Every finding on record at Brookdale Overland Park

Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 1 was treated with dignity and respect when Certified Nurses Aide (CNA) M snapped her fingers at R1 in order to get his attention so he would stop acting out.Findings included:- R1's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dysphagia (swallowing difficulty), muscle weakness, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), lack of coordination, dementia (progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness).R1's Admission/ Five Day Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R1 required partial to moderate assistance with oral hygiene, upper body dressing, personal hygiene, rolling in bed, sitting to lying, lying to sitting on the side of the bed, sit to stand, and chair to bed/bed to chair transfers, and toilet transfers. R1 required substantial to maximal assistance with toileting hygiene, shower/bathing, lower body dressing, putting on and taking off footwear. R1 felt down, depressed, or hopeless two to six days. R1 had physical behavioral symptoms directed towards others, he rejected care one to three days.R1's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/21/25 documented he had one episode of pushing and rejecting cares. R1 had cognitive impairment issues and cognitive deficits that could affect his mood, behavior, and ability to understand things. R1 required redirection, encouragement, and ongoing cueing to make safe decisions.R1's Activities of Daily Living (ADL) Care Plan initiated on 12/17/25 directed that he required assistance to dress and for his ADLs.Review of the surveillance footage of R1's room dated 12/21/25 at 11:17 PM revealed four staff members attempting to help R1 get dressed. R1 sat on his bed. There were three staff members, CNA M, CNA N, and a third unidentified staff member in front of him. There was a fourth staff member, Licensed Nurse (LN) G standing behind the group of three staff members in front of R1. CNA M attempted to help R1 get his right arm into his shirt. While doing this CNA M's right arm moved forward quickly, and a snap or pop sound can be heard. After that noise, R1 turned and looked directly at CNA M with a somber look on his face. CNA M continued to attempt to pull his shirt up to his shoulder on his right arm.On 04/14/26 at 12:37 PM, CNA M stated that she snapped her fingers at R1 but did not strike him. CNA M further stated that the snap was to get R1's attention. CNA M explained R1 had been acting out so she snapped her fingers at R1 to get his attention. CNA M revealed that she did not know that there was a camera in R1's room until the next day.On 04/14/26 at 01:15 PM, CNA O stated that in the event that a staff member snapped their fingers at a resident, she would assure the resident that it was not ok to be treated like that and she would report it. CNA O stated that the behavior of snapping at a resident was not ok and she would definitely report it.On 04/14/26 at 01:18 PM, LN H stated that if a staff member snapped at a resident in front of her, LN H would nicely say in front of the resident that was not how staff communicated with residents and have that staff member leave the room. LN H would make sure the resident ok and then report it to management. LN H revealed that she felt a snap was not respectful and it was rude.On 04/14/26 at 02:38 PM, Administrative Nurse D stated that the surveillance video startled her. Administrative Nurse D stated she expected staff to acknowledge that event, address the staff member, and let the on-call staff know. Administrative Nurse D stated that CNA M said the snap was to get R1's attention. Administrative Nurse D further stated that she attempted to explain to CNA M that snapping at a resident could be perceived as derogatory.The facility's Resident Rights policy, reviewed October 2022, documented associates should adhere to and respect resident's rights as applicable to state and federal regulations.The facility's Quality of Life - Dignity policy, last revised March 2026, documented residents should be cared for in a manner that promoted and enhanced their sense of well-being level of satisfaction with life, and feelings of self-worth and self-esteem. The policy documents demeaning practices and standards of care that compromise dignity are prohibited.

The facility had a census of 77 residents. The sample included 18 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure a blanket warming equipment and pressurized supplemental oxygen tanks in a safe, locked area and out of reach of the eight cognitively impaired, independently mobile residents. Findings Included:- On 01/19/26 at 07:04 AM, a walkthrough of the facility revealed an unsecured storage closet next to the nurse's station on the 400 hallway. An inspection of the unsecured closet revealed 25 (full size) and six (small) fully pressurized cylindrical oxygen containers in the oxygen racks. An inspection of the unsecured closet also revealed an Enthermics EC2060 blanket warming unit. The unit was warm to touch and set to 200 degrees Fahrenheit. On 01/19/26 at 07:10 AM, Licensed Nurse (LN) G verified the room was unsecured and stated staff were expected to ensure the door was fully closed before exiting the room. She stated the room was to always remain locked. On 01/22/26 at 11:20 AM, Administrative Nurse D stated the storage closet and oxygen areas were to remain locked. She stated the residents were not allowed to access those areas. A review of the Enthermics EC2060 blanket warming unit operator's manual revealed the risk of exposure to burns and chemicals. A review of the facility's Oxygen policy, revised 08/2023, indicated oxygen cylinders would be stored in a locked, well-ventilated room separated from electrical appliances. A review of the facility's Environment policy, revised 08/2023, indicated the facility would provide a safe, functional, sanitary, and comfortable environment for the residents.

The facility identified a census of 77 residents. The sample included 18 residents, with six residents reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 70's as-needed Lorazepam, antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date, or a physician's rationale for extended use.Findings included:- R70's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (elevated blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), aphagia (loss of the ability to swallow), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), and encounter for palliative care.The Significant Change Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R70 needed substantial to maximal assistance for eating and oral care and was dependent on staff for toileting and bathing. The MDS documented R70 had an impairment of both sides of her upper and lower body. The MDS documented R70 received an antidepressant (a class of medications used to treat mood disorders) medication during the observation period.R70's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/05/25 documented R70 was admitted to the facility for skilled rehabilitation and nursing care with the goal of returning to her home. The CAA documented R70 had continued overall decline in self-care and transitioned to long-term care with hospice services. The CAA documented R70 needed substantial to total assistance of one to two staff for daily activities (ADL). The CAA documented that R70 had depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and took depression medication.R70's Care Plan documented:10/20/25- R70 had a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression.10/20/25- R70 would remain free of drug-related complications.10/20/25- Nursing staff were to administer medication as ordered and monitor for side effects and effectiveness.10/20/25- Nursing staff were to discuss with the physician and family of the ongoing need for the use of the medication.R70's EMR under Orders documented the following physician's order:Lorazepam oral tablet 0.5 milligrams (mg), give one tablet by mouth every four hours as needed for anxiety or hallucination (sensing things while awake that appear to be real, but the mind created), start date 12/12/25.R70's EMR lacked a 14-day stop date for Lorazepam or a physician's rationale for extended use.On 01/22/26 at 10:24 AM, R70 sat in her wheelchair at an activity with peers. R70s head was down, and eyes were shut.On 01/22/26 at 08:21 AM, License Nurse (LN) H stated the physician handled all the 14-day stops on antianxiety medication. LN H stated upon admission, orders were placed in the charts, the night nurse completed a chart check, and the next day, the facility's quality management performed a chart check. LN H stated she was unsure who double-checked hospice orders and monitored the orders for accuracy. On 01/22/26 at 10:58 AM, Administrative Nurse D stated the facility's policy was to follow regulation for as-needed psychotropic medication. She stated that psychotropic medications should have a 14-day stop date or a physician's rationale for extended use. She stated the interdisciplinary team met daily and reviewed new orders and new admissions.The facility's Psychotropic Drug Management Policy, revised 10/2025, documented non-drug interventions should be implemented to the extent possible to assist the resident attain a satisfactory quality of life. The policy documented to provide a therapeutic environment and use only those medications with a therapeutic benefit to the individual resident. Unnecessary drugs should be avoided. An unnecessary drug was any drug when used in excessive dose including duplicate drug therapy, for excessive duration without adequate monitoring, without adequate indication for its reduction or discontinuation.

The facility identified a census of 77 residents. The sample included 18 residents, with one resident reviewed for hospice services. Based on interviews, observation, and record review, the facility failed to provide a description of the medication, services, and equipment provided to Resident (R) 51 by hospice.Findings included:- R51's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), Lewy body dementia (a type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), and major depressive disorder (major mood disorder that causes persistent feelings of sadness).The Significant Change Minimum Data Set (MDS) dated 09/10/25 documented a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition, and no staff interview was completed. The MDS documented R51 received hospice services during the observation period. R51's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/16/25 documented she was admitted on to hospice services on 09/03/25.R51's Care Plan documented the following: 09/03/25- Staff would provide assistance at meals as needed, assistance with transfers as needed, provide incontinence care as needed, and assist R51 with turning and positioning as needed.09/04/25- Staff would assist R51 with dressing and grooming as needed.09/04/25- Staff would coordinate care with the hospice nurse and aides.09/04/25- Staff would notify hospice nurse of changes in condition as needed, give medication(s) as ordered, monitor for relief and document results, notify the physician and hospice if relief was not obtained, and monitor R51 for pain and/or discomfort.The care plan lacked direction for the staff regarding the medications, equipment, and services provided by hospice.R51's EMR under the Orders tab revealed the following physician orders:Admit to hospice with a diagnosis of Alzheimer's disease, early onset, dated 09/03/25.On 01/21/26 at 08:20 AM, R51 was asleep on a chair in the common area. She was seated with her legs over the arm of the chair.On 01/22/26 at 08:37 AM, Certified Medication Aide (CMA) R stated what equipment, supplies, and services provided by hospice should be on the care plan.On 01/22/26 at 08:44 AM, Licensed Nurse (LN) I stated the frequency of hospice staff visits, the equipment, and supplies provided by hospice should be listed on the care plan.On 01/22/26 at 10:56 AM, Administrative Nurse D stated the services, equipment, and medications provided by hospice should be placed on the residents' care plan. Administrative Nurse D stated the unit manager was responsible for ensuring the resident's care plan was updated when a resident was admitted on to hospice services.The facility's Hospice Care policy, revised 12/2025, documented hospice care may be provided when ordered by the health care provider and agreed to by the resident and or representative. The selected hospice would have a current contract with the community which followed federal requirements. The purpose of this policy was to provide hospice care for residents who elected hospice services who have known terminal illnesses or end-stage conditions.

The facility identified a census of 78 residents. The sample included 23 residents. Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards were followed during Resident (R)189's enteral meal (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food) administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases. Findings Included: - On 03/04/24 at 07:17 AM an inspection of the 400 Hall clean linen storage closet revealed a dusty, visibly soiled vacuum cleaner stored in the closet next to uncovered clean linen. On 03/04/24 at 07:52 AM, an inspection of R290's room revealed his continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask placed face down on the nightstand next to his bed. No clean storage container was present in his room for his tubing or mask. On 03/06/24 at 08:30 AM Licensed Nurse (LN) G prepped R189 for her morning enteral nutritional meal via her percutaneous endoscope gastrostomy tube (PEG-a tube inserted through the wall of the abdomen directly into the stomach). LN G completed hand hygiene and entered R189's room. LN placed enteral feeding supplies on a clean barrier on the table. LN G washed her hands in the bathroom sink and donned protective gloves. LN G grabbed an enteral syringe (a large syringe used to assist with feedings and flushes) and attached it to the catheter port. LN G checked for residual fluid volume within R189's stomach and removed the syringe plunger. LN G placed a clean barrier over R189's stomach area and removed her gloves. LN G donned new gloves but did not complete hand hygiene in between glove changes. LN G flushed the syringe with 30 milliliters (ml) of water and then added the premixed enteral solution to the syringe. LN G completed the tube feedings without further issues or concerns. On 03/06/24 at 10:01 AM Certified Nurses Aid (CNA) M stated oxygen tubing and CPAP masks were to be stored in a plastic bag when not in use. She stated hand hygiene should be completed in between glove changes. She stated the vacuum should not be stored in the same closet as the uncovered linens. On 03/06/24 at 11:31 AM Administrative Nurse E stated staff were expected to perform hand hygiene in between changing all personal protective equipment including glove changes. She stated oxygen equipment should be stored in a clean bag to prevent contamination of the masks. She stated dirty or soiled equipment should not be stored in the same area as clean linen. On 03/06/24 at 02:13 PM Administrative Nurse D stated staff were expected to complete hand hygiene in between glove changes. She stated each resident with oxygen equipment should have been provided a bag to store when not in use. She stated soiled equipment should not be stored with clean linens. On 03/06/24 at 08:45 AM LN G stated she would complete hand hygiene in between glove changes. She stated oxygen equipment and masks should be stored in a clean barrier bag to prevent contamination and respiratory infections. The facility's provided Handwashing / Hand Hygiene policy revised 01/2021 indicated staff will complete hand hygiene before, during, and after encountering contaminated surfaces, in between changes of personal protective equipment (PPE), and when visibly soiled. The facility's provided Infection Prevention and Surveillance policy revised 01/2020 indicated the facility will ensure the separation of room and equipment storage between soiled and clean surfaces. The policy indicated clean equipment will never be stored in soiled areas to prevent cross-contamination. The facility failed to ensure appropriate infection control standards were followed during R189's enteral meal administration and storage of R290's oxygen therapy equipment. The facility additionally failed to ensure clean linen storage. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 78 residents. The sample included 23 residents with 10 reviewed for pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to ensure the resident and/or resident's representatives were informed and educated on the pneumococcal vaccination options and provided the current Vaccination Information Statements (VIS) for Residents (R) 30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 03/06/24 at 08:00 AM a review of pneumococcal immunizations was completed for R13, R20, R30, R32, R33, R48, R50, R59, R66, and R76. R30's (severely cognitively impaired resident) Electronic Medical Record (EMR) indicated she was admitted to the facility on [DATE]. The EMR noted she received the Pneumovax 23 (PPSV23-pneumococcal vaccination) before her admission in 2018. An electronically filed Informed Consent for Pneumococcal Vaccine was signed by R30's representative on 09/26/23 but lacked dates the pneumococcal vaccinations were offered, dates of the vaccination information statement (VIS), and dates the vaccination information statement was given to the representative. R48's (severely cognitively impaired resident) EMR indicated she was admitted to the facility on [DATE]. The EMR indicated her last pneumococcal vaccination was PPSV23 in 2006. An Informed Consent for Pneumococcal Vaccine was completed on 11/08/21. The consent form indicated a declination of the pneumococcal conjugate vaccine (PCV13- pneumococcal vaccination) and PPSV23. The form acknowledged her last vaccine was in 2006. The form lacked a signature or verbal consent to decline confirmation from her responsible representative. R50's (severely cognitively impaired resident) EMR indicated she was admitted to the facility on [DATE]. The EMR indicated she received a PPSV23 vaccination before her facility admission on 09/15/21. An Informed Consent for Pneumococcal Vaccine completed on 09/19/23 noted that R50's resident representative declined consent for the pneumonia vaccinations. The consent form lacked dates the pneumococcal vaccinations were offered, dates of the vaccination information statement (VIS), and dates the vaccination information statement was given to her representative. R66's (severely cognitively impaired resident) EMR indicated he was admitted to the facility on [DATE]. The EMR indicated no previously documented pneumococcal vaccination for R66. R66's electronically filed Informed Consent for Pneumococcal Vaccine was signed by his representative on 09/29/23 but lacked information regarding which pneumococcal vaccination was offered and if a vaccination information statement was provided for the vaccines. R76's (severely cognitively impaired resident) EMR indicated he was admitted to the facility on [DATE]. R76's EMR indicated he had no previous pneumonia vaccinations documented. R76's electronically filed Informed Consent for Pneumococcal Vaccine was signed by his representative on 02/01/24 but lacked information regarding which pneumococcal vaccination was offered and if a vaccination information statement was provided for vaccines. On 03/06/24 at 08:20 AM R48's representative stated R48 had been in the facility for quite a while but was not offered a pneumococcal vaccination or education related to R48's pneumococcal vaccination options. She stated that R48 recently started hospice (end-of-life comfort care) services in January 2024 and may not need more vaccinations now, but the facility has not offered the vaccinations since her admission. On 03/06/24 at 08:45 AM R76's representative stated that R76 was admitted recently, and she could not remember being offered any pneumonia vaccination for R76. She stated she would not refuse them if offered. On 03/06/24 at 10:01 AM R66's representative stated he notified the facility he wanted R66 fully immunized and consented to all the vaccines. He stated that R66 received his COVID-19 (highly contagious respiratory virus) and influenza (highly contagious viral infection) vaccinations but was not aware that R66 was due for a pneumococcal vaccination. He stated the facility never offered or discussed R66's pneumococcal vaccination options with him. On 03/06/24 at 10:25 AM R50's representative stated she didn't think R50 needed another vaccination since she received one before she came to the facility but had not been informed by the facility or offered other pneumonia vaccinations since her admission. She stated she would not decline the vaccinations if newer vaccinations were out and offered to R50. On 03/06/24 at 12:04 PM, R30's representative stated the facility had not offered any pneumonia vaccinations for R30 since her admission. She stated she would not decline any immunizations to keep R30 safe or improve her health. She stated that R30 received her influenza and COVID-19 vaccinations recently but was never offered a pneumococcal vaccination. On 03/06/24 at 01:10 PM Administrative Nurse E stated the pneumonia vaccinations were offered by the floor nurses upon admission. She stated the nurses asked at the time of admission and got the orders to give the vaccines. She stated the nurses should provide education related to the vaccinations to the representative and ensure they understand the information provided to them before asking them to sign the paperwork. She stated the facility was currently working on a system to track the updated pneumococcal guidelines. On 03/06/24 at 02:13 PM Administrative Nurse D stated the vaccination consents were provided to the residents upon admission by the nurses. She stated the nurses gave the vaccinations once the physician's order was placed. She stated the nurses were expected to provide education related to the vaccinations and ensure the representatives received the VIS statements. She stated the consent and VIS statements were mailed out to the representative but said she was not sure why resident representatives were not aware of the vaccines or declinations. The facility's provided Pneumococcal Vaccine policy revised 05/2023 indicated each resident will be offered pneumococcal vaccinations when medically eligible. The policy indicates the facility will provide information and education to the resident or representative reflective of benefits and potential side effects. The policy indicated that pneumococcal vaccinations will be offered following the Centers for Disease Control (CDC) recommendations. The facility failed to ensure the resident's representatives were informed and educated on the pneumococcal vaccination options and provided a VIS for R30, R48, R50, R66, and R76. This deficient practice placed the residents at risk for complications related to infectious diseases.

The facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to promote care for Resident (R) 30, who was dependent on staff assistance for all ADLs, in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment. Findings included: - On 03/04/24 at 11:06 AM R30's room was located across from an open communal dining room. R30's door was open. R30 lay in her bed; she wore an incontinence brief and was uncovered from the waist down. R30 was visible from the hallway and part of the dining room while she lay in her bed, with her brief and legs exposed. Staff walked past her room in the hallway while some residents sat in the dining room. On 03/05/24 at 03:25 PM, R30's door was open. R30 lay in bed and slid her bare feet across her mattress. R30 wore only an incontinence brief, and she was uncovered. R30's exposed body was visible from the hallway and part of the dining room across from her room. There were some residents in the dining room. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she was unsure if R30 was able to see or not. CNA M stated R30 was dependent, and staff had to do everything for her which included helping her get dressed. CNA M stated R30's door was left open so staff would keep an eye on her as R30 was a fall risk. CNA M further stated if R30 removed her clothing or blankets, CNA M would go in, cover her up, and help her get situated in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated R30 could not see very well but she was able to track to some degree. LN H stated R30 was dependent, and staff had to do everything for her which included dressing and helping her eat. LN H stated R30's door was left open for fall safety. LN H further stated that she would try and go by R30's room often to cover her up when she would pull her blanket off. LN H stated R30 was more comfortable wearing a nightgown instead of pants, and that staff were aware of her preference as they worked with her regularly. LN H stated that she was unsure if R30's clothing preferences were on her care plan. On 03/06/24 at 02:11 PM Administrative Nurse D stated she was not sure of the level of assistance R30 needed; however, she stated that she believed R30 at least required extensive assistance. Administrative Nurse D stated if R30 was in her room, in only a brief and was uncovered, that it was R30's choice as some people were comfortable that way and R30 did not always want the door shut. Administrative Nurse D further stated she believed staff knew R30's preferences as they worked with her regularly and R30's preferences did not necessarily need to be on her care plan. Administrative Nurse D further stated she expected staff to get to know the resident and their family, and stated, Let us be real here, staff are not reviewing an entire care plan. Administrative Nurse D stated the staff that cared for R30 were consistent, worked with her often, and knew what her preferences were. The facility provided a Quality of Life - Dignity policy with a last revised date of 10/22, documented that residents should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents should be treated with dignity and respect. Associates should promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility failed to promote care for R30, who was dependent on staff assistance for all ADLs in a manner that preserved R30's dignity. These deficient practices placed the resident at risk for impaired psychosocial well-being and an undignified living environment.

The facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 33 with the addition of hospice services. This deficient practice placed R33 at risk for unidentified care needs. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 12/09/23 documented staff would keep hospice informed of durable medical equipment (DME) and supplies needed. Hospice would notify staff of any additional DME or supplies recommended or delivered. The plan of care dated 12/09/23 also documented the staff would adjust the provision of activities of daily living (ADL) to compensate for R33's changing abilities and staff would encourage his participation to the extent that he wished to participate. The plan of care also documented alternate bath days with hospice to promote and provide additional skin care unless R33 preferred alternate arrangements. The plan of care documented that staff would anticipate weight loss, decrease in fluid and/or caloric intake, skin alteration, ADLs, and/or cognitive decline related to terminal illness. The plan of care lacked a description of the services provided by hospice. R33's EMR under the Orders tab revealed the following physician orders: Admit to hospice with a diagnosis of CVA; the resident has six months or less of life dated 10/19/23. A review of R33's clinical record lacked evidence the facility completed a Significant Change MDS to address the resident's recent physical decline and addition of hospice services within the required timeframe. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 11:34 AM, Administrative Nurse F stated she followed the Resident Assessment Instrument (RAI) manual when completing the resident's MDS. Administrative Nurse F stated she relied on the clinical team to inform her of any changes regarding a resident's decline or admission to hospice services. Administrative Nurse F stated she was not informed of R33's admission to hospice services until December 2023 and that is when she completed the Significant Change MDS for R33. The RAI Manual documented that a Significant Change MDS must be completed no later than 14 days after a resident was admitted to hospice services. The facility's MDS Completion and Submission Timeframes policy last revised in July 2017 documented the facility would conduct and submit resident assessments in accordance with current federal and state submission timeframes. The facility failed to identify a significant change and addition of hospice services for R33's physical condition and complete a comprehensive Significant Change MDS, placing the resident at risk of not receiving needed care.

The facility identified a census of 78 residents. The sample included 23 residents. Based on observations, record reviews, and interviews, the facility failed to ensure accurate assessment and documentation on the Minimum Data Set (MDS) related to Resident (R)87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs. Findings Included: - The Medical Diagnosis section within R87's Electronic Medical Records (EMR) included diagnoses of atrial fibrillation (A-fib: rapid, irregular heartbeat), hypertension (high blood pressure), muscle weakness, history of sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), syncope (fainting or passing out), and repeated falls. R87's Admission MDS completed 12/13/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated he was dependent on staff for bed mobility, toileting, bathing, dressing, and hygiene. The MDS indicated he used a wheelchair for mobility and required staff assistance. The MDS indicated he received speech, physical, and occupational therapy services. R87's Discharge MDS completed 01/10/24 documented he was discharged to a short-term general hospital with no anticipated return. R87's Functional Abilities Care Area Assessment (CAA) completed 12/20/23 indicated he was hospitalized at an acute care facility before his admission related to a fall at his home. The CAA noted he was treated for A-Fib and diverticulitis with infection (pouch-like herniations through the muscular layer of the colon) and admitted to the skilled nursing facility. The CAA noted he had deficits with his activities of daily living (ADLs). R87's Care Plan initiated on 12/07/23 indicated he was at risk for falls, skin breakdown, weight loss, and ADL deficits related to his medical diagnoses. The plan indicated he required moderate to extensive assistance from staff related to bathing, bed mobility, dressing, and transfers. The MDS indicated his goal was to complete therapy services and discharge home. R87's EMR under Progress Notes indicated he was discharged home from the facility on 01/10/24 with physical, occupational, and nursing services. The note indicated he received his discharge paperwork and medication review. The note indicated he verbalized an understanding of his provided services and medications. The note indicated he left the facility with his personal belongings with his friend taking him home. On 03/06/24 at 11:34 AM Administrative Nurse F stated R87 was not hospitalized and left the facility as a planned discharge. She stated the MDS should have been coded as a discharge to home/community. The facility's provided Comprehensive Assessment revised 03/2022 the comprehensive assessment will be free of significant errors related to coding of the MDS and changes in the resident status. The facility failed to ensure accurate assessment and documentation on the MDS related to R87's discharge location. This deficient practice had the risk of miscommunication related to R87's continued care needs.

The facility identified a census of 78 residents. The sample included 23 residents with five residents reviewed for activities of daily living (ADLs). Based on observations, record review, and interviews, the facility failed to provide ADL assistance to Resident (R) 30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of restless leg syndrome (a condition that causes a very strong urge to move the legs), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R30 had a Brief Interview for Mental Status (BIMS) score of 00 which suggested severely impaired cognition. The MDS documented R30 used a wheelchair and required substantial/maximal assistance for bathing, and upper body dressing. The MDS documented R30 was dependent on staff for toileting hygiene, lower body dressing, moving from lying to sitting position, and transfers. The MDS documented R30 had severely impaired vision with either no vision at all or only being able to see light, colors, or shapes; eyes do not appear to follow objects. The MDS Section F for resident preferences, which included R30's daily clothing choices, was not addressed. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 02/05/24, documented R30 had a diagnosis of Alzheimer's Disease and severe cognitive impairment. R30's Care Plan with an initiated date of 01/04/23, documented R30 had an ADL self-care performance deficit related to functional decline, malnutrition, weakness, and pain and was receiving hospice services. Interventions initiated on 01/04/23 documented R30 required assistance to turn and reposition in bed, personal hygiene, bathing, eating, and toileting. R30's care plan lacked the level of assistance for dressing, or clothing preferences. On 03/04/24 at 11:06 AM R30's room was located across from an open communal dining room. R30's door was open. R30 lay in her bed; she wore an incontinence brief and was uncovered from the waist down. R30 was visible from the hallway and part of the dining room while she lay in her bed, with her brief and legs exposed. Staff walked past her room in the hallway while some residents sat in the dining room. On 03/05/24 at 03:25 PM, R30's door was open. R30 lay in bed and slid her bare feet across her mattress. R30 wore only an incontinence brief, and she was uncovered. R30's exposed body was visible from the hallway and part of the dining room across from her room. There were some residents in the dining room. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she was unsure if R30 was able to see or not. CNA M stated R30 was dependent, and staff had to do everything for her which included helping her get dressed. CNA M stated R30's door was left open so staff would keep an eye on her due to R30 was a fall risk. CNA M further stated if R30 removed her clothing or blankets, CNA M would go in cover her up, and help her get situated in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated R30 could not see very well but she was able to track to some degree. LN H stated R30 was dependent, and staff had to do everything for her which included dressing and helping her eat. LN H stated R30's door was left open for fall safety. LN H further stated that she would try and go by R30's room often to cover her up when she would pull her blanket off. LN H stated R30 was more comfortable wearing a nightgown instead of pants, and that staff were aware of her preference as they worked with her regularly. LN H stated that she was unsure if R30's clothing preferences were on her care plan. On 03/06/24 at 02:11 PM Administrative Nurse D stated she was not sure of the level of assistance R30 needed; however, she stated that she believed R30 at least required extensive assistance. Administrative Nurse D stated if R30 was in her room, in only a brief and was uncovered, that it was R30's choice as some people were comfortable that way and R30 did not always want the door shut. Administrative Nurse D further stated she believed staff knew R30's preferences as they worked with her regularly and R30's preferences did not necessarily need to be on her care plan. Administrative Nurse D further stated she expected staff to get to know the resident and their family, and stated, Let us be real here, staff are not reviewing an entire care plan. Administrative Nurse D stated the staff that cared for R30 were consistent, worked with her often, and knew what her preferences were. The facility provided a Supporting Activities of Daily Living policy with a last revised date of 02/2024, documented appropriate care and services should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and, or resident representative and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming and oral care. The facility failed to provide ADL assistance to R30, who was dependent on staff assistance for all ADLs. These deficient practices placed the residents at risk of decreased psycho-social well-being and impaired ADL.

The facility identified a census of 78 residents. The sample included 23 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure two residents, Resident (R) 13 and R28 received pressure-reducing interventions for pressure ulcers. This placed R13 and R28 at increased risk for pressure ulcer development. Findings included: - R13's Electronic Medical Record (EMR) documented diagnoses of venous insufficiency (poor circulation), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) with diabetic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), generalized atherosclerosis (the buildup of fats, cholesterol, and other substances in and on the artery walls that can cause arteries to narrow, blocking blood flow), abnormalities of gait and mobility, lack of coordination and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE], documented R13 had a Brief Interview for Mental Status (BIMS) score of 10 which suggested moderately impaired cognition. The MDS documented that R13 used a wheelchair and required substantial/maximal assistance for bathing, dressing, and personal hygiene, and he was dependent on staff for mobility and transfers. The MDS further documented that R13 had two unhealed Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers. The MDS documented R13 was frequently incontinent of urine with seven or more episodes of incontinence, but at least one episode of continent voiding. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 01/11/24, documented that R13 had experienced a functional decline, had a recent fracture, and was no weight bearing to his left lower extremity. The CAA documented R13 required assistance with turning and repositioning. The CAA further documented R13 was readmitted to the facility with Stage 2 wounds to his bilateral (both sides) buttocks. R13's Care Plan with an initiated date of 12/22/23, documented R13 had potential, or actual impairment, to skin integrity related to mobility limitations, incontinence, peripheral vascular disease, venous insufficiency, and an immobilizer to his left lower extremity. An intervention initiated on 01/25/24, documented R13 needed his heels floated. An Order with a start date of 01/08/24, directed staff to float R13's heels while in bed as tolerated, every shift for pressure prevention. R13's Treatment Administration Record (TAR) documented on 03/04/24 day shift that R13's heels were floated. R13's TAR from 03/01/24 - 03/05/24 lacked evidence R13 refused to allow staff to float his heels while in bed. On 03/04/24 at 08:18 AM R13 rested in his bed. R13's heels rested directly on his mattress and the soles of his feet were pressed against the footboard of his bed. There was no evidence of a pillow, wedge, or other device in place to float R13's heels as he lay in bed. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she had access to the Kardex which contained the appropriate information for her to provide appropriate care for the residents. CNA M stated any relevant skin interventions, such as floating a resident's heels, would have been found in the Kardex. CNA M stated when floating a resident's heels, their heels could rest on a pillow, but not rest on a mattress or the footboard of the bed. CNA M stated she was not sure if staff were supposed to float R13's heels while he was in bed. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated everyone had access to the care plan or Kardex which would allow staff to know which residents required pressure-relieving items or interventions. LN H stated R13 was at risk for skin breakdown and his heels should have been floated while in bed. LN H further stated when staff floated R13's heels, staff would place an item under his legs so that his heels were off the bed and that the soles of his feet should not be pressed against the footboard of the bed. LN H stated if a resident refused to have their heels floated, nurses would document the refusal in the resident's TAR. On 03/06/24 at 02:11 PM, Administrative Nurse D stated heels should not rest on the bed or footboard; however, she stated the residents would move around while in bed and sometimes end up with their heels no longer floating. Administrative Nurse D stated the expectation was that staff did not place the resident's heels on the bed or footboard and would use an item such as a pillow or heel risers to float the resident's heels. Administrative Nurse D stated if a resident refused to have their heels floated, she expected the CNAs to inform the nurse on duty, and if the resident continued to refuse that should have been documented somewhere. The facility provided a Skin Observation and Wound Prevention policy with a last revised date of 10/22, documented the charge nurse should observe the condition of the resident's skin on admission and a routine basis. The policy further documented the charge nurse should initiate treatment interventions and the plan of care. The facility failed to ensure R13's heels were floated while he was in bed to prevent pressure ulcers. This placed R13 at increased risk for pressure ulcer development. 41037 - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 was at risk of developing pressure-related injuries and there were pressure-reliving measures in place on her bed and in her wheelchair. R28 had nutritional measures in place during the observation period. The MDS documented R28 did not have any unhealed pressure-related injuries during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented that R28 was at risk for the development of pressure-related injuries and had pressure-relieving measures in place on her bed and in her wheelchair during the observation period. The MDS documented R28 had one unhealed pressure ulcer during the observation period. R28's Pressure Ulcer Care Area Assessment (CAA) dated 10/23/23 documented pressure relieving measures in place for R28 was a low air loss mattress, cushion in her wheelchair and staff would float her heels. R28's Care Plan revised 10/25/23 documented R28 had a low air loss mattress on her bed, a pressure relieving cushion in her wheelchair, and staff would float her heels. R28's Care Plan dated 11/03/23 documented R28 was to wear Prevalon boots (special pressure reducing heel protectors) on her bilateral (both sides) extremities at all times. R28's EMR under the Orders tab revealed the following physician order: Prevalon boots at all times as tolerated. Float heels when resident refused boots dated 03/04/24. On 03/05/24 at 11:00 AM R28 laid on her bed with her head slightly elevated. R28's bilateral heels rested on a pillow at the foot of her bed. Her heels were not floated, and she was not wearing Prevalon boots. On 03/06/24 at 10:28 AM Certified Nurse Aide (CNA) M stated she had access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident) which contained the appropriate information for her to provide appropriate care for the residents. CNA M stated any relevant skin interventions, such as floating a resident's heels, would have been found in the Kardex. CNA M stated when floating a resident's heels, their heels could rest on a pillow, but not rest on a mattress or the footboard of the bed. CNA M stated she was not sure if the staff was supposed to float R28's heels while she was in bed, and she was sure R28 did not have any Prevalon boots. On 03/06/24 at 10:51 AM Licensed Nurse (LN) H stated everyone had access to the care plan or Kardex which would allow staff to know which residents required pressure-relieving items or interventions. LN H stated R28 was at risk for skin breakdown and her heels should have been floated while in bed. LN H further stated when staff floated a resident's heels, staff would place an item under her legs so that her heels were off the bed. LN H was not sure if R33 was to wear Prevalon boots. LN H stated if a resident refused to have their heels floated, nurses would document the refusal in the resident's Treatment Administration Record (TAR). On 03/06/24 at 02:11 PM, Administrative Nurse D stated heels should not rest on the bed or footboard; however, she stated the residents would move around while in bed and sometimes end up with their heels no longer floating. Administrative Nurse D stated the expectation was that staff did not place the resident's heels on the bed or on a pillow or heel risers to float the resident's heels. Administrative Nurse D stated if a resident refused to have their heels floated, she expected the CNAs to inform the nurse on duty, and if the resident continued to refuse that should have been documented somewhere. The facility's Skin Observation and Wound Prevention policy with a last revised date of 10/22, documented the charge nurse should observe the condition of the resident's skin on admission and a routine basis. The policy further documented the charge nurse should initiate treatment interventions and the plan of care. The facility failed to ensure that pressure-reducing measures were placed on R28's bilateral lower extremities as ordered. This deficient practice placed these residents at risk of development of pressure ulcers, and of wound worsening.

The facility identified a census of 78 residents. The sample included 23 residents with three reviewed for bowel and bladder management. Based on observations, record review, and interviews, the facility failed to ensure appropriate Foley catheter care (a tube inserted into the bladder to drain urine into a collection bag) for Resident (R)340 when staff failed to maintain the urine collection bag below R340's bladder to encourage dependent drainage. This deficient practice placed R340 at risk for complications related to urinary tract infections (UTI). Findings Included: - The Medical Diagnosis section within R340's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), history of falling, recent hip fracture (broken bone), retention of urine, and cervical spondylosis (age-related breakdown of bones in her hip) R340's EMR indicated she was admitted on [DATE] and a Minimum Data Set (MDS) was not completed for review. R340's Care Plan initiated 02/29/24 indicated she had an indwelling catheter related to her urinary retention. The plan indicated staff were to check the catheter and provide care as ordered. The plan instructed staff to ensure the catheter's tubing and urine collection bag were positioned lower than her bladder. The plan instructed staff to check the catheter tubing for kinks. R340's Physician's Orders indicated an order dated 02/29/24 for staff to monitor her indwelling catheter and provide catheter care each shift. The order noted she had a size 16 French (Fr-size of the indwelling catheter) and ordered staff to ensure the urine collection bag was secured below her bladder. On 03/05/24 at 10:03 AM R340 sat in her wheelchair in her room. R340's catheter bag was placed in a dignity bag mounted on the right armrest of her wheelchair parallel to her bladder. Urine pooled in the tubing. As R340 adjusted her positioning in the chair the pooled urine back flowed towards her bladder. R340 stated she had just been admitted to the facility after a recent fall while at home. On 03/06/24 at 08:23 AM, R340 returned to her room after breakfast. R340's catheter urine collection bag and dignity bag still hung on her right armrest. Urine was visibly pooled in the tubing. On 03/06/24 at 10:01 AM Certified Nurse Aid (CNA) M stated the catheter tubing and bag should be placed below the bladder to ensure the urine drained down to the collection bag with gravity. She stated staff checked the urine collection bag position during each encounter. On 03/06/24 at 11:10 AM Licensed Nurse (LN) G stated the catheter bag should be placed in a manner that allowed the urine to flow downward to the bag. On 03/06/24 at 02:10 PM Administrative Nurse D stated staff were expected to ensure the catheter bag was placed below R340's bladder. She stated urine should not be allowed to pool in the catheter tubing. The facility's provided Urinary Cather Care policy indicated staff was expected to check each urinary catheter placement and ensure the drainage bag should be held or positioned lower than the bladder to prevent urine backflow into the tubing. The facility failed to ensure appropriate Foley catheter care and services for R340. This deficient practice placed R340 at risk for complications related to urinary tract infections.

The facility identified a census of 78 residents. The sample included 23 residents with one resident sampled for intravenous (IV-administered directly into the bloodstream via a vein) therapy. Based on observation, record review, and interview, the facility failed to assess and document the location, appearance, and patency (the quality of being open and unobstructed) each shift for Resident (R) 191's IV access site. This placed R191 at risk of infection and complications related to IV therapy. Findings included: - The electronic medical record (EMR) for R191 documented diagnoses of infection and inflammation reaction due to internal joint prosthesis (a device that is placed inside a person's body during a procedure to permanently replace joint), and methicillin-susceptible staphylococcus aureus infection (MSSA- a bacterial infection that develops when bacteria enter the body through a cut or wound on the skin). The Admission Minimum Data Set (MDS) for R191 had not been completed yet due to her admitted [DATE]. The Care Area Assessments (CAA) for R191 had not been completed yet. R191's IV Medications Care Plan initiated 02/27/24 directed staff to monitor, document, and report to the physician any signs and symptoms of complications. Staff was to change the IV dressing as ordered. Staff was to check the dressing site daily. Staff was to monitor, document, and report signs and symptoms of infection or infiltration (leakage of fluid out of the vein) at the site including drainage, inflammation, swelling, redness, and warmth. The Treatment Administration Record (TAR) for R191 documented to observe the peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) site and document in a progress note every shift with intermittent therapy before and after administration of medications, during dressing changes and as needed for infiltration and extravasation (leakage of intravenously administered solution into surrounding tissues) every shift for PICC site observation. R191's TAR documented an order dated 03/05/24 to change the valved PICC needleless connector and transparent dressing weekly and as needed. Document upper arm circumference in centimeters (cm) and external catheter length in cm with each dressing change. Compare to previous measurements. Notify the physician if the length has changed since the last measurement. One time a day every Tuesday for PICC line maintenance and measurements. A review of R191's Progress Notes from her admission on 02/27/24 through 03/06/24 lacked evidence staff monitored, assessed, and documented R191's PICC line access site before and after the administration of any medication or flush including the type of access, the location of site, or any sign or symptoms of infection or infiltration. On 03/04/24 at 10:53 AM R191 lay in bed with her right arm in an immobilizer (a device used to keep the arm stable and close to the body) and elevated on a pillow. R191 had a PICC line access to her right arm. On 03/06/24 at 08:28 AM Licensed Nurse (LN) G stated that R191's PICC line access was observed and documented on each shift after administration of her medication. LN G stated she only documented on R191's PICC line if she noted any abnormal findings or complications during the administration of her antibiotic (a medication used to treat infections). On 03/06/24 at 02:40 PM Administrative Nurse D stated the facility charted the status of IV access sites by exception (only if there were abnormal findings). Administrative Nurse D stated in the TAR records that the nurse observed the access site, but nursing staff only documented the appearance of the IV site if an abnormality was noted. The facility did not provide a policy regarding the care of IV access sites. The facility failed to ensure that nursing staff appropriately assessed and documented the location, appearance, and patency of R191's PICC line IV access site. This placed R191 at risk of infection and complications related to IV therapy.

The facility identified a census of 78 residents. The sample included 23 residents with seven residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 33. This deficient practice had the risk of unnecessary medication use and physical complications for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 03/22/23 documented that nursing staff would administer medications as ordered by the physician. R33's EMR under the Orders tab revealed the following physician orders: Voltaren external gel one percent (topical) apply to the neck topically three times a day for neck pain dated 03/24/23. A review of the Monthly Medication Review (MMR) provided by the facility from June 2023 through February 2024 lacked evidence of notification for a lack of dosing instructions for Voltaren. The facility provided an order dated 03/06/24 for R33's Voltaren gel that included dose instructions. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated she did not review or handle the MMRs provided by the pharmacist. On 03/06/24 at 02:13 PM, Administrative Nurse D stated R33's Voltaren gel should have a dose for application. Administrative Nurse D stated she would expect the CP to identify that irregularity during their monthly reviews. Administrative Nurse D stated that Voltaren orders that needed a dose added were one of the most common recommendations from the pharmacist. The facility's Medication Regimen Review (MRR) Policy dated July 2018 documented a drug regimen review was performed for each resident at the time of admission, monthly thereafter, and as indicated, based upon a resident's condition. This Medication Regimen Review (MRR) included, but was not limited to, time frames for different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The Consulting Pharmacist would review each resident's medical record (including lab tests/results), progress notes, and other applicable documents as necessary per state and federal regulations, to determine whether irregularities exist in his/her medication regimen and complete a Medication Regimen Review (MRR). The facility would maintain copies of MRRs within resident's medical records. The facility failed to ensure the CP identified and reported irregularities in the lack of dosing instructions for Voltaren gel for R33. This deficient practice placed R33 at risk for unnecessary medication use, side effects, and physical complications.

The facility identified a census of 78 residents. The sample included 23 residents with five residents sampled for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a dosage was indicated for the use of Voltaren (a topical gel used for the treatment of pain) for Resident (R) 73 and R33. This deficient practice placed R73 and R33 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R73 documented diagnosis of effusion (accumulation of fluid) of the left knee, pain in the left knee, and fracture of the left tibia (the inner and typically larger of the two bones between the knee and the ankle) The Admission Minimum Data Set (MDS) dated [DATE] documented R73 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R73 had a functional limitation in the range of motion on one side of both upper and lower extremities. R73 required substantial/maximal assistance to dependence with activities of daily living (ADL). R73 received scheduled pain medications. R73 frequently had pain. R73 received an opioid (a medication used for pain relief) while being a resident. The Pain Care Area Assessment (CAA) dated 02/05/24 documented R73 had a fractured left tibia and reported pain at a six out of 10 on the pain scale (0 to 10 scale with zero being no pain and 10 the worst pain imaginable) that interfered with his sleep and day to day activities. R73 received routine and as-needed pain medication. R73's Pain Care Plan initiated 01/29/24 for R73 directed staff to encourage the resident to report pain. The March 2024 Treatment Administration Record (TAR) in the EMR for R73 documented an order dated 02/15/24 for Voltaren topical gel 1% to be applied to the left knee topically every morning and a bedtime for pain. The order on the TAR lacked an indicated dose amount to apply. On 03/05/24 at 02:05 PM, R73 sat in his wheelchair with his feet on foot pedals. Staff propelled R73 down the hall. On 03/06/24 at 08:28 AM Licensed Nurse (LN) G stated she expected all medications that were to have a dosage amount. LN G stated she believed typically the dose was included in the order for Voltaren. On 03/06/24 at 02:42 PM Administrative Nurse D stated that R73's order for Voltaren under the Orders tab of the EMR did show the amount to apply for the medication. Administrative Nurse D could not state a reason why the amount to apply for the Voltaren did not show up on the MAR/TAR. The facility policy Physician Order Chart Audit last revised in July 2015 documented the resident's physician order section of the medical record and electronic orders would be reviewed every 24 hours for accuracy. The charge nurse would verify the order had been written correctly and that all medications and treatments were transcribed accurately to the electronic MAR and TAR. Notify the health care provider as indicated for any discrepancies found in the orders. The facility failed to ensure a dosage was indicated on R73's order for Voltaren. This deficient practice placed R73 at risk for unnecessary medication administration and possible adverse side effects. 41037 - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 03/22/23 documented that nursing staff would administer medications as ordered by the physician. R33's EMR under the Orders tab revealed the following physician orders: Voltaren external gel one percent (topical) apply to the neck topically three times a day for neck pain dated 03/24/23. The facility provided an order dated 03/06/24 for R33's Voltaren gel that included dose instructions. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated she did not know if R33's Voltaren gel had dose instructions included for administration. LN H stated she would clarify the order if the order lacked dosage instructions. On 03/06/24 at 02:13 PM, Administrative Nurse D stated R33's Voltaren gel should have a dose for application. Administrative Nurse D stated she would expect there to be clarification. Of the order. The facility's Physician Order Chart Audit policy last revised in July 2015 documented the resident's physician order section of the medical record and electronic orders would be reviewed every twenty-four hours for accuracy on a designated shift. Ensure orders have been written correctly. Notify the health care provider as indicated for any discrepancies found in the orders. The facility failed to ensure dosing instructions for Voltaren gel for R33. This deficient practice placed R33 at risk for unnecessary medication use, side effects, and physical complications.

The facility identified a census of 78 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure that physician-ordered laboratory test results for Resident (R) 28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R28's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R28 received diuretic medication (medication to promote the formation and excretion of urine) during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 12 which indicated moderately impaired cognition. The MDS documented that R28 received diuretic medication during the observation period. R28 's Dehydration Care Area Assessment (CAA) dated 10/15/23 documented fluids for hydration would be provided and labs as available. R28's Care Plan dated 10/10/23 documented that nursing staff would monitor labs and report abnormal lab values to the physician. R28's EMR under the Orders tab revealed the following physician orders: Complete Blood Count (CBC-laboratory blood test) and comprehensive Metabolic Panel (CMP- laboratory blood test) on 11/22/23 dated 11/21/23. Obtain Basic Metabolic Panel (BMP-laboratory blood test) on Monday dated 11/23/23. Repeat potassium level (laboratory blood test) on 11/30/23 dated 11/27/23. Obtain potassium level on 12/05/23 for follow-up hypokalemia (low level of potassium in the blood) dated 12/01/23. Obtain CBC on 12/05/23 dated 12/02/23. Obtain CBC, and CMP on 12/21/23 for follow-up hypokalemia dated 12/19/23. Obtain CBC, BMP on 01/16/24 dated 01/12/24. A review of R28's clinical record lacked evidence of the results of the physician-ordered laboratory tests. The facility was able to provide unsigned copies of the results after a request on 03/06/24. On 03/05/24 at 11:00 AM R28 laid on her bed with her head slightly elevated. R28's bilateral heels rested on a pillow at the foot of her bed. Her heels were not floated, and she was not wearing Prevalon boots (special pressure-reducing heel protectors). On 03/06/24 at 10:05 AM, Administrative Nurse D stated she was not sure if the laboratory results for R28 were in R28's clinical record. Administrative Nurse D stated she printed the results from the laboratory provider's portal. Administrative Nurse D stated the facility expected the physicians to log into the laboratory portal and review the lab work that was ordered daily. Administrative Nurse D stated the facility nurses did not print or review the lab results or notify the physician unless a critical lab value was called to the facility. The facility's Laboratory Services and Critical Lab Values Policy last revised August 2023 documented that the purpose of this policy was to provide laboratory services to meet the needs of residents and to provide information concerning critical lab values to the healthcare provider. Reporting laboratory results, the laboratory would submit the results of tests to the community. The nurse would submit the results of laboratory tests to the healthcare provider. The facility failed to ensure that physician-ordered laboratory test results for R28 were included in R28's clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

The facility identified a census of 78 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 33 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R33. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of atrial fibrillation (rapid, irregular heartbeat), cerebrovascular accident (CVA-stroke- the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R33 received hospice services during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated severely impaired cognition. The MDS documented that R33 received hospice services during the observation period. R33's Functional Abilities Care Area Assessment (CAA) dated 12/23/23 documented R33 had a CVA, and hospice services were provided to add additional support for him. R33's Care Plan dated 12/09/23 documented that staff would keep hospice informed of durable medical equipment (DME) and supplies needed. Hospice would notify staff of any additional DME or supplies recommended or delivered. The plan of care dated 12/09/23 also documented the staff would adjust the provision of activities of daily living (ADL) to compensate for R33's changing abilities and staff would encourage his participation to the extent that he wished to participate. The plan of care also documented alternate bath days with hospice to promote and provide additional skin care unless R33 preferred alternate arrangements. The plan of care documented that staff would anticipate weight loss, decrease in fluid and/or caloric intake, skin alteration, ADLs, and/or cognitive decline related to terminal illness. The plan of care lacked a description of the services provided by hospice. R33's EMR under the Orders tab revealed the following physician orders: Admit to hospice with a diagnosis of CVA, the resident has six months or less of life dated 10/19/23. On 03/05/24 at 11:06 AM, R33 sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. R33 was asleep with his head tilted to the right side. On 03/06/24 at 10:28 AM, Certified Nurse Aide (CNA) M stated she knew which residents were on hospice services from the shift report. CNA M stated if a hospice person needed anything, she would tell the nurse. CNA M stated she did not know for sure if any of the hospice information was found on the care plan or Kardex (a nursing tool that gives a brief overview of the care needs of each resident). On 03/06/24 at 10:52 AM, Licensed Nurse (LN) H stated all staff had access to the Kardex and care plan to review for information regarding each resident's care. LN H stated hospice information should be on the Kardex for the staff to be aware of the care provided by hospice. On 03/06/24 at 02:13 PM, Administrative Nurse D stated hospice information and services provided by hospice should be included in R33's care plan for collaboration of care. The facility's Hospice policy last revised on 10/20/16 documented that hospice care may be provided when ordered by the health care provider and agreed to by the resident and or legal representative. The selected hospice would have a current contract with the community which follows federal requirements. The purpose of this policy was to provide hospice care for the resident who was terminally ill and to coordinate the care of residents who elect hospice services. A designated member of the interdisciplinary group who was responsible for providing the overall coordination of hospice care with the skilled nursing community. A collaboration on a revised, integrated care plan. A significant change Minimum Data Set (MOS) would be completed per Resident Assessment Instrument (RAI) guidelines. The community and hospice staff would collaborate regularly concerning the resident's care. Hospice progress notes would be included in the resident's medical record and nursing associates would be informed of any changes recommended by the hospice staff. The facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider and failed to provide a description of the services, medication, and equipment provided to R33 by hospice. This deficient practice placed R33 at risk for delayed services which could affect her mental, and psychosocial well-being.

The facility reported a census of 77 residents. The sample included three residents identified at risk for falls. Based on record review and interviews, the facility failed to ensure staff provided Resident (R) 1 with adequate supervision and assistance to prevent accidents. R1 was cognitively impaired and required assistance of two staff for transfers and toileting. R1 was at high risk for falls with a previous fall in the facility resulting in a major injury on [DATE] and R1 received anticoagulants (blood thinners) daily. On [DATE] Certified Nurse Aid (CNA) M and CNA N assisted R1 to the bathroom. CNA M left the room and CNA N stepped out of the bathroom per R1's request. CNA N then heard a call for help from outside R1's room and left R1's room, leaving R1 unattended in the bathroom. A few minutes later, Licensed Nurse (LN) G heard hollering from R1's room and responded. LN G saw R1 lying on the floor bleeding from his head. Staff alerted emergency services and R1 went to the acute hospital where he was admitted to the Intensive Care Unit (ICU) for subdural hematomas (collection of blood between the covering of the brain (dura) and the surface of the brain) and intercranial bleeding (bleeding inside the skull). R1 passed away in the ICU five days later due to head trauma. The facility's failure to provide adequate supervision and staff assistance to promote safety and prevent accidents placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of right and left leg artificial hip joint replacement, a healing fracture of the right clavicle (broken shoulder bone), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat), post hemorrhagic anemia (a condition of a low number of red blood cells or a low amount of hemoglobin (oxygen) in the red blood cells, that develops when a large amount of blood is lost quickly), difficulty with walking, and a need for assistance with personal cares. R1's Entry Tracker Minimum Data Set (MDS) dated [DATE] recorded R1 admitted to the facility. R1's Discharge-Return Anticipated MDS dated [DATE] recorded R1 had an unplanned discharged to an acute hospital. The MDS recorded R1 had a fall with injury prior to admission. The MDS further noted R1 had one fall since admission which resulted in a major injury. R1's Admission MDS dated [DATE] recorded R1 had a Brief Interview for Mental Status score of eight which indicated severe cognitive impairment. The MDS documented R1 had no behaviors or rejections of cares. The MDS recorded R1 received an anticoagulant for six of the seven look back days. The MDS recorded R1 required extensive assistance of one staff for personal hygiene and locomotion using a wheelchair. The MDS documented R1 required extensive assistance of two staff for dressing, bed mobility, transfers, and toileting. The Care Area Assessment (CAA) dated [DATE] recorded R1 required ongoing cueing and redirection to make safe decisions; staff were to anticipate R1's needs and allow time for R1 to process and respond to request. The CAA recorded R1 had decreased function with activities of daily living (ADL), decreased functional mobility, and was transitioned to the facility for a short-term stay. R1 would receive therapy services and return to an apartment on memory care upon discharge from skilled services. The CAA noted staff would assist R1 by placing R1's call light, medical equipment and bedside items within reach and anticipate some of R1's needs to decrease R1's impulsivity. R1's initial Care Plan dated [DATE] and updated on [DATE] documented R1 was at risk for falls. R1's Care Plan documented directed staff to provide physical therapy (PT) evaluation and treatment, occupational therapy (OT) evaluation and treatment, and recorded an order dated [DATE] to transfer R1 to the emergency department for evaluation and treatment post fall. This initial Care Plan lacked documentation of any specific interventions to prevent fall., The Care Plan further lacked documentation to clearly identify the resident's mobility, transfer and, ambulatory status and amount of staff assistance required. The comprehensive Care Plan created [DATE] and revised [DATE] documented R1 sustained a fall with a fracture to his right hip, left hip, and lateral end of right clavicle. R1 was at risk for repeated falls, due to vascular dementia with agitation, atrial fibrillation, tachycardia (abnormally fast heart rate), decreased mobility, incontinence, and self-care deficits. The care plan documented R1 had a score of 20 on his fall assessment which indicated he was at high risk for falls. R1's Care Plan directed staff to make sure his call light was in reach, and to provide prompt response to requests for assistance (created [DATE] and revised on [DATE]); ensure R1's bed was in the lowest position when in use ([DATE]). The plan directed staff to place R1 in a room close to the nurses' station for increased observation ([DATE]), and directed staff to provide R1 with ongoing cueing, redirection, reminders, and encouragement ([DATE]). The plan directed OT and PT would evaluate and treat as ordered. The Care Plan further recorded a fall with laceration on [DATE]. R1's Care Plan dated [DATE], and revised on [DATE], directed staff R1 was on anticoagulation therapy and was at risk for increased bleeding and bruising. R1's Care Plan dated [DATE] directed staff R1 required One-Two Person Physical Assistance for both transfers and toilet use. R1's EMR recorded a Situation Background Assessment Recommendation (SBAR) report under the Progress Notes tab dated [DATE] at 06:47 PM which documented staff checked R1 for injuries and assisted R1 to bed after his fall. Staff recommended a Telehealth physician follow up. A Telehealth Progress Note dated [DATE] at 08:40 PM, R1 had a fall earlier in the day. He had a bruise on the right hip and complained of extreme pain, with any movement of extremity. The note recorded R1 fell and had extreme pain in his right hip/leg and was unable to move the leg. The note documented R1 had a protrusion above a bruise on his right hip. The note directed to send R1 to the emergency room (ER) for evaluation of right hip deformity with pain. The Hospital Discharge Report dated [DATE] documented R1 was admitted to the hospital after sustaining a fall at the skilled nursing facility and was found to have a right femoral neck (where the thigh bone meets the hip bone) fracture. The report documented R1's post- operative coarse was complicated by anemia, which was thought to be anemia of chronic disease and blood loss from two hip fractures, back-to-back. R1's EMR listed Physician Orders dated [DATE] for Plavix (antiplatelet medication which prevents blood from clotting) 75 milligrams (mg) daily and Xarelto (prescription blood thinner) 10 mg daily. Review of a Telehealth Progress Note dated [DATE] at 07:18 AM documented R1 had an unwitnessed fall in the bathroom and sustained a laceration to the back of the head with bleeding. Staff sent R1 to the hospital. The undated Facility Investigation noted on Friday [DATE] at 05:50 AM, CNA M and CNA M assisted R1 out of bed. The two CNAs transferred R1 to the toilet so R1 could attempt to void. R1 recently had a Foley catheter (tube inserted directly into the bladder to drain urine) removed and staff were helping retrain with toilet use. After assisting R1 onto the toilet with a two-person assist, CNA M went to assist another patient in the room next to R1's. The second CNA (CNA N) heard a scream and went to check the source. The charge nurse (LN G) heard a noise from R1's room and went to check on him. Upon entering the room, the bathroom door was slightly ajar, and LN G found R1 lying on his back on the bathroom floor. There was a blood visibly coming from R1's head. LN G applied pressure and called for assistance. R1 was alert with clear speech but unable to state how he fell . Staff notified emergency services immediately to transfer R1 to the emergency department for further evaluation and treatment. The investigation recorded the time from when staff transferred R1 on to the toilet to the time of fall was three minutes. The investigation stated interventions in place at time of fall were non-skid footwear. The investigation further noted R1 required two staff assistance for transfers and toileting and the investigation indicated that directives were followed by staff. The Witness Statement dated [DATE] from CNA M noted on [DATE] CNA M assisted R1 to the toilet with the help of CNA N. The statement recorded R1 did not want the CNA staff in the bathroom, so they handed R1 the call cord, placed it in his hand, and locked R1's wheelchair. The CNAs then went outside the bathroom door. CNA N stayed with R1, but outside the door, and CNA M went to assist another resident. CNA M later heard LN G call for help and went to R1's room and R1 was on the floor in the bathroom and his head was bleeding. LN G applied pressure and called 911. The Witness Statement dated [DATE] from CNA N recorded on [DATE] CNA N transferred R1 to the toilet with CNA M. After the transfer, staff locked R1's wheelchair and handed R1 the call cord. CNA N stayed outside R1's door when CNA M went to another resident's room. CNA N then heard a scream and went to check the source. CNA N then heard LN G call for help from R1's room. The Witness Statement dated [DATE] from LN G recorded LN G was rounding and doing morning medications. LN G heard a noise coming for R1's room. LN G entered R1's room and observed R1 on the floor, with no bottoms or briefs on. R1's head was partially in the doorway and his legs were extended towards the shower. He was laying on his back. R1 had blood coming from his head so LN G applied pressure and called 911. R1's head scan result dated [DATE] at 08:07 AM and signed by Consultant II listed the following findings: Left paraflacine (area of the brain) subdural hematoma, 7 millimeters (mm) in thickness, left temporal (area of the skull on the side by the ears) subdural hematoma 3 mm in thickness and left posterior (towards the back) parietal (side of the skull above the temporal area) subdural hematoma 5 mm in thickness. Intraventricular (inside the spaces in the brain that contain the cerebral spinal fluid) hemorrhage within the left lateral (away from the midline of the body) ventricle posterior dura. Mild subarachnoid (the space between the brain and the tissue covering the brain) hemorrhage. At the time of the survey, LN G, CNA M, and CNA N were no longer employed by the facility and were not available for interview. On [DATE] at 03:15 PM Consultant HH stated R1 admitted to the facility with a broken hip after a fall in an assisted living. He stated the resident was in the facility for two days and fell and broke his other hip. Consultant HH stated R1 returned to the facility on [DATE] following surgery to repair the broken hip from the [DATE] fall. Consultant HH stated R1 received two different anticoagulants. Consultant GG reported the resident admitted to the ICU for multiple brain bleed and died five days later. Consultant HH indicated R1's death certificate listed head trauma as the cause of death. Interviewed on [DATE] at 03:47 PM CNA O stated staff should stay in the bathroom with the resident during toileting to be safe, especially if the resident required two staff assistance. Interviewed on [DATE] at 03:53 PM CNA P stated she worked with R1 a few times. CNA P said she stayed in the bathroom with R1. She said R1 had never asked her to step out. Interviewed on [DATE] at 03:59 PM CNA Q stated she vaguely remembered R1 but knew that R1 required two-person assistance. CNA Q said R1 resisted care sometimes so for R1's safety, she stayed with the resident in the bathroom. She said she would not leave R1 alone in bathroom because he was a fall risk. On [DATE] at 03:41 PM Administrative Nurse D explained CNA N left R1's because another resident, who was a high fall risk, fell and the CNA was trying to assist. Administrative Nurse D said only three minutes elapsed from the time staff transferred R1 to the time R1 fell . Administrative Nurse D reported it was unreasonable to expect staff to remain with the resident once the resident asked for privacy. Administrative Nurse D said it was difficult to say that someone should have stayed with the resident, as R1 was not even standing at that point. Administrative Nurse D went on to say not all residents who require a two person assist with toileting were cognitively impaired so a staff member would not remain in the room. Administrative Nurse D stated in R1's fall, it would not have made a difference if staff were present in the room. The facility policy Falls Prevention last revised ,d+[DATE] directed that while all falls cannot be prevented, certain interventions may reduce the risk of falling. Early identification of risk for falls and reduction of multiple falls may enable residents to maintain their dignity and maximize their level of independence. The facility's failure to provide adequate supervision and staff assistance to promote safety and prevent accidents placed R1 in immediate jeopardy. The facility implemented corrective actions which included staff education and competencies on fall prevention and management, ADL training, and safe resident transfer training. The facility implemented a performance improvement plan via Quality Assurance and Performance Improvement (QAPI). The corrections were completed on [DATE] therefore the citation was issued as past noncompliance and remained at the scope and severity of J.

The facility identified a census of 80 residents. The sample included 18 residents with seven reviewed for medication regimen review. Based of observations, record review, and interviews, the facility failed to ensure that the Consulting Pharmacist (CP) identified Resident (R)27's blood pressure medication given outside of physician ordered parameters. The CP also did not identify and report an inappropriate diagnoses for R11, R31, and R64's antipsychotic medications (class of medications used to treat [CONDITION(S)] and other mental emotional conditions). This placed the residents at risk for unnecessary medication and adverse side effects. Findings Included: - The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), [CONDITION(S)] (low blood pressure), [CONDITION(S)] (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), neuralgia (severe pain due to damaged nerves that causes severe burning pain), and muscle weakness. R27's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted that he required extensive assistance from two staff members for bed mobility, dressing, and toileting. The MDS indicated that he was totally dependent on two staff for all transfers and bathing. The MDS noted he had been taking opioid (narcotic pain medication) medication for pain. A review of R27's Pain Care Area Assessment (CAA) dated 07/25/22 noted that he had alterations with his comfort levels due to his neuralgia (severe pain due to damaged nerves) and neuritis (inflammation of a or nerves, usually causing pain and loss of function) associated with his [CONDITION(S)]. The CAA noted that staff were to assess and treat with ordered medications. R27's Care Plan initiated 07/12/22 indicated that he had an alteration in movement, pain, pulse (heart rate) and touch sensations. The care plan instructed staff to give medications as ordered. The care plan indicated that staff were to monitor and document the treatment for effectiveness and side effects. A review of R27's EMR under Physician's Order revealed an order for [MEDICATION(S)] (medication used to treat low blood pressure). The order noted for staff to give 10 milligrams (mg) of [MEDICATION(S)] three times daily for [CONDITION(S)]. The order's parameters instructed that staff were to hold the medication if R27's systolic blood pressure (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) was greater than (>) 140 millimeters of mercury (mmHg). R27's Medication Administration Record (MAR) review from 07/12/22 throught 09/08/22 (59 days reviewed)revealed that the medication had been given on eight occasions outside of the ordered parameters. R27's EMR lacked documentation indicating why the medication had been given and if the physician had been notified. The dates noted were 8/3, 8/20, 8/23, 8/26, 8/28, 9/1, and 9/4. A review of R27's Pharmacy Medication Regimen Reviews completed for August 2022 revealed that the pharmacy had no concerns or recommendations related to R27's medications or physician's orders. On 09/07/22 at 09:40AM R27 was in his room preparing for his discharge. Staff transferred R27 from his bed to electric wheelchair with a mechanical lift with two staff assisting. R27 was weighed using the lift's weight scale and transferred to his chair. R27 completed personal hygiene and awaited his transportation for discharge. On 09/08/22 at 03:45PM Administrative Nurse D stated that nursing staff were required to review the medication parameters before administering the medications and notifying the physician. She stated that medications given should always be noted. She stated that the physicians were always around to ask in person if a medication should have been given and the nurse would not have noted it down. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/2022 at 02:49PM the CP was unavailable for interview. A review of the facility's Medication Regimen Review (MRR) policy revised 07/2018 noted that a medication review is completed for each resident at the time of admission, monthly, and as indicated upon the resident's condition. The policy noted that the consulting pharmacist (CP) will identify and report medication irregularities identified during the review to the facility. The facility failed to ensure that the CP identified and reported R27's blood pressure medication was given on eight occasions outside of the ordered parameters. This deficient practice place R27 at risk for complications related to his cardiovascular health. - The electronic medical record (EMR) for R11 documented diagnoses of: dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal and physical aggression, wandering and hoarding), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusional disorder (a type of serious mental illness in which a person cannot tell what is real from what is imagined). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R11 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R11 required extensive assistance with activities of daily living (ADLS) of one to two staff. R11 received an antipsychotic medication on seven of seven days during the lookback period. R11 received an antipsychotic medication on a routine basis. The Quarterly MDS dated [DATE] documented R11 had a BIMS score of zero which indicated severely impaired cognition. R11 showed behaviors of inattention that fluctuated. R11 required extensive assistance of one staff member for her ADLs. R11 received antipsychotic medications on a routine basis on seven of seven days during the lookback period. The [CONDITION(S)] Drug Use Care Area Assessment (CAA) documented R11 had the potential for adverse side effects due to the use of antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) and antipsychotic medications. Both depression with behaviors and medications used to treat them can have a negative impact on the resident. Staff was to maintain adequate control of signs and symptoms with minimal to no adverse side effects. The Anti-psychotic Care Plan revised 03/28/22 documented R11 used antipsychotic medication [MEDICATION(S)] related to dementia with behaviors. Staff was to administer medication as ordered. Pharmacy was to consult month and as needed. The September 2022 Medication Administration Record (MAR) documented an order for [MEDICATION(S)] tablet 100 milligrams (mg) to give one tablet by mouth in the morning for anxiety/agitation related to dementia with behavioral disturbance with a start date of 08/23/2022. The September 2022 MAR documented an order for [MEDICATION(S)] tablet 200mg to give one tablet by mouth at bedtime for standard with a start date 06/27/2022. Upon review of the Medication Regimen Review (MRR) for the months of January 2022 through August 2022 the CP noted no irregularities related to R11's [MEDICATION(S)] order. The CP only made recommendations in January 2022 and March 2022 for a gradual dose reduction of the [MEDICATION(S)]. The physician's response dated 04/14/22 was to decline the recommendation due to R11 being on hospice services with behaviors, combative and delusions. No changes made at that time. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 01:45PM R11 sat in her wheelchair in her room her spouse present with her. R11 was actively trying to stand up from her wheelchair to reach her spouse seated in front of her. On 09/08/22 at 07:32AM R11 laid upon her bed that was in low position, fall mats present on floor beside the bed. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether or not irregularities exist in his/her medication regimen and complete a MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R11. - R131's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) and dementia with behaviors disturbances (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS) was in progress. R131 admitted [DATE]. R131's Care Area Assessment (CAA) was in progress. R131's Care Plan dated 08/29/22 documented medications would be administered as ordered and monitored for effectiveness and side effects. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] ([MEDICATION(S)]) oral tablet 100 milligrams (mg) give one tablet by mouth four times a day related to dementia in other diseases classified elsewhere with behavioral disturbance dated 08/29/22. The Monthly Medication Review (MMR), performed by the CP for August 2022 lacked identification of the inappropriate diagnosis for R31 who received antipsychotic medication with a diagnosis of dementia. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 08:33 AM R131 sat in dining room as nursing staff sat next to R31 and assisted her with breakfast. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether or not irregularities exist in his/her medication regimen and complete a MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R131. - R64's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated moderately impaired cognition. The MDS documented that R64 was dependent on two staff members assistance for activities of daily living (ADL's). The MDS documented R64 received antipsychotic medication class of medications used to treat [CONDITION(S)] {any major mental disorder characterized by a gross impairment testing} and other mental emotional conditions), antidepressant medication, (class of medications used to treat mood disorders and relieve symptoms of depression) and antibiotics (class of medication used to treat bacterial infections) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of four which indicated severely impaired cognitive. The MDS documented that R64 required extensive assistance of two staff members for ADL's. The MDS documented R64 received antipsychotic medication, antidepressant medication and antibiotics for seven days during the look back period. R64's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 12/15/21 documented a dose reduction was done 09/22/21. R64's Care Plan dated 03/03/16// documented the pharmacist consultant would review R64's medication monthly. The Care Plan dated 03/01/18 documented [MEDICATION(S)] ([MEDICATION(S)]) increased mortality in R64 with dementia related [CONDITION(S)]. Documentation of benefits verse risk and gradual reductions of antipsychotic medications if possible. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] tablet (antipsychotic) give 12.5 milligram (mg) by mouth at bedtime related to dementia with behavioral dated 09/22/21. The Monthly Medication Review (MMR), performed by the CP reviewed from August 2021 through August 2022 lacked identification of the inappropriate diagnosis for R64 who received antipsychotic medication with a diagnosis of dementia. The clinical record lacked evidence the prescribing physician documented thoroughly the indication for the medication including the benefits versus risks, the multiple attempts to implement care-planned, non-pharmacological approaches. On 09/07/22 at 09:54 AM R64 was asleep in bed, bed was in the lowest position and the head of her bed was slightly elevated, no distress or behaviors were noted. On 09/08/22 at 01:20 PM Licensed Nurse (LN) I stated that she did not have anything directly to do with the pharmacy recommendations and were taken care of by the unit nurse managers. On 09/08/22 at 02:44 PM Licensed Nurse (LN) H stated that the unit managers would receive the monthly pharmacy recommendations from Administrative Nurse D and the unit managers would take care of the recommendations. On 09/08/22 at 04:00 PM Administrative Nurse D stated that the pharmacy recommendations got emailed to her and all the unit managers. The unit manager was then responsible for following up with and completing the recommendations. On 09/12/22 at 01:30 PM the CP was unavailable for interview. The facility policy Medication Regimen Review Policy dated July 2018 documented the CP should review each resident's medical record, progress notes and other applicable documents as necessary per state and federal regulations, to determine whether irregularities exist in his/her medication regimen and complete an MRR. The facility failed to ensure the CP identified and reported an incorrect diagnosis for the antipsychotic This failure had to potential of unnecessary antipsychotic medication use and related side effects for R64.

The facility identified a census of 80 residents. Based of observations, record review, and interviews, the facility failed to promote adequate infection control practices related to wound care for Residents (R)72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased the risk for cross contamination. Findings Included: - On 09/07/22 at 10:20AM while performing wound care to R180, Licensed Nurse (LN) G gathered supplies and placed a Chux pad (absorbent disposable barrier) under R180. LN G washed her hands and donned gloves. LN G opened the supplies onto the Chux pad. LN G then removed the old bandages and threw them into the trash can. LN G then cleaned the wound area with the same soiled gloves. LN G removed her gloves and threw them in the trash. LN G donned a new pair of gloves without completing hand hygiene and applied new bandages. LN G gathered the used supplies and repositioned R180 in a comfortable position. LN G removed her gloves and completed hand hygiene. On 09/07/22 at 10:30AM R33 received wound care from LN G. LN G washed her hands and donned gloves. LN G placed Chux pad on the floor and used scissors to remove the dressing from R33's left heel. LN G placed the soiled scissors in a container holding clean wound care supplies. LN G replaced her soiled gloves. LN G cleaned the left heel then set the heel directly onto the Chux pad. LN G used the soiled scissors to trim the new dressing and applied it to R33's left heel wound. LN G wrapped the wound with kerlix (woven absorbent gauze). On 09/08/22 at 10:51AM R73 received wound care from LN G. LN G washed her hands, donned gloves, and placed a Chux pad on the bed under R73's heel-boots. LN G removed R73's boots and rested R73's stocking feet on the Chux pad. LN G then removed R73's socks and rested the feet on Chux pad. LN G removed R73's soiled wound dressing from the left heel then placed her heel on the Chux Pad. LN G sprayed wound cleanser onto R73's heel and then placed the heel back onto the same Chux pad. LN G repeated the process with R73's right heels. LN G reapplied the soiled socks and boots and removed the barrier. LN G doffed her gloves and completed hand hygiene. On 09/08/22 at 10:50AM R72 received wound care from LN G. R72 laid in bed and wore her Prevalon boots (boots that protect heel and feet from pressure surfaces). LN G washed her hands and donned gloves. LN G lifted R72's legs and placed a Chux pad down. LN G lowered R72's legs down onto the Chux pad and removed R72's Prevalon boots and lowered her feet back down to the Chux pad. LN G removed R72's socks and lowered her bare feet back down to the Chux pad. LN G assessed R72's heels and removed the left ankle pressure injury dressing. LN G cleansed the wound with [MEDICATION(S)] wound wash and allowed wound to air dry. LN G applied pre-prepared dressing to the left ankle wound. LN G then assessed R72's left heel wound. LN G applied [MEDICATION(S)] cleaner to the left heel wound and allowed to dry but then placed left heel back down on soiled Chux pad. LN G repeated the process with the right heel and returned it directly to the soiled Chux pad. LN G put R42's same socks and Prevalon boots back on after the wound care and positioned her in a comfortable position. LN failed to change her gloves throughout the wound care. In an interview on 09/08/22 at 02:55PM with LN G, she stated that hand hygiene should have been performed throughout providing wound care. She stated that clean surfaces should never be placed on soiled or contaminated surfaces. In an interview on 09/08/22 at 03:20PM with Administrative Nurse E stated that staff are regularly trained and reminded to complete hand hygiene in between providing cares to residents. She stated that staff complete annual in-services on infection control and have monthly training on topics like hand hygiene, peri-care, and infection prevention. A review of the facility's Skin and Wound Care protocol revised 09/2017 stated that heel ulcers must be assessed frequently for evidence of infections. The noted evidence included increased drainage, color change, warmth, pain, swelling, and fever. The protocol noted for staff to clean wound with cleanser and notify the physician. The facility failed to promote adequate infection control practices related to wound care for R72, R33, R73, and R180. This deficient practice placed the residents at risk for complications related to wound infections and increased potential for spread of infectious disease

The facility reported a census of 72 residents with 27 residents in the sample. Based on observation, interview, and record review the facility failed to complete wound care according to physician orders [REDACTED]. (#359) and failed to develop and implement interventions to prevent and treat pressure ulcers to promote healing for 1 of 3 resident's sampled for pressure ulcers (#53). Resident #53 developed unstageable pressure ulcers to his/her toes. Findings included: - Review of resident #53's signed physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated 10/2/2014 documented a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive impairment. He/she did not reject cares. The resident required extensive assistance of 2 or more staff with bed mobility, transfers, and toileting and used a wheelchair for mobility. The resident was frequently incontinent of urine and bowel and was not on a toileting schedule. The resident was not at risk for the development of pressure ulcers and had no pressure ulcers, venous ulcers (wound cause by improper valve function), arterial ulcers (wound caused by inadequate blood flow), diabetic ulcers (wound caused by complications from high blood sugars), or other skin issues. The resident had a pressure reducing device for the bed and chair and had ointment/medications applied to his/her feet. Review of the quarterly MDS dated [DATE] documented the resident scored a 9 on his/her BIMS, which indicated moderate cognitive impairment. He/she did not reject cares. The resident required extensive assistance of 2 staff with bed mobility, transfers, and toileting, and used a walker and a wheelchair for mobility. The resident was frequently incontinent of urine and bowel and was not on a toileting schedule. The resident had no pressure ulcers, venous ulcers, arterial ulcers, diabetic ulcers, or other skin issues. Review of the Cognition Loss CAA (Care Area Assessment) dated 10/6/2014 documented the resident had dementia and scored a 12 on his/her BIMS, which indicated moderate cognitive impairment. Review of the ADL (Activities of Daily Living) CAA dated 10/8/2014 documented the resident required extensive assistance with transfers, bed mobility, and toileting and he/she worked with therapy to improve his/her strength and endurance. Review of the Pressure Ulcer CAA dated 10/8/2015 documented the resident was at risk for the development of pressure ulcers due to his/her incontinence and need for assistance with bed mobility and transfers. Review of the Braden Skin Assessments dated 12/17/2014, 12/24/2014, 12/31/2014, and 5/20/2015 documented scores of 17, which indicated the resident was at risk for the development of pressure ulcers. Review of the resident's care plan dated 3/25/2015 documented the resident was at risk for the development of pressure ulcers. The care plan directed staff to consult with dietary as needed to adjust the diet and supplements as indicated, reposition frequently, toilet regularly to avoid incontinence, inspect the skin daily during routine ADL assistance, encourage by mouth intake, elevate heels off of the mattress, check every 2 hours for incontinence, provide peri care with skin barrier treatment, keep skin clean, dry, and well lubricated, and use pillows, pads, or wedges to reduce pressure on heels and pressure points On 6/29/2015 staff revised the care plan to include an infection to the resident's 2nd toes on both feet. The care plan directed staff to administer antibiotic as ordered, maintain universal precautions when providing cares, and to monitor/document/report any signs/symptoms of infection and/or antibiotic complications. Review of a dietitian assessment dated [DATE] documented the resident's skin was intact. Review of a dietitian assessment dated [DATE] documented a recommendation for Multivitamin with minerals and Zinc Oxide for 14 days for preventative skin protection. Review of nursing notes documented the following: On 8/13/2015 at 3:44 P.M. nursing staff notified the physician of a new area to the resident's right inner buttock and staff obtained new treatment orders. Review of weekly skin assessments documented the following: The resident had a history of [REDACTED]. On 6/17/2015- skin intact. On 6/24/2015- open areas to the second right and the second left toes. The assessment lacked measurements and descriptions of the wounds. On 6/26/2015- noted with a wound infection and the resident started on an antibiotic. The assessment lacked measurements and descriptions of the wounds. On 7/1/2015- open area to the second right and the second left toes. The assessment lacked measurements and descriptions of the wounds. Week of 7/8/2015 lacked an assessment. The record lacked documentation the wounds had healed. On 7/15/2015- skin was intact. The record lacked documentation the wounds had healed. On 7/29/2015- skin was intact. The record lacked documentation the wounds had healed. On 8/5/2015- scabbed areas to the left and right second toes. The assessment lacked measurements and descriptions. On 8/12/2015- scabbed areas to the second right and left toes. The assessment lacked measurements or description of wounds. A review of practitioner progress notes dated 6/8/2015 and 6/12/2015 documented the resident had no wounds to his/her toes. A review of a practitioner progress note dated 6/20/2015 documented a resident's family member expressed concern with the resident's right and left second toes. The resident had wounds to both second toes, had a small scab with no drainage on the second left toe and both toes were red and inflamed. The resident denied pain with range of motion and touching. He/she had significant [MEDICAL CONDITION] (a disease which affected sensation and movement). A review of practitioner progress note dated 6/22/2015 documented the resident had a right second toe wound with improved redness. The assessment lacked that staff assessed assessment resident's left second toe. A review of a progress note from wound consultant GG dated 6/26/2015 documented the resident had pressure ulcers to his/her bilateral 2nd toes. The 2nd right toe had eschar (dead tissue) and early cellulitus (a skin infection caused by bacteria) and the left second toe had eschar. The physician ordered an antibiotic and [MEDICATION NAME] (an antiinfective medication) for treatment. A review of the resident's Medication Administration Record [REDACTED]. A review of physician orders [REDACTED]. Keflex (a medication to treat infection) 500 mg (milligrams) by mouth two times a day for 7 days to treat a right second toe infection, effective 6/22/2015. Apply [MEDICATION NAME] to both second toes twice daily in the morning and evening, 6/22/2015 Apply extra protective cream to the red area on the resident's right inner buttock after every incontinent episode until healed, effective 8/13/2015. During an observation on 08/13/2015 at 6:19 A.M. the resident was lying on a low air loss mattress on his/her left side. The resident's right foot was bare, partially exposed and laid on the outside cover on the bed. He/she wore no socks or protective footwear, and had no pillow or wedges to support his/her heels or other pressure points. The resident's toes were not visible for inspection due to a darkened room. At 7:04 A.M. the resident independently turned onto his/her back with his/her heels laid flat against the mattress. The resident's toes were uncovered, however not visible for inspection due to the darkness of the room. At 7:08 A.M. administrative nursing staff D entered the room and the resident asked if he/she could get out of bed. Staff D replied he/she would notify the aide and then exited the room. The resident remained lying flat on his/her back with his/her heels against the mattress. At 7:28 A.M. direct care staff O entered the resident's room and turned on the lights. The resident's left and right second toes were covered with an orange substance and the wounds were not observable. Staff O removed the resident's soiled brief, provided peri care, and applied protective ointment. There was a dime sized reddened area observed to the resident's right buttock. During an observation on 08/13/2015 at 11:44 A.M. licensed nursing staff K completed wound treatment to the resident's right and left second toes. Staff K washed his/her hands, removed the resident's socks, and cleansed both wounds, patted the areas dry and applied [MEDICATION NAME]. The resident's second toe on the right and left feet had dark pencil eraser sized black areas to the top surface of the toes. There was no scabbing present. Staff K assisted the resident to a standing position and assessed his/her buttocks. Staff K confirmed the resident had a reddened, non blanchable area to his/her right inner buttock. The resident's family member was present during the assessment and asked staff K if the resident needed a brief change. Staff K replied he/she did not know and checked the resident to determine if he/she needed a brief change. Staff K confirmed the resident was wet and had a bowel smear and stated he/she would send in the aide to assist with toileting. During an observation on 08/17/2015 at 7:10 A.M. the resident sat in the shower in his/her bathroom. The resident's right and left foot second toes had pencil eraser sized black area, without drainage or redness. Staff Q assisted the resident to his/her wheelchair, which had a cushion, at 7:20 A.M. At 7:59 A.M. the resident self propelled in his/her wheelchair to the dining room. At 8:46 A.M. the resident self propelled in his/her wheelchair from the dining room to his/her room. At 8:50 A.M. licensed nursing staff K entered the resident's room and started a breathing treatment. Staff K did not offer to assist with repositioning or check for incontinence prior to exiting the room. At 9:02 A.M. Staff K returned to the resident's, completed the resident's breathing treatment, and visited with the resident. Staff K did not offer to assist the resident with repositioning or check for incontinence prior exiting the room at 9:25 A.M. At 9:53 A.M. the resident remained seated in his/her wheelchair reading a newspaper. Staff did not reposition, toilet, or provide incontinence care for a total of 2 hours and 43 minutes. The surveyor requested a skin check and staff Q assisted the resident to a standing position using his/her walker. The resident's brief had a small about of soft bowel dried on the brief. There was a dime sized reddened area observed on the resident's right inner buttock, which did not resolve after 3 minutes of pressure relief from standing. During an observation on 08/17/2015 at 3:43 P.M. administrative nursing staff M assisted the resident to a standing position using his/her walker. Staff M pulled the resident's brief down and observed a small amount of soft bowel and a wet brief. Staff M removed bowel from the resident's bottom using wipes and assessed the resident's buttocks. The resident had one dime sized reddened area on the right inner buttock, which was non blanchable. Staff M informed the resident he/she needed his/her brief changed and the resident replied he/she was not aware he/she was soiled. During an interview on 08/13/2015 at 12:10 P.M. a resident's family member stated he/she believed the resident's wound to his/her right and left foot second toes were a result of scraping against his/her bed. The family member believed the room arrangement made it difficult for the resident to get to his/her recliner due to the positioning of his/her bed in relationship to his/her recliner. The family member stated he/she found the wounds on the resident's toes on June 20, 2015 and sent an email with photographs of the wounds to the facility and the practitioner on June 21, 2015. During an interview on 08/13/2015 at 7:36 A.M. direct care staff O stated the resident had previously stubbed his/her left toe. Staff O knew the nurse put medication on the resident's toes, but was unaware of the wound type. Staff O stated he/she was not aware of the reddened area to the resident's right buttock until today and would notify the nurse of any new skin conditions. During an interview on 08/17/2015 at 9:43 A.M. direct care staff said the resident had sores to his/her toes and bottom. Staff Q reported the resident's buttocks were red and chapped a couple of weeks ago and stated the nurse instructed him/her to apply protective ointment on the resident. Staff Q stated the current interventions to manage the resident's skin conditions included; applying protective ointment to the resident's bottom, keeping the resident's skin clean and dry, and repositioning frequently by going to his/her recliner from the wheelchair after lunch or restorative therapy. Staff Q stated the resident was not on a toileting program, but he/she checked the resident every 2-3 hours and asked the resident if he/she wanted to go to the bathroom. During an interview on 08/13/2015 at 11:44 A.M. licensed nursing staff K stated he/she was unsure what type of wound the resident had to his/her right and left foot second toes, I just know they are not pressure ulcers. Staff K stated the wound nurse measured and treated the wounds weekly. Staff K reported he/she was made aware of the reddened area to the resident's buttock this morning by direct care staff O. During an interview on 08/17/2015 at 1:39 P.M. licensed nursing staff K stated the resident currently had wounds to his/her right and left second toe and a red area to his/her right buttock. He/she stated the charge nurse was responsible for weekly skin assessments and the wound nurse measured and staged weekly. Staff K stated the resident had no pressure, venous, arterial, or diabetic ulcers. Staff K said staff classified the wounds as open wounds. He/she stated current interventions to manage skin problems included; repositioning every 2 hours, ask the resident if he/she was comfortable every 2 hours when in his/her wheelchair or recliner, and assist with toileting every 2 hours. Staff K was unsure whether the resident had a low air loss mattress and thought he/she had a wheelchair cushion. During an interview on 08/17/2015 at 2:08 P.M. administrative nursing staff M reported he/she was responsible for the measurement of wounds weekly. He/she reported the resident had a history of [REDACTED]. Staff M stated he/she first saw the wounds on 8/13/2015 and prior to then he/she did not know the resident had skin issues. Staff M said he/she was unaware the wound doctor classified the resident's toe wounds as pressure ulcers with eschar. Staff M stated he/she expected the charge nurse to verbally inform him/her when a resident had a wound. He/she stated no one informed him/her of the wounds to the resident's toes. Staff M stated he/she measured the right buttock wound on 8/13/2015 and the measurement was 2 cm (centimeters) x (by) 1.0, red and blanchable. He/she measured again on 8/17/2015 with results of 2.0 cm x 1.0 cm, red, nonblanchable, and classified as a stage I pressure ulcer. During an interview on 08/17/2015 at 5:14 P.M. administrative nursing staff D reported he/she believed the resident had an issue with his/her left toe. The wound doctor saw the resident, and a treatment was in place. He/she believed the resident's toe healed and staff used [MEDICATION NAME] as a preventative treatment. Staff D stated he/she heard about the email sent to the practitioner on 6/21/2015 for the first time today. Staff D stated he/she expected the practitioner or unit manager to notify him/her of the wounds to the resident's toes. Staff D stated he/she was not aware the wound doctor classified the wounds as pressure ulcers with eschar and expected staff to notify him/her immediately for follow up. Staff D expected the charge nurse to complete weekly skin assessments on all residents and expected the wound nurse to measure and describe the wound weekly. He/she expected the staff to notify the dietitian of the wounds for early intervention, expected staff to toilet and change the resident every 2 hours, provide pericare care and reposition every 2 hours when in bed, recliner, or wheelchair. During an interview on 08/17/2015 at 3:55 P.M., dietary consultant staff DD stated the resident had no skin issues other than a red area. He/she was unaware of the location of the red area. Staff DD reported he/she received a weekly skin report and the resident had no skin issues identified on the report. Staff DD stated he/she was not aware the resident had unstageable pressure ulcers to his/her right and left second toes. Staff DD stated he/she would recommend Vitamin C 500 mg (milligrams) daily, Zinc 220 mg daily for 2 weeks and a Multivitamin with Minerals daily for residents with wounds. If the wound showed signs of healing they could discontinue Zinc. During an interview on 08/17/2015 at :31:02 P.M. practitioner JJ stated the resident's family member sent photographs and emailed him/her on 6/21/2015 to inform him/her of wounds to the resident's right and left second toes. Staff JJ stated he/she knew the resident had a history of [REDACTED]. Staff JJ stated he/she was not aware the wound doctor classified the wounds as unstageable pressure ulcers, but knew [MEDICATION NAME] and antibiotics had been ordered. During an interview on 08/18/2015 at 1:02 P.M. physician consultant GG stated he/she believed the wounds to the resident's bilateral toes were from pressure. He/she confirmed the resident had eschar on the right and left second toes of each foot. Staff GG stated he/she ordered [MEDICATION NAME] to treat the wounds. Review of the facility revised skin assessment and wound prevention policy dated 4/1/2011 documented the licensed nurse would complete a head to toe assessment weekly, would stage, measure, and document all pressure ulcers on wound evaluation flow sheet, complete a weekly Braden Scale weekly for four weeks after admission, and for actual pressure ulcers would initiate the Braden Scale Checklist. The nursing staff would notify the dietary manager for actual pressure ulcers, treatment would be initiated, and the care plan updated. The facility failed to implement interventions to prevent the development of unstageable pressure ulcers to the resident's toes and a stage 1 pressure ulcer to the resident's buttock, failed to complete, measure, and assess wounds weekly, and failed to ensure care planned interventions were followed by staff. - Resident #359's electronic medical record (EMR) documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) The nurses' data admission sheet dated 8/11/15 recorded the resident received skilled services for post fall weakness and ulcers. He/she was alert and oriented to his/herself and sometimes place. The resident had confusion and forgetfulness. The resident received continuous feedings via a gastrostomy tube (a silicone tube through the abdomen for nutrition and medications), had normal vital signs and refused to get up out of bed. This same assessment recorded the resident had an indwelling urinary catheter and had a sacral and left outer ankle pressure sore. Review of the physician's orders [REDACTED]. Cleanse the resident coccyx wound with wound cleanser, apply skin prep to the surrounding area, apply Santyl (a chemical debreeding ointment) 1 gram per square inch to the wound bed and cover the area with saline soaked gauze, a dry gauze and secure with paper tape. The POS also recorded orders dated 8/14/15 for heel protectors at all times and prevalon boots (soft heel boots) while the resident was in bed. The resident's interim care plan dated 8/1115 directed staff to keep the resident's skin clean and dry. The care plan also documented the use of a pressure redistribution mattress. The care plan lacked documentation specific to the resident wound care and/or treatment. Observation on 8/13/15 at 7:30 A.M. revealed the resident laid in bed on his/her back, unshaven, wore a hospital gown, his/her catheter drainage bag touched the floor and he/she did not wear heel protective boots. During wound care observation on 8/13/15 at 4:05 P.M. the resident did not have protective heel boots. Licensed wound care nurse OO uncovered the resident's coccyx wound to reveal a stage 3 pressure sore that measured 5.8 centimeters (cm) long (L) by 3.0 cm wide (W) x .2 cm deep (D). The rest of the resident bottom had redness and excoriation and skin disruption. Licensed nurse OO cleansed the entire area with wound cleanser applied (a non-measured amount of) Santyl to his/her gloved hand and applied a thick layer over the residents entire buttocks. The nurse applied skin prep and an Allevyn foam bandage over the wound. Observation on 8/17/15 between 7:55 A.M. and 9:40 A.M. staff did not enter/exit the resident's room or reposition the resident. Observation on 8/18/15 at 10:00 A.M. revealed the resident in bed. Licensed nurse AM during wound care, measured the resident coccyx wound which measured 4.0 cm x 3.5 cm x by 0.8 cm. with sero-saquinase (blood tinged) drainage from the left buttock. Interview on 8/18/15 at 10:00 A.M. licensed nurse AM stated he/she thought the wound was improved but stated nursing was to apply Santyl only to the bed of the wound with an antiseptic Q-tip. Interview on 8/18/15 at 2:00 P.M. with administrative licensed staff nurse D stated he/she expected staff to follow the physician's orders [REDACTED]. The facility Skin Assessment and Wound prevention policy revised 3/2009 directed staff upon admission to initiate treatment interventions. The facility failed to perform wound care in accordance to the physician order, and maintain an infection free technique for this dependent resident with a pressure sore.

The facility reported a census of 72 residents. The sample included 27 residents. Based on observation, interview, and record review the facility failed to prevent repeated falls with injury for 1(#72) of 3 residents reviewed for falls. Findings included: - The electronic clinical record for resident #72 included [DIAGNOSES REDACTED]. Review of the 5 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident had highly impaired vision and wore corrective lenses. The resident required extensive assistance of 1 staff for transfers, toileting, was unsteady and able to stabilize with staff assistance when moved from seated to standing position, moving on and off the toilet, and had no lower extremity impairment. The resident received an antidepressant and a diuretic 7 of 7 days during the 7 day look back period, received Occupational Therapy (OT) and Physical Therapy (PT) 5 of 7 days during the 7 day look back period. Review of the 14 day MDS dated [DATE] revealed a BIMS of 15 which indicated no cognitive impairment. The resident had highly impaired vision and wore corrective lenses. The resident required extensive assistance of 1 staff for transfers, toileting, was unsteady and able to stabilize with staff assistance when moved from seated to standing position, moving on and off the toilet, had no lower extremity impairment. The resident had 1 major injury fall since admission. The resident received an injection, antidepressant, anticoagulant, and a diuretic 7 of 7 days during the 7 day look back period, received Occupational Therapy (OT) and Physical Therapy (PT) 5 of 7 days during the 7 day look back period. The Care Area Assessment (CAA) dated 6/1/15 for visual function revealed the resident was legally blind and staff assisted as necessary. The CAA dated 6/1/15 for Activities of Daily Living (ADL) function revealed the resident required extensive assistance with his/her ADLs due to poor vision and his/her recent surgery to repair a fractured hip. Review of the CAA dated 6/1/15 for urinary incontinence revealed the resident needed extensive assistance with his/her transfers on and off the toilet. He/she also had problems with retention of urine and needed intermittent catheterizations, and was also occasionally incontinent of urine. Review of the CAA dated 6/1/15 for falls revealed the resident was at high risk for falls due to his/her history of falls and his/her need for assistance with transfers due to his/her hip fracture which was repaired, he/she scored an 18 on the fall assessment on admission. The care plan dated 5/19/15 for falls recorded Physical Therapy (PT), Occupational Therapy (OT) evaluation and treat, the resident needed activities to minimize the potential for falls while providing diversion and distraction. The revised care plan dated 6/5/15 for falls recorded the resident's call light within reach and staff to encourage the resident to use it for assistance. The resident needed prompt response to all requests for assistance, and to encourage the resident to use proper footwear when ambulating or mobilizing in the wheelchair. The revised care plan dated 7/6/15 for falls recorded staff were to provide the resident appropriate assistive devices (not specified) as ordered. The revised care plan dated 6/5/15 for impaired vision function recorded staff were to arrange a consult with eye care practitioner as required and to arrange the resident room per resident preference. The care plan for ADL Self Care performance deficit dated 5/19/15 and 5/26/15 recorded PT and OT to evaluate and treat the resident. The revised care plan dated 6/5/15 revealed staff were to encourage the resident to use the call light for assistance, The revised care plan dated 7/7/15 recorded the resident was non-weight bearing on the right lower extremity in an immobilizer when up. The revised care plan dated 7/13/15 recorded the resident required extensive assistance of 1 staff with slide board transfer. The fall risk assessments completed on: 5/10/15 after the resident's fall, his/her fall risk score was 16, which indicated the resident was at high risk to fall 5/19/15 fall risk score of 18.0, which indicated the resident was at high risk to fall 6/27/15 after the resident's fall his/her fall his/her fall risk score was 22, which indicated the resident was at high risk to fall 7/6/15 fall risk score of 20, which indicated the resident was at high risk to fall. The nurse's note (NN) dated 5/10/15 at 8:30 P.M. recorded a direct care staff told the nurse the resident was on the floor in the bathroom in the shower and the resident complained of hip pain on his/her right side. Upon assessment the resident had full range of motion on the right lower extremity and no complaints of pain of the right lower extremity. The staff helped the resident to stand and he/she was able to bear weight. Staff assisted the resident to the toilet. Within 15 minutes the resident complained of knee pain and was unable to do range of motion to the right lower extremity. The physician was notified at 8:35 P.M. and the resident was sent to the hospital by ambulance for evaluation at 8:50 P.M. The undated Fall Investigation worksheet recorded the resident received Lasix (a medication used to increase urine output). The resident had increase in confusion in the last 90 days. The resident attempted to transfer self to the toilet from his/her locked wheelchair and the resident required supervision with transfers. The fall was unwitnessed, the resident was injured with uncontrolled knee pain and transferred to a hospital. The X-ray completed at the hospital dated 5/10/15 reported a periprosthetic fracture (a break in the bone around the implant in the femur (thigh bone). The resident required surgery to repair the fracture and replacement of the prosthesis in the femur on 5/12/15. The NN dated 6/27/15 at 3:18 P.M. recorded the resident attempted to take him/herself to the toilet. Nursing staff assessed the resident with no apparent injury and transferred him/her to the wheelchair per the gait belt, The staff notified the physician at approximately 2:25 P.M. and staff received an order for [REDACTED]. The undated witness statement recorded on 6/27/15 at 1 P.M. the staff in the admission's office heard the resident call for help. The resident was on the floor on his/her right hip and held on the wheelchair with his/her left hand. The resident stated he/she went to the bathroom, pulled up his/her pants, and then fell . The resident was able to move the upper and lower extremity. The physician was notified for an X-ray and the staff educated the resident to call for help by using the call light. The unsigned CNA Post Fall and/or Injury Review dated 6/27/15 recorded the resident was transferring from the toilet. The resident required 1 person assist for transfers, was alert and oriented, non ambulatory, able to use the call light and attempted to unsafely toilet. The call light was on. The resident complained of pain. The resident wore slipper socks. The report noted the staff failed to respond timely to the call light to prevent the fall. On 6/27/15 at 9:53 PM an X-ray of the resident's pelvis at the hospital recorded a loosening of the right hip prosthesis. On 6/30/15 the resident required surgery to replace the right hip femoral neck due to the fracture. On 8/17/15 at 5:40 P.M. the resident sat in the wheelchair at the dining room table and initiated feeding self and visiting with other residents. On 8/18/15 at 10:20 A.M. the resident sat in the wheelchair in his/her room and watched television. The resident was not wearing the right knee immobilizer. The call light was on the bed. On 8/18/15 at 10:22 AM an interview with the resident acknowledged he/she fell in the bathroom in May and June. He/she said the staff took too long to assist for toileting and he/she had to toilet so he/she did it him/herself. The resident stated he/she was sometimes incontinent because the staff took too long to respond to the call light. The resident stated he/she was lucky he/she was in a wheelchair so he/she could go get a staff member for assistance. On 8/18/15 at 12:19 P.M. an interview with direct care staff P stated the resident wore his/her leg immobilizer all the time, he/she required limited assist with transfers with a gait belt. This resident was not a fall risk but he/she had a previous fall. On 8/18/15 at 12:26 P.M. an interview with licensed staff L acknowledged the resident wore an immobilizer and it was to be off at night. He/she acknowledged the resident did not have it on earlier today. The resident required 1 staff person to assist with transfers. On 8/18/15 at 12:48 PM an interview with administrative licensed staff D expected staff to respond to call lights promptly. Review of the Falls Prevention policy dated 3/1/11 revealed staff were to place the resident on the Falling Star/Leaf program for a score of 10 or above on the Fall Risk Assessment form and to place a leaf/star on the resident's name plate outside his/her door to alert staff. The staff were to stay with the resident while on the commode or toilet and to answer the call light promptly. The facility failed to prevent this resident's repeated falls with fractures by not answering the call light promptly, not placing the resident in the Falling Star/Leaf program when identified at high risk for falls, and not staying with the resident while on the toilet.

The facility identified a census of 96 residents. The sample included 3 residents reviewed for falls. Based on observation, interview, and record review, the facility failed to provide adequate supervision and effective interventions to prevent falls for 1 of 3 residents reviewed for accidents (#3). Findings included: - [DIAGNOSES REDACTED].#3 of left proximal humerus fracture, (a broken bone in the arm), dementia, (progressive mental disorder characterized by failing memory, confusion), brain mass (an abnormal growth of tissue in the brain), hypertension, (elevated blood pressure), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), diabetes, (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), insomnia, (inability to sleep), [DIAGNOSES REDACTED], (condition characterized by decreased activity of the thyroid gland), mood disorder (category of mental health problems,feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time) and a history of falls. The admission Minimum Data Set ((MDS) dated [DATE] listed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS identified the resident required extensive assistance of 2 plus persons for bed mobility, transfers, locomotion on unit, dressing, and toilet use, and limited assistance of one staff for locomotion off the unit, eating, and personal hygiene. The resident did not walk in the room or the corridor, did not have a trial toileting program, and was frequently incontinent of bowel and bladder. The resident had a fall in the last month prior to admission/entry or reentry, had a fall in the last 2-6 months prior to admission entry or reentry, and sustained a fracture related to a fall in the 6 months prior to admission/entry or reentry. The resident was not steady, only able to stabilize with staff assistance moving from a seated to standing position, moving on and off the toilet and with surface to surface transfers. The Care Area Assessment (CAA) dated 6/2/14 for cognition listed the resident had a [DIAGNOSES REDACTED]. The resident was at risk for declines physically and cognitively due to the progressive nature of the disease and was referred to speech therapy (ST). The CAA for incontinence dated 6/2/14 listed functional incontinence of the bladder,and the resident required extensive assistance of staff to complete toileting, and had a fractured humerus. The CAA for falls dated 6/2/14 listed the resident was at risk for falls due to a history of falls and a fall risk assessment score of 20. Factors for fall risk included: a decline in function and mobility, decreased safety awareness due to [DIAGNOSES REDACTED]. Staff kept his/her bed in the low position and he/she did have a personal alarm to alert staff to unassisted transfers. Staff referred him/her to physical, and occupational therapies for rehabilitation. The interim Plan of Care (POC) dated 5/20/14 for falls listed to maintain safety from falls and or manage falls, introduced to call light, water pitcher, and roommate, move furniture as needed to make room for safe mobility. Personal alarms as needed, observe for unsteady gait, dizziness, and intervene as needed,keep adaptive devices within reach, verbally remind the resident not to ambulate alone, positioning devices as needed, low bed, fall mat at bedside, wheelchair for locomotion, assist with transfers and ambulation as needed, observe for any unsafe actions and intervene, and gripper socks or nonskid sole shoes. A nurse's note (NN) dated 5/23/14 at 10:30 A.M.. revealed the nurse was called to the room regarding resident's fall. Staff found the resident on the floor lying on his/her back the facility transferred the resident to the hospital at 10:40 A.M. by emergency medical technicians (EMT) with cervical collar on, (a device used to to prevent or minimize motion in the cervical spine). A NN dated 5/23/14 not timed, listed the resident received skilled nursing services for left hummers fracture, had a bruise on his/her left shoulder, complained of pain on the left shoulder, and headache after a fall this morning. Review of the Hospital Instructions emergency room form dated 5/23/14 at 3:39 P.M. listed the resident sustained [REDACTED]. The form further listed the resident had a new brain bleed that was inoperable. Hospital staff discussed this information with the attending physician at the facility, and he/she would initiate hospice care for the resident. Review of the facility reported incident dated 5/27/14 revealed when staff toileted the resident on 5/23/14, staff shut the door and the cognitively impaired resident with a high fall risk, and history of falls was left unattended in the bathroom. A loud noise was heard from the bathroom a few minutes later, and on entry to the bathroom staff observed the resident lying on the bathroom floor. The care plan revision dated 5/23/14 at 10:00 A.M. listed the resident fell in the bathroom. Interventions included: medications reviewed, laboratory results reviewed, continue previous fall interventions (floor mats at bedside, personal alarm on while in wheelchair and bed, low bed) and the resident was not to be left alone in the bathroom. The care plan for falls dated 6/8/14 listed the resident was at high risk for falls, due to a recent fall and fall risk assessment score of 20. Will have no fall with injury during the next review period. Interventions included: falling star program, star outside the door to alert staff of increased risk for falls, a personal alarm in the bed and chair, mats on the floor by the bed, a low bed placed in the lowest position, non skid shoes, star by my name on the nurses jot sheet so they were aware that the resident was a high fall risk, bed in the lowest position, if a fall occurs I will be further assessed to determine the need for other interventions such as mats at the bedside, personal alarms (PA),(both already on the care plan) bed against the wall, gait belt for transfers, currently on therapy caseload to improve strength and endurance and not to leave the resident alone in the bathroom. On 6/19/14 at 1:15 PM the resident sat in his/her room in the wheelchair (w/c) with the PA attached to the resident. The call light was not within reach. On 6/19/14 at 5:05 P.M. the resident sat in his/her room in the w/c. On the bed rested a PA, not connected to the resident or the wheelchair, and the call light was not in reach. Interview on 6/19/14 at 5:06 P.M. with direct care staff O stated he/she did all cares for the resident. He/she had floor mats when in bed, and a PA in the bed, but not in the chair, he/she did not try to get up when in the chair. The care plan identified the need for the PA when in the bed or the chair. Review of the jot sheet carried by direct care staff O listed interventions of: the low bed, PA, floor mat, and not left alone on the toilet. Interview on 6/19/14 at 5:20 P.M. with Administrative Nursing Staff D stated he/she was aware of the observation of the resident without a PA connected to the w/c, the jot sheet listed the PA and staff knew this was to connect the PA on the chair or bed if that was where the resident currently was. Interview with the resident on 6/23/14 at 11:36 A.M. the resident sat in front of the nurses station in a w/c with the PA attached. He/she stated he/she needed to find his/her clothes to leave. Interview with licensed nursing staff H on 6/23/14 at 1:30 P.M. the resident required extensive assistance, he/she was incontinent of bowel and bladder, had a bed and chair alarm, when he/she was in an activity or awake he/she was kept by the nurses station so all eyes were on him/her if he/she tried to stand up, which he/she did but not often. When he/she said he/she wanted to go home was the danger time when he/she would try to stand up. Interview with direct care staff P on 6/23/14 at 1:35 P.M. revealed the resident required set up with all cares, staff got him/her up in the morning and took him/her to the toilet. The resident had a chair and bed alarm that were on at all times, and floor mats went in place when staff laid him/her down. When staff toilet him/her staff place the resident on the toilet and close the door to provide privacy, but keep it cracked and watched, when he/she started using the toilet paper direct care staff P went in to help. The resident would stand up and tried to pull clothes up if staff did not get in to assist him/her quick. The resident sat at the nurses station when he/she was up in the chair so staff could watch him/her. Review of the facility policy for fall prevention dated revised 3/1/11 listed under the initial fall risk assessment if a resident scored above 10 he/she was at high risk for falls and would be placed on the Falling Star/Leaf Program. The care plan would reflect he/she was at high risk for falls and identify approaches that were implemented. A distinction would be made to alert all disciplines by placing a leaf/star on the resident's name plate outside his/her door to alert staff to observe safety precautions. Other possible staff interventions were to stay with the resident while on the commode or toilet if the resident permits. The facility failed to provide adequate supervision for this cognitively impaired, dependent resident with a history of falls that fell and received a compression fracture of the vertebra in the thoracic spine, and received a brain bleed when staff left him/her unattended on the toilet. The facility failed to provide interventions as planned for the prevention of additional falls.

The facility's census totaled 91 residents with 3 sampled. Based on observation, interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for 1 sampled resident (#1) found unresponsive and this failure placed the resident in immediate jeopardy. Findings included: - The admission Minimum Data Set 3.0 (MDS) for resident #1 dated [DATE] documented the Brief Interview for Mental Status score of 14 which indicated the resident's cognitive status was intact. The MDS further documented the resident required extensive assistance of 1 staff with toilet use, and limited assistance of 1 staff with bed mobility, transfers, locomotion on the unit, dressing and personal hygiene. The resident expected to be discharged to the community. The revised care plan dated [DATE] documented interventions which included the staff would conduct a weekly interdisciplinary meeting to discuss the progress with therapy, medical situation, and nutritional needs. The resident was monitored by a nurse on a daily basis. The resident's needs were communicated to the nursing staff by the nurse's jot sheets and certified nurse aides jot sheets. Review of the clinical record revealed a Code Status Sheet/Advanced Medical Directive form dated [DATE] which indicated the resident was a Full Code (provide all services needed to keep a person alive). The Physician order [REDACTED]. The untimed nurse's note documented on [DATE] revealed the resident's cognition was alert and the resident had no problems with speech, behaviors, skin, cardiovascular, respiratory, or pain. The nurse's note documented on [DATE] and timed 1:00 A.M. revealed the resident was in bed, denied pain, and had no shortness of breath (SOB) at this time. The nurse's note documented on [DATE] at 4:00 A.M. the resident was found to be unresponsive by an aide. The licensed nursing staff H documented, the resident had an absence of a pulse and cold bilateral lower extremities. The licensed nursing staff H verified with licensed nursing staff I the resident had no pulse or signs of life. The licensed nursing staff notified the physician and received an order to release the body to a mortuary. Licensed nursing staff H's notarized statement documented on [DATE] around 4:00 A.M. the certified nurse's aide reported something was wrong with the resident because he/she would not wake up. The lights were on in the room when licensed nursing staff H entered to assess the resident and he/she could tell the resident had no signs of life. Licensed nursing staff H checked the resident's wrist and neck to check for a pulse and did not feel a pulse. The resident felt cold to touch from the waist down but the resident's torso was warm. Licensed nursing staff H called licensed nursing staff I to assess the resident for pulses as well. Both nurses went to the nurses' station and the resident's chart revealed the resident was a full code. Licensed nursing staff H asked licensed nursing staff I what should we do now since we found the resident with no pulse. Licensed nursing staff I stated for the nurse to call the resident's doctor. Licensed nurse H called the doctor and explained the resident was found with no signs of life. Licensed nursing staff stated he/she asked the doctor what the nursing staff should do. The doctor asked what the resident's admitting [DIAGNOSES REDACTED]. Licensed nursing staff H stated he/she was waiting for the doctor to say to start CPR on the resident and the doctor said to release the body to the mortician. Licensed nursing staff I's notarized statement revealed on [DATE] (untimed) he/she assessed the resident with licensed nursing staff H and the resident was cold to touch. Licensed nursing staff I revealed the nursing staff did not try to resuscitate the resident because he/she had been gone for a long time. On [DATE] at 11:30 A.M. administrative nursing staff D revealed the nursing staff involved did not follow the facility's policy of starting CPR when the resident was found without vital signs. The nursing staff also did not tell the doctor the resident's code status. The residents' information and code status was written on the nurses' jot sheet which contained information about each resident's needs and their code status. On [DATE] at 9:55 A.M. administrative nursing staff D revealed the facility staff were in-serviced on the CPR policy on the date of hire and annually. The revised [DATE] facility's policy "Emergency Procedure- Cardiopulmonary Resuscitation (CPR)" documented if an individual (resident, visitor, or staff member) was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR shall initiate CPR unless it was known that a Do Not Resuscitate (DNR) order that specifically prohibited CPR and/or external defibrillation existed for that individual. The facility failed to ensure the nursing staff provided resident #1 with CPR as he/she requested when he/she entered the building, which placed this resident in immediate jeopardy. The facility abated this immediate jeopardy on [DATE] at 6:30 P.M. when: 1. The facility in-serviced the licensed nurses on what to do when findings someone unresponsive and how to "run a code." 2. In-serviced the staff on the CPR policy and procedure. 3. All staff in-serviced regarding Effective Emergency Communication. 4. In-serviced staff on the use of the Automated External Defibrillators (AED)/CPR. 5. Training of all new staff upon hire regarding first aide and what to do when finding someone not breathing. 6. Nurse Orientation Checklist to include instruction regarding code status, Advanced Directives, and running a code. 7. Mock code to involve nurses on all shifts. This deficient practice remains at a scope and severity of a D.