Every finding on record at Brewster Health Center

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 31 and R42's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 08:05 AM, observation of the facility's Meadowlark Hall medication room revealed the following: R31's Basaglar (long-acting insulin) flex pen was not labeled with an opened date or an expired date. R42's Novolog (fast-acting insulin) flex pen was labeled with an expiration date of [DATE]. On [DATE] at 08:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and discard the expired insulin flex pens. Medlineplus.gov directs open, unrefrigerated Basaglar and Novolog can be used within 28 days; after that time, they must be discarded. The facility's Labeling of Medications policy, dated [DATE], documented medications are labeled in accordance with facility requirements and Kansas and Federal laws. All drug contains would be labeled, and drug labels must be clear, consistent, legible, and in compliance with state and federal requirements. The policy documented upon opening insulin pens; the licensed nurse would write the date opened along with the resident's name on the pen itself. The policy documented medication containers having soiled, damaged, incorrect, illegible, or makeshift labels were returned to the issuing pharmacy for relabeling or to be destroyed in accordance with the medication destruction policy. - On [DATE] at 08:10 AM, during the initial tour of the rehabilitation unit medication room, Resident 70's Humalog) (Short-acting insulin and Lantus (long-acting insulin) pens stored in a tote drawer lacked open and expiration dates. Licensed Nurse (LN) I verified that the insulin (a hormone that lowers the level of glucose in the blood) pens should have open and expiration dates, and generally, the pens expire 28 days after being put in use. LN I recorded it on the pens. The facility's Labeling Medications policy, dated [DATE], documented that medications are labeled by facility requirements and Kansas, and Federal laws. All drug containers will be labeled, and drug labels must be clear, consistent, legible, and comply with state and federal requirements. Upon opening of insulin pens, the licensed nurse will write the date opened along with the resident's name on the pen itself.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R) 28 for Care Area Assessments (CAA) triggered from the Minimum Data Set (MDS). This placed R28 at risk for resident-centered unmet care needs. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of displaced fracture (broken bone) of the greater trochanter (hip joint area) of the right femur (thigh bone), malignant (cancer) neoplasm (tumor) of the mouth and mandible (lower jawbone), laceration (cut) without foreign body of right forearm, and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The admission Minimum Data Set (MDS), dated [DATE], documented that R28 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R28 had a functional range of motion impairment of one side lower extremity and required supervision or touching assistance with toileting, upper and lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and walking ten to 50 feet. The MDS further documented a walker and a wheelchair used for mobility. R28 had occasional incontinence of urine and frequent incontinence of bowel, and had almost constant pain which occasionally affected sleep. The MDS further documented that R28 had a fall in the prior month and six months before admission, with a fracture related to a fall. R28 had speech, occupational, and physical therapy services. R28 had complaints of difficulty or pain when swallowing and received opioids (medication used to treat pain), antiplatelet (medication that prevents blood clots), and anticonvulsant (drugs used to prevent seizures or abnormal electrical activity in the brain). The Cognitive Loss/Dementia (a progressive mental disorder characterized by failing memory and confusion) Care Area Assessment (CAA), dated 05/29/25, documented R28 had times of poor cognition, staff provided cuing, reminders, and assistance with decisions as needed. The Functional Abilities CAA, dated 05/29/25, documented R28 needed staff assistance to complete activities of daily living. Staff assisted as needed with all the cares. R28 had therapy services to improve strength and endurance. The Urinary Incontinence CAA, dated 05/29/25, documented R28 at times had bladder incontinene and was at risk for skin breakdown and infection. Staff assisted with all toileting and incontinent care as needed. The Psychosocial Well-Being CAA, dated 05/29/25, documented R28 was at risk for social isolation and situational depression. Staff to continue to offer/encourage R28 to participate in activities of interest. The Falls CAA, dated 05/29/25, documented R28 had impaired mobility, a recent fall with fracture, at risk for falling. Staff assist with all activities of daily living and care as needed. R28 had therapy to improve strength and endurance. The Nutritional StatusCAA, dated 05/29/25, documented R28 had a mechanically altered diet, which could lead to loss of appetite, weight loss, and malnutrition due to taste, texture, and appearance. The Pain CAA, dated 05/29/25, documented R28 had times of pain, and medication was received as ordered to control pain. R28 had pain assessed daily and as needed. The Dental Care CAA, dated 05/29/25, documented R28 had a diagnosis of mandible cancer and reported mouth pain. Staff were to assist with all oral care as needed. Weight and oral intake were monitored. The physician was notified as needed, and medications as ordered. R28's Care Plan, dated 06/01/25, included R28's risk for falls due to weakness, poor balance, medication use, and actual fall without injury. R28 received multiple medications for diagnosis, some of which have a black box warning (BBW- the highest safety-related warning that medications can have assigned by the Food and Drug Administration). R28's Comprehensive Care Plan failed to address cognitive loss/dementia, psychosocial well-being, nutritional status, and dental care as required within 21 days of admission. The Progress Note dated 05/16/25 at 01:08 PM documented that R28 arrived at the facility, having been a patient in the hospital. R28's admitting diagnosis of displaced fracture of the greater trochanter of the right femur was alert and oriented times four, had a port to the right chest, skin tear to the right forearm, scab to knees, and generalized bruising to both thighs. The Progress Note dated 05/23/25 at 08:36 AM, recorded R28 continued respite stay, was alert with some forgetfulness, pleasant, cooperative, and normal affect. The note further documented R28 complained of fatigue, had swelling of the jaw due to cancer of the mandible bone, had severe pain, was up with one staff stand-by assistance, and had occasional bowel and bladder incontinence. On 06/09/25 at 03:03 PM, R28 was sitting on the edge of the bed, with a gait belt around his waist. The walker was against the wall and not within reach of the resident. On 06/11/25 at 11:11 AM, Certified Nurse Aide (CNA) M reported she was aware of the cancer diagnosis and R28 was on a mechanically altered diet and had pain, and CNA M reported changes to the nurse. CNA M reported the temporary cares were kept in the care plan book. On 06/11/25 at 11:12 AM, Licensed Nurse (LN) I, R28's MDS was completed by the MDS coordinator. LN I stated she was unsure of who was responsible for the care plan process due to recent staff changes. LN reported that the admitting nurse and therapists were responsible for the baseline care plans. On 06/11/25 at 12:17 PM, Administrative Nurse D reported that the comprehensive MDS with triggered CAAs should have been part of the care plan process, and concerns should be addressed on the care plan. Upon request, the facility failed to provide a comprehensive care plan policy.

The facility had a census of 75 residents. The sample included 18 residents, of which six were reviewed for falls. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent falls for Resident (R) 28, R67, and R70. This placed the resident at risk for ongoing falls and injuries. Findings included: - R28's Electronic Medical Record (EMR) documented diagnoses of displaced fracture (broken bone) of the greater trochanter (hip joint area) of the right femur (thigh bone), malignant (cancer) neoplasm (tumor) of the mouth and mandible (lower jawbone), laceration (cut) without foreign body of right forearm, and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities). The admission Minimum Data Set (MDS), dated [DATE], documented that R28 had intact cognition, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), or exhibited behaviors. R28 had a functional range of motion impairment of one side lower extremity and required supervision or touching assistance with toileting, upper and lower body dressing, putting on and taking off footwear, personal hygiene, transfers, and walking ten to 50 feet. The MDS further documented a walker and a wheelchair used for mobility. R28 had occasional incontinence of urine and frequent incontinence of bowel, and had almost constant pain which occasionally affected sleep. The MDS further documented R28 had a fall in the prior month and six months before admission with a fracture related to a fall. R28 had speech, occupational, and physical therapy services. The Fall Care Area Assessment (CAA), dated 05/29/25, documented R28 had a recent fall with a fracture, and was at risk for falling, staff assistance to complete all activities of daily living and care as needed. The CAA further documented R28 had therapy to improve strength and endurance. R28's Care Plan dated 06/01/25 documented that R28 was at risk for falls due to weakness, poor balance, and medication use. The Care Plan directed staff to encourage mobility programs, check the environment for fall risk factors, and institute corrective actions; the floor should be uncluttered, and ensure that clothing does not cause tripping. The Care Plan documented a non-injury fall on 06/01/25, and R28 was often encouraged to ask for help and would get up without asking for help. The Care Plan directed the staff that the walker would be there to remind him to use it and to keep the walker in front of him. The Progress Note dated 06/01/25 at 06:23 PM, documented R28 sitting on the floor with his back up against the bed, with a pillow behind him, had shoes on, with pants and brief down and stool on the floor around him. The Progress Note further documented the walker and wheelchair were in the corner out of reach, and the call light was not on. R28 was educated to keep the floor free of clutter and would leave the walker in reach and encourage use. The Fall Investigation dated 06/01/25, documented that R28 was found on the floor of his room and incontinent of bowel. R28 appeared to have been attempting to use the bathroom without the walker. The intervention was to keep the floor free of clutter. The Progress Note dated 06/02/25 at 02:45 PM, documented R28 was on the floor of his room, wearing shoes, the walker and wheelchair were out of reach, and had a skin tear to the left elbow. R28 told staff he was going to the bathroom to refill the toilet paper roll. The Progress Note further documented that R28 was educated to use his call light and would continue with therapy for balance and strength. The Fall Investigation dated 06/02/25, documented that R28 was found on the floor of his room, and was attempting to refill the toilet paper roll in the bathroom without the use of the walker. The investigation note further documented that the walker was not within R28's reach. The intervention was documented to keep the walker within reach of the resident. The Fall Investigation lacked a new intervention to prevent further falls and did not implement the intervention of keeping the walker within reach of the resident. On 06/09/25 at 03:03 PM, R28 was sitting on the edge of the bed, with a gait belt around his waist. The walker was against the wall and not within reach of the resident. On 06/11/25 at 11:11 AM, Certified Nurse Aide (CNA) M reported to keep R28 safe and free of falls, staff continually checked on R28, reminded R28 to call for assistance, make sure the gait belt was on along with shoes, and to keep the walker close to him. On 06/11/25 at 11:22 AM, Licensed Nurse (LN) I stated the walker should remain within reach of the resident as directed to prevent falls. On 06/11/25 at 12:17 PM, Administrative Nurse D verified that the staff should follow fall prevention interventions to prevent further falls of R28. Administrative Nurse D stated fall management, investigations, and intervention have been an area the facility has been lacking in, due to staff changes. The facility's Fall Management and Prevention Policy dated 02/08/25, documented that each resident living at this facility will be provided with services and care to ensure that the resident's environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors of falling at the time of admission, quarterly, for a significant change of assessment, upon return from a health care facility, and after every fall in the facility. - Resident (R) 67's Electronic Medical Record (EMR) documented diagnoses of weakness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late-onset, dementia (a progressive mental disorder characterized by failing memory and confusion), mood disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R67's admission Minimum Data Set (MDS), dated [DATE], documented severe cognitive impairment, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception) or exhibited behaviors. R67 had no functional range of motion impairment and used a walker and wheelchair for mobility. R67 required partial/moderate assistance with toileting hygiene, lower body dressing, putting on and taking off footwear and supervision, and touching assistance with personal hygiene, rolling in bed, lying to sitting, transfers, and walking ten to 50 feet. The MDS further documented R67 was frequently incontinent of urine, and had frequent pain which occasionally interfered with day-to-day activities. R67 had a fall in the month prior to admission, and two falls within six months. The Fall Care Area Assessment, dated 03/20/25 documented R67 had impaired mobility, and weakness, and was at risk of falling, staff assisted R67 will all activities of daily living and care as needed. R67's Fall Care Plan initiated 04/22/25, documented R67 was a high fall risk related to confusion, left hip pain, glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and a history of falling. The care plan directed staff to keep frequently used items within easy reach, needed supervision/touching assistance with transfer, lower body dressing and walked up to 50 feet with supervision. The Progress Note dated 04/01/25 at 04:35 AM, documented at 03:45 AM R67 was in her room, on the floor trying to go to the bathroom. The call light was not utilized and R67 reported landing on her bottom. R67 had non-skid socks on, but a walker was not utilized. Upon request, the facility failed to provide a fall investigation for the unwitnessed fall on 04/01/25. The Progress Note dated 04/03/25 at 04:50 AM documented R67 found on the floor in the bathroom. Urine covered the floor, as R67 had urinated while attempting to self-transfer to the bathroom. R67 bed was locked and in the lowest position, the call light was not activated, no socks or shoes on, poorly lit room, no ambulatory aide, and the staff were not aware she was getting up to the bathroom. The Fall Investigation dated 04/03/25, documented that R67 had an unwitnessed non-injury fall in her bathroom. R67 was confused per baseline. The floor was wet since she was incontinent of urine during self-transfer in the bathroom. The call light intervention was to remind R67 to use the call light and wait for staff. The root cause was that R67 needed to use the bathroom and attempted to transfer self. No new fall intervention was added to the care plan. The Progress Note dated 04/11/25 at 01:12 AM, documented the location was the resident's room, baseline confusion, laceration, and hematoma to the back of the head. The Progress Note lacked a description of the event that led to the laceration and hematoma. The Fall Investigation dated 04/11/25, documented at 12:45 AM, R67 had an unwitnessed fall with injury in her room. R67 was found by nursing staff on the floor by her bed. R67 had a noticeable hematoma to her left lateral posterior head with a laceration at the top of her head. R67 was confused at her baseline and was attempting to ambulate without assistance. The fall investigation further documented interventions of placing a pancake light and took R67 to the toilet at midnight and 04:00 AM. The determined root cause was the need to use the bathroom. The care plan lacked initiation of intervention. The Progress Note dated 04/23/25 at 10:54 AM documented that R67 had an unwitnessed fall, was found lying on the floor, and had a bleeding abrasion to her forehead. R67 was not able to say what happened. R67 was left using the bathroom. Staff went to check on R67 and found her lying on the floor, bleeding to the forehead. The walker was in the bathroom, R67 had a pull-up on, and her pants were down to her feet. The Fall Investigation dated 04/23/25 documented that R67 had an unwitnessed fall with injury in the bathroom. R67 was unattended in her bathroom. The root cause was that R67 was ready to get up after toileting and fell, as cognition level is unsafe to do tasks alone. The intervention was not to leave R67 unattended in her bathroom. This intervention was not added to the care plan. On 05/01/25, R67 had a room change from the rehabilitation unit to a special care unit. The Progress Note dated 05/04/25 at 06:30 AM, documented R67 sitting on the floor at the end of her bed wearing a brief, sleep shirt, she had bare feet, and the call light was clipped to the bedrail. R67 stated she was trying to get to the bathroom. The intervention was to add 05:30 AM toileting to her care plan. This intervention was not added to the care plan. On 06/10/25 at 07:40 AM, R67 was sitting in the commons area in a recliner with her feet elevated and staff sitting next to her. R67 alert and wearing glasses. Staff provided oral medications, and she was able to take the medication without difficulty. On 06/11/25 at 11:02 AM, Certified Nurse Aide (CNA) N reported that R67 had fallen while in the rehabilitation unit. CNA N stated she would look at the care plan book and the computerized charting system for interventions related to falls and fall prevention. On 06/11/25 at 11:36 AM, Licensed Nurse (LN) I reported that due to staff changes, the management staff was uncertain who was responsible for making or adding changes to the care plan. LN I reported that the admitting charge nurse was responsible for baseline care plans, and the therapist also provided direction for staff. LN I stated that all fall-preventing interventions should be added to the care plan as appropriate. On 06/11/25 at 12:03 PM, Administrative Nurse D stated that fall management and intervention have been an area the facility has been lacking in, due to staff changes. Administrative Nurse D stated that the fall intervention should be added to the resident's care plan. The facility's Fall Management and Prevention Policy dated 02/08/25, documented that each resident living at this facility will be provided with services and care to ensure that the resident's environment remains as free from accident hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors of falling at the time of admission, quarterly, for significant change assessment, upon return from a health care facility, and after every fall in the facility. - Resident (R) 70's Electronic Medical Record (EMR) recorded diagnoses of non-pressure chronic ulcer of skin, ill-defined heart disease, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), morbid obesity (excessive body fat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R70's admission Minimum Data Set (MDS), dated [DATE], documented R70 had intact cognition, and was dependent on staff for toileting and lower body dressing, sitting to standing chair/bed-to-chair transfers, and toilet transfers. R70 was frequently incontinent of urine and bowel. The MDS further documented that R70 received a scheduled pain medication regimen and as-needed pain medication, and frequently had pain. R70 had two unhealed pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), two arterial (referring to blood vessels that carry blood away from the heart) ulcers, and macerated associated skin damage (softening and breaking down of skin as a result of prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) upon admission. R70 had pressure-reducing devices for the bed and chair, pressure ulcer care, application of ointment other than to feet, and applications of nonsurgical dressings. The MDS documented R70 received insulin (a hormone that lowers the level of glucose in the blood), anticoagulant (a class of medications used to prevent the blood from clotting), diuretic (a medication to promote the formation and excretion of urine), and opioid (medication used to treat pain), along with physical and occupational therapy services. The Urinary Incontinence Care Area Assessment (CAA), dated 04/16/25, documented R70 had bladder incontinence and further risk for skin breakdown, and R70 required staff assistance with toileting needs and therapy to improve independence. The Fall CAA did not trigger. R70's Care Plan dated 04/23/25, documented R70 at increased risk of falls and had actual falls. The care plan directed staff to check the environment for fall risk factors and institute corrective actions. R70's floors should be uncluttered, ensure that lighting is adequate, and lights are functional, including nightlights, and keep frequently used items within easy reach. R70's Care Plan dated 05/21/24, documented R70 had a fall without injury. The care plan initiated on 05/12/24 directed staff not to leave R70 alone on a bedpan, and on 05/18/25 directed staff to not wake R70 up as she became confused and delusional. The Progress Note dated 05/04/25 at 01:17 AM, documented staff heard R70 screaming from her room. R70 was sitting on the edge of her bed, gripping the side rail, lying on her back with her bottom beginning to slip off the bed. R70 was not on the floor nor fell off the bed. Three staff able to get R70 pulled back onto the bed safely. R70 confused, tearful, and panicking. R70 stated she was dreaming and thought she was going to get up and go to breakfast. The bed was lowered. Staff checked R70 every half hour for safety at that time. The facility failed to provide a fall investigation for the near-miss fall. The interventions were not added to the plan of care. The Progress Note dated 05/18/25 at 06:34 AM documented staff assisting R70 to get ready at 06:16 AM, and after getting her shirt on, she declined to get out of bed. Staff left the room after lowering the bed. At approximately 06:30 AM, R70's family member called the nurse's cell phone and reported witnessing via in-room camera R70 sliding out of bed slowly on the floor then turned over and was on her knees, and then ended up sitting on the floor. The nurse and staff assisted R70 off the floor using a mechanical lift. R70's family requested that staff not wake her for care at night and not before 07:30 to 08:00 AM. The family wanted staff to check on her to make sure she was safe and offer care if she was already awake. The staff were educated on the request. The Fall Investigation dated 05/18/25 documented R70 awakened early AM and denied wanting to get up. R70 has a camera in the room, and staff were notified that she was on the floor. At times, it was decided that she would stay in bed past 08:00 AM and to not wake R70 up as she became confused and delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue). She slid out of bed onto her knees after staff woke her up at 06:16 AM to get her dressed. This intervention was not added to the care plan until 05/21/25. The Progress Note dated 05/26/25 at 02:45 PM, documented nursing staff went to R70's room due to R70 falling out of the stand-up lift while getting up from the toilet. Two staff present at the time of the fall reported R70 appeared to have let go of the lift and fallen. R70 reported she may have passed out for a second but was unsure. R70 had pain and would not allow staff to move her. Called placed to 911 and went to the hospital. The Fall Investigation dated 05/25/25, documented to check R70's blood pressure if she felt dizzy when she stood, and she fell out of the sit-to-stand lift when getting up from toileting. The investigation lacked any further comments to an investigation. The Progress Note dated 05/26/25 at 07:55 PM, documented R70 returned from the hospital, and x-rays and CT scan were all negative. R70 had a sling to the right arm, no new orders On 06/09/25 at 03:45 PM, Certified Nurse Aide (CNA) O and CNA P assisted R70 to the wheelchair utilizing the sit-to-stand lift. Staff instructed the resident to keep her hands on the handles. CNA O and CNA P gave step-by-step instructions to R70 as they prepared to transfer the resident to the wheelchair. R70 was fastened into the mechanical lift and transferred to the wheelchair without difficulty. CNA O and CNA P both reported knowing about the fall but were not aware of any new interventions. On 06/11/25 at 11:25 AM, Licensed Nurse (LN) I reported following the fall from the mechanical lift, the intervention was to take R70's orthostatic blood pressure, but the resident refused. LN I stated they would continue to try to get the orthostatic blood pressure if R70 allowed, but not sure if this had been communicated in the care plan or electronic charting system. On 06/11/25 at 12:03 PM, Administrative Nurse D stated that fall management and intervention have been an area the facility has been lacking in, due to staff changes. Administrative Nurse D stated that the fall intervention should be added to the resident's care plan. Administrative Nurse D stated the investigation lacked a root cause. The facility's Fall Management and Prevention Policy dated 02/08/25, documented that each resident living at this facility will be provided with services and care to ensure that the resident's environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents. Every resident will be assessed for the causal risk factors of falling at the time of admission, quarterly, for significant change assessment, upon return from a health care facility, and after every fall in the facility.

The facility had a census of 75 residents. The sample included 18 residents. Based on interview and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R) 34's facility-initiated discharge to the hospital. This placed R34 at risk for impaired rights. Findings included: - R34's Electronic Health Record (EHR) revealed diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure) with behavioral disturbance, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and encephalopathy (inflammatory condition of the brain.) R34's 5 Day scheduled Minimum Data Set (MDS), dated [DATE], recorded R34 had severe cognitive impairment (problems with thinking, learning, remembering, and using judgment.) The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADL). The MDS documented the resident had frequent incontinence and ambulated with a walker and wheelchair. The Care Area Assessment (CAA), dated 07/25/24, recorded R34 required staff assistance with ADLs due to impaired functional ability. The CAA documented the resident had incontinence of urine with a diagnosis of chronic kidney disease and required assistance with toileting transfers and hygiene. R34's Care Plan, dated 04/23/25, recorded R34 required staff assistance with most ADL care. R34's Care Plan documented the resident required staff assistance with incontinent cares and assistance. The care plan documented staff were to allow the resident privacy when using the restroom, however, stay near the bathroom and ready to provide assistance when R34 required it. The care plan documented R34 had the potential for falls related to needing assistance with ADL and staff would encourage her to call for assistance when needed. On 05/20/25 at 03:25 PM, Nurse's Notes documented R34 complained of hoarseness and the staff notified the physician, and received an order for a Coronavirus disease Covid (a contagious respiratory illness caused by the SARS0CoV-2 virus) test, to increase fluids, and saltwater gargle three times a day for three days was received. The Covid test results were negative. On 05/21/25 at 12:07 PM, Nurses Notes documented R34 had a change in mental status and was not helping staff with routine cares and was unable to help with transfers that she normally would help with. The note documented staff notified the physician and she came to the facility to examine R34 and stated the resident was just slow this morning. At 11:30 AM the speech therapist notified the nurse R34 leaned to the left and drooled from her mouth. The physician was notified and ordered R34 to be sent to the hospital for evaluation. The [NAME] Power of Attorney (DPOA) agreed to send R34 to the hospital for evaluation. At 11:57 AM the facility called for an ambulance transport, and they arrived at 12:10 PM. The resident left the facility at 12:17 PM. On 05/21/24 at 05:30 PM, Nurse's Notes documented the hospital called the facility stating R34 would be admitted to the hospital for a Urinary Tract Infection (UTI) and Para Influenzas 2 (one of the four types of human parainfluenza viruses (HPIVs) viruses that cause upper and lower respiratory illnesses). On 05/24/25 at 11:40 AM, Nurse's Notes documented the resident was admitted back to the facility at 11:00 AM, per facility van, and in a wheelchair. R34 was alert and oriented and was placed on contact precautions until 05/29/25. The physician and the DPOA were notified of the resident's readmission. R34's clinical record lacked documentation staff notified the LTCO of R34's discharge from the facility. On 06/10/25 at 08:25 AM, Administrative Staff A stated they do not send any notification of discharge to the Ombudsman regarding the resident discharge. Administrator Staff A stated they sent the Assisted Living Residents' discharge to the Ombudsman but did not and have not sent any long-term Care Residents to the Ombudsman but would start. The facility's Admission, Discharge and Transfer, policy, dated 06/05/24, documented the transfer out of the facility and discharge includes movement of a resident to a bedroom outside of the certified neighborhoods of the facility whether the bed is on a larger facility campus or not. The policy documented if/when staff mandates a transfer out of the facility or discharge from the facility, staff will document the reason(s) and for conditions under which the resident is mandated to transfer out of the facility or be discharged and the method(s) for transitioning the responsibility for the resident's care from one clinical, organization, program or service to another, in addition, the following document documentation requirements include the basis of the transfer and the specific resident need(s)that cannot be met at the facility. The policy documented the facility staff would document in the clinical record the discharge information provided to the resident and the receiving organization. The policy documented if applicable; the basis for the transfer, specific needs that could not be met by the facility, the facility attempts to meet the needs of the resident, a physician progress note to include why the resident needs to be transferred or discharged , why the facility cannot meet the needs of the resident, what services the resident needs following discharge that cannot be met by the facility, and the reason for transfer, discharge, or referral. The policy documented the State Ombudsman would be notified of any/all facility-initiated discharges for assistance with transition and support for the resident and representative.

The facility had a census of 75 residents. The sample included 18 residents, with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff reported and investigated the physical incident between R63 and R66. This placed the residents at risk for ongoing abuse and/or mistreatment. Findings included: - R63's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by falling memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R63's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R63 had severely impaired cognition. The MDS recorded he required staff assistance for transfers and activities of daily living (ADL.) The MDS further documented R63 had no behaviors and had two falls and no injuries. R63's Care Plan, dated 05/14/25, recorded R63 requires staff assistance with most ADL cares. R63's Care Plan documented the resident ambulates with a walker but will try to ambulate without the use of the walker. The resident does not like someone walking directly beside him due to not liking others being in his personal space, staff to walk within reaching distance for the resident's safety. The care plan documented the resident was restless, combative, and received antipsychotic medications. The care plan directed staff to watch for targeted behaviors that include pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff and others, and document per facility protocol. The Nurse's Note, dated 05/13/25 at 04:44 AM, documented resident was noted with increased anxiety on the evening shift and some physical aggression as well. The nurses' notes documented R63 would not use his walker and insisted on ambulating unassisted for short distances. R63 kept going to different seats in the living room area. R63 moved to different residents, trying to sit in the seats those residents were already seated in. R63 did try to push R66 (severely cognitively impaired resident) at one point and did actually touch her chest. Staff intervened immediately and R63 was assisted back to his room. The notes documented he has come out a few more times on the night shift, and he cannot stay long in one spot. The notes documented staff continued to monitor and check R63 frequently. On 06/10/25 at 04:00 PM, observation revealed R63 stood in front of his walker on the Meadowlark unit hall and staff was standing 1:1 with the resident. Continued observation revealed that R63's wife was seated in the dining room adjacent to the hall and the resident walked over to his wife and firmly put his hands on her walker, looked directly at her, and said something that was word salad. Staff intervened and directed R63 away from his wife and the wife stood and quickly ambulated out of the unit. On 06/10/25 at 03:05 PM, Administrative Staff A and Administrative Nurse D stated they had not been informed of R63's resident-to-resident incident on 05/11/25 and the staff should report an incident involving a resident-to-resident altercation to the unit supervisor and administration and an investigation would be completed along with witness statements and reports to the state if needed. Administrative Staff A and Administrative Nurse D verified the facility had an Abuse Neglect Exploitation Inservice in April 2025, and the nurse who failed to report the incident attended the in-service. The facility's Reporting Abuse, Neglect, or Misappropriation policy, dated 06/05/24, documented the policy of the facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported per Federal and State law. The facility would ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of residents' property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency and adult protective services in accordance with State law through these established procedures. In addition, local law enforcement would be notified of any reasonable suspicion of a crime against a resident in the facility per agreement with the local law enforcement agency. All employees are expected to report all actual or potential incidents of abuse, neglect, or misappropriation of a resident's property immediately to their team leader, the Administrator, or the State Agency Complaint hotline. The facility reviews all actual or potential incidents involving residents who live in the facility through the multi-disciplinary team. The policy documented all employees and volunteers are educated during new-employee orientation and at least annually concerning their responsibility to immediately report any abuse, neglect, or exploitation they witness, are aware of, or suspect to the Administrator and to the State any abuse or neglect they witness, are aware of or suspect. The DON, Administrator, or other designated investigating individual would begin their own internal investigation and notify the State Agency within twenty-four hours of cooperating with the investigative agency.

- R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R25's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R25 had severely impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/30/24, recorded R25 received antipsychotic medication and had dementia, anxiety, and depression diagnoses. R25's Care Plan, dated 05/21/25, recorded R25 received antipsychotic medication for the diagnosis of dementia with behaviors and staff were to monitor for side effects and effectiveness. The care plan documented the facility would consult with the pharmacist and physician to consider dose reduction when clinically appropriate. The Physician's Order, initial order date 06/03/25, directed the staff to administer Seroquel 25 milligrams (mg), take 12.5 mg once daily for diagnoses of anxiety and senile degeneration of the brain. R25's EMR lacked a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits statement for the Seroquel use. On 06/10/25 at 10:00 AM, observation revealed R25 sat in a wheelchair dressed in street clothes and nicely groomed, in the living room. Continued observation revealed the resident watching TV with three other residents. On 06/09/25 at 03:25 PM, Administrative Nurse D verified the resident received Seroquel, an antipsychotic medication, with a diagnosis of anxiety with senile degeneration of the brain. Administrative Nurse D verified the facility had been working with the physician to get the appropriate diagnoses for the residents on antipsychotic medications. The facility's Medication Management policy dated 09/18/24, recorded the facility would ensure that all medications and biologicals were managed by the licensed nursing staff or medication aides in accordance with state standards of practice, and a medical care provider's order, each manufacturer's recommendations, and in a safe and sanitary manner. The policy recorded each resident who was prescribed psychotropic medications would have a medication review conducted for the desired response and possible side effects of the medication. The licensed nurse is responsible for communicating the evaluation of the medication to the physician or health care provider for follow-up action. Medications completed for review include antipsychotic medications, and documentation of the review by a pharmacist or contracted pharmacist review would be reviewed by the attending physician or the medical director. The facility identified a census of 75 residents. The sample included 18 residents, with six sampled residents who were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility to ensure that Resident (R) 11, R17, and R25 were free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use without a Centers for Medicare and Medicaid (CMS) appropriate indication for use. These deficient practices placed R11, R17, and R25 at risk of unnecessary medication administration and related complications. Findings included: - R11's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and psychosis (any major mental disorder characterized by a gross impairment perception). R11's Annual Minimum Data Set (MDS) dated 12/30/24 documented she had a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. R11 displayed no behavioral signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis. R11 the use of a walker or wheelchair to assist with mobility. R11 required supervision to partial assistance from staff for her daily functional abilities. R11 was dependent on staff for bathing. R11 received an antipsychotic and an antidepressant (a class of medications used to treat mood disorders) on a scheduled routine basis. R11's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/30/24 documented R11 used an antipsychotic and an antidepressant and was at risk for adverse effects. Staff monitored R11 for drug effects and the physician would be notified as needed. A gradual dose reduction (GDR) would be completed when indicated. R11's Care Plan last revised on 03/31/25 directed staff that she used psychotropic (alters mood or thought) medications and to administer medications as ordered by the provider. The care plan directed staff to monitor R11 for side effects each shift. The care plan directed staff to consult with the pharmacy and the provider to consider dosage reduction when clinically appropriate at least quarterly. The care plan directed staff to discuss with the provider and the family regarding the ongoing need for use of medication. Staff were directed to review behaviors, interventions, and alternate therapies attempted and their effectiveness as per facility policy. The care plan directed staff to monitor, document, and report as needed any adverse reactions to Zyprexa (brand name for the medication olanzapine, an atypical antipsychotic primarily used to treat certain mental health conditions). The care plan directed staff to complete an Abnormal Involuntary Movement Scale (AIMS- a 12-item rating scale used to assess involuntary movements) assessment quarterly. R11's Orders tab of the EMR documented a physician's order dated 02/21/24 for Zyprexa 5 milligrams (mg) tablet, give one tablet by mouth two times a day for hallucinations (sensing things while awake that appear to be real, but the mind created). This order was discontinued on 02/21/24. R11's Orders tab of the EMR documented a physician's order dated 02/21/24 for Zyprexa 5 mg, give one tablet by mouth two times a day for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) as evidenced by hallucinations. This order was discontinued on 04/29/25. R11's Orders tab of the EMR documented a physician's order dated 04/29/25 for Zyprexa 5 mg tablet to be given by mouth twice daily for hallucinations. This order was discontinued on 05/27/25. R11's Orders tab of the EMR documented a physician's order dated 05/27/25 for Zyprexa 5 mg tablet to give one tablet by mouth two times a day for psychotic disorder with delusional thinking-associated agitation. The Note to Attending Physician/Prescriber recommendation dated 04/09/25 in the EMR documented this resident was currently taking Zyprexa 5mg twice daily with a diagnosis of anxiety (resident has dementia). Per CMS guidelines, only Food and Drug Administration (FDA) approved indications were allowed for the continued use of antipsychotics in patients with dementia due to the increased rate of mortality and risk for other significant adverse effects. Please consider a trial reduction of Zyprexa to 2.5 mg twice daily to reduce inappropriate antipsychotic use and provide a clinical rationale for using this medication for this indication. If no changes were warranted, please provide a clinical rationale, along with a risk versus benefit statement. The 04/11/25 signed providers' response located under the Misc. tab of the EMR to the 04/09/25 Note to Attending Physician/Prescriber recommendation with the clinical rationale for use of the medication was this medication was effective for delusional thinking manifested by agitation and aggression. Continue the medication as ordered, risk/benefit statement: the benefit was clearer thinking, decreased agitation, and increased quality of life. The risk was increased sedation and weight gain. The benefit outweighs the risk. On 06/10/25 at 09:27 AM, staff assisted R11 to the toilet. R11 ambulated with the use of a walker. On 06/10/25 at 10:05 AM, Consultant GG stated the antipsychotic medications had been a topic that had been addressed monthly in QAPI. The facility, herself, the pharmacist, and the families had been making every effort to eliminate the use of antipsychotic medications without an appropriate indication. Consultant GG stated the problem mostly came down to the families wanting the resident to continue the medication. On 06/11/25 at 12:10 PM, Consultant HH stated the facility, herself, and the medical director had been holding monthly meetings about the antipsychotic medications. Consultant HH stated it had been a group effort to get the antipsychotic medications gone, however, the families a lot of the time were the ones that wanted the resident to remain on the medications. Consultant HH stated she continued to work with the facility, medical director, and providers to ensure an appropriate indication for use was used, but that was not always possible. The facility's Medication Management policy dated 09/18/24 documented each resident who was prescribed psychotropic medications would have a medication review conducted for the desired responses and possible side effects of the medication. Each antipsychotic medication should be reviewed on a separate Psychotropic Medication Review form from the contracted pharmacy. Documentation of the review was completed by the pharmacist or pharmacy consultant and reviewed by the attending physician or medical director as defined by the pharmacy review process. The facility's consultant pharmacist would review the medication regiment of each resident upon admission, at least monthly or upon request for adverse consequences related to current medications. Findings and recommendations would be reported to the facility Administrator, Director of Nursing, the attending physician, and the medical director. The attending physician must document that the identified irregularity had been reviewed and what if any, action had been taken to address it. The facility's Behavioral Health policy dated 02/28/25 documented that psychotropic medications should only be prescribed when non-pharmacological interventions had been proven insufficient and there was a clear clinical indication. The orders must have a proper diagnosis, dosage, duration, and expected outcomes. A gradual dose reduction (GDR) must be attempted at least every six months unless contraindicated. - R17's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychosis (any major mental disorder characterized by a gross impairment perception), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). R17's Annual Minimum Data Set (MDS) dated 07/10/24 documented she had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. R17 required partial to substantial assistance from staff for her daily functional abilities. R17 received an antipsychotic and an antidepressant (a class of medications used to treat mood disorders) on a scheduled basis. R17 required supplemental oxygen therapy. R17's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/15/24 documented she received an antidepressant medication related to depression and an antipsychotic medication for anxiety. R17 was at risk for adverse side effects. R17's Care Plan last revised on 06/10/25 directed staff that she took an antipsychotic medication related to inconsolable crying, fretting, and pacing. The Care Plan directed staff to always assess for and incorporate nonpharmacological interventions to alleviate room temperature discomfort, hunger, thirst, boredom, chair or bed discomfort, and toileting issues. The Care Plan directed staff to consider pharmacological interventions using medications other than antipsychotics, such as pain medication, observing for lessening behaviors, and collaborating with the interdisciplinary team. The Care Plan directed staff to discuss a reduction in dosing when target behaviors were absent and were easily altered for a specified period, but no less than quarterly. The Care Plan directed staff to discuss and educate the resident on the need to prescribe the medication, including discussion of benefit/risk issues. The Care Plan directed staff to monitor and identify potential side effects of the selected medication and monitor for clinical appearance. The Care Plan directed staff to monitor R17's social interactions, participation in activities, and self-care, as well as the frequency and intensity of symptoms; document benefits/risks, including the impact of medication on behaviors. R17's Orders tab of the EMR documented a physician's order dated 02/21/24 for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) by mouth one time a day for anxiety as evidenced by inconsolable concerns, crying, fretting, and pacing. This order was discontinued on 04/11/25. R17's Orders tab of the EMR documented a physician's order dated 04/25/25 for Seroquel 12.5 mg by mouth one time a day for anxiety as evidenced by inconsolable concerns, crying, fretting, and pacing. The Note to Attending Physician/Prescriber recommendation dated 03/12/25 in the EMR documented that R17 currently took Seroquel 12.5 mg twice daily with a diagnosis of anxiety (resident has dementia). Per CMS guidelines, only Food and Drug Administration (FDA) approved indications were allowed for the continued use of antipsychotics in patients with dementia due to the increased rate of mortality and risk for other significant adverse effects. Please consider a trial reduction of Seroquel to reduce inappropriate antipsychotic use and provide a clinical rationale for using this medication for this indication. If no changes were warranted, please provide a clinical rationale, along with a risk versus benefit statement. R17's Misc. tab contained the 03/14/25 physician's response to the 03/10/25 Note to Attending Physician/Prescriber that documented that a trial dose reduction was not appropriate at that time. The clinical rationale for the use was the medication was currently effective for sleep and worked on a therapeutic plan. The continuation of the medication benefited her sleep, decreased her anxiety, and decreased her aggressions. The risk was increased sedation and increased weight gain. The benefit outweighs the risks. R17's 04/09/25 provider Medication Regimen Review in the Misc. tab of the EMR documented a review of the Pharmacy Consultant's medication recommendations. R17 was currently taking Seroquel 12.5 mg nightly. It was reduced from 25 mg on 03/17/25 with no untoward consequences. Consider a discontinuation at this time. R17 was seen in her room and appeared comfortable with no distress. The Pharmacy Consultant's recommendations had been seen and reviewed in the chart as well as spoke with the appropriate staff and family to make my determination. Agree with the Pharmacy Consultant's recommendations: The resident has done well and would discontinue the medication and monitor the resident closely. R17's 04/25/25 provider Medication Regimen Review in the Misc. tab of the EMR documented a review of the Pharmacy Consultant's medication recommendations. On 04/09/25 a communication was received regarding a potential for gradual dose reduction (GDR). R17 was taking Seroquel 12.5 mg nightly. The Seroquel was reduced from 25 mg on 03/17/25 with no untoward consequences. Consideration was requested to discontinue the Seroquel. This was done effective 04/11/25. On 4/22/25, a communication was received from the nursing staff that R17 was consistently up all night and day, and was confused, anxious, angry, crying, and scared. This provider spoke with the neighborhood manager, who reviewed entries in the behavior documentation and per her review 4/12- current Insomnia, physical aggression, crying wandering, refusal of care, anxiety, not participating in activities, decreased intake at meals. Physical Exam: The patient seen in the room, appeared comfortable with no distress. The Pharmacy Consultant's recommendations had been seen and reviewed the chart as well. Have spoken with the appropriate staff and the family to make my determination. It appears that it was not in R17's best interest to discontinue the Seroquel. This is the 3rd attempt to gradually wean and the 3rd failure. At this time the Seroquel will be restarted at 12.5 mg daily. On 06/10/25 at 10:05 AM, Consultant GG stated the antipsychotic medications had been a topic that had been addressed monthly in QAPI. The facility, herself, the pharmacist, and the families had been making every effort to eliminate the use of antipsychotic medications without an appropriate indication. Consultant GG stated the problem mostly came down to the families wanted the resident to continue the medications. On 06/11/25 at 12:10 PM, Consultant HH stated the facility, herself, and the medical director had been holding monthly meetings about the antipsychotic medications. Consultant HH stated it had been a group effort to get the antipsychotic medications gone, however, the families a lot of the time were the ones that wanted the resident to remain on the medications. Consultant HH stated she continued to work with the facility, medical director, and providers to ensure an appropriate indication for use was used, but that was not always possible. The facility's Medication Management policy dated 09/18/24 documented each resident who was prescribed psychotropic medications would have a medication review conducted for the desired responses and possible side effects of the medication. Each antipsychotic medication should be reviewed on a separate Psychotropic Medication Review form from the contracted pharmacy. Documentation of the review was completed by the pharmacist or pharmacy consultant and reviewed by the attending physician or medical director as defined by the pharmacy review process. The facility's consultant pharmacist would review the medication regiment of each resident upon admission, at least monthly or upon request for adverse consequences related to current medications. The findings and recommendations would be reported to the facility Administrator, Director of Nursing, the attending physician, and the medical director. The attending physician must document that the identified irregularity had been reviewed and what if any, action had been taken to address it. The facility's Behavioral Health policy dated 02/28/25 documented psychotropic medications should only be prescribed when non-pharmacological interventions had been proven insufficient and there was clear clinical indication. The orders must have a proper diagnosis, dosage, duration, and expected outcomes. A gradual dose reduction (GDR) must be attempted at least every six months unless contraindicated.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 57 who had a coccyx wound ( pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed the resident at risk for possible exposure to infection. Findings included: - On 06/10/25 at 07:50 AM, observation revealed License Nurse (LN) G entered the bathroom of R5, who was sitting on the toilet. LN G donned gloves but no gown and assisted R57 to stand with the assistance of the grab bar. Continued observation revealed LN G cleansed R57's coccyx wound with normal saline applied zinc oxide to the wound area then applied an Opti foam dressing. Continued observation revealed LN G discarded her gloves in the trash can in the room. LN G assisted the resident in pulling up his attends and sweatpants and assisted him in walking to the recliner. Observation revealed the resident did not have any PPE available in the room or instructions for the use of PPE when providing cares for the resident with the pressure ulcer wound. On 06/10/25 at 12:55 PM, LN G verified she wore gloves to change the R57's coccyx wound dressing and she had not been instructed by administrative staff to wear PPE with the resident's wound care. LN G verified there was no PPE available in the resident's room and no EBP guidelines available for R57. On 06/11/25 at 10:30 AM, Administrative Nurse D stated the staff should wear PPE for EBP when providing cares for R57. Then Administrative Nurse D verified they lacked PPE equipment or a sign on the door that indicated the staff should wear PPE when providing R57's wound care. Administrative Nurse D verified she would post the necessary signage on the resident's door and have the PPE available for staff to wear. The facility's Enhanced Barrier Precautions policy, dated 02/28/25, documented it was the policy of the facility to have all staff and external consultants that perform high-contact resident care were responsible for following EBP policies and procedures. EBP precautions were implemented based on an evaluation of the resident's risk of acquiring a Multidrug-resistant organism (MDRO) infection, such as an indwelling medical device or wound present as described by this policy or the resident's history of known colonization or infection with a targeted MDRO. Residents with any of the one risk factors would require EBP precautions: indwelling medical devices, wounds, colonization, or infection with targeted MDRO's or any MDRO of epidemiologic concern specific to the facility. If EBP is indicated the facility would notify the following: resident, resident representative, Infection Preventionist, Management Team, Unit Nurse, and therapy, if applicable. EBP signage would be placed outside of the resident's room such as the door or wall that clearly indicates the high-contact resident care activities that require the use of gowns and gloves. The facility would ensure accessibility of alcohol-based hand sanitizer, gowns, and gloves for use during high-contact resident care activities done in a resident's room, and in select common areas such as bathrooms and therapy services requiring high-contact care.

The facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent falls for Resident (R) 67 and R70. This placed the residents at risk for injuries due to uncommunicated care needs. Findings included: - R67's Electronic Medical Record (EMR) documented diagnoses of weakness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) with late-onset, dementia (a progressive mental disorder characterized by failing memory and confusion), mood disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R67's admission Minimum Data Set (MDS), dated [DATE], documented severe cognitive impairment, no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment in reality perception) or exhibited behaviors. R67 had no functional range of motion impairment, and used a walker and wheelchair for mobility. R67 required partial/moderate assistance with toileting hygiene, lower body dressing, putting on and taking off footwear and supervision, and touching assistance with personal hygiene, rolling in bed, lying to sitting, transfers, and walking ten to 50 feet. The MDS further documented R67 was frequently incontinent of urine, and had frequent pain which occasionally interfered with day-to-day activities. R67 had a fall in the month prior to admission, and two falls in the last 6 months. The Fall Care Area Assessment, dated 03/20/25 documented R67 had impaired mobility, weakness, and was at risk of falling. Staff assisted R67 with all activities of daily living and care as needed. R67's Fall Care Plan initiated 04/22/25, documented R67 was a high fall risk related to confusion, left hip pain, glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and a history of falling. The care plan directed staff to keep frequently used items within easy reach, needed supervision/touching assistance with transfer, lower body dressing, and walk up to 50 feet with supervision. The Progress Note dated 04/01/25 at 04:35 AM, documented at 03:45 AM R67 was in her room, on the floor trying to go to the bathroom. The call light was not utilized and R67 reported landing on her bottom. R67 had non-skid socks on, but a walker was not utilized. Upon request, the facility failed to provide a fall investigation for an unwitnessed fall on 04/01/25. The Progress Note dated 04/03/25 at 04:50 AM documented R67 found on the floor in the bathroom. Urine covered the floor, as R67 had urinated while attempting to self-transfer to the bathroom. R67 bed was locked and in the lowest position, the call light was not activated, no socks or shoes on, poorly lit room, no ambulatory aide, and the staff were not aware she was getting up to the bathroom. The Fall Investigation dated 04/03/25, documented that R67 had an unwitnessed non-injury fall in her bathroom. R67 was confused per baseline. The floor was wet since she was incontinent of urine during self-transfer in the bathroom. The call light intervention was to remind R67 to use the call light and wait for staff. The root cause was that R67 needed to use the bathroom and attempted to transfer self. No new fall intervention was added to the care plan. The Progress Note dated 04/11/25 at 01:12 AM documented the location in the resident's room, baseline confusion, laceration, and hematoma to the back of the head. The Progress Note lacked a description of the event that led to the laceration and hematoma. The Fall Investigation dated 04/11/25, documented at 12:45 AM, R67 had an unwitnessed fall with injury in her room. R67 was found by nursing staff on the floor by her bed. R67 had a noticeable hematoma to her left lateral posterior head with a laceration at the top of her head. R67 was confused at her baseline and was attempting to ambulate without assistance. The fall investigation further documented interventions of placing a pancake light and taking R67 to the toilet at midnight and 04:00 AM. The determined root cause was the need to use the bathroom. The care plan lacked initiation of intervention. The Progress Note dated 04/23/25 at 10:54 AM documented that R67 had an unwitnessed fall, was found lying on the floor, and had a bleeding abrasion to her forehead. R67 was not able to say what happened. R67 was left using the bathroom. Staff went to check on R67 and found her lying on the floor, bleeding on the forehead. The walker was in the bathroom, R67 had a pull-up on, and her pants were down to her feet. The Fall Investigation dated 04/23/25 documented that R67 had an unwitnessed fall with injury in the bathroom. R67 was unattended in her bathroom. The root cause was that R67 was ready to get up after toileting and fell, as R67s cognition level was unsafe to do the task alone. The intervention was not to leave R67 unattended in her bathroom. This intervention was not added to the care plan. On 05/01/25, R67 had a room change from the rehabilitation unit to a special care unit. The Progress Note dated 05/04/25 at 06:30 AM, documented R67 sitting on the floor at the end of her bed wearing a brief and a sleep shirt. She had bare feet and the call light was clipped to the bedrail. R67 stated she was trying to get to the bathroom. The intervention was to add 05:30 AM toileting to her care plan. This intervention was not added to the care plan. The intervention of taking R67 to the bathroom at midnight, 04:30 AM, and 05:30 AM was not initiated on the care plan until 06/09/25. On 06/10/25 at 07:40 AM, R67 sat in the commons area in a recliner with her feet elevated and staff sitting next to her. R67 alert and wearing glasses. Staff provided oral medications, and she was able to take the medication without difficulty. On 06/11/25 at 11:02 AM, Certified Nurse Aide (CNA) N reported that R67 had fallen while in the rehabilitation unit. CNA N stated she would look at the care plan book and the computerized charting system for interventions related to falls and fall prevention. On 06/11/25 at 11:36 AM, Licensed Nurse (LN) I reported that due to staff changes, the management staff was uncertain who was responsible for making or adding changes to the care plan. LN I reported that the admitting charge nurse was responsible for baseline care plans, and the therapist also provided direction for staff. LN I stated that all fall-preventing interventions should be added to the care plan as appropriate. On 06/11/25 at 12:03 PM, Administrative Nurse D stated that fall management and intervention have been an area the facility has been lacking in, due to staff changes. Administrative Nurse D stated that the fall intervention should be added to the resident's care plan. The facility's Fall Management and Prevention policy, dated 02/08/25, documented that each resident living at the facility will be provided with services and care to ensure that the resident's environment remains as free from accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. The development and implementation of appropriate fall risk interventions. Individual fall prevention care plan interventions will be developed and will be included in the resident's care plan. - Resident (R) 70's Electronic Medical Record (EMR) recorded diagnoses of non-pressure chronic ulcer of skin, ill-defined heart disease, chronic kidney disease, diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), morbid obesity (excessive body fat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R70's admission Minimum Data Set (MDS), dated [DATE], documented R70 had intact cognition, and was dependent on staff for toileting and lower body dressing, sit-to-standing, chair/bed-to-chair transfers, and toilet transfers. R70 was frequently incontinent of urine and bowel. The MDS further documented that R70 received a scheduled pain medication regimen and as-needed pain medication, and frequently had pain. R70 had two unhealed pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), two arterial (referring to blood vessels that carry blood away from the heart) ulcers, and macerated associated skin damage (softening and breaking down of skin as a result of prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) upon admission. R70 had pressure-reducing devices for the bed and chair, pressure ulcer care, application of ointment other than to feet, and applications of nonsurgical dressings. The MDS documented R70 received insulin (a hormone that lowers the level of glucose in the blood), anticoagulant (a class of medications used to prevent the blood from clotting), diuretic (a medication to promote the formation and excretion of urine), and opioid (medication used to treat pain), along with physical and occupational therapy services. The Urinary Incontinence Care Area Assessment (CAA), dated 04/16/25, documented R70 had bladder incontinence and further risk for skin breakdown, and R70 required staff assistance with toileting needs and therapy to improve independence. The Fall CAA did not trigger. R70's Care Plan dated 05/21/24, documented R70 had a fall without injury. The care plan initiated on 05/12/24 directed staff not to leave R70 alone on a bedpan, and on 05/18/25 directed staff not to wake R70 up as she became confused and delusional. R70's Care Plan dated 04/23/25, documented R70 at increased risk of falls and had actual falls. The care plan directed staff to check the environment for fall risk factors and institute corrective actions. R70's floors should be uncluttered, ensure that lighting is adequate, and lights are functioning, including nightlights, and keep frequently used items in easy reach. The Progress Note dated 05/04/25 at 01:17 AM, documented staff heard R70 screaming from her room. R70 was sitting on the edge of her bed, gripping the side rail, lying on her back with her bottom beginning to slip off the bed. R70 was not on the floor nor fell off the bed. Three staff able to get R70 pulled back onto the bed safely. R70 was confused, tearful, and panicking. R70 stated she was dreaming and thought she was going to get up and go to breakfast. The bed was lowered. Staff checked R70 every half hour for safety at that time. The facility failed to provide a fall investigation for the near-miss fall. The interventions were not added to the plan of care. The Progress Note dated 05/18/25 at 06:34 AM documented staff assisted R70 to get ready at 06:16 AM, and after getting her shirt on, R70 declined to get out of bed. Staff left the room after lowering the bed. At approximately 06:30 AM, R70's family member called the nurse's cell phone and reported witnessing via in-room camera, R70 slid out of bed slowly on the floor, then turned over and was on her knees, and then ended up sitting on the floor. The nurse and staff assisted R70 off the floor using a mechanical lift. R70's family requested that staff not wake her for care at night and not before 07:30 to 08:00 AM. The family wanted staff to check on her to make sure she was safe and offer care if she was already awake. The staff were educated on the request. The Fall Investigation dated 05/18/25 documented R70 awakened early AM and denied wanting to get up. R70 has a camera in the room, and staff were notified that she was on the floor. At times, it was decided that she would stay in bed past 08:00 AM and not to wake R70 up as she became confused and delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue). She slid out of bed onto her knees after staff woke her up at 06:16 AM to get her dressed. This intervention was not added to the care plan until 05/21/25. The Progress Note dated 05/26/25 at 02:45 PM, documented nursing staff went to R70's room due to R70 falling out of the stand-up lift while getting up from the toilet. Two staff present at the time of the fall reported R70 appeared to have let go of the lift and fallen. R70 reported she may have passed out for a second, but was unsure. R70 had pain and would not allow staff to move her. Staff placed a call to 911 and R70 went to the hospital. The Fall Investigation dated 05/25/25, documented to check R70's blood pressure if she felt dizzy when she stood, and she fell out of the sit-to-stand lift when getting up from toileting. The investigation lacked any further comments to an investigation. The Progress Note dated 05/26/25 at 07:55 PM, documented R70 returned from the hospital, and x-rays and CT scan were all negative. R70 had a sling on the right arm, but no new orders. The Care Plan lacked documentation related to obtaining R70's blood pressure or a new intervention reflected on the care plan. On 06/09/25 at 03:45 PM, Certified Nurse Aide (CNA) O and CNA P assisted R70 to the wheelchair utilizing the sit-to-stand lift. Staff instructed the resident to keep her hands on the handles. CNA O and CNA P gave step-by-step instructions to R70 as they prepared to transfer the resident to the wheelchair. R70 was fastened into the mechanical lift and transferred to the wheelchair without difficulty. CNA O and CNA P both reported knowing about the fall but were not aware of any new interventions. On 06/11/25 at 11:25 AM, Licensed Nurse (LN) I reported following the fall from the mechanical lift, the intervention was to take R70's orthostatic blood pressure, but the resident refused. LN I stated they would continue to try to get the orthostatic blood pressure if R70 allowed, but not sure if this had been communicated in the care plan or electronic charting system. On 06/11/25 at 12:03 PM, Administrative Nurse D stated that fall management and intervention have been an area the facility has been lacking in, due to staff changes. Administrative Nurse D stated that the fall intervention should be added to the resident's care plan. Administrative Nurse D stated the investigation lacked a root cause. The facility's Fall Management and Prevention policy, dated 02/08/25, documented that each resident living at the facility would be provided with services and care to ensure that the resident's environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents. The development and implementation of appropriate fall risk interventions. Individual fall prevention care plan interventions will be developed and will be included in the resident's care plan.

The facility had a census of 76 residents. The sample included 18 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 10/09/23 at 12:50 PM, the facility's Quality Assurance Performance Improvement (QAPI) meeting attendance sheets lacked signatures of attendees/committee members on the sheets. The sheets had just committee members names who were expected to attend listed. On 12/05/22 at 02:30 PM, Administrative Staff A stated staff do not sign in at the meetings; she recorded the attendees, but did not have them sign in. The facility's Quality Assurance Improvement Plan, revised 04/20/23, documented the purpose was to provide excellent quality resident/patient care and services. Quality was defined as meeting or exceeding the needs, expectations, and requirements of the residents cost-effectively while maintain good resident outcomes and perceptions of patient care. The plan documented the QAPI would meet monthly and maintain minutes of all activity. The facility failed to retain evidence the required QAA and QAPI members attended meetings at least quarterly which placed residents at risk of unidentified quality care services.

The facility had a census of 76 residents. The sample included 18 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to monitor targeted behaviors related to the use of antipsychotic drugs (class of medications used to treat major mental conditions which cause a break from reality) for Resident (R) 67, placing the resident at risk for unnecessary psychotropic ( altering mood or thought) drugs. Findings included: - R67's Electronic Medical Record documented diagnoses of epilepsy (brain disorder characterized by repeated seizures), dementia (progressive mental disorder characterized by failing memory, confusion), and metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R67 required supervision for eating, and extensive staff assistance with all other activities of daily living. The MDS documented R67 received antipsychotic medication seven days of the lookback period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/09/23, documented R67 took psychotropic medications to assist with social phobia and behavioral disturbances and was at risk for adverse side effects and complications as outlined in the medications black box warning. The Medication Care Plan, dated 08/12/23, stated R67 took psychotropic medication to assist with social phobia and behavioral disturbances and was at risk for adverse side effects and complications as outlined in the medications black box warning. The care plan directed staff to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness every shift. The care plan directed staff to review R67's behaviors, interventions and alternate therapies attempted and their effectiveness as per facility policy. The plan directed staff to allow R67 time to answer questions and to verbalize feelings, perceptions, and fears. The care plan stated R67 was known to exhibit episodes of angry outbursts and yelling when he wanted something or wanted something done and he did not want to wait. The plan directed staff during those times, provide R67 immediate assistance if possible, reassure and explain to him staff were there to assist him. When conflict arose, remove R67 to a calm, safe environment and allow him to vent or share feelings. Social Services would provide R67 one to one support as needed and monitor for changes in mood and cognition. The Physician Order, dated 08/03/23, directed staff to administer risperidone (antipsychotic drug), 0.5 milligram (mg) twice daily, and monitor targeted behaviors. The Physician Order, dated 08/04/23, directed staff to administer risperidone, 2 mg, daily. R67's EMR lacked documentation of monitoring of targeted behaviors related to the use of risperidone. On 10/04/23 at 11:07 AM, observation revealed R67 sat in a dining chair at activities. He visited with staff and sat quietly. His mouth moved as if he was chewing gum. On 10/05/23 at 01:40 PM, Licensed Nurse (LN) K stated staff had not monitored or documented R67's behaviors. She stated after admission, R67 was irritable and cursed staff. On 10/09/23 at 01:28 PM, Administrative Nurse D verified staff should have monitored R67's behaviors related to the use of risperidone, as ordered. The facility's Antipsychotic Drugs policy, dated 03/18/23, stated all physician orders for antipsychotic drugs will be clear, accurate, and include a diagnosis, condition, or indication for use. The facility failed to monitor targeted behaviors related to the use of risperidone for R67, placing the resident at risk for continued antipsychotic drugs without monitoring for effectiveness and continued need.

The facility had a census of 76 residents. The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to obtain a current physician order for the use of supplemental oxygen for Resident (R)42 and failed to ensure staff provided care for R42's oxygen equipment including the tubing, humidifier and filter. The facility further failed to care plan R42's use of the supplemental oxygen. This deficient practice placed R42 at risk for respiratory issues related to oxygen use. Findings included: - R42's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke), paroxysmal atrial fibrillation (rapid, irregular heartbeat), cardiac pacemaker (implanted device to regulate the beating of the heart), and cardiomyopathy (heart disease). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R42 required staff supervision for eating, and limited assistance for bed mobility, walking, and hygiene. R42 required extensive staff assistance for transfers, toileting, and dressing. The MDS documented R42 had no shortness of breath, and she used oxygen. R42's Care Plan, dated 07/24/23, lacked any information regarding the resident's use of oxygen therapy. R42's Physician Order, dated 07/13/23, directed staff to provide supplemental oxygen, as needed, to maintain oxygen saturations (percentage of oxygen in the blood) above 90 percent (%), and adjust as indicated. The order directed staff to call the physician if R42's oxygen saturations were lower than 90%. The order was discontinued 08/03/23. The Physician Order, dated 07/14/23, directed staff to assess R42's temperature and oxygen saturations daily. The Physician Note, dated 08/08/23, stated the resident used oxygen therapy, supplemental oxygen, as needed, to maintain saturation above 90%. The Progress Note, dated 09/17/23, stated R42's oxygen saturation was 96% on room air, 97% on two liters per minute with the nasal cannula. R42 wore supplemental oxygen due to oxygen saturation percentages in the 70s earlier that day, and R42 chose to remain on oxygen due to comfort. On 10/04/23 at 08:59 AM, observation revealed R42 sat in her wheelchair at the dining table with oxygen on per nasal cannula from an oxygen tank. She stated she was tired but fine. On 10/04/23 at 10:27 AM, observation revealed Certified Nurse Aide (CNA) O assisted R42 to the dining room for exercise. R42 wore oxygen per nasal cannula and CNA O adjusted the nasal cannula. R42 asked if she could go without the oxygen and CNA O told her it would be a good idea to keep it on during exercise. On 10/04/23 at 03:00 PM, Certified Medication Aide (CMA) R stated R42 would call for staff to come check or adjust her oxygen. R42 had her own oximeter (device used to measure oxygen saturation) and liked to monitor her own oxygen saturation. On 10/05/23 at 01:52 PM, Licensed Nurse (LN) K stated staff provided oxygen as needed (PRN) for R42. LN K verified she could not find a current oxygen order. She stated staff changed all residents' oxygen tubing on Sundays, but she was unaware the concentrator had a filter on the side to clean. She verified care of the oxygen equipment had not been care planned or listed in the treatment record. On 10/05/23 at 02:34 PM, Administrative Nurse D verified the physician order for oxygen had been discontinued 08/03/23 and verified staff should care plan, and document care of the oxygen equipment. The facility's Administration of Oxygen policy, dated 03/08/23, directed staff to check the physician's order for flow and method of administration of oxygen, store nasal cannulas in a plastic bag when not in use, and change tubing and humidifier weekly. The facility failed to obtain a current physician order for the use of supplemental oxygen, failed to ensure staff provided care for the oxygen equipment including the tubing, humidifier, and filter, and failed to care plan the use of the supplemental oxygen, placing R42 at risk for respiratory issues related to oxygen use.

The facility had a census of 76 residents. The sample included 18 residents, with four reviewed for nutrition. Based on observation, interview and record review, the facility failed to monitor and record Resident(R)226's physician ordered fluid restriction (limitation of amount of liquid consumed each day). This placed the resident at risk for complications from fluid overlaod. Findings included: - R226's Electronic Medical Record (EMR) documented the resident admitted [DATE]. R226's EMR documented she had diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), chronic kidney disease (condition characterized by a gradual loss of kidney (a pair of organs that are found on either side of the spine, just below the rib cage in the back which filter waste materials out of the blood and pass them out of the body as urine) function), and atrial fibrillation (rapid, irregular heart beat). R226's Admission Minimum Data Set (MDS), dated [DATE], documented it was in progress. R226's Baseline Care Plan, dated 10/02/23, documented R226's favorite foods. The plan documented R226 had her own teeth and glasses, no skin issues, and she was continent of bladder and bowel. The care plan instructed staff to use a gait belt and two assist for transfers. The baseline care plan lacked directions to staff regarding R226's physician ordered fluid restriction. The Physician Order, dated 10/03/23, instructed staff to provide R226 with a 2-liter per 24 hour fluid restriction. R226's clinical record lacked evidence staff monitored the amount of fluid intake in each 24 hour period. On 10/04/23 at 08:30 AM, observation revealed R226 rested in bed with her eyes closed. She had a container of water, three-quarters full, on a bedside table. On 10/04/23 at 03:06 PM, Certified Nurse Aide (CNA) M stated she was unaware the resident had a fluid restriction. CNA M stated she would look at R226's care plan, or staff would pass on in report if R226 was on a fluid restriction, staff would fill out a form R226's intake for her shift and at the end of her shift would give it to the charge nurse. On 10/04/23 at 03:06 PM, Licensed Nurse (LN) G verified staff had not been monitoring and recording R226's fluid intake. LN G stated she had just noticed that day that R226 was on a fluid restriction. LN G stated she documented R226's fluid intake so far that shift. On 10/09/23 at 10:53 AM, Administrative Nurse D verified R226 had a physician order for fluid restriction and stated staff should monitor and record R226's fluid intake each shift. Upon request the facility did not provide a policy regarding fluid restriction. The facility failed to monitor and record R226's physician ordered fluid restriction. This placed the resident at risk for complications from fluid overload.

The facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to revise the care plan interventions related to Resident (R)48's diagnoses and medications, and for R52's dental orders. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs. Findings included: - R48's Electronic Medical Record documented R48 was admitted [DATE], and had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), iron deficiency anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), heart failure, type 2 diabetes mellitus, (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), diabetic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), hypertension (elevated blood pressure), pain in right and left knees, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), history of gastrointestinal hemorrhage (bleeding into the stomach and/or digestive tract) and Covid-19 (highly contagious respiratory virus). The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) was not conducted. Per staff interview, R48 had short- and long-term memory problems with severely impaired decision making. The MDS documented R48 required limited staff assistance with eating and extensive staff assistance for all other activities of daily living. The MDS documented R48 received insulin (hormone that lowers the level of glucose in the blood), diuretic (medication to promote the formation and excretion of urine), and antidepressant (class of medications used to treat mood disorders) medications for six days of the observation period and antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and antibiotic (medication used in the treatment and prevention of infections) medications seven days of the observation period. R48's Care Plan, dated 08/11/23, directed staff to monitor and document indicators of discomfort or distress and follow up as needed. The care plan lacked direction or intervention for problems related to diabetes, high blood pressure, anemia, neuropathy, and the history of gastro-intestinal bleed. On 10/04/23 at 11:50 AM, observation revealed R48 sat in his wheelchair at a dining table, smiling and pleasant but confused and replied with non-sensible words. On 10/05/23 at 11:27 AM, Licensed Nurse (LN) J stated the care plan was updated on 10/05/23 to include pain interventions but lacked direction or information regarding R48's other medication issues. On 10/09/23 at 01:28 PM, Administrative Nurse D verified R48's care plan should reflect concerns related to his diagnoses and medications. The facility's Care Plan Revision policy, dated 04/20/23, stated the care plan would be revised whenever the physician added, removed, or amended any medication in the resident's regimen to included diagnosis or medication, warnings or alerts, instruction to staff on potential adverse effects and specific administration instructions. Revisions to the care plan would be communicated with all staff, all shifts. The facility failed to revise care plan interventions related to R48's diagnoses and medications, placing R48 at risk for impaired quality of care related to uncommunicated care needs. - R52's Electronic Medical Record documented a diagnosis of early onset Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS documented R52 required limited staff assistance with eating and extensive staff assistance for hygiene. The ADL Care Area Assessment (CAA), dated 07/10/23, stated R52 had a self-care deficit related to her diagnosis of Alzheimer's Disease and she needed assistance from staff to fully complete activities of daily living (ADLs). R52's Dental Care Plan, dated 10/03/23, stated R52 had her own teeth, denied pain in her mouth. could tolerate her current diet texture and did not demonstrate trouble chewing or swallowing. The care plan stated R52 could complete her oral cares with reminders or set up from staff, initiated 02/10/2022. The care plan stated R52 would have oral hygiene completed at a minimum of once daily and directed staff to encourage and assist R52 to complete oral hygiene twice daily. The care plan revision on 05/24/2023 directed staff to monitor for non-verbal signs of dental issues such as decreased appetite or fluid intake, grimacing during meals or while drinking and bleeding gums during hygiene. Nursing would complete oral and dental assessments quarterly and as needed. Staff were to report prn any oral or dental problems needing attention and make referrals for dental exams as indicated. The care plan revision on 08/01/2023 stated R52 was able to complete her own dental hygiene at that time, however she does require assistance with setting up supplies and cueing. The care plan directed staff to assist to complete the task as needed. The Physician's Note, dated 05/22/23, lacked oral or dental concerns. The Quarterly Nursing Assessment, dated 07/26/23, documented no oral or dental problems. The Personal Hygiene task lacked documentation staff completed oral care twice daily 18 of 30 days (09/05/23 to 10/03/23). The Progress Note, dated 09/06/23 at 12:25 PM, documented R52 left the facility, accompanied by her representative for a dental appointment. The note documented R52 returned with the following progress notes: Very heavy plaque on teeth- hard to even see upper teeth because of all the plaque. Please help with daily home care. Use Clinpro toothpaste to help prevent tooth decay. The note stated R52 brushed her own teeth with staff cueing, but staff would now be encouraged to offer extensive assistance with brushing. On 10/04/23 at 09:15 AM, observation revealed Certified Nurse Aide (CNA) P greeted R52 and told her she would help her get ready for the day. CNA P assisted R52 to ambulate with a walker to her bathroom. Continued observation revealed after toileting and peri-care, CNA P assisted R52 to ambulate to the dining room without providing dental care or haircare. Observation revealed staff did not assist R52 to brush her teeth at any time during the morning. On 10/05/23 at 08:30 AM, CNA Q assisted R52 to sit up in bed, and R52 followed her directions as much as she could. CNA Q assisted R52 to toilet, provided incontinent cares, washed her hands, combed R52's hair, and dressed R52. CNA Q washed R52's eyeglasses and put them on her, then offered to assist R52 with toothbrushing. CNA Q applied [NAME] toothpaste to the brush and brushed R52's teeth for her. On 10/05/23 at 08:57 AM, CNA Q stated if a resident was standing with their hands on their walker, she would help brush their teeth. CNA Q stated she was not aware of the need to use Clinpro toothpaste. Upon request she found the tube of Clinpro in a basket on the sink, not the basket she had identified as the resident's personal items. On 10/05/23 at 11:57 AM, Licensed Nurse (LN) J stated R52 was mentally unable to know to brush her teeth, but she could brush them after staff set up the toothbrush. LN J stated she expected staff to provide oral care at least in the morning, at bedtime and as needed. LN J verified no new direction regarding toothbrushing had been added to care plan after the 09/06/23 dental appointment with the new order for special toothpaste and more assistance. On 10/05/23 at 02:34 PM, Administrative Nurse D verified staff should revise the dental care plan after the dental visit to ensure staff were aware to use the special toothpaste and provide extensive assistance with brushing. The facility's Care Plan Revision policy, dated 04/20/23, stated the care plan would be revised with any change for specific interventions and revisions to the care plan would be communicated with all staff, all shifts. The facility failed to care plan new dental interventions ordered by the dentist for R52, placing R52 at risk to not receive dental care with specialized toothpaste due to the uncommunicated care needs.

The facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to develop a complete baseline care plan for Resident (R)226 which included instructions to staff regarding R226's fluid restriction (limitation of amount of liquid consumed each day). The facility also failed to include information to staff regarding R226's hospice services. This placed the resident at risk for uncommunicated care needs. Findings included: - R226's Electronic Medical Record (EMR) documented the resident admitted [DATE]. R226's EMR documented she had diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), chronic kidney disease (condition characterized by a gradual loss of kidney (a pair of organs that are found on either side of the spine, just below the rib cage in the back which filter waste materials out of the blood and pass them out of the body as urine) function), and atrial fibrillation (rapid, irregular heart beat). R226's Admission Minimum Data Set (MDS), dated [DATE], documented it was in progress. R226's Baseline Care Plan, dated 10/02/23, documented R226's favorite foods. The plan documented R226 had her own teeth and glasses, no skin issues, and she was continent of bladder and bowel. The baseline care plan instructed staff to use a gait belt and two staff assist for transfers. The care plan lacked information regarding hospice services or fluid restriction instructions for staff. The Physician Order, dated 10/02/23, instructed staff to admit R226 for respite stay with hospice services. The Physician Order, dated 10/03/23, instructed staff to provide R226 with a 2-liter per 24 hour fluid restriction. On 10/04/23 at 08:30 AM, observation revealed R226 rested in bed with her eyes closed. She had a container of water, three-quarters full, on a bedside table. On 10/04/23 at 03:06 PM, Certified Nurse Aide (CNA) M stated she was unaware the resident had a fluid restriction. CNA M stated she would look at R226's care plan, or staff would pass on in report, what cares R226 required. CNA M said if R226 was on a fluid restriction, staff would fill out a form on fluid intake for the shift and give it to the charge nurse. CNA M stated she knew the resident was receiving hospice services but was not aware of when hospice staff came to the facility and what cares they provided. On 10/04/23 at 03:06 PM, Licensed Nurse (LN) G verified R226's baseline care plan lacked documentation regarding her fluid restriction and hospice information. On 10/09/23 at 10:53 AM, Administrative Nurse D stated R226's physician order for fluid restriction should be on the baseline care plan. Administrative Nurse D stated hospice service information should also be on the baseline care plan. The facility's Person-Centered, Comprehensive Care Plan, revised 04/20/23,documented the facility would provide an individualized, person-centered, interdisciplinary plan of care for all residents that was appropriate to the resident's needs, strengths, limitations and goals based on initial, recurrent and continual needs of the resident. The facility failed to develop a complete baseline care plan for R226 with instructions to staff regarding R226's fluid restriction and hospice services information. This placed the resident at risk due to uncommunicated care needs.

The facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for one day of the onsite survey. Findings included: - On 10/09/23 (Monday) at 11:30 AM, observation revealed the facility lacked postings of daily staff nursing hours in two of the four neighborhoods. On 10/09/23 at 12:10 PM, Licensed Nurse (LN) H stated on the rehabilitation neighborhood, the day shift nurse or the night nurse were responsible for posting the daily staff nursing hours and verified it was not posted that day. On 10/09/23 at 12:00 PM, LN I verified she had not filled out the daily staff nursing hours form for the Sunflower neighborhood. On 10/09/23 at 01:25 PM, Administrative Nurse D verified staff were to post the daily staff nursing hours daily in a public visible place. Upon request the facility did not provide a policy regarding daily nurse staffing hours posting. The facility failed to post the daily nurse staffing hours for one day of the onsite survey.

The facility had a census of 71 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 71 residents in the facility who received their meals from the facility kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 04/18/22 at 07:10 AM, during initial tour, observation revealed the following: Four - 24 inches by 24 inches ceiling air vent grills/registers, located above the food preparation area, covered with brownish-gray, fuzzy substance. Two - 24 inches by 24 inches ceiling air vent grills/registers, located above the dishwasher area, covered with brownish-gray, fuzzy substance. On 04/21/22 at 09:20 AM, Maintenances Staff U verified maintenance staff were responsible to clean the air vents grills/registers, and confirmed maintenance did not have a routine cleaning schedule. Maintenance Staff U verified the vents were covered with a brownish-gray, fuzzy substance. The facility's Main Kitchen Cleaning Schedule policy, dated December 01, 2012, documented the dining service staff are responsible for checking the cleaning schedules to ensure tasks scheduled for that day are performed. Environmental Services Team would ensure the following equipment would be cleaned monthly stove hood and filters, vent, ice machine, refrigerator, condenser, pans and coils. The dietary manager would review documentation or cleaning task and perform quality assurance process at least once a month. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 71 residents residing in the facility, who received meals from the facility kitchens.

The facility had a census of 71 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication (medications used to treat significant mental health problems) for two sampled residents, Residents (R) 36 and R51. This placed the residents at risk to receive unnecessary antipsychotic medications and have adverse medication side effects. Findings included: - The Physician Order Sheet, dated 04/01/22, recorded R36 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and [CONDITION(S)] (difficulty sleeping). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R36 had a Brief Interview for Mental Status (BIMS) score of three (severe cognitive impairment) with physical and verbal behaviors. The MDS recorded R36 required extensive staff assistance with most Activities of Daily Living (ADLs), had a diagnosis of dementia, and received scheduled antipsychotic medication seven days a week. The Medication Care Plan, dated 02/10/22, recorded R36 had physical and verbal behaviors, difficulty sleeping, and often rejected cares related to her progressing dementia. The Medication Care Plan recorded R36 received [MEDICATION(S)] (antipsychotic medication) with a Black Box Warning (highest safety-related warning that medications can have assigned by the Food and Drug Administration) that recorded the medication was not approved for treatment of elderly patients with dementia due to the medication's ineffectiveness and life-threatening side effects. The Physician's Order, dated 12/11/21, directed staff to administer [MEDICATION(S)] 12.5 milligrams (mg) two times a day to R36 for dementia with behaviors. The Pharmacist Medication Reviews, dated 01/10/22 and 02/08/22 lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R36's use of [MEDICATION(S)]. The Pharmacist Medication Recommendation, dated 03/10/22, recorded dementia was an inappropriate diagnosis for the use of [MEDICATION(S)], and recommended the physician attempt a dose reduction or provide a risk versus benefit statement for the inappropriate antipsychotic use. The Pharmacy Medication Recommendation, dated 03/25/22, recorded the physician did not address the inappropriate diagnosis, and refused the gradual dose reduction for R36's use of [MEDICATION(S)]. The Pharmacist Medication Review, dated, 04/05/22, lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R36's use of [MEDICATION(S)]. On 04/19/22 at 12:18 PM, observation revealed R36 sat in her wheelchair at the dining table eating lunch with two other residents and had no behaviors. On 04/19/22 at 02:19 PM, Licensed Nurse (LN) G stated R36 had severe cognitive impairment due to dementia, was resistive to cares at times, and the resident's occasional behaviors were easily directed. On 04/21/22 at 09:32 AM, Administrative Nurse D stated dementia with behaviors was an inappropriate diagnosis for R36's use of [MEDICATION(S)]. The facility's Medication Administration policy, dated 12/14/21, directed staff to ensure antipsychotic medications had an appropriate diagnosis for use, and nursing staff should monitor antipsychotic medications for adverse side effects. The facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication for R36, placing the resident at risk to receive unnecessary antipsychotic medications and have adverse medication side effects. - R51's Electronic Medical Record (EMR) documented R51 had a diagnose of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. R51's Significant Change Minimum Data Set (MDS), dated [DATE], documented R51 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated mildly impaired cognition. The MDS documented R51 required extensive staff assistance with bed mobility, transfers, dressing, locomotion on unit, and toilet use, limited staff assistance with walk in room and corridor, and locomotion off unit, and supervision with eating. The MDS documented the resident received scheduled antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication seven days a week. R51's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/21/22, documented the resident had a diagnosis of dementia, had BIMS score of 12, and required assistance with major decision making. The CAA documented R51 at times had physical behaviors directed at others and declined care, and had confusion and at times had exit seeking behaviors. R51's [CONDITION(S)] Drug Use CAA documented the resident received [MEDICATION(S)] (antipsychotic medication) such as [CONDITION(S)] (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), [CONDITION(S)](major mental illness that caused people to have episodes of severe high and low moods) for a diagnosis of anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and she was at risk for adverse side effects from the medication. R51's Multiple Medication Care Plan, revised 03/16/22, instructed staff to administer to R51 all her medications and treatments as ordered, monitor her for possible drug interactions, obtain routine labs and notify physician of lab results. R51's Physician Order, dated 01/31/22, instructed staff to administer [MEDICATION(S)] tablet, 2.5 milligram (mg), by mouth at bedtime for diagnosis of anxiety. R51's Pharmacist Regimen Review, dated 02/15/22, recorded the facility's consultant pharmacist (CP) recommended the physician provide an appropriate diagnosis for R51's [MEDICATION(S)], per Centers for Medicare and Medicaid Services (CMS) guidelines which only the Federal Drug Administration (FDA) approved diagnoses of [CONDITION(S)] (a disorder that involves repetitive movements or unwanted sounds (tics) that can't be easily controlled), [CONDITION(S)] (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), or [CONDITION(S)] were allowed for the continued use of antipsychotics in residents with dementia, due to increased rate of mortality (incidence of deaths) and lack of efficacy when used in patients with dementia related [CONDITION(S)]. The pharmacist also recommended a gradual dose reduction in R51's [MEDICATION(S)]. The physician responded no change in dosage but failed to address the change in diagnosis of [MEDICATION(S)]. On 04/21/22 at 10:11 AM, Administrative Nurse D verified on the 02/15/22 pharmacist regimen review the physician failed to address the recommendation for an appropriate diagnosis for R51's [MEDICATION(S)] and the facility failed to follow up with the CP's recommendation and obtain an appropriate diagnosis from the physician. The facility's Pharmacy Services policy, updated 12/14/21, documented staff should not administer an antipsychotic drug to a resident unless the antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. The facility failed to ensure an acceptable reason for continuing or an appropriate diagnosis for the use of an antipsychotic medication for R51. This placed the resident at risk to receive unnecessary antipsychotic medications and have adverse medication side effects.

The facility had a census of 71 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility's consultant pharmacist (CP) failed to notify the Director of Nursing (DON), medical director, or physician about an inappropriate diagnosis for the use of an antipsychotic medication (medication used to treat significant mental health problems, and/or the facility failed to act upon the pharmacist recommendations for two sampled residents, Resident (R) 36 and R51. This placed the residents at risk to receive unnecessary antipsychotic medications and have adverse side effects. Findings included: - The Physician Order Sheet, dated 04/01/22, recorded R36 had diagnoses of dementia with behaviors (persistent mental disorder marked by memory loss and impaired reasoning), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and [CONDITION(S)] (difficulty sleeping). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R36 had a Brief Interview for Mental Status (BIMS) score of three (severe cognitive impairment) with physical and verbal behaviors. The MDS recorded R36 required extensive staff assistance with most Activities of Daily Living (ADLs), had a diagnosis of dementia, and received scheduled antipsychotic medication seven days a week. The Medication Care Plan, dated 02/10/22, recorded R36 had physical and verbal behaviors, difficulty sleeping, and often rejected cares related to her progressing dementia. The Medication Care Plan recorded R36 received [MEDICATION(S)] (antipsychotic medication) with a Black Box Warning (highest safety-related warning that medications can have assigned by the Food and Drug Administration) that recorded the medication was not approved for treatment of elderly patients with dementia due to the medication's ineffectiveness and life-threatening side effects. The Physician's Order, dated 12/11/21, directed staff to administer [MEDICATION(S)] 12.5 milligrams (mg) two times a day to R36 for dementia with behaviors. The Pharmacist Medication Reviews, dated 01/10/22 and 02/08/22 lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R36's use of [MEDICATION(S)]. The Pharmacist Medication Recommendation, dated 03/10/22, recorded dementia was an inappropriate diagnosis for the use of [MEDICATION(S)], and recommended the physician attempt a dose reduction or provide a risk versus benefit statement for the inappropriate antipsychotic use. The Pharmacy Medication Recommendation, dated 03/25/22, recorded the physician did not address the inappropriate diagnosis, and refused the gradual dose reduction for R36's use of [MEDICATION(S)]. Review of R36's medical record lacked documentation the facility acted upon the pharmacist's recommendation for an appropriate diagnosis for the resident's use of an antipsychotic medication. The Pharmacist Medication Review, dated, 04/05/22, lacked documentation the pharmacist addressed the inappropriate diagnosis of dementia with behaviors for R36's use of [MEDICATION(S)]. On 04/19/22 at 12:18 PM, observation revealed R36 sat in her wheelchair at the dining table eating lunch with two other residents and had no behaviors. On 04/19/22 at 02:19 PM, Licensed Nurse (LN) G stated R36 had severe cognitive impairment due to dementia, was resistive to cares at times, and the resident's occasional behaviors were easily directed. On 04/21/22 at 09:32 AM, Administrative Nurse D stated the consultant pharmacist had not addressed R36's inappropriate diagnosis for the use of [MEDICATION(S)] on the January 2022, February 2022, and April 2022 medication reviews. Administrative Nurse D stated the facility had not acted upon the pharmacist's March 2022 recommendation that the resident had an inappropriate diagnosis for the use of an antipsychotic medication. The facility's Medication Regimen Review policy, dated 07/17/19, directed the consultant pharmacist to ensure the residents' medications had an appropriate diagnosis or adequate indication for use. The facility's consultant pharmacist failed to notify the DON, medical director, or physician about R36's inappropriate diagnosis for the use of an antipsychotic medication, and/or the facility failed to act upon the pharmacist recommendation, placing the resident at risk to receive unnecessary antipsychotic medications and have adverse side effects. - R51's Electronic Medical Record (EMR) documented R51 had a diagnose of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. R51's Significant Change Minimum Data Set (MDS), dated [DATE], documented R51 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated mildly impaired cognition. The MDS documented R51 required extensive staff assistance with bed mobility, transfers, dressing, locomotion on unit, and toilet use, limited staff assistance with walk in room and corridor, and locomotion off unit, and supervision with eating. The MDS documented the resident received scheduled antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication seven days a week. R51's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/21/22, documented the resident had a diagnosis of dementia, had BIMS score of 12, and required assistance with major decision making. The CAA documented R51 at times had physical behaviors directed at others and declined care, and had confusion and at times had exit seeking behaviors. R51's [CONDITION(S)] Drug Use CAA documented the resident received [MEDICATION(S)] (antipsychotic(medication used to treat severe agitation associated with certain mental/mood conditions) such as [CONDITION(S)] (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), [CONDITION(S)](major mental illness that caused people to have episodes of severe high and low moods) for a diagnosis of anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and she was at risk for adverse side effects from the medication. R51's Multiple Medication Care Plan, revised 03/16/22, instructed staff to administer to R51 all her medications and treatments as ordered, monitor her for possible drug interactions, obtain routine labs and notify physician of lab results. R51's Physician Order, dated 01/31/22, instructed staff to administer [MEDICATION(S)] tablet, 2.5 milligram (mg), by mouth at bedtime for diagnosis of anxiety. R51's Pharmacist Regimen Review, dated 02/15/22, recorded the facility's consultant pharmacist recommended the physician provide an appropriate diagnosis for R51's [MEDICATION(S)], per Centers for Medicare and Medicaid Services (CMS) guidelines which only the Federal Drug Administration (FDA) approved diagnoses of [CONDITION(S)](a disorder that involves repetitive movements or unwanted sounds (tics) that can't be easily controlled), [CONDITION(S)] (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), or [CONDITION(S)] were allowed for the continued use of antipsychotics in residents with dementia, due to increased rate of mortality (incidence of deaths) and lack of efficacy when used in patients with dementia related [CONDITION(S)]. The pharmacist also recommended a gradual dose reduction in R51's [MEDICATION(S)]. The physician responded no change in dosage but failed to address the change in diagnosis of [MEDICATION(S)]. On 04/21/22 at 10:11 AM, Administrative Nurse D verified on the 02/15/22 pharmacist regimen review, the physician failed to address the CP's recommendation for an appropriate diagnosis for R51's [MEDICATION(S)]. The facility's Pharmacy Services policy, updated 12/14/21, documented staff should not administer an antipsychotic drug to a resident unless the antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. The facility failed to ensure the physician responded to the CP request to document an acceptable reason for continuing or an appropriate diagnosis for the use of an antipsychotic medication for R51. This placed the resident at risk to receive unnecessary antipsychotic medications and have adverse medication side effects.

The facility had a census of 71 residents. The sample included 19 residents with two reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R)30 and R51 with dignity, when staff failed to cover their urinary catheters (insertion of a catheter into the bladder to drain the urine into a collection bag) with a privacy bag leaving the urine collection bag visible to other residents and guests in the facility. This placed the resident at risk for impaired psychosocial well-being. Findings Included: - R30's Electronic Medical Record (EMR) documented she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's Quarterly Minimum Data Set (MDS) dated [DATE] documented R30 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented the resident required total staff assistance with activities of daily living (ADLs) and had an indwelling urinary catheter. R30's Indwelling Urinary Catheter Care Plan revised 03/18/22 documented R30 had a 15 french (fr) indwelling urinary catheter in place for urinary retention and comfort related to her terminal status. The care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from entrance room door and check the catheter tubing for kinks during cares. The care plan instructed staff to empty the catheter bag and record output every shift and ensure that a dignity bag was placed over the catheter drainage bag at all times. R30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/19/22 at 07:44 AM, observation revealed R30 sat in a Broda chair in the family living area with an uncovered urinary catheter bag clearly visible. On 04/21/22 at 09:02 AM, observation revealed R30's room door wide open and her uncovered urinary catheter bag was on the side of the bed closest to the door, clearly visible from the hall. On 04/21/22 at 09:05 AM, Licensed Nurse (LN) H verified R30's room door was wide open and her urinary catheter bag was uncovered. LN H stated staff were to cover R30's urinary catheter bag with a dignity bag only when she was out of her room. On 04/21/22 at 09:55 AM, Administrative Nurse D stated staff should cover the resident's urinary catheter bag when she was out of her room. She stated the bag did not require a cover when the resident was in her room. The facility's Resident Orientation Booklet, revised 07/01/18, under the Residents Rights section documented residents had the right to be treated with respect and dignity. The facility failed to treat R30 with dignity, when staff failed to cover her urinary catheter bag with a privacy bag when it was visible to others. This placed the resident at risk for impaired psychosocial well-being. - R171's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) R171's Admission Minimum Date Set (MDS) dated [DATE] recorded R171 had a Brief Interview for Metal Status (BIMS) score of 15, indicating intact cognition, and an indwelling urinary catheter. The temporary Peri Care and Toileting Care Plan dated 04/13/22 did not address or document the resident had a urinary catheter. On 04/18/22 at 11:30 AM, observation revealed R171 sat in a recliner in her room. An uncovered urinary catheter bag hung on her walker frame, with yellow urine in the catheter tubing and bag. On 04/19/22 at 08:30 AM, observation revealed R171 rested in bed, with the uncovered urinary catheter bag hung on the right side of the bed, with yellow urine in the catheter tubing and bag. On 04/21/22 at 10:45 AM, Administrative Nurse D stated the resident's urinary catheter bag should be covered to protect her dignity. She stated the bag did not ahve to be covered when the resident was in her room regardless of whether it was visible to other residents or guests. The facility's undated Resident Rights policy documented the facility would promote care for the resident in a manner that maintains each resident's dignity and respect. The facility failed to cover R171's urinary catheter bag placing the resident at risk for embarrassment and an undignified living environment.

The facility had a census of 75 residents. Based on observation, record review, and interview, the facility failed to provide a backflow device (unwanted flow of water in the reverse direction) or floor drain with a two inch air gap for the drainage system of the kitchen ice machine, used by the 75 residents who resided in the facility. Findings Included: - On 03/24/21 at 11:34 AM, observation revealed two flex hoses (flexible water supply tubes that connect plumbing fixtures and appliances to the plumbing system) from the back of the ice machine connected to plastic drainpipes. Continued observation revealed the drainpipes extended approximately three inches into the floor drain, and the ends of the drainpipes were soiled and wet. On 03/24/21 at 11:34 AM, Maintenance Staff U verified the ice machine drainage system did not have a backflow device, and the drainpipes should have a two to three inch air gap above the floor drain to prevent possible backflow contamination into the ice supply. On 03/24/21 at 11:34 AM, Dietary Staff BB stated the ice machine drainage system should have an air gap above the floor drain to prevent possible backflow contamination into the residents' ice supply. The facility's Ice Machine policy, dated 10/25/11, directed staff to maintain sanitary conditions for the ice machine to prevent contamination of the ice supply. The facility failed to provide a backflow device or floor drain with a two inch air gap for the drainage system of the kitchen ice machine, placing the 75 residents who reside in the facility at risk for contaminated ice.

The facility identified a census of 86 with 13 residents sampled. Based on observation, record review, and interview, the facility failed to implement timely interventions to avoid significant weight loss of 12.39% or 17.2 pounds in 180 days for 1 (#84) of 3 residents sampled for nutrition. Findings included: - The physician's orders [REDACTED].#84 documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] noted the resident with a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderately impaired cognition. The resident weighed 139 pounds (lbs). The assessment identified no weight loss more than 5% in the prior month or 10% in the prior 6 months. The resident ate independently and had no dental, swallowing or skin issues. The Quarterly MDS dated [DATE] noted the resident with a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderately impaired cognition. The resident ate independently but required set up help. The dental or nutrition areas did not trigger. The Quarterly MDS dated [DATE] noted the resident with a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderately impaired cognition. The resident required cueing with meals and set up help. The dental or nutrition areas did not trigger. The care plan for nutrition dated 2/29/16 noted the resident began to take medication to increase appetite and included the resident's favorite foods. This included egg sandwiches, jello, applesauce, toast, pancakes, and chicken nuggets dipped in white gravy. The resident's favorite snacks included sweets such as cookies, kettle corn and milk shakes. The nutrition care plan dated 5/24/16 documented the resident consumed a regular diet and ate independently. Staff were directed to offer the resident food preferences and substitutes as needed, monitor and document the resident's meal intake. The resident was identified at risk for altered nutritional status related to the [DIAGNOSES REDACTED]. The admission nutritional risk assessment dated [DATE] documented a weight of 135.8 pounds, a loss of 2.3% in 1 month, and the resident meal consumption at 65% which put the resident at moderate risk. The quarterly nutritional risk assessment dated [DATE] documented a weight of 137.2 pounds, a loss of 0.29%, or 5.6 pounds in 3 months. The resident's overall meal consumption documented at 63%. The quarterly nutritional risk assessment dated [DATE] documented a loss of 4 lbs., or approximately 3% weight loss in 1 month. The quarterly nutritional risk assessment dated [DATE] documented a weight of 128.6 pounds, a loss of 4.74% in 3 months The clinical record revealed the resident's weights over 180 days as follows: 1/12/16 138.8 pounds 2/12/16 131.8 pounds 4/12/16 129.2 pounds 5/10/16 129.4 pounds 6/14/16 127 pounds 6/21/16 126.4 pounds 6/28/16 124.4 pounds 7/5/16 124.4 pounds 7/12/16 121.6 pounds This is a loss of 17.2 pounds, a 12.39% in 6 months. The nutritional status quarterly review dated 5/20/16 included the resident continued to feed himself/herself a regular diet with no chewing or swallowing problems. The average meal intake was 63%, snacks 11%, and fluids 1096 cubic centimeters (cc) daily. The estimated nutritional needs of the resident were 1339 calories, 58 grams of protein, and 1740 cc of fluid. The resident's current weight was 128.6 pounds, a loss of 4.74% in 3 months. The resident's BMI (body mass Index) was 21.3 which wass below the desired level. The physician's orders [REDACTED]. The Nurse's note dated 7/13/16 stated the Physician and his/her Advanced Registered Nurse Practitioner (ARNP) saw the resident, reviewed the resident's weight loss and ordered [MEDICATION NAME] 7.5 mg, po, qd for appetite. Staff called the physician to clarify the order received from the ARNP as the resident was already taking that dose of the medication. There were no new orders. Review of the resident's meal percentage charting revealed the following: April 2016 - 17/90 meals 0-25% of meal consumed, 3 meals not charted, 16/19 meals 50% consumed, 34/90 meals 75% consumed. May 2016 - 16/93 meals 0-25% consumed, 1 meal not charted, 19/93 meals 50% consumed, 31/93 meals 75% consumed. June 2016 - 12/90 meals 0-25% of meal consumed, 7 meals not charted on, 16/90 meals 50% consumed, 27/90 meals 75% consumed. July 2016 - 8/53 meals 0-25% of meal consumed, 3 meals not charted, 16/53 meals 50% consumed, 11/53 75% of meal consumed. The clinical record lacked evidence the facility reassessed the resident's weight loss, and implemented timely and effective interventions to prevent further weight loss. Observation on 07/14/2016 at 11:54 AM included the resident sat in his/her wheelchair (w/c), at a dinner table. At 12:01 PM staff served the resident the noon meal of a sandwich, sun chips (a type of chip snack) and water . The staff asked if they could bring him/her anything else, he/she replied this was fine. His/her wheelchair was positioned 1-2 feet from the table, which caused the resident to reach back and forth across this distance to reach his/her plate. Staff did not offer to push her/him up to the table. Staff did not offer assistance opening the bag of chips, which took him/her approximately 5 minutes to open. At 12:30 PM staff assisted the resident out of the dining area. The resident consumed 75% of the meal. Observation on 07/18/2016 at 7:34 AM included the resident sat in his/her w/c at the breakfast table. A dietary staff pushed him/her close to the table, and asked if he/she would like to fill out a menu. The staff explained the choices to him/her. The staff served the resident eggs and a bowl of oatmeal. The staff then poured milk on the oatmeal. At 7:45 AM the resident picked at the food, and ate very slowly. At 8:05 AM, he/she continued to pick at the food. Staff did not offer encouragement or assistance. At 8:16 AM the resident did not eat anything for 10 minutes, and was distracted with other activities. At 8:28 AM the resident continued to sit at the table, not eating, and received no encouragement from staff. At 8:35 AM, nearly an hour after being served, staff assisted the resident back to his/her room in the wheelchair. The resident consumed 5-10% of the meal, without encouragement from the staff. During an interview on 07/18/2016 at 2:02 PM direct care staff P stated his/her duties included taking the resident to the dining room. He/she stated the resident ate independently, and staff just watched the resident. Staff was able to look at the care plan, and had not noticed any decline in appetite or eating ability. Staff P report to the charge nurse any resident concerns. If there was a change in the resident's care plan the charge nurse will tell the direct care staff. The nursing staff had not mentioned the resident's weight loss to direct care staff P. On 07/18/2016 at 3:49 PM direct care staff Q stated if the resident was hungry, he/she ate. The resident was kind of mentally going downhill. The resident usually ate in the dining room, did not require help, and ate cookies for snacks. Staff Q was not aware if the resident received a protein shake. On 7/18/16 at 1:50 PM licensed staff K, stated if there was a weight loss the nurse on duty notified the doctor and charted in the ID (interdisciplinary) notes. Staff could offer shakes bid (twice a day) without a doctor's order and it should be charted what is offered in the Point of Care record (where the direct care staff document). Staff K confirmed the resident had declined in cognition. On 07/19/16 at 1:29 PM licensed staff K stated the dietician received the printed weekly report, regarding the resident's 12.39% weight loss of 7/12/16. On 7/18/16 at 1:40 PM dietary staff FF, stated if a resident lost enough weight he/she would be on a supplement, which would be 5% in 30 days. This should be charted in the weight tracker. On 07/19/16 at 10:45 AM registered dietary staff DD, stated he/she normally received an email from nurses if a resident had weight loss. He/she further stated today was the first day he/she was aware of the resident's significant weight loss. Staff DD did not get an email last week regarding the resident's weight loss. Staff DD stated the nurses decide on weight loss interventions and talk with staff DD about them. Staff DD was not aware of what kind of snacks the resident received. Staff DD expected nursing staff to order protein shakes if a resident had weight loss. On 07/19/16 at 2:46 PM administrative nursing staff D and E stated the resident was not triggered for weight loss until last week so they were not looking at the resident's weight loss. Staff D stated they do need to look at to look at the facilities weight loss policy and look at certain percentages, and the need to look at the process of how soon weight loss triggered. Staff D acknowledged that the staff had a week to respond to a significant weight loss according to policy. On 7/20/16 at 3:00 PM physician staff KK stated he/she had been aware of the resident's gradual weight loss since February 2016, but it was not triggered as a concern as it did not meet the facility's criteria for weight loss until last week. He/she was aware that he/she had ordered [MEDICATION NAME] in February when the resident began to have problems with eating. When physician KK was notified on 7/13/16 he/she did not increase the [MEDICATION NAME] or change the medication as he/she believed if the [MEDICATION NAME] didn't help, nothing would. Physician staff KK stated that lab tests were performed in March and April when the resident had digestive problems and was started on [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] reflux disease and ulcers) 1 gram orally every day. Physician staff KK further stated that he/she would expect nursing staff to notice the downward trend in the resident's weight even though it did not trigger for the facility and that they would notify him/her and put in place interventions such as protein shakes and encourage increased nutritional intake. The policy dated 7/2/2010 for assisting elders with unintended weight loss stated: Elders will be promptly identified when they experience a weight loss and a plan that reflects the elders preferences will be developed to prevent further unintended weight loss. The policy dated 8/17/11 for nutritional documentation documented each elder will be assessed for nutritional needs at move in and periodically during their residency. The facility failed to identify this residents avoidable significant weight loss of 12.39 in 180 days, and failed to implement timely interventions to prevent further weight loss.

The facility had a census of 95 residents. The sample included 15 residents. Based upon observation, record review and interviews the facility failed develop and implement timely interventions to prevent the development of an avoidable pressure ulcers and to promote the healing of pressure ulcer for 1 of 2 residents sampled for pressure ulcers (#6). Findings included: - Resident #6's [DIAGNOSES REDACTED]. within a blood vessel). The Admission Minimum Data Set ((MDS) dated [DATE] identified the resident admitted to the facility on [DATE], scored 12 (moderately impaired cognition) on the Brief Interview for Mental Status (BIMS), required extensive staff assistance with bed mobility, transfers, walking in the room, locomotion on/off the unit, dressing, toilet use and personal hygiene. The resident was continent of urine, utilized a walker and a wheelchair. The MDS identified the resident was at risk for the development of pressure ulcers, had no unhealed pressure ulcers, utilized a pressure relieving device on his/her bed and chair, and was not on a turning/repositioning program. The Significant Change Minimum Data Set ((MDS) dated [DATE] identified the resident scored 15 on BIMS which indicated the resident had intact cognition. The MDS identified the resident required limited assistance with bed mobility, transfers, walking in the room/corridor, dressing, toilet use, personal hygiene, extensive staff assistance with locomotion on/off unit and independent with eating. The MDS coded the resident utilized a walker and a wheelchair and was occasionally incontinent of urine. The MDS identified the resident was at risk for the development of pressure ulcers and had (1) Stage 4 pressure ulcer not present upon admission that measured 2.8 centimeters (cm) by 1.0 cm and the most severe tissue type was slough. The MDS identified the resident had a pressure ulcer relieving device in his/her chair and bed, and was not on a turning/repositioning program. The Pressure Ulcer and Nutritional Status Care Area Assessments (CAAs) dated 1/27/15 documented the resident's pressure ulcer on his/her mid-spine was a stage 4 pressure ulcer after debridement . The resident's Braden Scale dated 10/21/14 identified the resident scored 16, at high risk for the development of pressure ulcer. The resident's temporary care plan with an admission date of [DATE] included the resident had a pelvic fracture, required assistance of 1 staff with ADLs, was continent of bowel and bladder, received a mechanical soft diet and staff performed weekly skin assessments. The care plan did not address how staff minimized pressure on the resident's bony prominences to prevent the development of pressure ulcers. The care plan dated 1/28/15 addressed the resident had impaired physical mobility related to a history of a pelvic fracture, the resident required stand by assistance for toileting and toileting transfers. The resident was at risk for altered nutritional status, received a mechanical soft diet, staff monitored and recorded the resident's nutritional intake, the resident's received lactose free Ensure (nutritional supplement used to increase calories and protein) as physician ordered since 11/19/14. On 1/8/15, staff offered the resident a lactose free protein shake in the P.M. and on 1/14/15 staff increased the resident's lactose free milkshakes to twice a day (BID) and on 2/4/15 the milkshakes were increased to three times a day (TID). Staff weighed the resident weekly and encouraged the resident to consume 75 percent (%) of each meal served. Since 11/6/14 staff encouraged and assisted the resident to change his/her position at least every 2 hours. The resident utilized a pressure relieving device on his/her bed and pressure relieving device in his/her chair. An undated entry marked through pressure reliving device on bed and and hand written entry included low air loss mattress. The resident chose not to have the heelz up cushion (device to offload the resident's feet) and the resident understood the risks (12/12/14). On 12/26/14 the resident utilized a donut pillow when he/he sat. On 12/27/14 staff discontinued the donut pillow because the resident chose not to use it. An undated entry included the resident received ProStat (supplement used to increase protein). On 1/14/15 the physician debrided the pressure ulcer on the resident's mid-back; since 2/11/15 staff cleaned the pressure ulcer on the resident's back with normal saline and covered the area with a pink polymen daily and as needed (PRN) (2/11/15). The resident received a mechanical diet, had some weight loss issues, staff offered the resident high caloric foods and the resident liked lactose free ice cream. The care plan did not address what education staff provided the resident regarding repositioning/turning prior to the development of the pressure ulcer. The care plan also did not include alternatives regarding off-loading the resident's feet after the resident chose not to use the heel up device. The care plan did not include interventions regarding preventing skin to skin contact of the resident's bony prominences or how staff minimized the pressure prior to the development of the pressure ulcer on the resident's spine even though staff assessed the resident was at risk for the development of pressure ulcers and presented with kyphoisis (unnatural curving of the upper back that creates a hunchback appearance in the posture, often associated with [MEDICAL CONDITION] (progressive bone disease characterized by a decrease in bone mass and density and can lead to a humped position) upon admission to the facility. The skin condition forms included the following: 12/11/14 and timed 7:36 P.M. the resident had a red mark in the center of his/her spine that measured 3 cm by 3.5 cm, and a red and brown circle was in the center of the area. Staff received a physician order [REDACTED]. 12/18/14: The resident had a dark red sac in the center of his/her spine. No measurement. 12/25/14: The area on the resident's spine went from a small scab to a bright red area 6.0 cm in diameter and a black scabbed area with a diameter of 2.0 cm. around. 1/7/15: The pressure ulcer on the resident's spine was due to persistent pressure on the resident's spine. The pressure ulcer had a black necrotic center with slough surrounding the back center, severe red raised skin surrounding the wound and measured 7.5 cm by 5.5 cm. 1/15/15: The pressure ulcer contained slough and measured 2.8 cm by 3.0 cm by 0.7 cm. 1/20/15: The pressure ulcer continued on the resident's spine and the physician debrided the pressure ulcer last week. A nurse's note (NN) dated 12/11/14 and timed 6:47 P.M. documented after staff observed the red area on the resident's back/mid-spine staff delivered an air mattress to the resident's room that afternoon. The note included the resident's physician's gave orders that included liquid protein BID, a Multivitamin once a day, change the Elasto Gel dressing to the red area on the center of the resident's back/spine daily for healing and protection. Staff to elevate the resident's heels up and off the bed with a heels off pillow when the resident was in bed. The above NN represented the facility received the orders An interdisciplinary note dated 12/29/14 documented staff informed the physician designee the area on the resident's back worsened. The physician's designee gave orders to start Santyl (an ointment used to remove dead tissue) approximately 1 gram to the eschar (dead tissue) area directly every day, and to securely cover the area with a dressing. The note included due to the thickness of the eschar it might be necessary to crosshatch (scoring of thin cuts into the surface of the dead tissue) with a sterile blade before applying the Santyl. The Director of Nursing should evaluate the wound and determine if crosshatching was necessary and to start the resident on Keflex ( an antibiotic) BID for 10 days due to [MEDICAL CONDITION] (bacterial skin infection). A (NN) dated 1/14/15 and timed 7:12 P.M. included the pressure ulcer on the resident's spine had a moderate amount of yellowish brown drainage and no odor at this time. The physician debrided the pressure ulcer and the wound bed contained 80% slough, the surrounding peri-wound measured 3.0 cm by 2.8 cm with a depth of 0.7 cm. A NN dated 1/17/15 and timed 9:21 A.M. included staff notified the resident's physician of the resident's weight loss and the resident's physician gave orders for the resident to receive a diet high in calories. An Interdisciplinary note dated 2/2/15 and timed 10:56 A.M. (a duration of greater than a month after the resident developed the pressure ulcer on his/her mid-spine) documented the resident admitted to the facility with a [DIAGNOSES REDACTED]. The resident received a mechanical soft diet, had weight loss and staff offered the resident lactose free foods and milkshakes BID, and lactose free Ensure and ice cream (no frequency noted). The note included on 12/11/14 staff noted the resident had a red area on his/her mid back where his/her bra line. Staff applied Elasto gel and notified the resident's physician of the red area and staff applied an air mattress to the resident's bed. The resident's physician ordered liquid protein BID, Multivitamin once day, change the Elasto gel twice daily and to offload the resident's heel when the resident was in bed. On 12/30/14 physical therapy/occupational therapy screened the resident for pressure relief. On 1/7/15 (a duration of 3 weeks after the development of the resident's pressure ulcer) the facility contacted the facility's Medical Director (not the resident's primary care physician) to assess the resident's wound due to the wound had drainage with slough around the edges. Staff educated the resident on repositioning and ways to relieve pressure. The resident did not wish to use the heels up or lie on his/her side and staff encouraged the resident to reposition. A NN dated 2/4/14 timed 4:06 P.M. documented the pressure ulcer measured 2.0 cm by 2.2 cm with a depth of 0.8 cm. A (NN) dated 2/16/15 and timed 11:36 A.M. documented the pressure ulcer on the resident's spine continued to have a slight odor, a large amount of creamy yellowish/green drainage and approximately 2.0 cm of deep red intact tissue surrounded the pressure ulcer. The resident continued turning side to side when in bed and he/she continued to report minimal discomfort to the area. A skin note dated 2/20/15 and timed 11:02 A.M. included the pressure ulcer on the resident's spine measured 2.8 cm by 1.8 cm with a depth of 0.6 cm and continued with a small amount of greenish drainage without odor. Review of the weight log revealed the following weights: 10/28/14: 122 pounds 11/11/14: 118 pounds 12/02/14: 116 pounds 12/09/14: 114 pounds 12/16/14: 114 pounds 2/10/15: 104 pounds A laboratory report dated 12/29/14 recorded the resident's serum [MEDICATION NAME] level at 3.4 grams/deciliter (gm/dl), normal reference range 3.6-5.3 g/dl. A Registered Dietician's (RD) note dated 10/30/14 included the resident received a mechanical soft diet, had no skin skin issues and did not make any recommendations. A RD note dated 1/8/15 documented the resident had weight loss, a loss of appetite and skin issues, the resident weighed 110.6 pounds and had slowly lost weight. The resident received Vitamin D, ProStat BID and a Multivitamin (MV). Lactose free milk and ice cream was delivered to his/her unit to increase his/her calcium intake and the availability of homemade high protein milkshakes added to the resident's diet. Staff monitored and made other adjustments to the resident's care as needed. A RD note dated 1/15/15 and timed 3:33 P.M. documented the resident enjoyed ice cream with caramel sauce at the end of the meal, chocolate lactose free ice cream had been ordered for her to provide more variety as well. The resident's weight declined 2.6 pounds in the past week, received a mechanical diet, and the resident's nutritional intakes in past week averaged 74% of meals, received a lactose free protein drink twice a day which he/she refused in the past 2 days. The resident received ProStat BID and Vitamin D and MV for further supplementation. A RD note 1/23/15 and timed 4:11 P.M. documented the resident received a mechanical soft diet, weighed 110 pounds, received lactose free drink supplement which has deferred further weight loss. The resident received Vitamin D, a multivitamin and 30 cubic centimeters (cc's) of liquid protein supplement BID for supplementation. The resident's estimated nutrient needs were 1128 calories and 60 grams of protein daily. A RD note dated 2/12/15 and timed 1:10 P.M. included the resident consumed an average of 80% of meals and 9% of snacks. The resident refused the morning lactose free supplement 8 of 12 times and the afternoon supplement only twice and did not refuse the liquid protein supplement (ProStat). Staff offering the liquid protein supplement TID versus BID would increase the resident's protein intake as well as provide additional calories; 15 grams of protein and 70 calories. The past week chocolate syrup was added to the supplement and he/she accepted it in the morning much more than he/she did the first week of February, resulting in a much needed weight gain of 0.4 lbs. The RD recommended the continuation of this as well as the addition of more ProStat. Review of the clinical record on 2/23/15 at 2:00 P.M. lacked evidence to support the facility followed up on the RD's recommendation made on 2/12/15 to increase the liquid protein supplement to three times a day (duration of 12 days) or add chocolate syrup to the resident's supplement. Review of the December, January and February Medication Administration Record/Treatment Administration Record revealed the resident at times refused the lactose free supplement (Ensure) in the A.M. and P.M. Further review revealed the resident consumed all of the ProStat offered. Review of the clinical record lacked evidence to support staff offered the resident another alternative or thoroughly assessed the causal factor as to why the resident refused the Ensure. Further review also lacked evidence to support staff documented the amount of Ensure the resident consumed when he/she did not refuse the Ensure. Review of the clinical record lacked evidence to support staff offered the resident the lactose free supplement TID and also did not support staff documented the percentage of the supplement the resident consumed. Review of the clinical record lacked evidence to support staff offered the resident lactose free ice cream. On 2/18/15 at 9:56 A.M. the resident sat in the recliner in his/her room and observation revealed a standard bed pillow behind his/her back and no pressure relieving device in the seat of the recliner. Further observation revealed the resident's back had a curved position. Observation revealed the resident had a low air loss mattress in place on his/her bed and a pressure relieving device in his/her wheelchair. The resident stated he/she developed an area on his/her spine after admission to the facility. He/she stated there was not a lot to do in the unit, he/she laid in bed on his/her back a lot and staff did not reposition him/her or cue him/her to reposition. He/she stated staff did not treat the area and the area worsened. The resident stated the facility placed the low air loss mattress on his/her bed after she developed the pressure ulcer on his/her spine. The resident stated now staff placed pillows under his/her back when he/she was in bed. On 2/18/15 at 10:15 A.M., 10:25 A.M., 10:43, A.M. and 11:02 A.M. the resident sat in the recliner in his/her room and observation revealed no pressure relieving device in the seat of the recliner and the pillow continued behind the resident's back. On 2/18/15 at 12:14 P.M. the resident sat in his/her wheelchair and consumed the lunch meal which consisted of strawberries, roast beef with gravy, mashed potatoes and gravy, vegetable medley, (2) glasses of water. Observation revealed the resident ate independently and ate the last of the strawberries. Further observation revealed no pressure relieving device behind the resident's back. On 2/18/15 at 12:20 P.M. the resident sat in his/her wheelchair in the dining room and observation revealed no pressure relieving device behind the resident's back. On 2/18/15 at 12:35 P.M. the resident had finished eating and the resident consumed 75% of the roast, mashed potatoes and gravy and vegetables. Further observation revealed no pressure relieving device behind the resident's back. On 2/18/15 at 12:37 P.M. staff offered a cookie, carrot cake and/or ice cream (not lactose free) and the resident chose carrot cake. Further observation revealed staff did not offer the resident lactose free ice cream. The resident consumed 75% of the cake. On 2/18/15 at 12:50 P.M. the resident wheeled himself/herself from the dining room table to his/her room and transferred himself/herself to the recliner. On 2/18/15 at 2:15 P.M. Medical Director KK stated the area on the resident's spine was a pressure ulcer. Medical director KK stated the resident would benefit from a lumbar support device to keep the pressure off of the resident's spine when he/she sat in a chair. On 2/19/15 at 7:45 A.M. the resident sat in his/her wheelchair at a dining room table and a blanket placed behind his/her back. On 2/19/15 at 8:06 A.M. the resident sat in his/her wheelchair at a dining room table and ate the breakfast meal which consisted of 2 cups of water, a cup of coffee and a bowl of oatmeal with brown sugar. At 8:15 A.M. observation revealed the resident consumed all of the oatmeal and coffee. On 2/19/15 at 9:15 A.M. licensed nurse N and administrative nursing staff E performed the treatment to the pressure ulcer on the resident's mid-spine. Observation revealed the old dressing had a visible drainage stain approximately the size of a half dollar. Observation revealed the resident had a pressure ulcer on his/her mid-spine which administrative nursing staff E stated was a Stage 4. Further observation revealed a small bud of skin at the top of the wound and slough within the wound bed of the Stage 4 pressure ulcer. Administrative nursing staff E stated the Stage 4 pressure ulcer measured 3.2 cm by x 3.0 cm, the wound bed contained 10% slough and the wound had no tunneling. He/She stated the dark red area surrounding the Stage 4 pressure ulcer measured 2 cm. Administrative nursing staff E stated the Medical Director planned on [MEDICATION NAME] the budding area and slough on the pressure ulcer on 2/23/15. On 2/23/15 at 8:00 A.M. the resident sat in his/her wheelchair at a dining room table and no pressure relieving device or blanket behind the resident's back. On 2/23/15 at 8:47 A.M. the resident sat in the recliner in his/her room, the red blanket the resident used at times behind his/her back when in the wheelchair was folded and laid on top of his/her bed, no pillow behind the resident's back and no pressure relieving device in the seat of the recliner. The resident stated he/she also used the blanket also for his/her bed, stated staff had folded the blanket this A.M. and placed it on his/her bed and he/she did not place the blanket behind his/her back when he/she sat in the wheelchair during breakfast. He/she confirmed no pillow was placed behind his/her back as he/she sat in the recliner at that time. The resident stated facility staff only offered him/her Ensure during the early afternoon each day. The resident stated he/she only refused the supplement if staff offered it too close to dinner time or offered him/her strawberry flavored versus chocolate flavored. He/she stated staff did not consistently offer him/her lactose free ice cream and did not offer him/her milkshakes. On 2/23/15 at 10:20 A.M. direct care staff W made milkshakes in the kitchenette. Direct care staff stated he/she offered the milkshakes to residents during snack time. A staff provided a list of residents that received nutritional supplements between meals. Review of the roster revealed this resident received lactose free milkshakes TID. According to the staff the resident received the lactose free milkshake at 10:00 A.M. , 2:30 P.M. and prior to going to bed each night. On 2/23/15 at 10:35 A.M. direct care staff W had 4 strawberry and 4 vanilla milkshakes and offered the milkshakes to 4 residents attending a group activity. Observation revealed the resident was not one of the residents that attended the activity. Direct care staff offered 2 residents in the general proximity the milkshakes and then offered the other 2 milkshakes to 2 other residents. Observation revealed the resident was not offered a milkshake. During interview direct care staff W stated he/she offered the milkshakes to the residents that attended the activity and then offered the remaining milkshakes to residents he/she thought would enjoy the shakes and not to residents included on list to receive milkshakes. Direct care staff W stated he/she made (2) pitchers of milkshakes and added a cup of protein powder to each pitcher of milkshakes. On 2/23/15 at 11:20 A.M.. licensed nurse LL stated the resident at times refused the A.M. Ensure. He/she stated the resident stated he/she did not like the vanilla flavored Ensure so staff now offered the resident either strawberry or chocolate flavored Ensure. Licensed nurse LL stated the resident received ProStat BID. On 2/23/15 at 11:45 A.M. direct care staff TT stated the resident was not on a turning/repositioning program. He/she stated the resident asked for staff assistance when he/she needed repositioning. Direct care staff TT stated staff placed a pillow behind the resident's back when the resident sat in the wheelchair and/or recliner. Direct care staff TT stated the resident was not offered a milkshake during evening snacks. On 2/23/15 at 1:33 P.M. licensed nurse N stated staff offered the resident (1) can of Ensure BID, and milkshakes with added protein BID. He/she stated direct care staff offered the resident the milkshakes between 9:45 A.M. to 10:15 A.M. and around 2:30 P.M. Licensed nurse N stated the resident consumed all of the liquid protein, typically refused the Ensure but did consume the milkshakes. He/she stated upon admission the resident had a fractured pelvis, was not moving much and was not compliant with turning and repositioning and the resident did not understand how bad his/her back was getting. Licensed nurse N stated the resident received pain medication and did not have full sensation to know that he/she was hurting. Licensed nurse N stated the resident was compliant in this unit, and turned from side to side. He/she stated the resident leaned over when he/she sat in the wheelchair and recliner and was cautious not to put pressure on his/her spine; therefore no pillow/pressure relieving device was placed behind the resident's back when the resident sat in the wheelchair or the recliner. Licensed nurse N stated at times the resident asked staff to place a pillow between his/her legs. On 2/23/15 at 2:23 P.M. dietician consultant DD stated the resident received Ensure BID, Lactose free milkshakes TID, and he/she recommended the resident receive ProStat TID versus BID. He/she stated if the resident received all of the above as planned the resident would have better wound healing. Dietician consultant DD stated he/she was unaware the ProStat was not increased to TID. On 2/23/15 at 2:45 P.M. dietician consultant DD stated nursing staff contacted the resident's physician and he/she gave the order to increase the ProStat to TID. On 2/23/15 at 5:18 P.M. nursing administrative staff D stated upon admission the resident was considered at risk for the development of pressure ulcer and required staff assistance with ADL's. He/she stated staff placed an air loss mattress on the resident's bed upon admission and was unsure of the date the facility placed the resident on a low air loss mattress. Nursing administrative staff D stated after staff observed the red area on the resident's back, they discussed repositioning/turning with the resident. He/she stated when the resident resided on the rehab unit the resident was not on staff's radar the resident did not turn. Nursing administrative staff D stated with staff persistence, encouragement and explaining the importance of turning/repositioning when in the wheelchair and recliner the resident was compliant with turning/repositioning. He/she stated the resident did not use a pressure relieving device/lumbar support when he/she sat in the wheelchair or recliner because Medical Director KK did not recommend it and the resident had not requested one. Nursing administrative staff D did not know why the resident utilized the pillow/blanket behind his/her back when in the wheelchair/recliner. Administrative nursing staff D stated he/she was not sure if the facility had thoroughly assessed why the resident refused the supplements. Nursing administrative staff D stated the facility documented the resident accepted/refused snacks but did not identify what snack staff offered the resident (milkshake, ice cream, etc.) He/she stated the facility should record the percentage of Ensure the resident consumed. Nursing administrative staff D confirmed the facility did not record the percentage of Ensure the resident consumed. The facility's Skin Protection Protocol for Elders at Risk for Pressure Ulcers approved 12/15/14 included characteristics of elders at risk for pressure ulcers included residents who scored 16 or lower on the Braden scale...A pressure relieving device would be placed in the resident's chair if the resident scored 16 or below on the Braden Scale. The pressure relieving device would be placed in any chair the resident sat in...If the resident had a condition or presented with bony prominences measures would be taken to prevent breakdown. Examples included residents with kyphosis-Elastogel would be applied. The facility failed to develop and implement appropriate interventions to prevent the development of an avoidable stage 4 pressure ulcer, and failed to ensure the resident received the milkshakes as planned, failed to ensure the resident had an adequate pressure relieving device/lumbar support to minimize the pressure off of his/her spine when he/she sat in the wheelchair and also failed to develop a temporary care plan that addressed pressure ulcers interventions for this resident assessed upon admission at risk for the development of pressure ulcers.

The facility identified a census of 90 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to provide supervision as care planned to resident #1 to prevent a fall that resulted in a fractured leg, and failed to follow through with the care plan intervention implemented for resident #2 after a fall. Findings included: - The undated electronic face sheet recorded resident #1 with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident with a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The resident wore glasses for impaired vision, required extensive assistance with bed mobility, and limited staff assistance with transfers, dressing, toilet use, and personal hygiene. The resident had impaired balance, was only able to stabilize with staff assistance, used a wheelchair or walker for mobility, and experienced a non-injury fall since the last assessment. The Care Area Assessment for falls dated 7/1/14 documented on 5/24/14 the resident stood up to transfer him/herself and fell . Review of the quarterly MDS dated [DATE] recorded the resident with a BIMS score of 14, which indicated intact cognition, and no longer used a walker for mobility. Review of the Fall assessment dated [DATE] recorded a total score of 25, which indicated the resident was a high risk for falls. The plan of care for falls dated 7/1/14 recorded risk factors related to weakness and vertebroplasty (a procedure where special bone cement was injected directly into a fractured bone of the spinal column to relieve pain). The care plan directed staff to keep the call light within reach, room clutter-free, well lit, and with a night light on. Intervention added on 2/28/14 directed staff to stay with resident in the bathroom (not to be left alone in the bathroom) provide verbal reminders to call for help when getting out of a low bed, and supervise ambulation. Nursing note dated 10/8/14 timed 1:50 P.M., recorded at 9:20 A.M., staff heard the resident yelling for help and found the resident lying on his/her left side in the bathroom with his/her head facing the bedroom hallway. The resident had a small laceration to his/her left scalp with bruising around area. The resident ' s left leg faced outward and appeared significantly shorter than right leg. Three staff members assisted the resident to a supine (lying on the back) position in bed and called for a portable x-ray of the resident ' s left hip. Nursing note dated 10/8/14 timed 1:54 P.M. recorded at 10:30 A.M., a mobile x-ray arrived at the facility and obtained a pelvic (bones that connect the base of the spine to the supper end of the rear legs) x-ray. Nursing note dated 10/8/14 timed 1:55 P.M. documented at 12:00 P.M. the facility received a fax that recorded a left hip fracture on the x-ray. Nursing note dated 10/8/14 timed 2:35 P.M. recorded at 1:40 P.M. the emergency transport transferred the resident to an acute care hospital. On 11/7/14 at 12:00 P.M. licensed nursing staff I reported he/she observed the resident lying on the floor partially out of the bathroom and his/her left leg was shorter and turned outward. On 11/7/14 at 12:10 P.M. direct care staff O revealed staff read the resident care plans for care interventions and stayed with the resident while he/she was on the toilet. On 11/7/14 at 12:17 P.M. direct care staff R reported the resident required extensive assistance from staff with all cares and was weaker and more confused. The resident ' s care plan directed he/she was not to be left alone on the toilet. On 11/7/14 at 12:30 P.M. interview with direct care staff S revealed the resident called out for help and he/she found the resident lying on the bathroom floor. On 11/7/14 at 12:35 P.M. direct care staff P reported he/she transferred the resident to the toilet, told the resident to use the call light when he/she was finished, and left the resident on seated on the toilet without supervision. On 11/7/14 at 12:41 P.M. direct care staff Q revealed staff provided care as directed on the resident care plans and stayed with the resident after he/she transferred to the toilet. On 11/7/14 at 1:05 P.M. licensed nursing staff H reported the resident was weaker and confused during the 3 days prior to his/her fall. Staff should stay with the resident while he/she was on the toilet. On 11/7/14 at 2:00 P.M. administrative nursing staff D stated staff should have stayed with the resident after assisting him/her to the toilet. The facility provided a policy for Fall Prevention and Management Protocol dated 12/1/13 that recorded staff provided optimal communication regarding the elder ' s condition and potential for fall with other care providers. Each team member was responsible for checking the care plan of elders who were at risk for falls when beginning work each day. The facility failed to follow care plan interventions as planned to provide supervision to this resident who experienced a fall that resulted in a left hip fracture and required hospitalization and treatment. - The annual Minimum Data Set (MDS) assessment dated [DATE] recorded resident #2 with a Brief Interview for Mental Status (BIMS) score of 3, which revealed the resident had severe cognitive impairment, required limited assistance from staff for bed mobility, transfers, ambulation, toilet use, dressing, and personal hygiene. His/her balance was not steady but he/she was able to stabilize without staff assistance and used a walker or wheelchair for mobility. The resident experienced one fall with a minor injury fall since the previous assessment. The care area assessment for falls dated 5/22/14 documented the resident with dementia (progressive mental disorder characterized by failing memory, confusion), impulsiveness, and experienced a fall on 5/3/14, ambulated with a walker independently and staff provided supervision and cueing for ambulation. The quarterly MDS dated [DATE] recorded no change from the resident ' s previous assessment. The resident ' s care plan dated 8/21/14 identified the resident at risk for falls and revealed staff encouraged the resident to wears shoes or slippers when getting up, supervised ambulation and minimized distractions, and encouraged the resident to use the call light for help. Staff provided the resident assistance to the bathroom a half-hour before meals, kept the night light on the bathroom and tried to keep the room door ajar to check on the resident frequently for safety. Staff encouraged the resident to ask for assistance with toileting and provided reminders to use the walker for ambulation. A new intervention placed on the resident ' s care plan dated 10/25/14 recorded physical therapy was to evaluate the resident for a recent fall. A nursing note dated 10/25/14 at 4:18 P.M. documented staff found the resident sitting on the floor of his/her room with a 2 centimeter skin tear to the right elbow. Review of the facility investigation revealed on 10/25/14 at approximately 4:00 P.M. staff found the resident on the floor in his/her room and documented a new intervention for a physical therapy evaluation. 11/5/14 at 9:09 A.M. the resident was sitting in the main common area with his/her walker in front of him/her, glasses on, when asked how he/she was doing he/she mumbled .... Observations on 11/7/14 at 7:45 A.M., revealed direct care staff L walked side by side the resident with his/her walker from the living room to the resident ' s room. On 11/7/14 at 1:50 P.M., therapy staff HH walked around the living room with the resident with his/her walker. On 11/7/14 at 8:00 A.M. licensed nursing staff J reported the resident did not receive physical therapy and confirmed the care plan intervention for a physical therapy evaluation on the resident ' s care plan dated 10/25/14. On 11/7/14 at 9 A.M. therapy staff GG reported the staff record all therapy notes in the computer and there were no notes for a therapy screen or therapy treatment for [REDACTED]. On 11/7/14 at 10:45 A.M. direct care staff L reported staff provided stand by assistance with ambulation and the resident did not receive physical therapy. On 11/7/14 at 2:15 P.M. direct care staff M reported the resident recently experienced a fall and required staff supervision and standby assistance. On 11/7/14 at 2:25 P.M. direct care staff N reported the resident required staff supervision with ambulation and in his/her room due to a fall. On 11/7/14 2:45 P.M. administrative nursing staff D reported the physical therapy screen recorded on the resident ' s care plan dated 10/25/14 was not done until today, 11/7/14. The facility provided policy Caring for an Elder that has Fallen, dated 10/11/11 recorded a fall was documented on the care plan with interventions to prevent further falls. The facility failed to provide interventions as planned to prevent falls for this cognitively impaired resident that experienced a recent fall.

The facility reported a census of 88 residents and the sample was 4. Based on observation, record review, and interviews the facility failed to assess for the safe use of lift recliners for 3 (#1, #4, and #3) residents of the sample. The facility also failed to have interventions in place for the prevention of falls for 1 (#1) of 4 residents reviewed for falls. Findings included: - Resident #1's quarterly Minimum Data Set (MDS) 3.0 dated 9/10/12 recorded a Brief Interview for Mental Status (BIMS) score of 11 (mild impairment), needed extensive assistance for bed mobility, transfer, locomotion on unit, dressing, toileting and hygiene, was not able to balance without staff assistance, had no falls, and was occasionally incontinent of bladder/bowel. The CAA (Care Area Assessment) dated 1/17/12 for falls recorded the resident was at risk for falls related to requiring staff assist for transfers, toileting, and mobility for safety. The resident had a [DIAGNOSES REDACTED]. The annual MDS 12/3/12 recorded a BIMS score of 11, needed extensive assistance for bed mobility, transfer, dressing, and toileting, needed limited assistance with walking in room, was not able to balance without staff assistance, had 2 falls, 1 with no injury, 1 with injury (except major), and was occasionally incontinent of bladder. The Fall risk assessment dated [DATE] recorded the resident was at risk for falls due to requiring assistance with incontinence, used mobility device when ambulating, had unsteady gait, had transfer difficulties, had impaired judgement/decision making, and had periods of confusion/disorientation. The assessment noted the resident slept in the recliner. The Lift Chair assessment dated [DATE] (after the resident had 2 falls out of the lift recliner) recorded the resident had physical/cognitive limitations, recorded the staff discussed in length with the resident about his/her using a lift chair. The chair belonged to the resident and had it for years. The resident said "where would I sleep if I did not have it?". The resident agreed to have the remote stored in the chair's side pocket along with the cord. The resident did not want to give up his/her lift chair. It was felt the resident could get out of any chair/recliner when he/she had the desire to get up by him/herself. Thirty minute checks continued. The resident said he/she appreciated the staff for their concern about his/her safety and getting hurt worse the next time, but he/she did not want to change anything at this time. Evaluation of Learning: learning accomplished, verbalized understanding. The care plan dated 9/25/12 for falls recorded the resident was at risk for falls, injuries and drug related side effects due to weakness, confusion, and Parkinson's Disease and included the following interventions: The resident slept in recliner in his/her apartment and had recliner moved to his/her room here, assist him/her in transferring to/from the recliner, remind him/her to use call light, and wait for assistance before transferring into or out of recliner, reinforce proper foot wear when up to decrease fall risk, assist as needed to help him/her apply shoes before standing, ambulated with 2 wheel walker for short distances, and used wheel chair for longer, provide stand by and guided assistance for his/her safety, non skid strips in front of recliner and in front of toilet to help prevent slipping. Nurses notes (NN) dated 11/5/12 at 11:57 A.M. late entry the resident slid to the floor at the bottom of his/her recliner after raising the lift chair to the high position without assistance at approximately 6:40 A.M. on 11/2/12. The resident was alert with confusion and staff noted a strong odor of urine. The resident said he/she just slowly slid down to the floor, denied any pain/discomfort. The facility notified the physician for submission of urine culture/sensitivity test due to positive urine dip stick. Order received to start Keflex, an antibiotic. The staff suggested to the resident, only use lift chair controls with staff assist and the resident and family were in agreement. On 11/2/12 fall prevention included the resident would request assist with transfers, permission requested and received to remove lift (recliner) controls from the resident's reach. NN 11/20/12 at 3:13 P.M. late entry recorded at approximately midnight on 11/17/12, direct care staff called this nurse to resident's room. The direct care staff told the nurse over the phone that the resident "fell and laying in a pool of blood." Upon arrival the resident lay on his/her back, legs and arms extended. The vitals signs were fine. Range of motion noted to be full. Eyes tracked within limits. The resident said he/she was not in pain when asked. The staff assisted the resident to a sitting position and noted the occipital area (back part of the head) had a laceration. The nurse cleaned and held pressure to the site of injury. Staff notified security, the local ambulance called and paged the physician to get order to send the resident to the emergency room . NN 11/17/12 at 4:53 A.M. the resident returned from the emergency room via nursing home transportation. Six staples to laceration to back of head, to be removed in 14 days, also returned with a prescription for Levaquin (an antibiotic) for UTI. NN 11/17/12 at 12:50 P.M. the resident had a laceration closed with staples to the occipital area of his/her head that continued to ooze serosanguinous (blood appearance) fluid, denied any recollection of what he/she did or how he/she came to fall. Continued to be confused and having difficulty expressing needs/thoughts. Commuted tomography (CT) scan at hospital during early A.M. showed no evidence of intracranial issues and no fracture. Laboratory tests done showed UTI and the resident started on Levaquin (an anti biotic) and neurological checks continued. The Facility investigation into the event night of 11/16/12 at midnight, the resident had an unwitnessed fall. The staff found him/her on the floor at midnight in front of his/her recliner, he/she had blood pooled under his/her head. The resident could not say how he/she got on the floor except that ' I hit my head. " On 11/16/12 at 11:21 P.M. the resident put on his/her call light that the staff answered in less than 1 minute and assisted the resident to the bathroom. The staff assisted the resident back to the recliner where he/she preferred to sleep. The staff placed the recliner remote in the side pouch out of her reach (as the care plan specified). When the staff found the resident on the floor the recliner was in the incline position half way and the remote was on the floor. There was no staff in the room between the time the staff left and the time the staff found the resident on the floor. We believed by the way the resident lay and the condition the recliner was in that the resident attempted to get up (he/she had not put on his/her call light) and fell out of the chair. On 11/17/12, staff provided thirty minute visual checks for safety and when resident was in the recliner unattended in room staff placed the walker out of resident's reach to ensure he/she used the call light. On 11/19/12 preventative medications to help with frequent urinary tract infections (UTI's). NN 11/17/12 at 5:45 P.M. the staff had just transferred the resident to the recliner from the wheel chair, needed assist of 2 staff due to weakness, denied pain to laceration site, staples intact, remote in side pocket, walker out of reach. NN 11/17/12 at 11:45 P.M. recorded resident voiced no complaints, asleep in recliner, staples remained intact, area was clean/dry, remote to lift chair in side pocket and walker out of reach. NN 11/18/12 at 7:34 P.M. some confusion as to time noted when talking about things in general. The resident used call light for assist to bathroom, reminded not to use remote for chair but to use call light and wait for assistance. NN 11/19/12 at 3:17 A.M. "the resident was confused and did not remember what he/she did when he/she fell , 30 minute checks done for safety, recliner control is out of reach as is walker, and call light clipped to chair." Observation on 12/17/12 at 9:25 A.M. direct care staff D came out of the resident's bathroom with the resident who walked with a 2 wheel roller walker. The staff had a gait belt around the resident and the resident walked slowly to the lift recliner. The staff assisted the resident to his/her lift recliner and sat down in the chair. The staff reached for the remote that was in the pocket by the recliner on the right side. The staff placed the wheel chair by the resident's glass cupboard that stood on his/her left side, and placed the call light in reach. The resident had non skid strips by his/her lift chair and in front of the toilet seat. Interview with direct care staff E on 12/17/12 at 2:20 P.M. said the resident had a lift recliner and the staff placed the controls in the pocket next to the side of the recliner. They removed the wheel chair and the walker and placed it behind the resident's chair so he/she could not reach them. The staff said the resident could reach down into the recliner pocket and get the control for the lift recliner, but said if it was out of sight he/she would not think of using it. The staff said they clipped the call bell by the resident's hand so that it was what he/she saw first and then would use it. Interview with administrative nursing staff B on 12/17/12 at 2:40 P.M. the staff said after the resident's fall out of the lift recliner they became aware that they had to start assessing all the resident ' s who had a lift recliner. The staff said they had not started yet, but the plan was to do it on admission and then quarterly. He/She said the facility did not have a written policy on that. The staff were aware the resident had fallen out of the lift recliner before and the intervention at the time was to keep the lift chair control out of his/her reach. The staff said the staff might not have tucked the cord all the way in the pocket so the resident was able to get a hold of it. The facility failed to assess the cognitively impaired resident's lift recliner for safe usage, and failed to provide effective and timely interventions for the prevention of falls for this resident who experienced two falls from the lift recliner one in which resulted in the resident requiring staples to the head. - Resident #4's annual Minimum Data Set (MDS) 3.0 dated 11/5/12 recorded a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact), needed extensive assistance with bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene, had difficulty balancing without staff support, did not walk in room, had impairment on both sides of lower extremities, used a walker and a wheel chair, and had no falls since last assessment. The CAA (Care Area Assessment) dated 11/6/12 for delirium recorded the resident had a 1 point decrease on the BIMS from his/her last assessment. Due to the resident's short term memory loss he/she did have some difficulties making decisions and relied on staff for reminders of events and relied on his/her family for assistance with finances and complex medical decisions. CAA for falls dated 11/6/12 recorded the resident had no falls recently, but was at risk for falls related to requiring assistance with toileting due to incontinence, his/her history of heart disease, arthritis, impaired hearing, impaired vision, required nursing assistance with transfers due to transferring difficulty, had to wear built up shoe, had periods of confusion/disorientation, had impaired judgement and decision making, had decline in cognitive skills, used multiple medications, at times used a mechanical lift for transfers with 2 staff assist for safety. The resident slept in his/her recliner at night by his/her preference. Fall risk assessment dated [DATE] recorded the resident was at risk for falls. The care plan dated 11/20/12 recorded for falls, injury, and drug related side effects due to limited mobility, pain and use of pharmaceutical interventions and for the staff to take orthostatic blood pressure/pulse weekly, fold the walker and place out of reach when not in use, remind the resident to use call light for needs, and on 4/7/12 keep the recliner remote out of reach when he/she was in the recliner. Nurses notes (NN) dated 4/7/12 at 3:18 A.M. recorded that at 2:20 A.M. the staff heard the resident calling for help. The staff found the resident on the floor, lying on his/her back, in front of his/her electric recliner, which was in the highest position. The resident said he/she did not know what happened, and said "I must have pushed the button in my sleep". The staff noted no injury, and the resident denied hitting his/her head. The clinical record lacked evidence the facility assessed for the safety of the resident's use of an electric lift recliner. Observation on 12/17/12 at 9:40 A.M. the resident sat in a wheel chair in the TV room. Observation on 12/17/12 at 10:40 A.M. the resident had an electric lift chair in their room. The controls of the lift chair hung down onto the floor. An interview on 12/17/12 at 2:20 P.M. with licensed nursing staff C said he/she believed the resident had a lift recliner in his/her room and believed the resident lifted him/herself out of the chair, but needed staff help to get in/out of the chair. An interview 12/17/12 at 2:24 P.M. with direct care staff E said the resident had a lift chair/recliner in his/her room. The staff said the resident was able to use the controls but did not generally do that unless staff were in the room. The staff said they did not have to hide the control from the resident. The staff said the resident needed help with transfers. Interview 12/17/12 at 2:40 P.M. with administrative nursing staff B said the resident fell out of wheel chair in the past, and that the facility had no assessment for the safe use of the lift recliner for this resident. The facility failed to follow care plan interventions for the prevention of falls and failed to assess for the safe use of the lift recliner. - Resident #3's admission Minimum Data Set (MDS) 3.0 dated 11/6/12 recorded a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact), needed limited assistance from staff for bed mobility, transfer, walk in room, locomotion on/off unit, dressing and toileting, had a fall history on admission but no falls since admission. The CAA (Care Area Assessment) for falls dated 11/6/12 recorded the resident had a fall on 10/26/12 in the wellness center, and was sent to the emergency room for an evaluation. The resident sustained [REDACTED]. Per nursing assessment dated [DATE], the resident was at risk for falls due to partial loss of balance while walking, unsteady gait, gait pattern changes when walking, and loss of arm movement. The Fall risk assessment dated [DATE] recorded the resident's favorite chair was his/her rocking chair, but that he/she slept in bed, and that he/she was at risk for falls. The care plan for falls dated 11/26/12 recorded the resident had a fracture of the left wrist and for the staff to monitor orthostatic blood pressure weekly, remind the resident to use the call light for assist for safety, ensure it was always in reach, to keep the room well lit/clutter free, and for the staff to use a gait belt for transfer/ambulation. Observation on 12/17/12 at 10:40 A.M. the resident sat in his/her wheel chair reading a book. The resident was alert/oriented. The resident said he/she broke his/her left wrist when he/she stood up in exercise class while living in his/her apartment, his/her foot caught something and he/she fell . The resident said the cast will come off tomorrow, and then will have physical therapy so he/she would stay for another week at the facility. Observation on 12/17/12 at 2:15 P.M. the resident sat in his/her lift chair with the control next to him/her on the table. Interview on 12/17/12 at 2:35 P.M. with direct care staff E said the resident had falls, took him/herself to the bathroom and that was the issue. The staff said they constantly gave the resident several cues/reminders that if he/she needed to do anything, he/she must use the call light. The staff said the resident was alert/oriented and not confused. An interview 12/17/12 at 2:40 P.M. with administrative staff B said the facility did not conduct an assessment for the lift chair in resident's room. The facility failed to assess for the safe use of the lift recliner.