confirmed he had a loss in 180 days of 10.7% with his documented weight on 10/06/20. Dietary staff BB revealed that R36 had not been receiving the fortified food since the RD recommendation on 04/10/20, and that he received finger foods as snacks between meals. Furthermore, dietary staff BB revealed R36 should not be on weekly weights because he has not had a significant weight change in 30 days. He ate a good breakfast and lunch and usually his intake was poor at supper. Dietary staff BB confirmed R36 needed reviewed closer for his weights. The recommendations from the RD assessment on 04/10/20 were not acted on by the staff, and that he received the fortified foods now for at least a month. The staff placed the residents on a list if they received fortified foods, and the server had that list. The list included R36 and had been that way for at least a month, but unknown to the exact date it started. The quarterly diet note, dated 10/05/20, should have included that he received fortified foods as well as fortified food to be included on the resident's care plan. On 10/29/20 at 12:26 PM, Administrative Nurse E, revealed the dietary manager reviewed the monthly weights in the weekly risk meeting, and if staff identified a slight weight loss, then the resident was put on the weekly weight list. We try to identify if the residents are not eating, or the possible cause of the weight loss, and staff monitor meal intakes. If we can determine that they are not eating, then we will start a supplement, such as Med Pass or a health shake. R36 was not on the list as a significant weight loss, but he was when he came here in March. We monitored R36 in risk meeting weekly in May and we were monitoring his intakes. His weight started to come up at the end of May. The Med Pass started in April and was effective for a while. On 10/29/20 at 03:45 PM, Administrative Staff A revealed that during the risk meetings minutes are kept that included what we discussed, but notes were not made in the resident's individual medical record. On 11/02/20 at 10:43 AM, Administrative Staff A confirmed the resident had significant weight loss on 10/06/20 and lacked new interventions to prevent further weight loss. The RD recommendations made on 04/10/20 were not acted upon by the facility staff to promote the resident's nutritional status and weight. On 11/03/20 at 04:18 PM, Consultant Staff GG, revealed that Dietary staff BB communicated with her regarding residents who had weight loss or gain, skin integrity issues, hospital return, significant changes, and diet changes. She confirmed she would expect the facility to follow her recommendations unless they had a reason, like they have tried the recommendation and it did not work. Additionally, she confirmed that she should have been notified regarding R36's continued weight loss and that she could have helped them to try something else. The facility policy Nutritional Status, revised 06/07/19, included that if the monthly weight supports significant unplanned weight loss, initiate weekly weight monitoring and document in the medical record, notify dietary, the primary care provider and family of weight loss, and document in the interdisciplinary notes. Weekly weights will be obtained and reviewed if residents receiving supplements or nutritional supplement medication pass if clinically indicated. The facility failed to implement interventions to prevent significant weight loss and failed to follow recommendations from the registered dietician for Resident (R)36, who experienced a significant weight loss three different months This included a 9.66 percent loss in three months, from 04/06/20 to 07/06/20, an 8.7 percent loss in three months from 05/05/20 to 08/04/20, and a 10.8 percent loss in six months, from 04/06/20 to 10/06/20.

The facility reported a census of 45 residents with 13 residents sampled which included seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate to determine contributing factors and causes of falls to ensure appropriate interventions and/or provide supervision and adaptive equipment to prevent further falls for six of the seven sampled residents, including Resident (R)4, R 22, R 25, R 43, R 5, and R 36. Findings included: - Review of Resident (R)4's Physician Orders, dated [DATE], documentation included [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set ((MDS) dated [DATE], documentation included the resident with the Brief Interview for Mental Status (BIMS) score of 99, which indicated resident unable to complete the interview. The resident had verbal behaviors directed towards other and other behavioral symptoms not directed towards others. Her behaviors significantly intruded on privacy or activity of others and disrupt care and living environment. The resident rejected care on one to three days of the look back period. Behaviors were reported as worse. The resident required extensive assistance with bed mobility, transfers, walking, locomotion, dressing toilet use. Her balance during transition was not steady and was only able to stabilize with staff assistance. No functional limitation in ROM in upper or lower extremities. She used a walker and wheelchair as assistive devices. She experienced 1 non injury fall in the look back period. The ADL Functional/Rehabilitation Potential and Fall Care Area Assessment (CAA), respectively, dated [DATE], documentation included she required extensive assistance with most of her ADL tasks, including bed mobility, transfers, ambulation, wheelchair locomotion, and dressing. She used a FWW with transfers and ambulation and staff were to apply a gait belt for these activities to assist her. She could propel her wheelchair, sometimes very quickly, but not to any purposeful destinations. Over the past few days, she has been repeatedly saying, Help. Help. Help. This has not been a typical behavior for her in the past. The resident has a history of falls. She used a front wheeled walker (FWW) with all ambulation and staff put a gait belt on her and aids by contact guard with all transfers and ambulation. Staff report that her balance is fair. The resident always had a TABS alarm due to her fall history, but staff discontinued it on [DATE] due to no falls in 60 days. However, she then had a non-injury fall in her bathroom on [DATE]. Staff will re-evaluate whether she will benefit from the reinstatement of the TABS alarm. The care plan (CP), dated [DATE], directed staff the resident became confused off and on throughout the day. The resident does not walk much but when she does, she uses a walker and gait belt with limited assistance of the staff. She can walk short distances. The staff should make sure she has nonskid footwear. The resident uses a wheelchair for most of her locomotion and requires limited to extensive assistance of the staff for locomotion. She self-propels her wheelchair, but her movements are not always purposeful. The resident requires limited to extensive assistance with transfers, and toilet use. Additional CP interventions included: 1. On [DATE], toileting plan reviewed and adjusted to include 12:45 AM, as a scheduled toileting time. This was a high fall time for her. Please assist the resident to the toilet if she was awake and check and change her if she was asleep. 2. On [DATE], tab alarm discontinued. 3. On [DATE], tabs alarm to bed and recliner discontinued. 4. On [DATE], toileting plan adjusted to include 04:30 PM, due to high fall risk time. Do not leave unattended in the bathroom. The resident sometimes transfers herself to the toilet. If you observe me unattended in the bathroom, please stay with me until my toileting tasks are complete. Review of the facility fall log, dated ,[DATE] through [DATE], revealed the resident had a history of [REDACTED]. Review of the resident's nurses notes and fall investigation notes for the above falls revealed the staff failed to provide needed supervision, toileting, and/or complete a thorough investigation to determine the causes and contributing factors related to the residents fall as follows: 1. On [DATE] at 05:05 PM, the Nurses Notes (NN) documentation included the certified nurse aide (CNA) responded to the resident hollering for help. She found the resident on the floor in her bathroom. The resident stated she got up off the toilet. The resident had a coat wrapped around her ankles and feet. The resident reported she was trying to get her coat and fell . The alarm was in place on her recliner. The nurse new intervention was for the resident to always use the alarm. The fall Investigation/Follow-Up, dated [DATE] (25 days after the fall), documentation included the findings that the resident's feet probably became tangled in her coat during the unassisted transfer and caused the resident to lose her balance and fall. The intervention to prevent further falls was to educate the staff the resident was to have a tab alarm on at all time. The analysis of findings failed to address the cause of the fall to prevent other falls. Additionally, upon review of the care planned interventions the alarm was discontinued on [DATE] and should not have been present on the recliner at the time of the fall. Furthermore, the alarm was not added as an intervention on the care plan as indicated by the investigation. 2. On [DATE] at 03:28 PM, the NN documentation included the CNA responded to the resident hollering and found the resident on the floor in the bathroom with her wheelchair positioned approximately two feet behind her. The wheelchair brakes were not locked. The fall Investigation/ Follow-up, dated [DATE] at 03:28 PM, documentation included the CNA assisted the resident to toilet at 12:20 PM, the CNA left the resident unattended in the bathroom while she checked on the resident's meal intake. The CNA was educated not to leave the resident unattended in the bathroom due to her being a high risk for falls. The fall investigation failed to identify the root cause of the fall and address the contributing factors which include the resident's wheelchair brakes not locked, to prevent further falls. 3. On [DATE] at 06:41 PM, NN documentation included the CNA responded to than alarm and found the resident on the floor in front of her straight back chair. The fall Investigation/Follow-up, dated [DATE] at 6:41 PM, documentation included the nurse noted the resident did not have an order for [REDACTED]. The new intervention was to initiate the alarm at all time. The facility failed to thoroughly investigate the root cause of the fall to implement an appropriate intervention to prevent further falls, was discontinued on [DATE] according to the care plan interventions but still being used. On [DATE] at 09:07 AM, the resident was sitting in her recliner with her legs elevated, positioning pillows and alarm were in place. Certified Nurse Aide (CNA) NN entered the resident's room to check on the resident who was yelling out she did not like the wet repetitively. The CNA stated the resident was at risk for falls because she tries to get up by herself. She reported the resident's interventions to prevent falls included tabs alarm and a toileting program. CNA NN reported the resident's CP provided guidance for care related to the resident's specific toileting plan and other fall interventions. She reported the resident does not walk any longer they use positioning pillows to try and keep her comfortable while up in her chair and reduce her agitation. On [DATE] at 04:03 PM, the resident sat in the chair in the lobby the CNA transferred the resident to the wheelchair with the use of a gait belt. The CNA moved the alarm from the chair in the lobby to the wheelchair. On [DATE] at 10:39 AM, Licensed Nurse (LN) G reported the resident at risk for accident, and interventions always included a tab alarm. The resident gets confused and she tries to get up. She can walk to the bathroom with help of one staff we must stay with her while she is toileting. LN G reported the care plan provided guidance for resident care. She stated the Quality Assurance Nurse (QAN) gets a copy of the incident report obtains witness statements from every aide on the hall. We want to know when they were toileted last and if the care planned interventions were in place. The charge nurse should initiate a new intervention every time a resident fall related to the reason the resident fell . The investigation is followed up by the QAN who does a root cause analysis. On [DATE] at 10:39 AM, Administrative Nurse E confirmed the fall investigations as noted above. She stated the staff left the dependent resident unattended instead of providing expected supervision. Additionally, the facility failed to conduct a timely investigation and root cause analysis to identify what the resident was doing when she fell to determine an appropriate intervention to prevent further falls. She agreed the appropriate use of the tab alarm was not clearly defined for staff. On [DATE] at 11:43 AM, Administrative Nurse D confirmed the fall and Investigative/Follow-Up, as noted above demonstrated the facility staff failed to provide supervision to prevent the resident from falling. She stated when a fall occurred, she expected the staff to do a root cause analysis to determine an appropriate intervention in a timely manner to prevent further falls.in place related to the cause of the fall. Administrative Nurse D agreed the root cause analysis was not done for the resident's fall. The facility policy Falls, dated [DATE], lacked address of staff supervision, assistive devices, and timeliness of investigation to include the root cause analysis of and contributing factors for a fall in order to determine appropriate interventions to prevent further falls. The facility failed to thoroughly investigate the residents repeated falls to determine the contributing factors and causes of her fall to ensure appropriate interventions were implemented to prevent further falls. Additionally, the facility failed to provide adequate supervision to prevent further - Review of Resident (R) 22's Physician Orders, dated [DATE], documentation included [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], documentation included the resident was not able to complete the Brief Interview for Mental Status (BIMS). She had short and long-term memory loss. The resident was severely Impaired for cognitive decision-making skills and experienced disorganized thinking. She required extensive assistance of staff with bed mobility, transfers, walking, locomotion, and toileting. Her balance during transition was not steady and she was only able to stabilize with staff assistance. The resident had no functional limitation in range of motion in the upper or lower extremities. She was frequently incontinent of bowel and bladder and had a trial toileting program which did not result in improvement. The resident had two or more no injury falls since the last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documentation included the resident with [DIAGNOSES REDACTED]. She had poor short term and poor long-term memory. There are times that she can complete requests although she usually was not able to put words together. The staff must anticipate the resident's needs. She had limited attention span. She was rarely and/or never understood. Her speech when recognizable but usually did not make any sense. The Falls CAA, dated [DATE], documentation included the resident with [DIAGNOSES REDACTED]. She had balance problems with transitions and required staff assistance with all transfers and ambulation. She no longer received [MEDICATION NAME] or [MEDICATION NAME] ([MEDICAL CONDITION] medication) which could have affected her balance. She required one or two caregivers using hand hold assistance for transfers and ambulation. Caregivers use a gait belt as she will allow. There are times that she will refuse to ambulate, and she must be approached later due to her dementia. The resident always has a tabs sensor pad to her bed and wears lace up nonskid footwear due to her history of falls with injury. Even with all these approaches in place to prevent falls she has had six non-injury falls since the previous assessment. Unless she was in bed she was found in the lobby where staff can keep a close eye on her. She now always has a one-way slide when she was sitting up and staff provided diversional activities when she was in the lobby. The Incontinence and Indwelling Catheter CAA, dated [DATE], documentation included the resident was frequently incontinent of urine. She was on a scheduled toileting plan and needed assistance of staff with all her toileting tasks. The care plan (CP), dated [DATE], directed staff the resident had cognitive loss/dementia with short and long-term memory problems, impaired decision making due to [DIAGNOSES REDACTED]. She rarely/never could make herself understood and although her words were occasionally recognizable, she seldom made sense. Staff should anticipate the resident's needs. She required extensive assistance of one to two staff for repositioning, toilet use, transferring, locomotion, and ambulation. The staff were to use a gait belt. The resident was incontinent of bladder and bowel due to functional incontinence secondary to dementia with behaviors. She was on a scheduled toileting program for 07:00 AM, 10:00 AM, 01:00PM, 04:00 PM, 06:30 PM, and 08:00 PM. Additional CP interventions included: 1. On [DATE], When resting in the lobby, encourage the resident to sleep in her bed and toilet her per her toileting plan. 2. On [DATE], the CNA reminded to use gait belt due to resident unsteady gait and balance. 3. On [DATE], staff should always provide a one-way slide. Review of the facility fall log, dated ,[DATE] through [DATE], revealed the resident had a history of [REDACTED]. Review of the resident's nurses notes and fall investigation notes for the above falls revealed the staff failed to provide needed supervision, toileting, and/or assistive devises for the resident to prevent further falls for three of the noted falls as follows: 1. On [DATE] at 02:30 PM, the Nurses Notes (NN) documentation included the resident was found on the floor in the lobby. The certified nurse aide (CNA) assisted the resident to the bathroom for toileting and peri care, The nurse provided the CNA with education to check the resident during shift change and bed check when the resident sits in the lobby and to toilet her per her toileting plan. The fall Investigation/Follow-Up, dated [DATE], documentation included the staff did not follow the toileting plan due to the resident resting in the chair with her eyes closed. The nurse provided education to the CNA regarding toileting assistance should be offered to the residents based on their toileting schedule to prevent falls. 2. On [DATE] at 05:30 PM, the NN documented the CNA assisted the resident to stand up from the dining room table without the use of the gait belt. The fall Investigation/Follow-Up, dated [DATE], documentation included the CNA failed to use the gait belt when assisting the resident to a standing position when in the dining room. The CNA was re-educated to use the gait belt when assisting a dependent resident to a standing position to prevent falls. 3. On [DATE] at 04:00 PM, the resident was found in her room sitting on the floor in her bedroom right in front of her recliner. The resident did not have the one-way slide under her while in her recliner. The fall Investigation/Follow-Up, dated [DATE], documentation included the resident was in her recliner sleeping at shift change, so she did not check her for the placement of the one-way slide at shift change. The CNA was re-educated that the one-way slide was always to be in place. On [DATE] at 08:52 AM, CNA O and Certified Medication Aide (CMA) R assisted the resident from the dining room table. They pulled the chair back while the resident remained seated, applied the gait belt, aligned her feet flat on floor, and gave verbal cues while providing extensive assistance to the resident to stand and walked with her to the lobby where she sat in the chair with dicem and the one way slide. CNA O and CMA R stated the resident was on every two-hour toileting program and required a gait belt when standing. They confirmed she was a fall risk and reported she had a habit of sliding out of her chair. CNA O and CMA R verified the resident was to have a one-way slide when in a chair and staff stayed in attendance throughout her meal. On [DATE] at 03:59 PM, the resident was in her bed with her tennis shoes on. Staff entered room and assisted the resident to the toilet. On [DATE] at 10:15 AM, CMA S, stated the fall interventions are on the care plan. She identified the resident was at risk for falls. She usually slept in the chair and her gait was wabbly. CMA S stated the resident required two staff to walk with her and the resident gets antsy when she wants to go. On [DATE] at 10:39 AM, Licensed Nurse G, identified the resident at risk for falls because of her dementia and getting up on her own. She reported the resident was on a toileting program and used a one-way slid pad to prevent her from sliding from the chair. On [DATE] at 10:39 AM, Administrative Nurse E confirmed the fall investigations as noted above. The staff did not follow the resident's toileting plan on [DATE], did not use the required gait belt when assisting the resident on [DATE], and did not place the one-way slide in the resident's chair on [DATE]. She stated the investigation revealed the facility staff failed to provide supervision and/or assistive devices to prevent the resident from further falling. Administrative Nurse E stated that the fall investigation for root cause analysis to determine the contributing factors were not done in a timely manner as exhibited by the [DATE] fall Investigation/Follow-Up: dated [DATE]. On [DATE] at 11:43 AM, Administrative Nurse D confirmed the fall and Investigative/Follow-Up, as noted above demonstrated the facility staff failed to provide supervision and/or assistive devices to prevent the resident from further falling. She stated when a fall occurred, she expected the staff to do a root cause analysis to determine an appropriate intervention in a timely manner to prevent further falls.in place related to the cause of the fall. The facility policy Falls, dated [DATE], lacked address of staff supervision, assistive devices, and timeliness of investigation to include the root cause analysis of causes, and contributing factors for a fall in order to determine appropriate interventions to prevent further falls. The facility failed to thoroughly investigate the residents repeated falls to determine the contributing factors and causes of her fall to ensure appropriate interventions were implemented to prevent further falls. Additionally, the facility failed to provide adequate supervision to prevent further falls for this resident. - Review of Resident (R)43's Physician Orders, dated [DATE], documentation included [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS), dated [DATE], documentation included the resident with the Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. The resident required extensive assistance of staff with bed mobility, transfers, locomotion, and toilet use and limited assistance with walking. Her balance during transition was not steady and she was only able to stabilize with staff assistance. She had no functional limitation in range of motion in her upper or lower extremities. The resident used a walker and wheelchair for assistive devices. The resident has had 2 or more non injury falls since admission. The Falls Care Area Assessment (CAA), dated [DATE], documentation included the resident had several falls. She fell on [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. The resident had a decline and during the look back period for this assessment she used the wheelchair for locomotion in the hallway and ambulated in her room with extensive assistance using the walker and staff assistance with the gait belt. Due to the several falls, her physician requested a therapy evaluation. Therapy evaluated her on [DATE] and stated she had falls due to her loss of postural control. Her falls resulted in no specific injuries. Due to problems with balance and coordinated movement, therapy started seeing her. The care plan (CP), dated [DATE], directed staff the resident with moderately impaired cognition with a BIMS score of nine. The resident had a [DIAGNOSES REDACTED]. She wore nonskid footwear and needed reminders to use her walker when ambulating, especially in the evenings. The resident required staff to provide set-up or supervision with activities of daily living (ADLs), which included bed mobility, transfers, dressing and ambulating. She forgot to use her call light due to her impaired cognition. The staff were to check her frequently (no specific time frames or intervals). The resident had functional incontinence related to her confusion and noted to have frequent bowel leakage. She required limited assistance of one staff with toileting and was on a scheduled toileting program (no specific times were provided for toileting schedule). The resident received [MEDICAL CONDITION] drugs which may have related complications such as confusion/sundowners with agitation. Additional CP interventions included: 1. On [DATE], tabs alarm at all times. 2. On [DATE], assist the resident to the bathroom, then the lobby., CNA education to keep the bed positioned at height for easy exit/entrance for the resident and to offer as needed (prn) toileting after meals and activities. 3. On [DATE], the resident required extensive assistance of one to two staff for toileting tasks. 4. On [DATE], aid to the toilet when restless, may be looking for bathroom and not able to let staff know. Sensor pad/tabs alarm always and CNA education of the toileting plan to assist the resident to the bathroom prn. Offer the resident diversional activities. 5. On [DATE], one-way slide to the wheelchair seat. 6. On [DATE], staff replaced the resident's alarm with a new functioning alarm. Staff to assist the resident to the bathroom, then lobby, and with one to one supervision until resident returned to bed. 7. On [DATE], one to one supervision provided. 8. On [DATE], dicem in wheelchair when one-way slide is being laundered. Non-skid socks applied. CNA educated to transfer the resident to the lobby chair and ensure one-way slide was in the wheelchair seat. Review of the facility fall log, dated ,[DATE] through [DATE], revealed the resident had nine falls on [DATE] at 06:10 PM, [DATE] at 07:30 AM, [DATE] at 01:10 PM, [DATE] at 10:15 AM, [DATE] at 06:53 PM, [DATE] at 05:40 PM, [DATE] at 02:56 PM, [DATE] at 11:00 PM, and [DATE] at 09:06 PM. Review of the resident's nurses notes and fall investigation notes for the above falls revealed the staff failed to provide needed supervision, and/or a root cause analysis to identify the causes and contributing factors for falls to determine appropriate interventions to prevent further falls as follows: 1. On [DATE] at 06:10 PM, Nurses Notes (NN), documentation the resident found on the floor. The Certified Nurse Aide (CNA) walked past the resident room and observed the resident lying on the floor. The resident reported she got dizzy and fell . She was lying in front of her TV and her walker was positioned in front of her recliner, across the room. The fall Investigation/Follow-Up, dated [DATE] at 08:09 PM, included documentation that all fall interventions were in place at the time of the fall. Staff were to continue frequent checks. The investigation lacked a thorough investigation including a root cause analysis, as to what the resident was doing or trying to do to determine an appropriate approach to prevent further falls. The intervention was to continue frequent checks and one to one supervision, which were in place at the time of the fall. The resident was always to have her walker with her, and it was across the room at the time of her evening fall. The intervention did not provide direction regarding the time frames or intervals of the frequent checks and the nursing staff had different opinions related to the meaning of one to one supervision. 2. On [DATE] at 10:15 AM, NN, included documentation that the CNA responded to an alarm sounding and found the resident sitting on the floor next to her bed. Her bed was in the low position. The resident was assessed, assisted by two staff to the bathroom where she was toileted and then escorted to the lobby for increased visualization. The fall investigation/follow-up, dated [DATE], included documentation which indicated the resident fell due to the height of the bed. The resident could control the height of the bed with the control. The control was moved to the head of the bed, where the resident continued to have access and education was provided to the CNA regarding the resident was not to have her bed in the low position. The analysis of findings during the investigation did not address the root cause of the resident's ability to change the height of her bed or an intervention to address the resident lowering the bed. The investigation documentation did not include a method the guide the staff in observation and checks for the proper height of the resident's bed. 3. On [DATE] at 06:53 PM, NN, included documentation which indicated the resident was found on the floor with the string to her tab alarm detached from her clothing. A Sensor pad was added to the tabs alarm. Nurse Order written to change the TABS alarm/Body alarm sensor pad as always on, and to check for placement and function each shift. The resident had previously removed the string to her alarm on [DATE], without staff addressing the removal prior to this event. The fall investigation/follow-up, dated [DATE] at 12:12 PM, documentation included the string on body alarm was not attached to the resident. 4. On [DATE] at 02:56 AM, NN, included documentation the CNA responded to the resident hollering Help and found the resident sitting on the floor next to her bed. The resident's bed was in the low position. The intervention was to remind the CNA to ensure the bed was at an appropriate height for the resident to enter /exit safely. This was the second time the bed was in the low position at the time of a fall as noted above on [DATE]. The fall Investigation/Follow-Up, dated [DATE] at 02:38 PM, (seven days after the fall) the alarm was under her on the floor and was not sounding. The nurse educated the staff regarding the resident's bed height. 5. On [DATE] at 01:40 AM the NN addressing the fall that occurred on [DATE] at 11:00 PM, documentation included the CNA responded to resident hollering, Help and found the resident sitting on the floor next to her bed. The bed was in the low position. The intervention was to keep the bed at chair height, with assistive devices within reach. Both interventions were initiated prior to the fall. The sensor pad alarm was not sounding, and staff replaced the alarm. The staff toileted the resident and took the resident to the lobby for one to one supervision and increased visualization. The fall Investigation/Follow-up, dated [DATE] at 03:10 PM, the alarm was on and not sounding, staff replaced the alarm, which was noted on the floor during a visual check. The investigation lacked root cause analysis to determine an appropriate approach to prevent further falls. On [DATE] at 12:13 PM, the resident self-propel her wheelchair with her feet about the facility. The alarm was on the chair and she had tennis shoes in place. On [DATE] at 09:22 AM, the resident was asleep in the recliner with her feet elevated, with the one-way slide positioned in the chair. Alarms were in place and functioning. On [DATE] at 04:06 PM, the resident sat in the recliner with her feet elevated, and with her body alarm in place. Non-skid slippers were on her feet. The one-way slide was present in the recliner. On [DATE] at 09:22 AM, CNA NN, confirmed the resident sleeps in the recliner with her feet elevated, she was to have non-skid footwear, the one-way slide and alarms always. She reported that the staff should perform visual checks. When asked to clarify the meaning of visual checks she stated just check on her frequently. CNA NN reported the resident had increased confusion and restlessness since her husband passed away. She stated the staff would walk her when she became restless and agitated. On [DATE] at 10:15 AM, Certified Medication Aide S stated that the nurse would be notified when a resident fell . The nurse would assess the resident and try and determine the reason for the fall sometimes the toileting plan must be adjusted. The CMA stated she did not know how to access the toileting times for a resident that pretty much they toileted residents at least every two hours, before and after meals as a matter of routine. She identified the resident as being at risk for falls indicating the resident changed rooms to a private room since her husband died and she seemed more content. CMA S stated she was not sure about all the interventions for the resident but that she had an alarm and the staff keep an eye out for her. On [DATE] at 10:39 AM, Licensed Nurse (LN) G stated when a resident fell the charge nurse should assess for placement of current interventions and try to determine the contributing factors when a resident fall. The

The facility identified a census of 53 residents with 17 residents sampled for review, including 4 residents sampled for accidents. Based on observation, interview and record review, the facility failed to keep planned interventions in place to prevent falls for 2 (#102 and #23) of the sampled residents. Findings included: - The POS (physician's orders [REDACTED].#102 had [DIAGNOSES REDACTED]. The admission MDS, (Minimum Data Set), dated 9-13-17, documented the resident had a BIMS (Brief Interview for Mental Status) score of 3, indicating the resident had severe cognitive impairment. The resident required extensive assistance of 2 for bed mobility and transfers and had not fallen since admission to the facility. The CAA (Care Area Assessment) for falls, dated 9-13-17, documented the resident had no falls since admission to the facility. The resident required extensive assistance of 2 for transferring and had balance issues. The quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed the resident's cognition to be moderately impaired. The resident required extensive assistance of 2 of bed mobility and transfers and had 1 non-injury fall and 2 or more injury (except major) falls since the prior assessment. The care plan for falls, dated 9-21-17, instructed staff the resident had poor balance during transfers and required non-skid socks or shoes while transferring. The revised care plan, dated 12-30-17, instructed staff to keep a fall mat next to the resident's bed. Review of the resident's medical record, dated 1-03-18, revealed staff discovered the resident on his/her right side on the floor beside the bed. The resident had a hematoma (collection of blood trapped in the tissues of the skin) to his/her right forehead, measuring 4 X 4 cm (centimeters). The resident's bed was in the low position, however, facility staff had failed to put the floor mat in place next to the resident's bed. The facility investigation revealed the resident had rolled out of bed. On 7-26-18 at 10:08 a.m., direct care staff E stated the resident had fallen out of bed and received a bruise to his/her eye. Fall interventions at the time of the fall were to have a floor mat next to his/her bed, and the floor mat was not in place. On 7-26-18 at 11:20 a.m., licensed staff F stated the floor mat had not been in place at the time the resident fell on [DATE], resulting in a hematoma to the resident's forehead. On 7-26-18 at 11:26 a.m., administrative staff A stated his/her expectations were for interventions to be in place, once initiated. The facility policy for falls, revised 5-29-18, included: Residents will be identified for risk of falls and interventions implemented to reduce risk. The facility failed to keep planned interventions in place to prevent injury for this dependent resident, during a fall. - This deficient practice of failure to keep planned interventions in place also affected resident #23, when staff failed to ensure the resident's electric lift chair controller was kept in the chair's side pocket, as planned, to prevent the resident from unsafe positioning in the chair.

The facility had a census of 53 residents with 3 residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to ensure 1 (#1) of the 3 residents reviewed, remained free from neglect when staff left the resident unattended in the bathroom for an extended period of time (4 hours and 20 minutes). Findings included: - The POS (physician's orders [REDACTED]. The annual MDS (Minimum Data Set), dated 7-03-17, documented the staff assessment for cognition revealed the resident had moderately impaired decision making. He/she required extensive assistance of 1 for toilet use, transfers and personal hygiene. The resident was frequently incontinent of bowel and bladder. The CAA (Care Area Assessment) for cognition, dated 7-03-17, documented the resident does not remember to use the call light to request assistance from the staff. The quarterly MDS, dated [DATE], documented the resident required extensive assistance of 2 staff for transfers and extensive assistance of 1 staff for toileting. The care plan, dated 7-18-17, instructed staff the resident required extensive assistance of 1 for toileting. The resident used large pull-up incontinent products and staff were to ensure they were on appropriately. Furthermore, the care plan instructed staff the resident could be left for short periods of time to complete toileting. Review of the nurses notes on AOD (Answers on Demand, an electronic documentation system) revealed on 9-15-17, staff found the resident on the toilet at 9:50 p.m. The resident had a reddened area around the circumference of his/her buttock which matched the toilet seat. The resident denied pain. Staff notified the physician and the resident's DPOA (Durable Power of Attorney) of the incident. On 9-16-17 at 1:36 p.m., a nurses note revealed the resident's buttocks appeared intact and to have good circulation. No redness was present, at that time. Staff initiated a new order to apply an air mattress to the resident's bed for prevention of skin breakdown. On 9-16-17 at 2:57 p.m., a nurses note revealed the facility initiated the standing order for [MEDICATION NAME] (a high protein supplement to aide in the healing of wounds) twice daily and a multivitamin with minerals every day to aide in the prevention of skin breakdown. A physician progress notes [REDACTED]. The resident had no pain. An employee disciplinary report, dated 9-16-17, by administrative staff A, documented the direct care staff member D provided substandard care which put the resident at risk for skin breakdown. On 9-26-17 at 10:38 a.m., direct care staff E and F entered the resident's room to take him/her to the toilet. The resident was attached to the sit to stand lift and transferred to the toilet where he/she was continent of urine. On 9-26-17 at 10:42 a.m., revealed the resident's buttocks to have no redness or bruising. The resident's skin was warm, dry and pink. Review of a written statement by direct care staff D, dated 9-16-17, included: The staff member had taken the resident from the dining room to his/her room at 5:20 p.m. Staff D asked the resident if he/she needed to use the bathroom which the resident replied he/she did need to use the bathroom. Staff D assisted the resident to the toilet and left the resident's room to answer other resident call lights. Staff D left the facility at 6:05 p.m. and did not hear about the incident until the following morning. A verbal statement from staff D on 9-28-17 at 9:52 a.m., revealed the staff member placed the resident on the toilet at approximately 5:20 p.m., when the resident stated he/she needed to toilet. Staff member D stated he/she left after their shift without removing the resident from the toilet, stating it had slipped his/her mind. On 9-26-17 at 12:02 p.m., direct care staff F stated the staff transfer the resident to the toilet with the sit to stand lift. Staff F stated staff now stay in the room with the resident while he/she was on the toilet. On 9-26-17 at 2:08 p.m., direct care staff G stated staff did not normally leave the resident alone while he/she was on the toilet, prior to and after the incident. Some days the resident was able to use the call light, but other days he/she was not able to remember to use the call light. On 9-26-17 at 2:18 p.m., direct care staff H stated on the evening of the incident, he/she saw direct care staff D take the resident from the dining room at approximately 5:15 p.m. Staff H took his/her break at approximately 6:00 p.m. When he/she came back from break, he/she believed the resident was in bed. At approximately 9:45 p.m. that evening, staff H was doing bed checks when he/she entered the resident's room and discovered the resident remained on the toilet. Staff H asked his/her co-workers if they had put the resident on the toilet and they all stated they had not put the resident on the toilet. The other direct care staff on the shift stated to staff H the last person they had seen the resident with had been staff D, who had left the facility at 6:00 p.m. Staff H stated the resident needed to be turned and repositioned every two hours, but staff had failed to do so during this shift. On 9-26-17 at 12:16 p.m., licensed nursing staff I stated staff are to toilet the resident before and after meals. The resident was not able to use the call light to request assistance. The direct care staff will stay close by when the resident was on the toilet to see when he/she finished with the toilet. After the incident, the facility put an air mattress on the resident's bed and started the wound prevention protocol. The red area to the resident's buttock had cleared by the following morning. On 9-26-17 at 2:31 p.m., licensed nursing staff J stated the direct care staff D should not have left the facility while the resident was still on the toilet. The resident had confusion and would not use the call light to let staff know he/she was done toileting. On 9-26-17 at 12:28 p.m., administrative nursing staff B stated the facility notified the resident's physician immediately following the incident, as per protocol, and re-educated all of the staff who worked that evening. The facility policy for abuse/neglect prevention, dated August, 2016, included: It is the responsibility of employees to promptly report to community management any occurrence of neglect. All reports of neglect are promptly and thoroughly investigated by community management. The facility failed to ensure this dependent resident remained free from neglect as staff left him/her unattended in the bathroom from 5:20 p.m. until 9:45 p.m., a period of 4 hours and 25 minutes.

The facility reported a census of 49 residents with 4 reviewed for pressure ulcers. Based on observation, interview and record review, the facility failed to assess, identify and implement measures in a timely manner for treatment of [REDACTED].#2) of the 4 residents reviewed. Findings included: - The significant change MDS (minimum data set), dated 2-25-16, assessed the resident with a BIMS (brief interview for mental status) score of 07, which indicated severe cognitive deficit (0-7), required extensive assistance with bed mobility, had no impairment of upper or lower extremities, was frequently incontinent of bladder, and was on a toileting plan. The resident received scheduled pain medication, a therapeutic diet, and was at risk for pressure ulcer development, with a stage 2 pressure ulcer identified on 3-3-16. This MDS documented the resident had a pressure reducing device for their chair and bed and was on a turning program. The quarterly MDS, dated [DATE], assessed the resident with moderately impaired cognitive status, required extensive assistance with bed mobility, was frequently incontinent of bladder, occasionally incontinent of bowel and was on a toileting plan. This MDS, assessed the resident with no impairment of the upper or lower extremities, and he/she was at risk for pressure ulcers, with none present during this look back period. The resident had a pressure reducing device for the chair and bed; and was on a turning program. The CAA (care area assessment) for pressure ulcers, dated 3-25-16, assessed the resident with a history of a pressure ulcer to the buttock, with a stage 2 pressure ulcer to his/her right buttock that measured 1.2 by 0.8 by 0.1 cm (centimeter) and was healing. Interventions included a Roho (specialized pressure reducing cushion) chair cushion, low air loss mattress, multivitamin, and Sensicare (medicated ointment) to these areas. The CAA indicated staff were to assist the resident to reposition every 1 -2 hours and as needed. Furthermore, the CAA stated the resident was able to shift his/her weight when she/he became uncomfortable. Nursing staff advised to monitor these areas regularly for healing. Then CAA for activities of daily living, dated 3-25-16, stated the resident required extensive assistance for bed mobility, and had severely impaired cognition. The CAA for nutrition, dated 3-25-16, assessed the resident with a normal BMI (body mass index), on a fortified diet with diabetic precautions, multivitamin with minerals for dietary supplement, and the registered dietician recommended MedPass (a nutritional supplement) 6 ounces, twice a day, for the history of pressure ulcer. The care plan, updated 12-29-16, advised staff of the resident's risk for alterations in nutrition and indicated the resident required a fortified diet with diabetic precautions. The care plan revealed the resident was frequently incontinent of bowel, and was on a scheduled toileting program. The care plan advised staff the resident was at risk for pressure ulcers and needed assistance with bed mobility, required a Geomax (pressure relieving) mattress on his/her bed to reduce pressure, and a pressure relieving cushion in his/her wheelchair. The care plan directed staff to monitor the resident's coccyx(sacral) area and notify the charge nurse if observations made of redness or open area. The care plan, with a 1-25-17 update, advised staff of an unstageable pressure ulcer to the resident's sacrum/coccyx, low air loss mattress, Santyl (a [MEDICATION NAME] medicated ointment) to the pressure ulcer daily and cover with kerrafoam (a dressing). This entry advised staff the physician ordered, Keflex(an antibiotic), 500 mg (milligrams), three times a day, for 7 days, for wound healing. Review of the TAR (treatment administration sheet), dated 12-15-16 through 1-14-17, indicated a sacral dressing of [MEDICATION NAME] to the residents's sacrum for pressure relief and instructed staff to change the dressing on bath days on Wednesday and Saturday and as needed. The entries were by the charge nurse. This TAR, indicated one prn (as needed) entry on 1-8-17, without indication of skin condition. Review of the TAR (treatment administration sheet), dated 1-15-17 through 2-14-17, revealed a treatment for [REDACTED]. Review of the weekly skin screenings, dated 1-3-17, 1-10-17, 1-17-17, 1-24-17, and 1-31-17, indicated the skin assessment as completed with no new skin problems for all the above days. Review of the annual dietary history and screening, dated 12-12-15, assessed the resident started a fortified diet, offer finger foods, cut up foods, use food positioning, med pass 4 ounces twice a day, blue divider plate, picnic silverware, and no water at meals, only in his/her room. The electronic record lacked an updated (2016) annual/significant change dietary history. Review of the nurse's note, dated 1-26-17, revealed on 1-22-17, the licensed nursing staff changed the dressing to the resident's coccyx and noted the wound was red around the edges with a white center and cleansed the wound and applied the kerra foam dressing. This entry lacked measurements of the wound or physician notification of the pressure ulcer decline for a change in treatment. A nurses note, dated 1-25-17 at 1:43 am, documented a partial thickness pressure ulcer, 2.4 by 4 (cm) centimeters with a depth of 0 centimeter. This note documented moderate exudates (drainage) and unstageable slough (dead tissue) due to necrotic (dead) tissue and described the drainage as serosanguineous(containing watery and bloody drainage), malodorous (having a foul smell) and documented that staff changed the kerra foam sacral dressing on bath days and as needed until healed. A nurses' note, dated 1-25-17 at 9:52 am, described the wound as an unstageable pressure ulcer to his/her coccyx with 95% eschar (hard dead tissue) and 5 % clean tissue, without granulation (new tissue growth). The length measured as 4 by 4 cm with a depth of 0.2 cm. Further description included necrotic(dead tissue) eshcar with purulent (containing pus) beige drainage and a foul odor. A physician's orders [REDACTED].{breakdown} eschar) and cover with kerrafoam, daily, and as needed until healed and administer Keflex (an antibiotic), 500 mg (milligrams), three times a day, for 7 days, for wound healing. An electronic note from the registered dietician, dated 1-25-17, recommended Med Pass or [MEDICATION NAME], (already on multivitamin with minerals), and fortified milk at lunch and supper. A nurses' note, dated 1-27-17, described the wound as a full thickness pressure ulcer with a red area surrounding the wound bed which measured 11 by 9 cm. Staff described the tissue as necrotic eshcar with purulent, brown, moderate exudates. Observation, on 2-1-17 at 11:27 am, revealed licensed nursing staff C, positioned the resident on his/her right side, with the dressing to the resident's sacrum wrinkled along the lower edge and saturated with a foul brown drainage. Staff C removed the dressing, and cleansed the wound with wound cleanser and measured the area as 4.5 by 3.5 cm. The wound contained black eschar and yellow slough, and 2 white areas on the lower wound edge. Staff C stated the wound began with 95 % eshcar, and now contained 50% eshcar. Staff C stated the resident completed 7 days of Keflex and felt the wound improved. Observation revealed the resident moved his/her legs and arms but did not purposely follow commands. Interview, on 2-1-17 at 4:45 pm, with administrative staff B revealed the facility wound specialist trained the direct care nursing staff to apply the preventive foam dressings. The direct care staff should document skin changes in the kiosk (electronic charting tool) and notify the charge nurse. The licensed nursing staff, who did the weekly skin assessments, should remove the preventative dressing to complete a thorough skin assessment. Staff B confirmed licensed nursing staff failed to identify the resident's pressure ulcer on the weekly skin assessments and the nurses did not remove the preventative dressing to actually visualize the pressure area. Interview, on 2-1-17 at 5:16 pm, with licensed nursing staff D, revealed he/she performed the skin assessment on 1-3-17, but did not remove the dressing to the sacrum. Nursing staff D stated on 1-22-17, he/she replaced a dressing to the coccyx, and noted that the wound was moist, but not draining, however staff D did not measure or document the status of the wound. He/she did not notify the oncoming shift of the wound status as he/she thought the day (6 am- 6pm) nurse assessed the wound on bath days, as the TAR indicated. Staff D stated the dressing would have been changed by the day nurse on 1-21-17, approximately 12 hours earlier. On about 1-25-17, he/she noticed an odor from the wound and at this point measured the wound and documented in the nurses' note as a partial thickness pressure ulcer, 2.4 by 4 (cm) centimeters with a depth of 0 centimeter. This note documented moderate exudates and unstageable slough due to necrotic tissue and described the drainage as serosanguineous (containing serum (watery) and blood), malodorous and documented the staff changed the kerra foam sacral dressing, on bath days and as needed until healed. Interview, on 2-2-17 at 7:30 am, with licensed nursing C, revealed he/she trained the direct care staff to apply the foam dressing to the resident's coccyx after he/she received their bath. The [MEDICATION NAME] foam dressing was a preventative measure. Direct care staff were to document any new skin conditions in the kiosk and notify the charge nurse. The direct care staff were to document skin conditions each shift, and indicate the areas of concern on the kiosk. Staff C stated any skin issues, identified by the direct care staff, flowed over to the charge nurse, director of nursing and quality assurance nurse electronically for action. Interview, on 2-2-17 at 9:10 am, with direct care staff E, revealed he/she routinely applied the foam dressing to the resident's coccyx after his/her bath, but if he/she noticed anything unusual (redness or open areas), he/she notified the charge nurse and documented the findings in the kiosk. Staff E stated he/she gave the resident a bath on Wednesday, 1-25-17, noticed a red area on the resident's coccyx and also noted an odor. Staff E stated he/she notified the charge nurse. Interview, on 2-2-17 at 9:30 am, with direct cares staff F, revealed he/she applied the preventive foam dressing to the resident's coccyx after bathing. Staff F revealed he/she bathed the resident, on 1-21-17, and noticed his/her coccyx more red than usual, but thought the redness would resolve. Staff F stated he/she did not document the redness in the kiosk and did not notify the charge nurse. Interview, on 2-2-17 at 10:00 am, with dietary staff G, revealed the registered dietician made electronic recommendations after he/she faxed the resident's medical information, but had not completed an annual or significant change evaluation which was overdue. The facility policy for skin integrity: Nursing intervention and wound treatment guidelines for health care center, dated 8-10-16, advised staff the weekly skin evaluation were completed by the licensed nurse and were documented on the skin evaluation form. If skin alterations were found, there was a skin evaluation form opened on the date of the skin evaluation, documenting the skin alteration and the treatment if indicated as ordered by the doctor. Certified nursing staff inspected the resident's skin during bathing and during other times of assistance and new or unusual findings were reported to the licensed nurse and documented in the care tracker (electronic charting tool) . The licensed nurse would follow up by completing a skin evaluation in the electronic record. If new alterations were noted, the licensed nurse would indicate treatment per guidelines and document as indicated. The facility failed to thoroughly assess and identify the change in this resident's sacral skin condition for this cognitively impaired resident, at risk for pressure ulcers and with a history of a pressure ulcer on the sacrum, to prevent the redevelopment of an unstageable pressure ulcer.

The facility reported a census of 52 residents. Based on observation, interview and record review the facility failed to maintain a clean and sanitary dietary department, for the storage, preparation, and service of food to the residents of the facility. Findings included: - On 11/29/16 at 8:40 AM, the initial tour of the kitchen revealed the following areas of concern: 1.) One oven, on the 4th floor, with heavily soiled food debris across the bottom. Dietary staff I reported, at that time, the activiy department was responsible for the use of the oven. 2.) The drawers under the juice machine with juice residue, and sticky to the touch. 3.) The bottom shelf under the sink with accumulated black, flaky debris in the corner. 11/29/16 at 8:40 AM, dietary staff I verified all the above areas needed cleaned. On 12/1/16 at 8:30 AM, the sanitation tour of the kitchen revealed the following areas of concern: 1.) One counter in front of the coffee pot, presented with a chipped surface approximately 4 X 6 inches, exposing the wood beneath, dietary staff I verified the surface of the counter needed repair. 2.) Four full cookie sheet pans with black debris, on all four inside corners. 3.) One 10 X 15 cookie sheet with black debris, on all four inside corners. 4.) Five full sheet cake pans with with black debris, on all four inside corners. 5.) Four (1/3 size) steam table pans stored wet. 6.) Three (1/2 pan size) steam pan stored wet. 7.) Two plastic storage containers with 3 drawers each, had visible dust/debris in the bottom drawer( stored variety of utensils. On 12/1/16 at 9:00 AM, dietary staff J reported he/she always rinsed the items before using. 8.) Twenty, medium sized spice containers with visible dust covering the tops, and were sticky to touch. 9.) Five, gallon size spice containers had visible dust and spice residue on the tops and on the outside of the containers. On 12/1/16 at 9:20 AM, dietary staff I verified all the areas identified as soiled in the environmental tour and in need of cleaning. The facility 2016 guideline for cleaning dietary areas documented the dietary staff to clean pots and pans after each use, and to clean the drawers, shelves, and ovens weekly. The facility failed to store, prepare, and serve food to the residents of the facility under sanitary conditions to prevent food borne illness.

The facility reported a census of 52 residents with 18 residents sampled. Based on observation, interview, and record review, the facility failed to ensure that 1 (#35) resident was free of any significant medication errors. Findings included: - The resident's POS (physician's orders [REDACTED].#35 resident admitted to the facility with a [DIAGNOSES REDACTED]. The care plan, dated 8-11-16, documented the resident had a BIMS (Brief Interview for Mental Status) score of 10, indicating the resident had moderately impaired cognition. His/her cognition fluctuated due to a [DIAGNOSES REDACTED]. Review of the resident's chart revealed an order for [REDACTED]. A faxed order, dated 9-13-16, included an order to hold the resident's [MEDICATION NAME] for 7 days due to blood in the resident's stools. Review of the MAR (medication administration record) for September 14, 2016, revealed the staff held the resident's daily dose of [MEDICATION NAME], as ordered. Review of the MAR for September 15-21, 2016, revealed the resident received the [MEDICATION NAME] 75 mg po every day. The [MEDICATION NAME] was held on 9-22-16, pending clarification from the physician. An order, received from the physician, on 9-22-16, directed staff to (DC) discontinue the use of the [MEDICATION NAME]. Staff discontinued the medication from the MAR, at that time. On 12-05-16 at 1:51 p.m., licensed nursing staff H stated, when an order comes into the facility to hold a medication, the nurse was to write hold on the days the staff were not to administer the medication, on the MAR. Staff H stated he/she would leave a note on the MAR for the other nurses to know the medication was to be held. The MAR turnover (when the MARS are changed out) occurs on the 15th of each month. The hold was not added to the medication on the new MAR and that was how the hold order of the [MEDICATION NAME] was missed. It was only held one day before the start of the new MAR. On 12-05-16 at 3:14 p.m., administrative nursing staff B stated, the physician had ordered the medication to be held for 7 days. The nurse only wrote it on the MAR which ended on 9-14-16 and did not write the hold on the MAR beginning 9-15-16. The medication was only held on 9-14-16, but should have been held for the 7 days, as the physician ordered. Staff B stated he/she did not believe there had been an adverse effect from the medication not being held. Education was done with all nursing staff to ensure this type of medication error did not occur again. The facility policy for medication administration, revised January, 2012, included: Medications are administered as prescribed in accordance with good nursing principles and practices. The facility failed to ensure the resident was free of any significant medication errors, as the resident received [MEDICATION NAME], for 7 days, without a physicians order.

The facility reported a census of 52 residents, with 18 residents sampled. The sample included 6 residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow-up the effectiveness of medication for 3 residents (#72, #38, and #52) that required prn (as needed) medications. Findings included: - The signed physician orders, dated 10/26/16 of resident #72 , documented the resident re-admitted on [DATE], with the following [DIAGNOSES REDACTED]. The physician orders [REDACTED]. 1. [MEDICATION NAME] HCL ([MEDICATION NAME]), anti-nausea medication, 4 milligram, every 6 hours, as needed, for nausea/ vomiting, ordered 10/28/16. 2. Milk of Magnesia (laxative), 30 milliliter, daily, as needed, for constipation, ordered 10/13/16. 3. [MEDICATION NAME]/ [MEDICATION NAME] ([MEDICATION NAME]), 0.5 milligram, inhalation, 4 times a day, as needed, for pneumonia, ordered 10/13/16. Review of the MAR (medication administration record), from 9/15/16 to 12/1/16, revealed the resident received [MEDICATION NAME] on 10/15/16, and 10/28/16, and lacked documentation for follow-up of the effectiveness of the medication. Review of the MAR, from 9/15/16 to 12/1/16, documented staff administered Milk of Magnesia on 9/17/16, and 11/11/6, and lacked follow-up documentation for the effectiveness of the medication. Review of the MAR, from 9/15/16 to 12/1/16, revealed the resident received [MEDICATION NAME] inhalation treatment on 10/17/16, and lacked documentation for the follow-up effectiveness of the medication. On 11/30/16 at 2:48 PM, the resident sat in his/her room without signs of discomfort. On 12/01/16 at 8:18 AM, the resident lay in the bed with his/her eyes closed. No signs of discomfort or behaviors observed. On 11/30/16 at 2:06 PM, licensed nursing staff C, stated when the resident received prn medication, staff should complete follow-up for the medication's effectiveness within 1 hour. Licensed nursing staff C, verified the MAR indicated [REDACTED]. On 11/30/16 at 3:09 PM direct care staff D, stated when the resident received a prn medication, then staff should document follow-up for effectiveness of the medication, on the back of the MAR. On 12/05/16 at 10:13 AM, administrative nursing staff B reported the staff should flag the MAR by a pull tab that indicated whether the prn medication documentation had been followed up. Administrative nursing staff B reported staff should follow-up all prn medications for effectiveness. The facility's medication administration policy, dated 1/12, documented staff should record the prn medication in the MAR, and document the results achieved. Staff should flag the MAR indicated [REDACTED]. The facility failed to effectively follow-up on the prn medication administration for this resident, as required. - physician's orders [REDACTED].#38: 1.) Milk of Magnesia, 60 ml, give by mouth once daily as needed for Constipation, ordered 4/10/14. 2.) [MEDICATION NAME], 10 mg, give 1 suppository rectally once daily as needed for Constipation, ordered 4/10/14. Review of the August and October, 2016, Medication Administration Records, revealed the administration of Milk of Magnesia on 8/19, 10/3, 10/4 and 10/9, and [MEDICATION NAME] on 8/21 and 8/22. Upon further review, the MARs lacked follow-up documentation for effectiveness of these medications. Interview, on 11/30/16 at 2:06 pm, with licensed nursing staff C, stated when the resident received as needed medication, follow-up for the medication's effectiveness should be completed within 1 hour. Interview, on 12/5/16 at 10:13 am, with administrative nursing staff B, stated that the staff should flag the Medication Administration Record [REDACTED]. Staff B also stated that all as needed medications should be followed up for effectiveness. The facility's medication administration policy, dated 1/12, documented to record the PRN (as needed) medications in the MAR (Medication Administration Record), and document the results achieved. The MAR indicated [REDACTED]. The facility failed to effectively follow-up on the PRN medications for this resident, as required. - physician's orders [REDACTED].#52: 1.) Milk of Magnesia, 30 cc, by mouth once daily as needed for constipation, ordered 3/4/16. 2.) Immodium A-D, 2 mg, by mouth every 56 hrs for loose stools (notify the physician if loose stools persist more than 24 hrs or greater than 6 loose stools in 24 hrs), ordered 10/1/16. Review of the October, 2016, Medication Administration Record, [REDACTED]. Upon further review, the MARs lacked follow-up documentation for effectiveness of these medications. Interview, on 12/5/16 at 10:13 am, with administrative nursing staff B, stated that the staff should flag the Medication Administration Record [REDACTED]. Staff B also stated that all as needed medications should be followed up for effectiveness. The facility's medication administration policy, dated 1/12, documented to record the PRN (as needed) medications in the MAR (Medication Administration Record), and document the results achieved. The MAR indicated [REDACTED]. The facility failed to effectively follow-up on the PRN medications for this resident, as required.

The facility reported a census of 55 residents with 6 residents identified as elopement risks. Based on observation, record review and interviews, the facility failed to provide adequate supervision for 1 (#01) of 3 sampled elopement risk residents. Findings included: - The medical record evidenced the facility admitted resident #01 on 3/27/15. The admission history included wandering away from home and the inability of the spouse to continue to care for the resident at home. [DIAGNOSES REDACTED]. The MDS, dated [DATE], identified the resident with a severe cognitive deficit, wandering daily, in need of limited assist with all activities of daily living and no psychological medications. The care area assessment, dated 4/3/15 included: Cognition: BIMS (basic intelligence monitoring) score of 3 indicates severely impaired cognition. Behaviors: Exhibits wandering behaviors. He/she is ambulatory without the use of any kind of assistive devices and displays wandering behaviors quite frequently throughout the facility. The first few days in the facility, staff documented the resident having gone to the facility exit doors. An electronic wanderquard bracelet was applied on the day of admission due to risk of elopement. After a few days he/she became less anxious. The care plan, dated 4/23/15 included, I have severely impaired cognition with a BIMS score of 3 second to my [DIAGNOSES REDACTED]. I have self care deficit related to my Alzheimer's Disease. I ambulate independently most of the time without the use of any assistive devices. I sometimes need cueing/directions for where I need or want to be going. I have a behavior problem as evidenced by wandering and rejection of care related to my [DIAGNOSES REDACTED]. I have a wanderguard in place. Please check placement every shift and functioning every day and PRN (as needed). I like to stay busy some days. Please use any opportunity to involve me in an activity. I typically love to help. Diversional activities include volunteer work activities such as cleaning tables, sweeping floors, wrapping potatoes, cooking and baking, folding napkins and towels and listening to music. On 7/13/15 at 11:30 A.M., administrative staff A reported resident #01 left the faciity on [DATE] at approximately 3:40 P.M., when a group of visitors exited the building. The resident wore a wanderguard which sounded the alarm on the doors. The administrative assistant in the foyer had stepped away from his/her computer and did not witness the resident leaving the facility. On 7/8/15 at 6:09 P.M., dietary staff B, confirmed he/she was going to deliver food to the units, on 6/9/15 when an alarm went off. There were 12-13 family members/visitors in the foyer. He/she turned off the alarm. The dietary staff member reported he/she thought they were all with the group of visitors, so turned the alarm off. On 7/13/15 at 11:30 A.M., administrative staff A explained the family members of another resident realized on 6/9/15, when they were were cutting across the south lawn, they had an unknown male/female walking with them. The family members determined at that point to continue to walk to their house a couple of doors south and across the street from the facility. When they reached their home they assisted the resident in their car and drove him/her back and escorted the resident into the building to the receptionist. The wanderguard system sounded properly when they reentered the facility. On 6/15/15 administrative staff A completed an investigation and determined all alarms were functioning and sounding properly. The facility elopement policy, dated 2/8/1999, included: If door alarms sounds, staff will visual check inside and outside the area and /or exit triggering the alarm to determine the reason for the alarm. If the reason for the alarm cannot be immediately identified, residents in the affected area will be accounted for, beginning with resident assessed at risk for an unwitnessed exit. The charge nurse will be responsible for coordinating this resident check and ensuring each resident accounted for. The known wandering exit seeking resident left the facility with a group of visitors on 6/9/15 at approximately 3:40 P.M. The visitors recognized the resident as they walked to their home just south and across the street from the facility. They returned the resident by car to the facility. The administrative investigation determined the resident out for approximately 10 to 15 minutes and returned without injury or discomfort. The facility failed to provide adequate supervision and monitoring for the sounding alarm per facility elopement policy and the resident exited the facility without staff knowledge.

The facility reported a census of 55 residents. Based on observation and interview, the facility failed to provide palatable, attractive, food for the residents of the facility. Findings included: - On 5/18/15 residents complained of being served cold non-palatable foods including: On 5/18/15 at 9:13 AM, resident #21 reported the food was never hot and the same vegetables were repeated too often. On 5/18/15 at 10:03 AM, resident #8 reported the food did not taste good, and was never hot. On 5/18/15 at 12:18 PM, resident #18 reported breakfast was always cold. We have too much pasta and need more variety in the fruits we are served. On 5/18/15 at 2:40 PM, resident #61 reported the green beans and the fried potatoes were always cold. On 5/18/18 at 7:4 5 AM, dietary staff D reported the facility meal times were open dining for the residents as follows: Breakfast from 7:00 AM through 9:00 AM, Lunch from 11:00 AM through 1:00 PM, and Supper from 4:00 PM through 6:00 PM. On 5/20/15 at 11:35 AM, dietary staff E, reported the staff tested the food temperatures 3 times during a meal service, after being put on the steam table. These times included; when placed on the steam table, at (8:00 AM, 12:00 PM, and 5:00 PM) and at the end of each meal service. He/she added the food was also tested before leaving the kitchen. On 5/20/15 at 11:35 AM, upon request and after checking the food temperatures of the food items on the steam table, dietary staff E stopped the meal service. Staff E reported he/she thought the food was not hot enough because the lids were not kept over these items on the steam table during serving. On 5/21/15 at 9:15 AM, dietary staff D verified the chicken livers, the chicken drummies, the chicken gravy, and the winter vegetables had lost temperature, and thought it was due to being uncovered between meals served. Staff D reported he/she instructed the dietary staff to keep the food covered at all times between serving. Staff D verified the food temperatures were not scheduled to be rechecked until noon, and several resident could have been been served the cooler food items during this time without staff knowledge. In addition, on 5/18/15, other residents also complained of the facility food palatability/food quality as follows: On 5/18/15 at 9:57 AM, resident #36 reported the food was good sometimes. On 5/18/15 at 9:56 AM, resident #50 reported he/she did not like the food very much with too much spicy stuff served. On 5/18/15 at 10:36 AM, resident #6 reported he/she did not like the food at times, and the facility needed to have softer foods. On 5/18/15 at 12:18 PM, Resident #65 reported the facility served too many casseroles. On 5/18/15 at 12:47 PM, resident #2 reported the food was not home cooking, and did not care for it. The resident reported having some meals brought in to them. The facility's undated policy for Steam Table Serving Temperature for Hot/Cold Food documented the minimum serving/holding temperatures: Meats,casseroles- 135-170 F. Gravy 135-170. Vegetable- 135-170 F. If the serving /holding temp of a hot food is not 135 F or higher, the item will be reheated to at least 165 F for minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. Any reheated item that is left after meal service or held longer than 2 hours is discarded. The facility failed to provide palatable, attractive food items for the residents of the facility.

The facility had a census of 56 residents, with 6 residents reviewed. Based on observation, interview, and record review, the facility failed to provide adequate treatment and services to promote healing for 2 of the 3 residents reviewed with stasis and/or venous ulcers (#1 & #6). Resident #1 developed a venous ulcer (lesion of a vein in the lower extremity) on the right foot from an ace wrap left in place from 6/11/14 until 6/24/14, (13 days). Findings included: - The facility admitted resident #1 to the facility on [DATE], according to the admission sheet in the clinical record, with [DIAGNOSES REDACTED]. The resident's 5/22/14 annual MDS (Minimum Data Set) recorded the inability to complete a BIMS (Brief Interview for Mental Status) with severe cognitive impairments, identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff for transfers and bed mobility, walking did not occur, dressing and personal hygiene, required extensive assistance of 1 staff, toilet use required extensive assistance of 2 staff, used a wheelchair, and with an indwelling urinary catheter. The resident's 6/5/14 care plan had the following interventions: Skin - Please assist with a position change every 1-2 hours and as needed. Wears heel protectors at all times when in bed. Intervention of 6/11/14 recorded a right ankle contusion. Keep foot elevated, keep ACE wrap applied. Use cold pack 10-20 minutes every hour while awake for 24 hours. Tylenol/[MEDICATION NAME] as ordered for pain. Non-weight bearing to the right lower extremity. Increase the [MEDICATION NAME] from 25 mcg (micrograms) to 50 mcg, every 72 hours for pain. Intervention of 6/24/14 recorded to DC (Discontinue) the Ace wrap. Clean front of Right ankle with saf clens (cleaning solution for a wound), apply [MEDICATION NAME] (Antiseptic solution-Helps prevent infection in cuts, scrapes and minor burns.) twice a day until healed. Intervention of 6/30/14 recorded right lateral foot venous stasis and right Achilles (area above the heel) blister/venous stasis. Staff recorded in the 6/9/14 nursing notes at 7:20 PM, documented the resident fell two times this day. Upon skin assessment, staff did not identify any skin concerns to the resident's feer/ankles. Staff recorded in the 6/10/14 nursing notes at 10 AM, staff called the nurse into the east spa to look at the resident's right ankle. Staff recorded the resident's right ankle was slightly swollen on the lateral aspect (the side of the foot). The resident allowed staff to perform passive range of motion (moving of a joint through its range of motion without exertion by the resident) without signs/symptoms of pain. The resident was able to bear a little weight on the right ankle. Staff faxed the physician about the resident's right ankle. Staff recorded in the 6/11/14 nursing notes at 3:44 PM, the on call physician faxed no new orders in response to the 6/10/14 fax regarding the condition of the resident's right ankle. Staff recorded in the 6/11/14 nursing notes at 5:52 PM, staff noted 2+ [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) to the resident's right ankle, and the resident's ankle was externally rotated (turned outward). Staff attempted passive range of motion, and the resident exhibited signs/symptoms of pain, with grimacing and became combative. Staff paged the on call physician. At 6:18 PM, the physician called the facility and ordered the resident sent to the hospital due to right ankle pain and swelling. Staff recorded in the 6/11/14 nursing notes at 11:15 PM, the resident arrived back to the facility per the facility van. Physician orders [REDACTED]. Staff recorded the resident had an ace wrap in place to the right ankle at that time. Staff recorded in the 6/13/14 nursing notes at 11:45 AM, a telephone order received from the physician to discontinue the follow-up appointment related to the emergency room visit. The x-ray was normal, and the resident had no change in condition. The telephone order included to notify the resident's primary care physician if there was any change in condition. Review of the resident's computerized and paper clinical record lacked evidence of additional assessment or documentation regarding the resident's right foot and/or the ace wrap until 6/15/14. Staff recorded in the 6/15/14 nursing notes at 1:33 PM, the resident's family member approached the nurse with concerns related to the resident's right ankle wrap and the follow-up appointment. Staff recorded the resident's ace wrap was intact to the right ankle, the resident was able to wiggle his/her toes, pedal pulse palpable (able to feel the foot's pulse), and no signs/symptoms of pain noted. At 6:30 PM, staff recorded notifying the resident's family member of the cancellation of the follow-up appointment. The resident's family member requested the staff contact the physician to ask if the staff were able to remove the ace wrap. Staff recorded the staff faxed the physician as requested. Staff recorded in the 6/15/14 nursing notes at 2:30 PM, the resident's family member reported to the nurse the resident's right leg was hurting, and requested an MRI (Magnetic Resonance Imaging) done of the resident's entire right leg from the right hip down to the ankle and foot area as the resident's family member was he/she was unsure where the resident had pain. Staff called the physician and left a message requesting an order for [REDACTED]. Review of the 6/16/14 and 6/17/14 nursing notes lacked evidence of an assessment of the resident's right ankle and/or right ankle ace wrap. Staff recorded in the 6/17/14 nursing notes at 9:07 AM, staff recorded the staff then contacted the physician and requested an increase in the dose of the [MEDICATION NAME] or an additional pain medication. Staff recorded in the 6/17/14 nursing notes at 2:45 PM, they received a call from the physician with an order to increase the [MEDICATION NAME] from 25 mcg to 50 mcg, change every 3 days for pain control. Staff informed the doctor the resident had an x-ray previously taken only of the right ankle. Staff recorded they informed the physician of the family's request for an MRI of the right leg/hip, awaiting response from the doctor. Staff recorded in the 6/17/14 nursing notes at 5:46 PM, received an order to obtain an x-ray of the right hip at the hospital. Staff recorded in the 6/18/14 nursing notes at 11:07 AM, staff sent the resident to the hospital for an x-ray of the right hip, with a [DIAGNOSES REDACTED]. Staff recorded in the 6/18/14 nursing notes at 3:16 PM, the physician called the facility and stated the resident's right hip x-ray indicated no fracture was present. Review of the nursing notes reviewed form 6/18/14 to 6/24/14 lacked documentation of any assessment of the resident's right ankle and/or the ace wrap. Staff recorded in the 6/24/14 nursing notes at 1:56 PM, staff called into the spa after the resident's bath and found the venous stasis area on the front of right ankle. The podiatrist was here and gave new order to clean venous stasis area to the front of the right ankle with Saf-clens (wound cleaning solution), apply skin prep (solution applied to the skin to increase skin integrity) twice a day until healed. Staff recorded in the 6/24/14 nursing notes at 4:43 PM, the physician ordered to discontinue the right ankle ace wrap. Staff recorded in a late entry for 6/24/14 6-2 shift: The charge nurse reported a clear fluid filled blistered area to the resident's right foot/ankle, with dark red/purple discolored skin which was rough when touched, podiatrist here and consulted, podiatrist examined area and ordered skin prep to area to toughen skin, stated that blister should reabsorb, and he/she stated to apply skin prep and leave the area open to air. On this date, the resident' family member reported a concern that the ankle was worse, consulted charge nurse who had already observed and treated the area today, noted blister had grown in size, and the charge nurse stated that he/she had no further concerns other than blister was larger. Staff recorded on the 6/24/14 wound report form the following: Front of the right ankle - venous ulcer of the front right ankle, measurements of 8.2 cm (centimeters) x 6 cm, no drainage. Staff recorded a later entry for 6/30/14 at 11 AM, administrative licensed nurse performed head to toe skin assessment while the resident was in the bath. Staff recorded the resident with a venous stasis ulcer to the right foot/ankle the blister had ruptured (opened), skin flap intact, skin was dry and flaking, no redness, swelling, warmth noted, no sign/symptoms of pain or discomfort noted upon cleansing of the wound. Review of the CNA (Certified Nurse Aide) daily skin screening detail, recorded from 6/11/14 at 3:53 AM through 7/8/14 at 1:39 PM, revealed the form with the only question of, "Did you see a new skin problem?" Review of this form revealed lacked documentation of any unusual concerns and/or dressings/wraps in place on the resident's right foot. On 7/2/14, the resident had an appointment with the wound clinic, and the physician recorded on the progress notes, the resident fell on e month ago with treatment of [REDACTED]. The resident developed blisters which ruptured. On 7/8/14 at 8:36 AM, observation revealed licensed staff F provided a treatment to the area on the resident's right foot. Observation revealed a small blister on the back of the resident's right foot which measured approximately 1 centimeter in diameter and an open blister area on top of the resident's right foot which measured approximately 4 cm in length by 2 cm in width. During interview on 6/26/14 at 11:55 AM, the resident's family member stated the resident complained of pain in the right ankle and wanted to take the resident back to the doctor on 6/11/14. The doctor reported the resident had a bad contusion (bruise) to the right ankle and the doctor wrapped the ankle with an ACE wrap. On 7/8/14 at 2:45 PM, licensed staff Q stated staff sent a fax to the doctor to get an x-ray. Staff Q remembered getting in report to leave the ace wrap on until a follow-up doctor's appointment. We should have addressed the ace wrap. Staff Q saw the ace wrap and never saw any concern. On 7/8/14 at 3:06 PM, licensed administrative nursing staff C stated the charge nurse did the skin assessment weekly on all the units and documented the skin assessments in the computer. The resident's ankle was hurting and an x-ray was done. The doctor called and canceled the follow-up appointment. I do not know if anyone asked the doctor about the ace wrap. Nursing staff C stated he/she looked at the resident's right foot on 6/24/14. The podiatrist was in the facility and gave treatment orders for the area. The podiatrist stated the area was a venous area and it was not normal to leave a dressing like that in place. On 7/10/14 at 10:49 AM, licensed administrative nursing staff B stated the facility received no response from the 6/15/14 fax sent to the doctor about discontinuing the ace wrap. There was no documentation of the ace wrap in the weekly skin assessment. I think the fax order for discontinuing the ace wrap needed clarification, and the nurses had an order to keep the ace wrap in place, so they did. On 7/10/14 at 11:33 AM, licensed staff F stated on 6/11/14, when he/she touched the resident's foot, the resident grimaced. Licensed staff reported passing the information onto the next shift during report. This licensed staff stated the family requested an x-ray of the resident's right foot. The physician saw the resident in the emergency room and ordered not to remove the ace wrap until a follow-up appointment. On 7/15/14 at 11:09 AM, direct care staff R stated the resident fell and had an ace wrap in place on the right foot. This staff member R stated he/she gave the resident a whirlpool bath and removed the resident's right foot ace wrap. This staff member R stated after removing the right foot wrap, he/she saw a huge blister on the top of the resident's right foot and notified the nurse. This staff member R stated he/she did not document anything about the wrap in the computer as he/she had told the nurse about the resident's skin condition. This staff member R stated he/she usually only told the nurse when he/she identified a new skin condition. On 7/15/14 at 3:01 PM, physician U reported he/she would expect an ace wrap left in place no longer than 4 to 5 days. The resident continued to complain of pain in the right leg, and then we did an x-ray of the right hip which was negative. He/she stated he/she did not know how long the ace wrap remained in place to the resident's right foot. The facility's skin integrity policy, revised on 4/13, recorded nursing staff would assess skin integrity, implement preventative measures as indicated and treat skin breakdown. The policy recorded promotion of skin integrity was a primary focus of the health care team members. A licensed nurse would complete a weekly skin screening on each resident focusing on bony prominences and document in the computer. If staff noted new alterations, this change would be recorded in the computer and the nurse should initiate treatment per guidelines. CNAs (Certified Nurse Aides) would inspect the resident's general skin condition at the time of the bath. New or unusual findings should be reported to the licensed nurse and documented in the computer. Licensed nurses should follow-up by completing a screening of the resident's skin condition and document the findings in the computer. The facility failed to assess the resident's right foot for 13 days after the application of an ace wrap. The resident developed a facility acquired large right foot blister, with an increase in pain medication during this time. - The physician order [REDACTED].#6 readmitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. The Quarterly MDS (minimum data set), dated 5/6/14, documented the resident with BIMS (brief interview of mental status) score of 14, indicating cognitively intact. The resident required limited assist of 1 staff for activities of daily living (ADL's), has no impairment in ROM (range of motion), and used a walker and wheelchair for mobility. The resident noted with skin tears and pressure reducing device in chair and bed, with a turn and repositioning program in place. The Care Plan, dated 5/14/14, lacked any documentation of the current stasis ulcers (a necrotic, crater like lesion of the lower leg caused by chronic venous congestion) to the resident's bilateral lower extremities. The Admission Nursing Assessment, dated 3/11/14, documented Skin Condition: 4+ [MEDICAL CONDITION] to both lower legs and feet with no wounds noted. A Faxed order from the physician (communication sheet), dated 6/19/14, documented: OK for ACE wraps (elastic type wraps to decrease swelling) toes to knees. The Wound Treatment physician orders, dated 7/8/14, documented: Venous Ulcer Right shin cleans with saf-clens, [MEDICATION NAME] extra [MEDICATION NAME], ABD (thick padded dressing) pad and Kerlix (stretchy thin wrap dressing) every day and PRN (as needed) until wound is healed, cover with ACE wrap from toes to knees. The Wound Treatment physician orders, dated 7/8/14: Venous Ulcer left lateral (outer) calf cleans with saf-clens, [MEDICATION NAME] extra [MEDICATION NAME], ABD pad and Kerlix every day and PRN until wound is healed, cover with ACE wrap from toes to knees. On 7/8/14 at 9:30 AM, Licensed Nursing Staff T and Administrative Nursing Staff C entered the resident's room to provide wound dressing treatment. Staff T and C washed their hands and placed gloves on, Staff T removed the old dressing, assessed the wound drainage and discussed changing the treatment for [REDACTED]. Staff C discussed changing the treatment from [MEDICATION NAME] foam to [MEDICATION NAME] hydro fiber based on the foam gelling up and not as effective. Staff T cleansed the wounds with cleanser, patted it dry with gauze and covered it with [MEDICATION NAME] fiber and four ABD's, and wrapped the right lower extremity with Kerlix. Both staff talked with the resident about the condition of the legs, the change and rationale in the treatment, and the resident was agreeable. Staff frequently asked the resident if he/she was doing ok, in pain, or needed anything. Staff then proceeded to the resident's left leg and repeated the process. The resident asked staff T if he/she was still supposed to be having ACE wraps on too, reporting to the staff that the wraps were supposed to get put on his/her legs in the morning and taken off when he/she goes to bed, but that had not been getting done by the staff. Staff replied to the resident that they were not sure, but did not think so, and would have to check the orders to clarify that for the resident. Staff T left the resident's room and returned with the current TAR (treatment administration record) and reported the resident was to have ACE wraps from the toes to below the knee every morning. The resident reported that recently he/she has not been getting them on, at least for the last 2 days they have not been on, and that he/she often goes days without them. Staff T began wrapping the left leg, using 2 ACE wraps staff found in the resident's room. Staff were unable to complete even one leg with the available wraps noting there were no other wraps in the room. Staff C then left the room to see if there were any in laundry for the resident and get some more wraps to be able to complete the treatment. Staff C returned with 4 new ACE wraps reporting that laundry had some wraps being cleaned, but were not able to tell if they belonged to this resident or not. Staff T used the new wraps and finished wrapping both legs. The staff had to re-wrap numerous times due to difficulty in placement of the wraps over the resident's [MEDICAL CONDITION] legs, then placed non-skid socks on the resident due to the resident's shoes being soaked from the fluid weeping from the resident's legs. On 7/8/14 at 10:20 AM, the resident reported he/she has been a resident here about 6 months now, and came here temporarily to get back on his/her feet after having a stroke, followed by kidney failure. The resident reported he/she needed a little extra help and to get the fluids off (swollen legs to decrease) and came here to get that done and to get some therapy. The resident's goal is to transfer and ambulate with the walker, get out of the wheelchair and regain some independence. He/she feels like the legs are getting better, however reported the staff do not know what they are doing when it comes to his/her legs. The resident reported that the treatment, wraps and ace bandages, have not been getting done for several days now. The resident just had the ACE bandages put on his/her legs, and while sitting in the wheelchair, visiting the bandages came loose and fell to the floor around the resident's ankles. The resident reported, that on the days staff does wrap his/her legs, this is typical, for the dressing to fall off. The resident reported that staff say he/she refuses treatment, but what happens is the bandages fall off because they are not put on correctly and when he/she pages for help to have them put back on, the staff get frustrated as if the resident has done something wrong and just take the ACE wraps off, instead of putting them back on. Then, the resident reported, it may be a few days until the ACE wraps are even put back on again. The resident confirmed he/she does not refuse the ACE wraps, and felt they helped. The resident had to call for the nurse to come back and re-wrap the bandages at that time. On 7/8/14, review of the TAR (treatment administration record), dated 6/15/14 to 7/14/14, documented: Starting 6/20/14 ACE wrap bilateral (both) lower extremities from toes to knee every day for [MEDICAL CONDITION]. The record was initialed daily, 6/20/14 through 7/8/14. On 7/10/14 at 1:26 PM, Licensed Nursing Staff I confirmed the resident is supposed to have both legs wrapped with ACE bandages daily in the morning and removed at bedtime. Staff I reported that the resident refuses to have the wraps placed sometimes and at those times staff does not re-approach to try again. Staff at that time opened the TAR, dated 6/15/14 to 7/14/14 and pointed out several days where the initials of the nurse were now circled for the treatment. Staff I reported that the circles around the nurse initials mean treatment was refused. Staff I confirmed that the wraps were not placed on the resident at least one day this week that Staff I worked because it was a busy day and the staff did not feel the resident's treatment was a priority. On 7/10/14 at 2:46 PM, Direct Care Staff J confirmed the resident should have ACE bandages every day on his/her legs. Staff J reported that the resident sometimes refuses care initially and can be a little grumpy but can always re-approach after a few minutes and he/she will allow the care at that time. Staff J confirmed the ACE wraps are not on the resident every day and does not recall if the wraps have been on the resident this week at all. On 7/10/14 at 2:56 PM, Direct Care Staff K confirmed the resident is supposed to have both legs wrapped every day. Sometimes the resident refuses care, but when he/she does, you just re-approach in a few minutes and he/she will always allow staff to do whatever is needed. Staff K reports that sometimes the wraps come undone, and the staff did not recall if the wraps were on the resident each day this week and confirmed there are definitely days the ACE wraps do not get put on the resident. On 7/10/14 at 11:11 AM, Administrative Nursing Staff B reported that the resident's legs are to be wrapped daily with ACE bandages and removed at night. Staff B reported that the nursing staff report to him/her that the resident refuses the wraps occasionally, so on days the wraps were not on, staff B assumed the resident had refused them. The facility failed to provide treatment as ordered to this resident with Venous Stasis Ulcers and weeping [MEDICAL CONDITION] fluid from the resident's bilateral lower extremities.