Every finding on record at Catholic Care Center, Inc

Based on record review and interview, the facility failed to notify Resident (R) 1's responsible party of a medication error that may have affected R1's physical health and may have required medical intervention. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), chronic pain, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated 03/31/26, documented R1 had a Brief Interview for Mental Status score of nine, which indicated moderately impaired cognition. The MDS documented R1 required moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. The MDS documented R1 received an anticoagulant (a class of medications used to prevent the blood from clotting) and antiplatelet (a class of medication used to reduce the ability of blood platelets to stick together reducing the risk of harmful blood clots from forming) medications during the lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 03/25/26, documented R1 had impaired cognitive function and impaired thought processes. R1 would be able to maintain her ability to communicate her basic needs and remain oriented to person, place, situation, and time. The Functional Abilities CAA, dated 03/25/26, documented R1 had impaired balance and transition during transfers and functional impairment in activity. The CAA documented R1 had weakness and decreased safety awareness. R1's Care Plan, initiated 03/20/26, documented R1 had impaired cognitive function and the care plan directed staff to ask R1 yes or no questions to determine her care needs, cue, orient, and supervise R1 as needed, and keep R1's routine consistent and provide consistent care givers. The care plan documented R1 was at risk for adverse medication interactions and R1 would no have adverse reactions to her medication regimen. R1's April 2026 Medication Administration Record (MAR) documented R1 was scheduled to take atorvastatin (a cholesterol-lowering medication), fluorometholone ophthalmic suspension (an eye drop used to treat swelling, redness, and itching), apixaban (an anticoagulant medication), and oxybutynin (a medication used to treat an overactive bladder). R2's April 2026 MAR documented R2 was scheduled to take atorvastatin, doxazosin (a medication used to treat high blood pressure), mirtazapine (a medication used to treat major depressive disorder with a side effect of drowsiness), ropinirole (a medication used to treat moderate to severe restless leg syndrome with common side effects of nausea, dizziness, and sudden sleepiness), amiodarone (a medication used to treat life-threatening heart rhythm problems with common side effects of difficulty breathing, coughing, or chest tightness), lacosamide (a medication used to treat seizures with common side effects of dizziness, nausea, headache, and tremors), and Humalog (a fast acting insulin used to manage blood sugars). The Progress Note, dated 04/23/26 at 06:43 AM, documented LN G walked into R1's room, asked R1 if her name was [R2's name], and R1 said, Yes. LN G administered all of R2's nighttime medications to R1. R1's heart rate prior to medication administration was 115 beats per minute. R1's blood sugar was checked and was over 300 milligrams per deciliter (mg/dL). Once staff determined that R1 was given the incorrect medication, an assessment was done. Initial vital signs were blood pressure 106/46 millimeters of mercury (mm/Hg), heart rate 111 beats per minute, oxygen percentage 85%, respirations 22 breaths per minute, and temperature of 97.9 degrees Fahrenheit (F). The primary care physician was notified. R1's EMR lacked evidence of family notification of the medication error. R1 was unavailable for observation. On 05/05/26 at 01:30 PM, Administrative Nurse D stated LN G had been an agency nurse and should have followed the facility's policy of medication administration and the five rights. Administrative Nurse D verified LN G did not notify R1's responsible party of the medication error. The facility's Change in a Resident's Condition or Status Policy documented the facility shall promptly notify the resident, his or her Attending Physician, and responsible party of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).

Based on record review and interview, the facility failed to ensure Resident (R) 1 remained free of significant medication errors when on 04/22/26, Licensed Nurse (LN) G prepared medications administered the wrong medications and five units of regular insulin (a vital hormone produced by the pancreas that regulates blood sugar levels by enabling cells to use glucose for energy) to R1. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), chronic pain, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated 03/31/26, documented R1 had a Brief Interview for Mental Status score of nine, which indicated moderately impaired cognition. The MDS documented R1 required moderate assistance from staff for toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. The MDS documented R1 received an anticoagulant (a class of medications used to prevent the blood from clotting) and antiplatelet (a class of medication used to reduce the ability of blood platelets to stick together reducing the risk of harmful blood clots from forming) medications during the lookback period. The Cognitive Loss/Dementia Care Area Assessment CAA), dated 03/25/26, documented R1 had impaired cognitive function and impaired thought processes. R1 would be able to maintain her ability to communicate her basic needs and remain oriented to person, place, situation, and time. The Functional Abilities CAA, dated 03/25/26, documented R1 had impaired balance and transition during transfers and functional impairment in activity. The CAA documented R1 had weakness and decreased safety awareness. R1's Care Plan, initiated 03/20/26, documented R1 had impaired cognitive function and the care plan directed staff to ask R1 yes or no questions to determine her care needs, cue, orient, and supervise R1 as needed, and keep R1's routine consistent and provide consistent care givers. The care plan documented R1 was at risk for adverse medication interactions and R1 would no have adverse reactions to her medication regimen. Review of R1's Vital Signs for April 2026 documented R1's oxygen percentage ranged from 92% to 99%. R1's April 2026 Medication Administration Record (MAR) documented R1 was scheduled to take atorvastatin (a cholesterol-lowering medication), fluorometholone ophthalmic suspension (an eye drop used to treat swelling, redness, and itching), apixaban (an anticoagulant medication), and oxybutynin (a medication used to treat an overactive bladder). R2's April 2026 MAR documented R2 was scheduled to take atorvastatin, doxazosin (a medication used to treat high blood pressure), mirtazapine (a medication used to treat major depressive disorder with a side effect of drowsiness), ropinirole (a medication used to treat moderate to severe restless leg syndrome with common side effects of nausea, dizziness, and sudden sleepiness), amiodarone (a medication used to treat life-threatening heart rhythm problems with common side effects of difficulty breathing, coughing, or chest tightness), lacosamide (a medication used to treat seizures with common side effects of dizziness, nausea, headache, and tremors), and Humalog (a fast acting insulin used to manage blood sugars). The Progress Note, dated 04/23/26 at 06:43 AM, documented LN G walked into R1's room, asked R1 if her name was [R2's name], and R1 said, Yes. LN G administered all of R2's nighttime medications to R1. R1's heart rate prior to medication administration was 115 beats per minute. R1's blood sugar was checked and was over 300 milligrams per deciliter (mg/dL). Once staff determined that R1 was given the incorrect medication, an assessment was done. Initial vital signs were blood pressure 106/46 millimeters of mercury (mm/Hg), heart rate 111 beats per minute, oxygen percentage 85%, respirations 22 breaths per minute, and temperature of 97.9 degrees Fahrenheit (F). The primary care physician was notified. The note lacked family notification of the medication error. The Nurse Practitioner's Progress Note, dated 04/23/26 at 01:57 PM, documented R1 was seen at staff's request after a medication error. R1 received amiodarone, Eliquis, and psych meds overnight. R1 was placed on oxygen overnight for hypoxia. R1 was seen that morning off oxygen in the dining room before breakfast. R1 endorsed she felt well, with no complaints of pain, shortness of air, nausea/vomiting, fever, or chills. R1 had been taken off the oxygen before coming out for breakfast. R1 was unavailable for observation. On 05/05/26 at 01:30 PM, Administrative Nurse D stated LN G had been an agency nurse and should have followed the facility's policy of medication administration and the five rights. Administrative Nurse D stated the nurse had not verified R1's name with her picture on the MAR prior to administering the wrong medications. Administrative Nurse D stated all staff who administered medications had education on medication administration and following the five rights of medication administration and all education was completed by 04/28/26. On 05/05/26 at 02:30 PM, LN H stated she was the nurse who came onto the unit the morning following the medication error. LN H stated LN G, who was an agency nurse, felt really bad about the medication errors. LN H stated R1 was lucky the administration of insulin had not been detrimental and instead showed she had high blood sugars even though she was not diagnosed as being diabetic. The facility's Administering Medications Policy, reviewed in 2022, documented medications are administered in a safe and timely manner, and as prescribed. Only people licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training. The individual administering medications verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include but are not limited to checking the photograph attached to the medical record and verifying the resident's identification with other facility personnel.

The facility identified a census of 155 residents and 61 residents with full code status (decision to receive resuscitative measures). The sample included three residents. Based on observation, interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when the heart stops beating) to Resident (R) 1, who had a documented desire for full resuscitative measures. On [DATE] at 04:30 AM, Certified Nurse Aide (CNA) O observed R1 in his bed not breathing and CNA O immediately reported this to Licensed Nurse (LN) G. LN G assessed R1, then went to the nurse station to verify R1's code status in the Electronic Medical Record (EMR) and advised CNA O that R1's hospice providers would take care of the rest. At 04:42 AM LN G called R1's hospice provider to report the event. At 05:15 AM, R1's hospice providers arrived at the facility, assessed R1, and initiated CPR (approximately 45 minutes after staff found R1 unresponsive), per R1's physician's orders and recorded directives. Staff provided resuscitative measures until 05:30 AM when Emergency Medical Services (EMS) arrived and took over the resuscitation attempt. R1 was pronounced dead at 06:03 AM. The facility's failure to ensure staff initiated resuscitative measures per the resident's recorded wishes and physician's orders placed R1 and all full code residents in Immediate Jeopardy. Findings included:- R1's EMR documented R1 had diagnoses of malignant neoplasm (cancer) of the bronchus (airway) or lungs, acute respiratory failure, and heart failure.R1's admission Minimum Data Set (MDS) dated , [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. The MDS documented R1 used a wheelchair for mobility and was independent for toileting, dressing, bed mobility, and transfer. The MDS documented R1 required continuous oxygen.The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R1's CAA triggered due to the low BIMS score.R1's Care Plan, dated [DATE], documented R1 requested CPR measures be performed (in the case of a cardiac event) and noted R1 was a full code. The care plan documented the facility staff would respect R1's wishes and rights to have CPR performed. R1's EMR recorded a Physician's Order, dated [DATE], that documented R1 was a full code.R1's Physician's Progress Note dated [DATE] at 07:00 PM documented R1 was a full code. The provider talked with the hospice nurse the day prior, and the hospice nurse reported R1 was a full code, and hospice staff would discuss with him the Do Not Resuscitate (DNR) recommendation. The note documented that when the provider talked to R1, the resident was in his room in his wheelchair with two liters of oxygen. R1 was irritable and stated he felt like he was not told the truth about hospice and that he was sent there, to the facility, to die.R1's Physician's Progress Note dated [DATE] at 05:43 PM noted that R1 was still listed as a full code, and the physician asked the nurse manager to check with hospice if there were any updates on the code status.R1's Progress Note-Late Entry dated [DATE] at 08:22 AM, documented staff found R1 unresponsive at approximately 04:30 AM. CNA O notified LN G of R1's status. LN G assessed R1, then went to the nurses' station to contact hospice. LN G verified R1's code status. LN G saw R1 was a full code and checked the chart for a DNR. LN G notified the hospice provider at 04:42 AM, and the hospice staff arrived at the facility at 05:15 AM. Upon arrival, the hospice nurse advised LN G that R1 was full code and a Code Blue (common term used to signify CPR initiation) was activated. LN G, with the assistance of another nurse, began CPR; the crash cart was taken to R1's room, the backboard was placed under R1, and CPR continued. EMS arrived at approximately 05:30 AM and took over compressions and the code. The time of death was called at 06:03 AM.LN G's Witness Statement dated [DATE] documented around 04:30 AM on [DATE], LN G assessed R1 and noted he had no pulse. LN G documented that since R1 was on hospice, she notified hospice at approximately 04:45 AM and then the staff straightened the resident on his bed and cleaned his body. When the hospice staff arrived at between 04:50 AM and 05:10 AM, they stated there was no DNR on file, so staff started CPR.The facility's investigation dated [DATE] documented the investigation conclusion was LN G failed to initiate CPR for R1 even after verifying the medical record which indicated R1 was a full code. The investigation documented during the facility's interview with LN G, she stated to Administrative Nurse D that she [LN G] used her nursing assessment and moral judgement not to initiate a code/administer CPR. LN G's CPR certification documented LN G had an active basic life support (BLS) CPR certification.Observation on [DATE] at 02:00 PM, a Code Blue was announced over the speakers with the location. Staff went to the location to find a mannequin on the floor. Staff inquired about the code status and were notified that the mannequin was a full code. Staff started CPR.On [DATE] at 09:45 AM, Administrative Nurse D stated that CNA O was the CNA who found R1 unresponsive and that she no longer worked at the facility.On [DATE] at 09:40 AM, CNA M stated if a resident had any kind of change (including not breathing or no pulse), the nurse would be notified immediately. CNA M stated new admissions would sometimes have a bracelet on from the hospital that had DNR on it, and some would keep it on. Also, the code status was also in the EMR. On [DATE] at 09:43 AM, CNA N stated the nurse would be immediately notified to assess the resident if there was any change. CNA N stated staff could look at the chart to know if residents were a full code, and the EMR listed the code status for each resident. On [DATE] at 09:45 AM, Administrative Nurse D stated that LN G was the charge nurse for R1's unit, and she had been terminated from employment after the incident. On [DATE] at 09:47 AM, LN H stated that the code status was in the residents' EMR, and said he carried a code report every morning when he started his shift. LN H said if he did not have the report, he could just go down the report sheet and mark everyone with an F or a D for full code or DNR based on the EMR information. LN H said he was not working when the incident with R1 occurred, and he came on shift after the incident. He stated if he was notified of a resident who had no pulse or breathing, he would look to see if they were a full code or DNR and start CPR immediately while calling for assistance to bring the crash cart and call 911.On [DATE] at 09:45 AM, Administrative Nurse D stated that the facility utilized a multi-system approach to code situations that had the nurse assess the resident while another staff member checked the resident's code status; a third staff member obtained the crash cart, and once the code status was verified, staff were to begin CPR. She said that she expected all staff to follow the multi-system approach. Administrative Nurse D verified code status was listed in the EMR, across the gray ribbon of the resident chart, and there were provider orders for full code or DNR, whatever the resident's code status was. Administrative Nurse D said all the nurses were BLS/CPR certified, and certification was verified upon hire, and education for certification is immediately provided if they are not.The facility policy Do Not Resuscitate order, dated 04/2017, documented the facility would not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident who had a DNR order in effect.On [DATE] at 02:41 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed that the facility's failure to ensure staff provided CPR to R1, who desired resuscitative measures, placed R1 and all 61 residents with full code status in IJ.The facility identified and completed the following corrective actions by [DATE]:1. The nursing staff were re-educated on residents' rights, including the right to self-determination and to formulate advanced directives, education on advanced directives, including DNR orders and DNR directives, Full Code status, and CPR protocols.2. All licensed nurses demonstrated competency with the Code Status written quiz and Code Blue Protocols, including return demonstration.3. Mock Code Drills were completed two to four times a week.4. The Annual Education Calendar was updated to include code blue protocols and honoring code status.5. The facility added code blue response protocols to be demonstrated upon hire during clinical competencies.On [DATE], an onsite survey verified the facility completed the above corrective actions prior to the survey, therefore the deficient practice was deemed past noncompliance at a scope and severity of K (pattern, immediate jeopardy).

The facility reported a census of 147 residents with four residents in the sample for indwelling catheter care. Based on observation, interviews, and record review the facility failed to ensure Resident (R) 1 received appropriate catheter care when staff inserted the wrong-sized suprapubic catheter (a tube inserted through the abdomen into the bladder to drain urine into a collection bag). This deficient practice placed the resident at risk for pain and catheter-related complications. Findings included: - R1's Physicians Orders dated 10/24/24 documented a diagnosis of neuromuscular dysfunction of the bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). R1's admission Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted R1 was independent with activities of daily living (ADL). The MDS did not indicate R1 had an indwelling catheter. R1's Quarterly MDS dated 05/28/25 recorded a BIMS score of 15. The MDS noted R1 had an indwelling catheter. R1's Care Plan dated 05/07/25 documented he had a suprapubic catheter, 20 French (external diameter of the catheter) with 10 cubic centimeters (cc) [NAME] and directed staff to change the catheter monthly on the fifth and as needed (PRN) for neurogenic bladder. On 05/07/25 at 02:04 PM, R1's Progress Notes documented the facility nurse attempted to replace R1's suprapubic catheter because staff had placed the wrong size catheter (12 French). The note documented the nurse attempted to place a 20 French catheter but was unable to place it after several attempts using descending diameter sizes. The note recorded the nurse was finally able to place the 12 French. On 05/09/25 at 03:46 PM, R1's Progress Notes documented R1 returned from a urology (specializing in the urinary system) appointment with a 16 French suprapubic catheter; R1's next scheduled appointment was 06/13/25. R1's Physician's Order dated 05/09/25 indicated R1 had a suprapubic catheter due to obstructive uropathy (urine flow is restricted due to an obstruction) and required a 16 French catheter. Observation on 06/16/25 at 12:35 PM revealed Licensed Nurse (LN) G provided suprapubic catheter care for R1. Observation further revealed no concerns with the catheter. R1 denied complaints of pain or discomfort during the procedure. On 06/16/25 at 03:45 PM, Administrative Nurse E said a facility nurse tried to replace the 12 French catheter that was placed in error with the 20 French catheter as ordered. Administrative Nurse E said that as soon as the 12 French catheter was removed, the site started closing quickly and the staff nurse was barely able to get the 12 French back in place. Administrative Nurse E said staff called the physician and the physician was stretching R1's catheter opening out again slowly. On 06/16/25 at 04:30 PM, Administrative Nurse D stated she expected staff to use the proper indwelling catheter size as ordered. The facility policy Catheter Care dated 2022 directed staff to report any complications the resident may have with burning, tenderness, or pain; and report other information in accordance with facility policy and professional standard of practice.

The facility reported a census of 147 residents; four residents were sampled. Based on observation, interviews, and record review the facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing indwelling suprapubic catheter care (a tube inserted through the abdomen into the bladder to drain urine into a collection bag). Additionally, staff failed to disinfect the Hoyer lift (full-body mechanical lift) after use. This placed the residents at risk for infections. Findings included: - Observation on 06/16/25 12:35 PM Licensed Nurse (LN) G providing suprapubic catheter care for Resident (R)1. LN G donned gloves but no gown and proceeded with the catheter care. Observation on 06/16/25 at 11:20 AM revealed LN H assisted Certified Nurse Aide (CNA) M with transferring R2 from her bed to the shower chair using the Hoyer lift. Upon leaving R2's room LN H took the Hoyer lift and placed it in the hallway cubby without wiping down the lift. On 06/16/25 at 03:40 PM, Administrative Nurse E stated the staff were supposed to follow the instructions on EBP. Administrative Nurse E further stated staff should clean the lifts after use and in between residents. On 06/16/25 at 4:30 PM, Administrative Nurse D stated she expected the staff to verify the EBP correctly and she expected the staff to wipe down the lifts between each resident. The facility's policy Enhanced Barrier Precautions dated 10/07/24 recorded EBP precautions in addition to standard and contact precautions will be implemented during high-contact care activities when caring for residents that have an increase to acquiring a multidrug-resident organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonized with MDRO. The facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment dated 2018 directed that resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Reuseable resident care equipment will be decontaminated and /or sterilized between residents.

The facility identified a census of 147 residents. The facility identified 41 residents on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and four residents on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact). Based on record review, observations, and interviews, the facility failed to ensure Resident (R)109's 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 and the nasal cannulas for R45, R27, and R57 were stored in a sanitary manner when not in use and further failed to implement adequate hand hygiene and ensure the shared blood pressure cuff was sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases. Findings included: - On 12/03/24 at 07:47 AM Certified Medication Aide (CMA) S obtained R93's blood pressure using a small blood pressure cuff. CMA S removed the small blood pressure cuff from the portable blood pressure machine and placed the cuff into the basket without sanitizing it. CMA S then removed the larger-sized blood pressure cuff from the basket, attached it to the blood pressure machine, and used it on R113 without performing hand hygiene first. CMA S did not sanitize the larger blood pressure cuff after use. On 12/03/24 at 08:19 AM R45's nasal cannula laid over the back of R45's wheelchair while he was eating breakfast in the dining room. On 12/03/24 at 11:57 AM R27's nasal cannula laid on the floor in the dining room, and a kitchen staff member passing trays to the resident's room stepped on the nasal cannula. R27's nasal cannula was then picked up and laid on the back of R27's wheelchair. On 12/03/24 at 12:01 PM, R57's nasal cannula hung over the bed rail in her room, R57 did not have any type of container to place the nasal cannula in. On 12/03/24 at 04:14 PM, R109 sat out at the dining room table. R109's CPAP mask and tubing were laid directly on her CPAP machine on the bedside table next to the bed. On 12/04/24 at 11:10 R27's nasal cannula was hanging over the back of R27's wheelchair. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would clean R109's CPAP in the morning after she assisted R109 out of bed. CNA N stated she would clean the CPAP mask with a disinfectant wipe and then store the mask in a plastic bag. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated all staff were educated to place nasal cannulas not in use in a pull string bag. LN G stated ensuring the nasal cannula were stored appropriately was all nursing staff's responsibility. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would clean the residents' CPAP masks every morning with soap and water and then hang them to dry. LN H stated the CPAP mask should never be placed on the bedside table or the CPAP machine. On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nurse on the unit to clean the CPAP mask with soap and water. Administrative Nurse D stated that the mask was to hung to air dry. Administrative Nurse D stated the CPAP mask should never be stored directly on the bedside table or top of the CPAP machine. Administrative Nurse D stated nasal cannulas not in use are to be stored in a plastic bag, she stated that was everyone's responsibility. Administrative Nurse D stated she expected her staff to clean or sanitize the blood pressure cuffs, between residents. The Infection Prevention and Control policy dated 2019 documented that the primary mission was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure R109's CPAP mask was stored in a sanitary manner, and nasal cannulas for R45, R27, and R 57 were stored in a sanitary manner and further failed to implement adequate hand hygiene ensuring shared blood pressure cuffs were sanitized after resident use. These deficient practices placed the residents at risk for infectious diseases.

The facility reported a census of 147 residents. The sample included 29 with 11 residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure a safe environment free from accident hazards for Residents (R)5 and R32. The facility additionally failed to implement care-planned fall interventions for R13 and R27. This deficient practice placed the residents at risk for preventable falls and injuries. Findings Included: - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) included diagnoses of cognitive communication deficit, transient ischemic cerebral attack (TIA- temporary episode of inadequate blood supply to the brain), weakness, history of falls, chronic kidney disease, and abnormalities with mobility. R5's Quarterly Minimum Data Set (MDS) completed 09/24/24 noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS noted she required partial to moderate assistance with transfers, bed mobility, toileting, bathing, personal hygiene, and oral hygiene. The MDS noted she required substantial to maximal assistance with lower body dressing and putting on her footwear. The MDS noted she had no falls since her admission. R5's Fall Care Area Assessment (CAA) completed 07/08/24 indicated she had a history of falls before her admission and was at risk related to her medical diagnoses. The CAA noted she could make her needs known to staff. R5's Functional Abilities CAA completed 07/08/24 indicated she required assistance with her activities of daily living (ADLs) and transfers. The plan instructed staff to anticipate her needs when indicated. The CAA noted she could make her needs known to staff. R5's Care Plan initiated 07/01/24 indicated she was at risk for falls related to her history of falls and medication side effects. The plan indicated she required partial to moderate assistance with transfers, dressing, bed mobility, personal hygiene, toileting, and bathing. The plan noted she had one fall since her admission to the facility on [DATE] related to her self-ambulating in her room without calling for staff assistance. The plan indicated she was placed on occupational therapy to improve mobility functions and continued her physical therapy program. The plan indicated she was on a functional maintenance program related to ambulation and ADLs. The plan did not include documentation related to moving her bed to a high position when not in use. On 12/02/24 at 11:30 AM staff propelled R5 to the dining room area in the Memory Care Unit. Upon moving R5 out of her room, the staff stated Let's put her bed in the high position so she can't get back in it. Staff then placed R5's bed in the highest position. On 12/03/24 at 08:23 AM R5's bed was in the highest position. R5 sat at the dining room table. On 12/04/24 at 07:11 AM R5 slept in her bed. Her bed was in the medium to low position. On 12/04/24 at 10:00 AM R5's empty bed was placed in the high position. On 12/04/24 at 10:20 AM Certified Nurses Aide (CNA) LL stated R5 was impulsive and often attempted to stand or transfer herself without staff assistance. She stated staff had to closely watch R5 while she was in her room and provided frequent checks for ADLs. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) RR stated staff had to closely watch R5 due to her impulsive behavior to self-transfer and attempt to ambulate without staff assistance. She stated staff should ensure her room was free of clutter and provide frequent toileting. She stated that R5 has had only one fall attempting to ambulate in her room. On 12/04/24 at 02:22 PM Administrative Nurse D stated R5's bed should not be left in the high position due to her risk of falling and cognitive impairment. She stated staff were to leave it in the low position and assist her into and out of bed. The facility's Falls-Clinical Protocol revised 05/2022 indicated the facility will assess each resident's functional abilities and identify pertinent interventions to prevent subsequent falls. The policy noted the facility will provide ongoing monitoring and assessment of individuals at risk for falls. The facility failed to ensure R5's care environment was free from accident hazards when staff intentionally placed the bed in a high position to try to prevent R5 from getting in bed herself. This placed R5 at risk for preventable accidents and injuries. 41713 - R32's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN- an elevated blood pressure), and absence of the left and right leg above the knee. R32's Significant Change Minimum Data Set (MDS) dated [DATE] documented R32 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated a moderately impaired cognition. R32 required partial assistance for rolling left and right, substantial to maximal assistance for sitting to lying, and was dependent on staff for transfers. R32 had not had any falls since the prior assessment. R32's Cognition Care Area Assessment (CAA) dated 09/19/24 documented he had a BIMS score of 11 and had mild cognitive impairment. Staff would assist and anticipate the resident's needs. R32 needed assistance with activities of daily living (ADLs), transfers, hygiene, dressing, and bathing. Staff would provide assistance every two hours and as needed. R32's Care Plan last revised on 11/05/24, directed staff that R32 was at risk for falls secondary to being dependent with transfers. Staff were directed that R32 had a visual reminder in his room to use the call light for assistance prior to getting up and to re-educate staff to keep his bedside table close for him to reach things. Staff were to ensure the call light was within reach while in his room unsupervised. Staff were to encourage R32 to use his call light to alert staff for assistance. Staff were directed to respond promptly. Staff were directed to ensure a safe environment with an even floor, free from spills and or clutter, and have personal items within reach. The care plan lacked staff guidance for bed height placement. R32's Fall Risk Evaluation dated 12/02/24 documented a fall risk score of seven. If the total score was 10 or greater, the resident should be considered at high risk for potential falls. On 12/02/24 at 08:00 AM R32 was lying in bed. The bed height was noted to be in a high position. On 12/02/24 at 12:15 PM, R32 was noted in his bed. The bed height was noted to be in a high position. On 12/04/24 at 12:55 PM Certified Nurse Aide (CNA) O stated no resident's bed should ever be in a high position unless care was being provided or that was the resident's personal preference. CNA O stated a resident's care plan should document a high bed level preference but would not expect a resident who was a fall risk to have their bed in a high level. On 12/04/24 at 01:00 PM Licensed Nurse (LN) I stated a resident's bed should not ever be in a high position unless a care was being provided. LN I stated R32 was at risk for falls so his bed should not be left in a high position by staff. On 12/04/24 at 02:21 PM Administrative Nurse D stated she expected her staff to ensure R32's bed was never left at high height due to the risk of falls. Administrative Nurse D stated that R32 was dependent on staff for transfers and the only time his bed would need to be in a high position was when staff were providing care to him. The Falls - Clinical Protocol policy revised in May 2022 documented that on admission the nurse would complete a Fall Risk Assessment. The nurse would identify individuals with a history of falls and risk factors for falling. The staff would document in the medical record a history of one or more recent falls. Chart high-risk status and interventions on the care plan. Ensure that the resident has therapy on admission as appropriate. The facility failed to ensure R32's bed was maintained at a safe height for fall prevention. This placed R32 at risk for fall-related injuries. 49634 - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 had no falls since admission. The Falls Care Area assessment dated [DATE] documented R13 was at risk for falls due to cerebral palsy, an antisocial personality, immobility, epilepsy, and the need for assistance. R13's Care Plan revised 08/24/24 documented R13 was at risk for falls related to poor vision, epilepsy, and the need for assistance with ambulation and transfers. R13's plan of care documented that staff should encourage the use of non-skid footwear during ambulation and transfers. R13's plan of care dated 09/18/24 documented that staff were to ensure R13 had adequate lighting during waking hours, and they could leave the bathroom light or night light on during hours of sleep. Staff were also to ensure R13's call light was within his reach while he was in his room unsupervised, and staff should promptly respond to his call light. R13's plan of care dated 11/18/24 documented that a Dycem (non-slip mat used for stabilization and grip to prevent slipping) was added to his wheelchair; R13 continued occupational therapy (OT) services for seating and positioning. The plan documented a hospice medication review for scheduled pain medication, and a perimeter mattress was to be applied to R13's bed. R13's EMR under Event Note dated 08/16/24 documented R13 was found on his side, on the floor mat in the fetal position by physical therapy (PT). R13 was unable to verbalize how he fell . The possible root cause was that R13 was impulsive, and had a mental diagnosis. R13 appeared combative, was in a new environment, or could be hungry or thirsty. Staff notified the physician of the fall and placed a scoop mattress. Staff checked and changed R13 due to incontinence. The lighting was appropriate, and R13 was offered fluids and snacks. R13's EMR under Interdisciplinary Team Note dated 09/19/24 documented a fall on 09/18/24. The root cause was R13 slid out of his wheelchair and the immediate intervention was a Dycem was added to his wheelchair. OT was to evaluate the cushion for his wheelchair. R13's EMR under Interdisciplinary Team Note dated 11/18/24 documented a fall on 11/18/24. The root cause of the fall was R13 was having behaviors; he was spitting out his medication and hitting his head on the table. The nurse aide was in the room when R13 put himself on the floor. The immediate intervention was a request for a medication review from R13's provider. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion or a Dycem in place. On 12/02/24 at 08:21 AM, R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion or a Dycem in place. On 12/03/24 at 08:17 AM, R13 sat in the dining area in his wheelchair. R13 did not have a cushion or a Dycem in place. On 12/04/24 at 11:43 AM Therapy Director GG stated therapy staff worked with R13 on positioning. She stated the therapy staff should have noticed R13 did not have a Dycem in his wheelchair. She stated nursing and therapy were responsible for ensuring the resident's care plan was followed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff have access to each resident's care plans. She that it was the Certified Nurse Aide's (CNA) responsibility to help the resident into their wheelchair, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the resident Dycem was in place; the charge nurse would be the second check, and the unit manager should have been notified the resident's Dycem was not in place. The facility's Falls policy revised on 05/22 documented that on admission the nurse would complete the fall risk assessment. The nurse would identify individuals with a history of falls and risk factors for falling. Nurses would chart high-risk status and interventions on the care plan and ensure that they have therapy on admission as appropriate. The facility failed to ensure R13's Dycem was placed in his wheelchair to prevent falls. This deficient practice placed R13 at risk for continued falls and related injuries. - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of obesity (excessive body fat), acute respiratory failure ( a serious condition that occurs when the lungs are unable to provide the body with enough oxygen or remove enough carbon dioxide), Down's syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), sleep apnea (a disorder of sleep characterized by periods without respirations), hypotension (low blood pressure), dysphagia (swallowing difficulty), aphasia (condition with disordered or absent language function), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Admission Minimum Data Set (MDS) for R27 dated 09/24/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R27 needed substantial to maximum assistance from staff for eating and was dependent on staff for dressing her upper and lower body and for all hygiene. The MDS documented R27 was dependent on staff for chair-to-bed transfers. The MDS documented R27 had not had a fall since admission. R27's Cognitive Loss/ Dementia Care Area assessment dated [DATE] documented R27 would maintain the current level of cognitive function through the review date. Staff were to engage in simple, structured activities that avoid overly demanding tasks. The CAA documented R27 had impaired cognitive function or impaired thought processes related to developmental delays. R27's Communication Care Area assessment dated [DATE] documented R27 was primarily nonverbal. At times, R27 would make verbal noises but nothing discernible. R27 did maintain eye contact when being spoken to, and staff were to meet R27's needs. R27's Care Plan revised 09/27/24 documented R27 was at risk for falls. R27's plan of care documented that staff were to ensure R27's call light was within her reach, and staff could leave the bathroom light on or night light on during hours of sleep. Staff should respond promptly to R27's call light. R27's plan of care dated 09/29/24 documented that R27 would have a fall mat on the floor next to her bed. R27's plan of care documented she would have a defined perimeter mattress and would be the first one up for dinner. R27's EMR under Progress Note dated 11/18/24 documented that R27's roommate informed staff that R27 was sitting on the side of her bed. When the Certified Nursing Aide (CNA) entered R27's room, the CNA observed R27 sitting upright on the floor next to her bed. Staff assisted R27 to the laying position and placed her sling under her. Staff transferred R27 to her bed with a Hoyer (total body mechanical lift) and noted an abrasion down the left side of R27's back. The nursing staff notified the unit manager and physician. R27's EMR under Interdisciplinary Team Note dated 11/22/24 documented the root cause of the fall from 11/18/24 was R27 was sitting on the side of her bed, and the immediate intervention was to place a defined perimeter mattress on R27's bed and a fall mat. On 12/02/24 at 01:14 PM R27 laid on her bed awake, with a stuffed animal beside her. R27 did not have a fall mat in place beside her bed. On 12/03/24 at 01:17 PM, R27 lay on her bed with her eyes shut. R27 did not have a floor mat in place beside her bed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff had access to each resident's care plan. She said that it was the CNA's responsibility to help the resident into their wheelchair or bed, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the resident's fall mat was in place; the charge nurse should also be following up to ensure what was in the care plan was being followed through. The facility's Falls policy revised on 05/22 documented that on admission the nurse would complete the fall risk assessment. The nurse would identify individuals with a history of falls and risk factors for falling. Nurses would chart high-risk status and interventions on the care plan and ensure that they have therapy on admission as appropriate. The facility failed to ensure that R27's fall mat was placed beside her bed per her plan of care. This deficient practice placed R27 at risk for fall-related injuries.

The facility identified a census of 147 residents. Based on record review and interviews, the facility failed to ensure direct care staff had received the required resident rights. This placed the residents at risk for impaired care and decreased quality of life. Finding included: - On 12/04/24 a review of the provided training for agency Certified Nurses Aid (CNA) MM, CNA NN, and CNA OO revealed the following: CNA MM's facility-provided credentialling file lacked evidence training was completed for resident rights training. CNA NN's facility-provided credentialling file lacked evidence training was completed for resident rights training. CNA OO's facility-provided credentialling file lacked evidence training was completed for resident rights training. On 12/04/24 at 02:21 PM Administrative Nurse D stated she reviewed all the nursing staff information sent by the agency staffing company before a staff member worked. Administrative Nurse D stated upon the nursing staff reporting for the first shift she would go over dementia training, infection control, abuse, falls, and change in condition. Administrative Nurse D stated she assumed that the agency group made sure the nurse aides had the required training and education needed to work. The facility did not provide a policy regarding nurse aide required training as requested. The facility failed to ensure direct care staff had received resident rights training. This placed the residents at risk for impaired care and decreased quality of life.

The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the as-needed (PRN) psychotropic (alters mood or thought) medication had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 75's and R13's PRN psychotropic medications. This placed these residents at risk for unnecessary medication administration and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R75 had received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R75's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/26/24 documented she was ordered an antianxiety medication for anxiety. R75's Care Plan dated 09/20/24 documented that nursing staff would assess R75's functional status prior to the initiation of drug use to serve as a baseline. R75's EMR under the Orders tab revealed the following physician orders: Ativan (antianxiety mediation) oral tablet 0.5 milligrams (mg) give one tablet by mouth as needed for anxiety or restlessness dated 10/10/24. The order lacked a stop date. On 11/27/24 call durable power of attorney (DPOA) prior to administration of the as-needed Ativan medication. R75's EMR lacked evidence of a physician documented rationale for the extended PRN Ativan which included a specified duration. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated she was unsure how long a PRN antianxiety medication order could be active. LN G stated the physician puts all narcotic orders in electronically, and the order goes directly to the pharmacy. LN G stated the unit manager was responsible for reviewing all new orders and responsible to ensure all PRN psychotropic medication had a duration for use. On 12/04/24 at 02:21 AM Administrative Nurse D stated the pharmacist reviews all orders entered electronically, and the unit nurse managers monitor every new order and was to ensure there was a duration. Administrative D stated the facility would have to review its process. She stated every psychotropic medication should have a 14-day stop date. The facility's Psychotropic Medication Use policy, revised in 2016, documented antipsychotic medications would be prescribed at the lowest possible dosage for the shortest t period and were subject to gradual dose reduction and re-review. Each resident's drug regimen must be free from unnecessary drugs. The facility failed to ensure R75's PRN Ativan had a stop date, or a physician ordered specified duration for administration. This placed R75 at risk for unnecessary medication administration and possible adverse side effects. 49634 - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 was taking anti-anxiety medication during the observation period. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and antisocial personality, and R13 had been prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. R13's CAA documented R13 would be monitored for behaviors and treated to help decrease his anxiety and depression. R13's CAA documented R13 received psychotropic medication and was at risk for adverse side effects. R13's Care Plan dated 12/02/24 documented R13 used Ativan (antianxiety medication) and nursing was to monitor and administer R13's antianxiety medication as ordered by the physician. The plan directed nursing to monitor for side effects and the effectiveness of the medication every shift. R13's plan of care documented nursing was to monitor the resident for safety and monitor for increased risk of confusion, loss of balance, and cognitive impairment. R13's EMR under Orders documented the following physician's order: Lorazepam gel (Ativan) one milligram (mg) per one milliliter(ml) every eight hours as needed for agitation or anxiety apply 0.5mg topically every eight hours as needed (PRN) agitation dated 11/24/24. The order lacked a stop date. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated she was unsure how long a PRN antianxiety medication order could be active. LN G stated the physician puts all narcotic orders in electronically, and the order goes directly to the pharmacy. LN G stated the unit manager was responsible for reviewing all new orders and responsible to ensure all PRN psychotropic medication had a duration for use. On 12/04/24 at 02:21 AM Administrative Nurse D stated the pharmacist reviews all orders entered electronically, and the unit nurse managers monitor every new order and was to ensure there was a duration. Administrative D stated the facility would have to review its process. She stated every psychotropic medication should have a 14-day stop date. The facility's Psychotropic Medication Use policy, revised in 2016, documented antipsychotic medications would be prescribed at the lowest possible dosage for the shortest period and were subject to gradual dose reduction and re-review. Each resident's drug regimen must be free from unnecessary drugs. The facility failed to ensure R13 had a stop date for his PRN antianxiety medication. This deficient practice placed R13 at risk for unnecessary psychotropic medication administration.

The facility identified a census of 147 residents. The sample included 29 residents with two reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record review, and observations, the facility failed to provide dementia-related behavioral services for Resident (R)30 to promote her highest practicable level of well-being. This deficient practice placed R30 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R30's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), history of seizures (violent involuntary series of contractions of a group of muscles), epilepsy (brain disorder characterized by repeated seizures), and insomnia (difficulty sleeping). R30's Significant Change Minimum Data Set (MDS) completed 10/30/24 noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS noted that verbal and physical behaviors were observed for one to three days during the assessment. The MDS noted her behaviors interfered with her care and put her at risk for injuries. The MDS noted her behaviors put others at risk for physical injury and intruded on the privacy of others. The MDS noted she rejected care one to three days during the assessment. The MDS indicated she had no upper or lower extremity impairments. The MDS noted she required substantial to maximal assistance with bed mobility, toileting, dressing, personal hygiene, and transfers. The MDS noted she required supervision or touch assistance while ambulating. R30's Cognitive Loss Care Area Assessment (CAA) completed 10/29/24 indicated she had impaired cognitive function and thought processes related to her medical diagnoses. The CAA instructed staff to identify themselves during each interaction, reduce distractions, and use consistent simple sentences. The CAA instructed staff to provide cues and report changes in cognitive function. R30's Functional Abilities CAA completed 10/29/24 indicated she required assistance with her activities of daily living (ADLs), transfers, and ambulation. R30's Behavioral CAA completed on 10/29/24 indicated she received herbal supplementation for her continued behaviors. The CAA noted she would be assisted and monitored during her behaviors. The CAA noted she had verbal and physical behaviors that were disruptive to her and other resident's treatment and care environment. R30's Care Plan 07/01/24 indicated she had a self-care deficit related to her decline of independence and medical diagnoses. The plan noted the level of ADL assistance needed was determined by her cognitive functioning from day to day. The plan noted most days she required set-up to partial assistance with personal hygiene, dressing, toileting, transfers, bed mobility, and personal hygiene. The plan noted her level of needed assistance would increase with confusion or behavioral episodes. The plan noted she had a communication deficit related to her cognitive decline and impaired thought processes. The plan instructed staff to keep her routine consistent and provide cues to reorient her. The plan instructed staff to supervise her as needed for confusion. R30's Care Plan indicated she had aggressive behaviors towards others and would refuse care at times. The plan noted she would scream out if staff did not provide one-to-one care for her. The plan instructed staff to anticipate her needs and administer her medications as ordered (07/01/24). The plan instructed staff to intervene during behaviors to protect the rights and safety of others (07/01/24). The plan noted to remove R30 from situations if she became combative or agitated (08/09/24). The plan instructed staff to monitor her behavior episodes and attempt to determine the underlying causes 08/09/24). The plan instructed staff to explain treatment and procedures prior to completing them on her (08/09/24). The plan indicated staff will assist her with developing coping methods to prevent behaviors (08/09/24). The plan instructed staff to provide one-to-one care during behaviors until she calmed down (08/12/24). The plan indicated she started cannabidiol (CBD - herbal supplementation used for anxiety and agitation) during behavioral episodes (09/20/24). The plan instructed staff to provide one-to-one walk and pray with her to help diffuse behaviors (09/20/24). The plan instructed staff to allow her time to process requests and speak in short sentences (11/20/24). The plan instructed staff to be at eye level when talking with R30 (11/20/24). The plan lacked potential triggers or causes for her behaviors toward others and individualized non-pharmacological interventions to prevent repeated behaviors around meal services. The plan lacked techniques related to redirecting R30 during confusion and agitation. R30's EMR under Progress Notes on 08/06/24 indicated she had an altercation with another resident in the dining room. The note indicated R30 became verbally aggressive towards other residents resulting in her arm being grabbed by the resident. The note indicated staff separated the residents and R30 was able to calm down. The note indicated she was given her CBD gummy and provided one-to-one supervision for the evening. R30's EMR under Progress Notes on 08/13/24 indicated she attempted to enter another resident's room and became aggressive with both staff and the resident in the room. The note indicated that R30 was started on her CBD gummy supplement and provided one-to-one supervision. R30's EMR under Progress Notes on 10/06/24 indicated she had become verbally aggressive during dinner and began yelling at other residents. The note indicated she struck another resident at the dinner table. R30's EMR under Progress Notes on 10/29/24 indicated she had an altercation with a resident upon being touched by the other resident. The note indicated no injuries were found. The note identified impulsive behaviors as the root cause. On 12/04/24 at 10:20 AM R30 walked around the circular hallway within the memory care unit. R30's representative assisted her around the circular hallway. R30 reported she enjoyed her walks around the unit with staff. She stated it kept her moving and happy. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) RR stated R30's behaviors have improved within the last two months. She stated that R30 would have good and bad days depending on her cognition. She stated that R30 could become physically aggressive with staff and other residents around mealtime or when she sat close to them. She stated the facility put her on CBD gummies recently for anxiety and her behaviors. She stated staff would have to provide one-on-one time with her at times to calm her down and prevent outbursts. She stated that R30's behaviors would be unpredictable and often no real triggers would be known. She stated that R30 liked to take walks and listen to music. On 12/04/24 at 11:25 AM Administrative Nurse E stated that R30 liked to take walks and have one-to-one time with staff. She stated that R30 liked to recite the Lord's Prayer and [NAME] prayers. She stated staff were expected to take their time explaining things to her and be patient. She stated that R30's behaviors would come and go. She stated that R30's representative visits her frequently to help keep her routine consistent. She stated medication changes were made to improve R30's behaviors and she's taking the CBD supplements. On 12/05/24 at 02:20 PM Administrative Nurse D stated staff were expected to monitor R30 during activities and mealtimes. She stated staff should remain close and intervene if she became confused or agitated. She stated staff were to offer her walks and talk with her if she became upset or agitated. She was not sure if the care plan identified potential triggers or causative factors for R30's behaviors. The facility's Behavioral Health Services policy revised 02/2019 indicated all residents will be provided behavioral health services as needed to attain or maintain the highest practicable level of psychical, mental, and psychosocial well-being. The policy noted the facility will provide service and treatment to include individualized interventions and supervision. The facility was unable to provide a policy related to dementia care as requested on 11/04/24. The facility failed to provide dementia-related behavioral services for R30 to promote her highest practicable level of well-being. This deficient practice placed R30 at risk for decreased quality of life, isolation, and impaired dignity.

The facility identified a census of 147 residents. The sample included 29 residents with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 75. This deficient practice placed R75 at risk for unnecessary medication use and possible adverse side effects. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R75 received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication during the observation period. R75's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/26/24 documented she was ordered an antianxiety medication for anxiety. R75's Care Plan dated 09/20/24 documented that nursing staff would assess R75's functional status prior to the initiation of drug use to serve as a baseline. R75's EMR under the Orders tab revealed the following physician orders: Ativan (antianxiety mediation) oral tablet 0.5 milligrams (mg) give one tablet by mouth as needed for anxiety or restlessness dated 10/10/24. The order lacked a stop date. On 11/27/24 call durable power of attorney (DPOA) prior to administration of the as-needed Ativan medication. R75's Monthly Medication Review (MMR) reviewed for September 2024 addressed the requirement for a rationale for continued availability and a specific future stop date for the antianxiety medication Ativan. The facility was unable to provide documentation the physician reviewed and addressed the CP's recommendations. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 09:30 AM, Administrative Nurse D stated she was unable to find a physician response to the CP's September 2024 MRR. Administrative Nurse D stated the CP would print the MRRs and hand-deliver them to her. Administrative Nurse D stated would divide the nursing portion of the MRRs out to each unit manager. Administrative Nurse D stated she expected the unit managers to address the nursing portion of the MRRs. Administrative Nurse D stated she would hand deliver the MRRs to each of the physicians. Administrative Nurse D stated once the physician had reviewed the MRRs, she would give them to the unit managers to make the changes if any new orders, and then they are given to medical records to be scanned into the resident's EMR. The facility's Medication Regimen Review policy last revised 05/2019 documented the consultant pharmacist reviewed the medication regimen of each resident at least monthly. The consultant pharmacist provided the director of nursing services and the medical director with a written, signed, and dated copy of all medication regimen reports. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. The facility failed to ensure CP recommendations had been addressed for R75's as-needed antianxiety medication Ativan which lacked a stop date. This deficit practice placed her at risk of adverse side effects of psychotropic medication and unnecessary medications.

The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 52's physician-ordered supplemental oxygen supply was turned on. The facility failed to ensure R109's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) was stored appropriately when not in use. This placed R52 and R109 at risk of respiratory complications and possible infection. Findings included: - R52's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition where your blood does not have enough oxygen), dysphagia (swallowing difficulty), aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit), dementia (a progressive mental disorder characterized by failing memory and confusion), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) with hypoxia (inadequate supply of oxygen). R52's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of six which indicated severely impaired cognition. R52 had impairment on both sides of his lower extremity and used a wheelchair for mobility. R52 required substantial assistance with bathing, lower body dressing, and transfers. R52 required oxygen therapy. R52 was on hospice services. R52's Functional Abilities Care Area Assessment (CAA) dated 09/23/24 documented R52 suffered from self-care deficit secondary to assistance required in activities of daily living (ADLs), impaired balance and transition during transfers, and functional impairment in activity related to COPD and dementia. R52's Care Plan last revised on 06/26/24 directed staff of R52's supplemental oxygen as needed. The plan directed staff may titrate to keep oxygen saturation (percentage of oxygen in the blood) level above 90 percent (%). R52's Order Summary under the Orders tab of the EMR documented a physician's order dated 09/11/24 for continuous oxygen at one liter (L) per nasal cannula (NC). May titrate to keep oxygen saturation above 91%. A nurse Progress Note dated 11/20/24 at 08:51 AM for R52 documented an order was received from the provider for a chest X-ray. A nurse Progress Note: dated 11/21/24 at 08:07 AM for R52 documented the chest x-ray results were received and noted right basilar airspace opacities (findings that indicate something is in the space where air should be in the lungs) that was concerning for developing pneumonia. R52's provider had reviewed the results and ordered Amoxicillin (a medication used to treat bacterial infections) twice daily for seven days for pneumonia (an infection of the lungs). R52's Orders Summary under the Orders tab of the EMR documented a physician's order dated 11/21/24 for Amoxicillin to be given two times daily by mouth for pneumonia. On 12/02/24 at 07:47 AM, R52 sat in his wheelchair in his room, his NC was on and connected to his oxygen concentrator (a machine that provides supplemental oxygen) but the concentrator was not turned on. R52 was having some slight trouble getting his breath. Staff were notified that R52's concentrator was not on. On 12/04/24 at 12:55 PM, Certified Nurse Aide (CNA) O stated R52 was on continuous oxygen and should either have a portable oxygen tank with him or his NC should be connected to his concentrator in his room and be on at all times. On 12/04/24 at 01:00 PM Licensed Nurse (LN) I stated a resident who was on continuous oxygen should have the concentrator with them or always have a portable oxygen tank with them. LN I stated the aides should be making sure the concentrator was on when they did rounds. On 12/04/24 at 02:21 PM Administrative Nurse D stated she would expect nursing staff to check residents when getting them up or during rounds to ensure that their oxygen was on. Administrative Nurse D stated that R52 had gone to the hospital back in September and had been treated for pneumonia last month, so he was more vulnerable to respiratory issues. The Oxygen Administration policy was revised in October 2010 and documented to verify that there was a physician's order for the procedure. Review the physician's order or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Oxygen therapy was administered by way of an oxygen mask or an NC. The facility failed to ensure R52's physician-ordered supplemental oxygen supply was turned on. This placed R52 at risk of respiratory complications and possible infection. 41037 - R109's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of the need for assistance with personal care, cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and sleep apnea (a disorder of sleep characterized by periods without respirations). The Quarterly MDS dated [DATE] documented R109 had moderately impaired cognition. The MDS documented that R109 used a CPAP during the observation period. R109's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/22/24 documented she required staff assistance related to her CVA. R109's Care Plan dated 03/24/24 documented staff would clean her CPAP mask cushion and nose with soap and water and then hang it to dry. R109's EMR under the Orders tab revealed the following physician orders: Clean CPAP mask and tubing daily with soap and water and hang to air dry dated 05/09/24. On 12/03/24 at 04:14 PM, R109 sat out at the dining room table. In her room, R109's CPAP mask and tubing laid directly on her CPAP machine on the bedside table next to the bed. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would clean R109's CPAP in the morning after she assisted R109 out of bed. CNA N stated she would clean the CPAP mask with a disinfectant wipe and then store the mask in a plastic bag. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would clean R80's CPAP mask every morning with soap and water and then hang it to dry. LN H stated the CPAP mask should never be placed directly on the bedside table or the CPAP machine. On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nurse on the unit to clean the CPAP mask with soap and water. Administrative Nurse D stated that the mask was to hung to air dry. Administrative Nurse D stated the CPAP mask should never be stored directly on the bedside table or top of the CPAP machine. The facility was unable to provide a policy related to the storage of respiratory equipment. The facility failed to ensure R109's CPAP mask was stored in a sanitary manner. This placed R109 at increased risk for respiratory infection and complications.

The facility identified a census of 147 residents. The sample included 29 residents with three residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 80's access site for complications at least daily and document the arteriovenous (AV-a surgically created connection between an artery and a vein used for hemodialysis) fistula for the thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with a stethoscope that may occasionally also be palpated as a thrill) every day. This deficient practice placed R80 at risk of adverse outcomes and physical complications related to dialysis. Findings included: - R80's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), a need for assistance with personal care, and cognitive communication deficit. 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 R80 received dialysis during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. The MDS documented that R80 received dialysis during the observation period. R80's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 05/13/24 documented he required staff assistance with toileting and personal hygiene. R80's Care Plan dated 09/24/24 documented that staff would monitor, document, and notify the physician of any signs or symptoms of infection of his access site. The plan of care documented nursing staff would check and change his dressing daily at the access site. R80's EMR under the Orders tab revealed the following physician orders: Dialysis on Monday, Wednesday, and Friday for end-stage renal disease. Arteriovenous fistula (AVF- is an abnormal connection between an artery and a vein) located on the left upper extremity dated 09/22/24. A review of R80's EMR under the Assessment tab revealed Pre/Post Dialysis Evaluation reviewed from 09/11/24 through 11/29/24. The assessments documented assessment for signs of infection of his AVF and bruit and thrill on the days he received dialysis (three days weekly). R80's clinical record lacked evidence of daily assessment of R80's AVF and monitoring of thrill and bruit. On 12/03/24 at 03:15 PM, R80 sat in a recliner in his room with his lower extremities elevated as he watched the news on the TV. On 12/04/24 at 12:25 PM, Certified Nurse Aide (CNA) N stated she would help R80 get dressed and ready for dialysis. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she would assess his access site every Monday, Wednesday, and Friday when received dialysis. LN H stated his AVF should be assessed at least daily and that would usually be documented on the Treatment Administration Record (TAR). On 12/04/24 at 02:21 PM, Administrative Nurse D stated she expected the nursing staff to assess R80's bruit and thrill every shift. Administrative Nurse D stated the nursing staff did not change the resident's dialysis access site dressing. Administrative Nurse D stated the nursing staff should monitor for any bleeding or any signs of infection. Administrative Nurse D stated the assessment of the access site would be documented on the resident's TAR. The facility's Dialysis policy last revised 09/2010 documented the staff would check thrills/bruit of grafts and fistulas, documented in EMR. When to remove the dressing from the access site placed on from the dialysis center. Monitor for signs and symptoms of infection including, but not limited to, fever, redness, tenderness, and bleeding at the fistula site. The facility failed to monitor R80's dialysis access site for the thrill, bruit, and signs of infection, bleeding, and the status of the dressing in place. This deficient practice placed R80 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 75's right to be treated with respect, and dignity when her clothing protector was not removed after the meal was finished. The facility also failed to ensure a dignified dining experience for R13 when staff stood over him instead of sitting beside him. This deficient practice placed these residents at risk for negative psychosocial outcomes and decreased dignity. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. R75's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/24 documented she was cognitively impaired. R75's Care Plan dated 09/12/24 documented she required substantial to maximum assistance with meals. The plan of care documented she was dependent on staff assistance with all other activities of daily living. The plan of care dated 09/24/24 documented it was very important to R75 to receive snacks between meals. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12: 25 PM, Certified Nurse Aide (CNA) N stated no resident should have a clothing protector on if they are not eating or drinking. CNA N stated having a clothing protector left on would be a dignity concern. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated R75 should not have a clothing protector left on after the meal had ended. On 12/04/24 at 02: 21 PM, Administrative Nurse D stated she expected all the clothing protectors removed after each meal. The facility's Quality of Life-Dignity policy last revised on 02/20 documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth, and self-esteem. Residents would be always treated with dignity and respect. The facility's culture was one that supports and encourages humanization and individuation for residents and honors resident choices, preferences, values, and beliefs. The facility failed to ensure R75's right to be treated with respect, and dignity when her clothing protector was not removed after the meal was finished. This deficient practice placed R75 at risk for negative psychosocial outcomes and decreased dignity. 49634 - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/15/24 documented that R13 had impaired cognitive function or impaired thought processes related to developmental delays. R13's Communication CAA dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and had impairment with communication. R13's Care Plan dated 12/02/24 documented R13 suffered from a self-care deficit related to a decline in his prior level of independence resulting in the need for continued medical care related to cerebral palsy, intellectual disabilities, low vision, schizoaffective disorder, epilepsy, and adult failure to thrive. R13's plan of care documented R13 was dependent on staff for oral hygiene, personal hygiene, and eating. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast, Certified Nurse's Aide (CNA) M walked by R13, grabbed his juice glass, and gave him a drink while standing over R13, and then walked away. CNA M did not speak to R13 during the observation. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G stated if a staff member was helping a resident eat or drink, the staff member should be at eye level with the resident and engaging with the resident. On 12/04/24 at 12:48 PM, Certified Nurse's Aide (CNA) M stated staff should sit next to the resident, and never just walk by the resident to give them a drink or a bite to eat. On 12/04/24 at 02:21 PM Administrative Nurse D stated staff should be engaging with residents when helping a resident eat or drink. She stated staff members should never stand over a resident while they assist the resident with eating. The facility's Quality of Life-Dignity policy revised on 02/2020 documented that each resident should be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth, and self-esteem. Residents would be always treated with dignity and respect. The facility's culture was one that supports and encourages humanization and individuation for residents and honors resident choices, preferences, values, and beliefs. The facility failed to ensure R13's dignity when staff stood over R13 to give him a drink of his juice and did not interact. This deficient practice placed R13 at risk for impaired dignity and decreased psychosocial well-being.

The facility identified a census of 147 residents. The sample included 29 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify Resident (R)13's guardian of changes related to the addition of psychotropic (alters mood or thoughts) medications. This deficient practice placed R13 at risk for uninformed care choices or inability to consent or decline treatment. Findings included: - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/15/24 documented R13 had impaired cognitive function or impaired thought processes related to developmental delays. R13's Psychotropic Drug Use Care Area Assessment (CAA) dated 11/15/24 documented R13 had a diagnosis of cerebral palsy and antisocial personality, and R13 had been prescribed antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications. R13's CAA documented he would be monitored for behaviors and treated to help decrease his anxiety and depression. R13's CAA documented he received psychotropic medication and was at risk for adverse side effects. R13's Care Plan dated 12/02/24 documented R13 used Ativan (antianxiety medication) and nursing was to monitor and administer R13's antianxiety medication as ordered by the physician. The plan directed nurses to monitor for side effects and effectiveness of the medication every shift. R13's plan of care documented nursing was to monitor the resident for safety and monitor for increased risk of confusion, loss of balance, and cognitive impairment. R13's EMR under Orders documented the following physician's order: Lorazepam gel (Ativan) one milligram (mg) per one milliliter(ml) every eight hours as needed for agitation or anxiety apply 0.5mg topically every eight hours as needed (PRN) agitation dated 11/24/24. The order lacked a stop date. R13's clinical record lacked evidence of guardian notification for the new Ativan gel order. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair, awaiting his breakfast. On 12/04/24 at 09:24 AM R13's guardian stated the nursing staff had called her about care plans and falls. R13's guardian stated she had never been called or informed about adding any medication, or medication changes. On 12/04/24 at 12:33 PM Licensed Nurse (LN) G stated it was the nurses' duty to call guardians and resident representatives and inform them of any medication changes. LN G stated when the guardian or representative was called, staff documented the communication in the progress nursing note section of the EMR. On 12/04/24 at 03:21 PM Administrative Nurse D stated it the charge nurse should call the resident's guardian with any changes. Administrative Nurse D stated the unit nurse managers run a report of all new orders daily, and unit managers could also follow up with a guardian or representative on any medication change or change of condition. The facility did provide a policy for notification of changes. The facility failed to notify R13's guardian of changes related to the addition of psychotropic medications. This deficient practice placed R13 at risk for uninformed care choices or inability to consent or decline treatment.

The facility identified a census of 147 residents. The sample included 29 residents reviewed for comprehensive assessments and timing. Based on observation, record review, and interviews, the facility failed to ensure the significant change Minimum Data Set (MDS) for Resident (R) 16 was accurately coded as required by the Resident Assessment Instrument (RAI) Manual. This placed R16 at risk for an inaccurate care plan and unmet care needs. Findings included: - R16 ' s Electronic Medical Record (EMR) recorded diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), and gastrostomy (the introduction of a nutrient solution through a surgically inserted tube into the stomach through the abdominal wall). R16 ' s Significant Change MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eight which indicated a moderately impaired cognition. R16 was on a physician-prescribed weight gain regimen. R16 ' s MDS section K0520 Nutritional Approaches lacked documentation of a feeding tube (administration of nutritionally balanced liquefied foods or nutrients through a tube) and the percent of calories and amount of fluids provided per the feeding tube. R16 ' s Nutritional Care Area Assessment (CAA) dated 10/01/24 documented R16 was currently on enteral feedings and water flushes. R16 was at risk for dehydration. The registered dietician would monitor her intake and nursing staff would provide feeding. R16 ' s Tube Feeding CAA was not triggered. R16 ' s Care Plan last revised on 09/18/24 directed staff that R16 was dependent on staff for tube feeding and water flushes. The staff was directed to see physician orders for current feeding orders. R16 ' s Order Summary Report in the EMR documented a physician ' s order dated 07/18/24 for Nepro (therapeutic nutrition designed to help meet the specific nutrition needs of people on dialysis) nutritional supplement oral liquid 237 milliliters (ml) via feeding tube twice daily. On 12/03/24 at 11:45 AM R16 wheeled herself out to the dining room for lunch. R16 stated she was able to eat regular meals but did have the enteral feeding to supplement her meals due to a recent weight loss and her being on dialysis (a procedure where impurities or wastes are removed from the blood) therapy. On 12/04/24 at 02:04 PM Administrative Nurse F stated it appeared the dietician did not mark R16 ' s MDS for the enteral feeding when they completed the nutritional and tube feeding parts of the MDS. Administrative Nurse F stated that R16 was on enteral feeding and that she would do a modification to the MDS to ensure it was marked correctly. On 12/04/24 at 02:21 PM Administrative Nurse D stated she did not complete any part of the MDS but would expect the MDS staff that completed them to make sure they would be coded correctly. The facility did not provide a policy regarding the MDS as requested. The facility failed to ensure R16 ' s significant change MDS section K050 Nutritional Approaches was accurately coded as required by the RAI Manual. This placed R16 at risk for an inaccurate care plan and unmet care needs.

The facility identified a census of 147 residents. The sample included 29 residents with Resident (R) 93 reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff provided appropriate and safe assistance with activities of daily living (ADL) to R93 during a transfer which resulted in bruises to both R93's arms. This deficient practice placed R93 at risk of decreased ADL ability, pain, and psychosocial distress. Findings included: - R93's Electronic Medical Record (EMR) documented diagnoses of repeated falls, hypertension (HTN-elevated blood pressure), blindness in one eye, and dementia (a progressive mental disorder characterized by failing memory and confusion). R93's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated a moderately impaired cognition. R93 required substantial to maximal assistance of staff for bed-to-chair (or wheelchair) transfers. R93 had a history of one fall without injury and one fall with injury since her prior assessment. R93 was on hospice services. R93's Quarterly MDS dated [DATE] documented she had a BIMS score of 13 which indicated intact cognition. R93 was dependent on staff for bed-to-chair transfers. R93 had not had any falls since the prior assessment. R93 was on hospice services. R93's Functional Abilities Care Area Assessment (CAA) dated 07/01/24 documented she suffered from a self-care deficit related to a decline in her prior level of independence resulting in the need for continued medical care. She was on hospice services, and further decline was anticipated due to a cognitive communication deficit. R93's Care Plan initiated on 03/28/24 and last revised on 11/20/24 directed staff that R93 was dependent on two staff, using a Hoyer lift (full body mechanical lift) for chair-to-bed or bed-to-chair transfers. Prior to the 11/20/24 revision, the care plan directed R93 required substantial to maximal assistance but did not indicate the use of a [NAME] belt or how many staff were required. A Progress Note in R93 ' s EMR dated 11/19/24 at 03:40 PM documented that on 11/19/24 the hospice nurse contacted Administrative Nurse D to report that a hospice aide reported that Certified Nurse Aide (CNA) P transferred R93 in a rough manner. The hospice nurse stated that R93 had a purple mark in the shape of a thumb on each arm. Administrative Nurse D and the nurse manager went to talk to R93 and assess her. R93 reported that CNA P transferred her on 11/17/24 to her chair. R93 wanted the pads in the chair smoothed out but CNA P did not smooth them out and CNA P used R93 ' s upper arms to transfer her to the chair. R93 had a bruise in the shape of a thumb on each of her upper arms which was purple in color. R93 ' s provider was notified and stated she would assess the resident the following day. A Progress Note dated 11/21/24 at 11:58 AM from R93 ' s provider documented the resident was seen that day per request of Administrative Nurse D. R93 was seen in her room and said a staff member was trying to get her to transfer to her wheelchair but the resident was concerned because the wheelchair was full of bed pads. The resident said she told the aide she did not want to move with all the pads in the wheelchair. R93 thought the staff looked frustrated and mashed her arms. R93 said she and the aide had not had any prior animosity and she was not sure why the CNA did that. R93 said the aide just seemed determined to make her do what CNA P wanted. R93 denied pain. Assessment of R93 revealed her bilateral upper extremity bicep areas (upper arm area) had nearly symmetric single ecchymotic (bruising) lesions in the shape of a thumbprint present, without edema. The nurse manager and Administrative Nurse D were notified and were reviewing the episode with plans to make changes for a safe transfer for R93. The facility report documented an incident with R93 and CNA P that occurred on 11/17/24. Administrative Nurse D was notified by the hospice nurse, that the hospice aide had reported that facility CNA P had transferred R93 in a rough manner. CNA P used R93 ' s upper arms to transfer her to the chair. R93 had a bruise in the shape of a thumb on each of her upper arms which was purple in color. CNA P reported that R93 refused to be transferred with the gait belt. CNA P attempted to transfer R93 with the help of another CNA and R93 became stiff, arched her back, and was unwilling to grab the wheelchair per direction from the aides to assist with the transfer. CNA P held R93 ' s arms to keep her from falling as she transferred R93 to her wheelchair. Licensed Nurse (LN) J was asked how the resident transferred and said she had not transferred R93 recently. LN J went to try to transfer R93 and she again arched her back and would not cooperate with the transfer. R93 was downgraded to a Hoyer lift for transfer and a referral was sent for therapy. CNA P was counseled on always using a gait belt and if the resident refused to use the gait belt the transfer was to be stopped and notify the charge nurse. CNA P grabbed R93 by the arm to prevent her from falling. R93 was care planned to be a partial moderate assist with transfers, revealing she needed assistance from staff during the transfer. CNA P attempted to use the gait belt and R93 refused to allow the aide to place the belt around her. R93 insisted on transferring without the gait belt. CNA P did get another staff to help to ensure R93 was safe. CNA P was unaware that if a resident refused to use the gait belt to transfer, the transfer should be downgraded to a Hoyer lift to ensure the resident's safety. CNA P was educated regarding the proper use of the gait belt during transfers and demonstrated competency with partial moderate assist transfers. On 12/02/24 at 01:08 PM, R93 sat in her wheelchair in her room and said that CNA P was trying to transfer her on 11/17/24 and would not straighten the pads in her wheelchair. R93 said that CNA P grabbed her upper arms to transfer her to her wheelchair from her bed and left bruises on her arms. On 12/04/24 at 12:58 PM, CNA P stated R93 was upset that the pads in her wheelchair were not flat, so she transferred R93 from her wheelchair back to her bed but R93 did not want to sit back in the wheelchair, so she went to get another aide to help her. CNA P stated R93 did not want the gait belt on her to transfer so CNA P grabbed R93 by her upper arms to prevent her from falling while transferred to her wheelchair. On 12/04/24 at 01:00 PM LN I stated she could not say, without looking at the care plan, how R93 transferred but thought R93 was a Hoyer transfer. On 12/04/24 at 02:21 PM Administrative Nurse D stated she had thought R93 had been a one-person assist using a gait belt prior to the incident on 11/17/24 but would have to look at the care plan to verify that information. Administrative Nurse D stated that R93 was a two-person Hoyer lift for transfers now. Administrative Nurse D stated an investigation was done regarding the incident with R93 and CNA P, which resulted in a suspension until the investigation was completed. Administrative Nurse D stated CNA P was reeducated regarding proper transfer technique. The Activities of Daily Living (ADLs), Supporting policy documented that residents would be provided with the care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities would be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice. The facility failed to ensure staff provided appropriate and safe ADL assistance to R93 during a transfer which resulted in bruises to both R93's arms. This deficient practice placed R93 at risk of decreased ADL ability, pain, and psychosocial distress.

The facility identified a census of 147 residents. The sample included 29 residents with seven residents reviewed for treatment and services to prevent and/or heal 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 Resident (R) 22's heels were offloaded either by boots or a pillow and further failed to ensure R13 was provided a pressure-reducing cushion for his wheelchair. This placed R22 and R13 at increased risk for pressure ulcer development and delayed healing. Findings Included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), Methicillin-resistant Staphylococcus aureus (MRSA-a type of bacteria resistant to many antibiotics), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) affecting the right dominant side, cognitive communication deficit, muscle weakness, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and dysphagia (swallowing difficulty). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented that R22 had an impairment on one side of his lower body. The MDS documented R22 was dependent on staff for lower body dressing and putting on and taking off footwear, oral hygiene, and toileting. The MDS documented R22 was at risk for pressure ulcers and had a Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) over a bony prominence, and had an unhealed pressure ulcer on admission. R22's Pressure Ulcer/ Injury Care Area assessment dated [DATE] documented R22 was admitted with a right lateral foot deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) and a surgical wound on 10/25/24. R22 required assistance with bed mobility. R22's Care Plan revised 11/12/24 documented R22 was admitted with a right lateral foot DTI and surgical wound. Staff were to ensure adequate and proper repositioning every two hours, and as needed (PRN). Staff were to monitor skin condition with care, for color or texture changes, redness, edema, and incontinence-associated skin damage and report findings to the charge nurse. R22 was to use a pressure-reducing device in his chair and wheelchair. R22's EMR under Orders documented the following physicians' orders: Reposition the resident every two hours. Always keep heels offloaded every shift dated 10/31/24. R22's medical record lacked documentation R22 refused offloading. On 12/03/24 at 12:10 PM, R22 lay on his bed. R22's heel rested directly on the mattress. R22's heels were not offloaded. On 12/03/24 at 12:30 PM R22 laid on his bed visiting with his family. R22's heels were directly on the mattress. R22's heels were not offloaded. On 12/04/24 at 12:31 PM, R22 stated he was unaware his heels were supposed to be off the mattress. He stated he had boots, and sometimes the staff put the boots on him. R22 stated staff would put a pillow under his legs, which was usually at night. R22 stated he was not able to take his boots off or remove the pillow from under his legs. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. CNA M stated it was not on the daily report to float R22's heels. On 12/04/24 at 12:33 PM, Licensed Nurse (LN) G said ensuring boots are on the resident or offloading their heels would be the charge nurses' responsibility. LN G stated she did not think R22 could take his boots off on his own or remove a pillow if his heels were offloaded. On 12/04/24 at 02:21 PM Administrative Nurse D stated applying boots to a resident or ensuring heels were offloaded would be on the nurse's task, but the charge nurse could delegate that duty to the CNA if the nurse was busy. Administrative Nurse D stated the staff all work together to ensure all tasks are completed. The facility's Pressure Ulcers/Skin Breakdown policy revised on 04/18 documented that the nursing staff and practitioner would access and document an individual significant risk factors for developing pressure ulcers. The medical provider will help identify medical interventions related to wound management. A medical provider will order pertinent treatments, including pressure reduction surfaces, wound cleansing, and or dressings. The facility failed to ensure R22's heels were offloaded either by boots or a pillow. This placed R22 at increased risk for pressure ulcer development and delayed healing. - The Diagnoses tab of R13's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), epilepsy (brain disorder characterized by repeated seizures), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), intellectual disabilities, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), sleep apnea (a disorder of sleep characterized by periods without respirations), adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). The Modification of Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R13 had an impairment on both sides of his body. The MDS documented R13 was dependent on staff for activities of daily living (ADLs). The MDS documented R13 was at risk for pressure ulcers and had one or more Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) or higher. R13's Pressure Ulcer/ Injury Care Area assessment dated [DATE] documented R13 was incontinent of bowel and bladder and required assistance with toileting and toileting hygiene. R13 would be assisted every two hours and as needed (PRN). R13's Care Plan dated 08/27/24 documented that staff were to ensure adequate and proper repositioning every two hours and PRN. Staff were to avoid massaging over bony prominences and may use lotions and moisturizers to prevent skin from drying out. Staff were to monitor skin condition with care, for color or texture changes, redness, edema, and incontinence-associated skin damage and report findings to the charge nurse Staff were to provide supplements as ordered for wound healing. R13 was to have a pressure-reducing device in his chair and or wheelchair and a pressure-reducing mattress. On 12/01/24 at 08:32 AM R13 sat in the dining area in his wheelchair. R13 had a blue and white blanket in his chair. R13 did not have a cushion in place. On 12/02/24 at 08:21 AM, R13 sat in the dining area in his wheelchair, R13 had a blue and white blanket in his chair. R13 did not have a cushion in place. On 12/03/24 at 08:17 AM, R13 sat in the dining area in his wheelchair. R13 did not have a cushion in place. On 12/04/24 at 11:43 AM Therapy Director GG stated therapy staff worked with R13 on positioning. She stated the therapy staff should have noticed that R13 did not have a cushion in his wheelchair. She stated nursing and therapy were responsible for ensuring the resident's care plan was followed. On 12/04/24 at 12:23 PM, Licensed Nurse (LN) G stated all staff have access to each resident's care plans. LN G stated she was unaware that R13 did not have a cushion in his wheelchair. She stated that it was the Certified Nurse Aide's (CNA) responsibility to help the resident into their wheelchair, but ultimately the nurse in charge was responsible for ensuring each resident had what they needed to stay safe. On 12/04/24 at 12:48 PM, CNA M stated he did have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), but he usually referred to the daily report sheet. CNA M stated he carried the daily report sheet and could refer to the sheet if he was unsure what each resident needed for care. CNA M stated he could not remember the last time there was a cushion in R13's wheelchair. On 12/04/24 at 02:21 PM, Administrative Nurse D stated the CNAs would be the first check to ensure the cushion was in place; the charge nurse would be the second check, and the unit manager should have been notified the resident's cushion was not in place. The facility's Pressure Ulcers/Skin Breakdown policy revised on 04/18 documented that the nursing staff and practitioner would access and document an individual significant risk factors for developing pressure ulcers. The medical provider will help identify medical interventions related to wound management. A medical provider will order pertinent treatments, including pressure reduction surfaces, wound cleansing, and or dressings. The facility failed to ensure R13 had a cushion in his wheelchair. This placed R13 at increased risk for pressure ulcer development.

The facility identified a census of 147 residents. The sample included 29 residents with two residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 75's and R107 posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R75 and R107 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R75's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational ion (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. R75's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/24 documented she was cognitively impaired. R75's EMR under the Assessments tab revealed Activities/Social history and Initial assessment dated [DATE] under the Trauma Informed Care section documented she had a history of trauma, and the intervention would be the staff would recognize her specific triggers and avoid re-traumatization. R75's Care Plan dated 09/27/24 documented staff would recognize her specific triggers to avoid re-traumatization. The plan of care lacked individualized interventions that identified ways to decrease exposure to triggers that could re-traumatize her. On 12/02/24 at 10:32 AM R75 sat in her high-back wheelchair in the dining room asleep. R75 had a clothing protector attached around her neck that had fallen off her left shoulder and arm. R75 was not positioned at a dining room table and there were no drinks or food on any dining room tables. On 12/04/24 at 12: 25 PM, Certified Nurse Aide (CNA) N stated she was not aware R75 had experienced trauma in her past. CNA N stated she was not aware of what triggers might retraumatize R75. On 12/04/24 at 12:35 PM, Licensed Nurse (LN) H stated she was not aware R75 had experienced trauma in her past. LN H stated she did not know what triggers could retraumatize R75. On 12/04/24 at 02:21 PM, Administrative Nurse D stated each resident was assessed for trauma-informed care at the time of admission to the facility, after changes in the psychosocial well-being of the resident and with every MDS. Administrative Nurse D stated if a resident had a history of past trauma personalized interventions should be listed on the resident plan of care to prevent the resident from being re-traumatized. The facility's Trauma Informed Care policy last revised 03/2019 documented the facility would guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. The facility supported a culture of emotional well-being and physical safety for staff, residents, and visitors. Trauma-informed care was culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. As part of the comprehensive assessment, identify the history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive. Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.). The facility failed to identify trauma-based triggers related to R75's history of trauma and implement individualized interventions to prevent re-traumatization. These deficient practices placed R75 at risk for decreased psychosocial well-being and ineffective treatment. - R107's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cognitive communication deficit, need for assistance with personal care, intellectual disability, PTSD, and schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. The MDS documented R107 had a diagnosis of PTSD. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R107 had a diagnosis of PTSD. R107's Psychosocial Well-Being Care Area Assessment (CAA) dated 08/20/24 documented she was having adjustment issues to admission affecting her desire to do things. R107's Care Plan dated 08/12/24 documented staff would engage her in simple, structured activities that avoided overly demanding tasks. The plan of care lacked individualized triggered -specific interventions that identified ways to decrease exposure to triggers that could re-traumatize her. R107's EMR lacked evidence of a Trauma Informed Care Assessment. The facility was unable to provide evidence a trauma-based care assessment was completed for R107 who had a diagnosis of PTSD. On 12/03/24 at 01:47 PM R107 sat in her wheelchair as she rolled herself up the hallway from her room to the dining room area. On 12/04/24 at 12:50 PM, Certified Nurse Aide (CNA) O stated she was not aware of any resident who had a diagnosis of PTSD. On 12/04/24 at 12:57 PM, agency Licensed Nurse (LN) I said she was not aware of any resident that had a diagnosis of PTSD. On 12/04/24 at 02:21 PM, Administrative Nurse D stated each resident was assessed for trauma-informed care at the time of admission to the facility, after changes in the psychosocial well-being of the resident and with every MDS. Administrative Nurse D stated if a resident had a history of past trauma personalized interventions should be listed on the resident plan of care to prevent the resident from being re-traumatized. Administrative Nurse D stated she was not sure why R107 was not assessed for trauma-based care at the time of her admission or at the time of her quarterly MDS. The facility's Trauma Informed Care policy last revised 03/2019 documented the facility would guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. The facility supported a culture of emotional well-being and physical safety for staff, residents, and visitors. Trauma-informed care was culturally sensitive and person-centered. Caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. As part of the comprehensive assessment, identify the history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. Interact with all residents and visitors in a manner that is welcoming and kind, without being intrusive. Reduce or eliminate unnecessary stimuli (noise, lighting, unwanted or sudden physical contact, etc.). The facility failed to identify trauma-based triggers related to R107's diagnosis of PTSD and implement individualized interventions to prevent re-traumatization. These deficient practices placed R107 at risk for decreased psychosocial well-being and ineffective treatment.

The facility reported a census of 147 residents. The sample included 29 residents with six reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow instructions related to medication monitoring when staff administered Resident (R)303's anti-hypertensive (class of medication used to treat high blood pressure) medications outside the physician-ordered parameters. This deficient practice placed R303 at increased risk for unnecessary medication and side effects. Findings included: - The Medical Diagnosis section within R303's Electronic Medical Records (EMR) included diagnoses of acute respiratory failure, atherosclerotic heart disease (reduced blood flow due to blockages in the arteries within the heart), atrial fibrillation (rapid, irregular heartbeat), hypertension (high blood pressure), and chronic kidney disease. R303's EMR revealed he was admitted on [DATE] and discharged on [DATE] to an acute care facility for emergency treatment. R303 did not have a Minimum Data Set (MDS) or Care Area Assessment (CAA) completed. R303's Care Plan initiated 11/07/24 indicated he required supervision or touch assistance with dressing, meal set-up, personal hygiene, dressing, transfers, toileting, and bathing. The plan indicated he took medications with Black Box Warning (BBW- the highest safety-related warning that medications can be assigned by the Food and Drug Administration) and he was at risk for adverse interactions. The plan instructed staff to monitor and report changes related to his anti-hypertensive medications to his medical provider. R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer 10 milligrams (mg) of amlodipine besylate (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303'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 less than (<) 110 millimeters of mercury (mmHg). R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer 20 mg of lisinopril (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303's SBP was less than 110 mmHg. R303's EMR under Physician Orders revealed an order dated 11/08/24 for staff to administer five milligrams of terazosin (antihypertensive medication) by mouth once daily for hypertension. The order instructed staff to hold the medication if R303's SBP was less than 110 mmHg. R303's EMR revealed he was admitted to an acute care facility on 11/15/24 related to low blood pressure. A review of R303's November 2024 Medication Administration Report (MAR) revealed his morning blood pressure was taken before his medications were administered on 11/09/24. The MAR revealed his SBP was 99 mmHg. The MAR revealed his lisinopril, terazosin, and amlodipine were administered. The EMR revealed his antihypertensive medications were held on 11/10/24, 11/12/24, and 11/14/24 due to low blood pressure. An inspection of R303's medication punch cards revealed all three medications were punched out on 11/09/24. On 12/04/24 at 11:01 AM Certified Medication Aide (CMA) R stated the MAR should flag documented blood pressures outside the parameters to prevent the medications from being given to residents with chronically low blood pressure. She stated that licensed staff were required to review the medication orders before administering all medications. She stated staff should check each resident's vital signs before administering antihypertensive medications. On 12/04/24 at 11:30 AM Administrative Nurse E stated the MAR would require a resident's blood pressure to be entered before medication administration. She stated staff were required to check the medication orders and parameters before giving the medications. On 12/04/24 at 12:20 PM Administrative Nurse D stated R303's antihypertensive medications should not have been given if his systolic pressure was 99 mmHg. She verified the medication had been administered. The facility's Administering Medications policy (undated) indicates the medication is to be administered in a safe and timely manner. The policy indicated staff were to administer medications in accordance with the prescriber's orders. The policy indicated that licensed staff will check to verify the correct residents, dosage amount, time, date, and route of the administration. The policy indicated staff would hold and notify the medical provider if the medications were outside the provided order parameters or not given. The facility administered R303's anti-hypertensive medication outside the physician-ordered parameters. This deficient practice placed R303 at increased risk for unnecessary medication and side effects.

The facility census totaled 92 residents with one resident sampled for neglect. Based on interview and record review, the facility failed to provide a safe environment free of injury/falls when Certified Medication Aide (CMA) R failed to follow the plan of care developed for Resident (R) 1 and transferred the resident without the assistance of another staff member and the use of a mechanical lift, resulting in the resident being lowered to the floor. R1 sustained injuries from the unsafe transfer, which included a bruise to R1's right eye, blood from her left nostril, an abrasion to her right shin, and the resident passing away shortly after the incident. After completion of an autopsy on R1, it was confirmed the resident had two fractured ankles, blunt force trauma to the head, and blunt force trauma to the abdomen because of the improper transfer. This failure placed the resident in immediate jeopardy. Findings included: - Resident (R) 1's signed Physician Orders dated [DATE] revealed the following diagnoses: severe dementia (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteoarthritis, and muscle weakness. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The resident had physical and verbal behaviors one to three days and rejection of cares on one to three days of the observation period. The resident required total dependence of two staff for transfers and was non-ambulatory. The resident had one non-injury fall since the last assessment. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated [DATE] revealed the resident would scream at staff while scratching and hitting staff during cares. She would scream help me when she moved herself into an uncomfortable position in her bed. The Care Plan dated [DATE] revealed R1 had a risk for falls related to her history of falls, cognitive loss, impaired mobility, and potential medication side effects. Staff would keep the resident's bed in the lowest position with brakes locked and would always keep the resident's call light in reach. Staff were to keep personal items and frequently used items within reach and provide toileting and repositioning assistance approximately every two hours and as needed. The resident required total assistance of two staff with transfers with the use of a mechanical lift. R1 was non ambulatory and rarely got out of bed. The Nurses Note on [DATE] at 10:49 AM revealed the resident was up in dining room for the morning meal and cooperative with cares thus far during the shift. R1 sat in her room watching TV with her call light in reach. The Nurses Note on [DATE] written at 10:52 AM for an event at 07:51 AM revealed the resident observed without pulses or respiration. The note lacked any additional information regarding the resident's condition on [DATE] prior to being noted without pulses and/or respirations. The Nurses Note on [DATE] at 09:40 AM revealed Physician JJ gave an order to release the resident's body to mortuary of choice. The Nurses Note on [DATE] at 09:59 AM revealed injuries which included a bruise to the right eye, blood from the left nostril, and abrasion to the right shin. LN G notified the resident's Durable Power of Attorney and asked for mortuary of choice. The note lacked any further details regarding how the resident sustained the injuries identified. The Nurses Note on [DATE] at 11:34 AM revealed the resident's body left the facility via mortuary transportation. Review of the Nurses Note labeled Event Investigation, dated [DATE] at 05:28 PM documented by Licensed Nurse (LN) G, revealed she called LN H (Nursing Manager on call) with concerns that an interaction between Certified Medication Aide (CMA) R and R1 may have contributed to the resident's passing. LN H then notified Administrative Nurse D and Administrative Staff A and both responded to the building. At 08:10 AM Administrative Nurse D arrived and went to assess the resident. The resident had expired and was lying in the bed. CMA R was immediately removed from duty and asked what happened. All nursing staff present were interviewed, and statements were obtained. CMA R was immediately suspended pending this investigation. When Administrative Staff A arrived at 08:39 AM, he and Administrative Nurse D went to R1's room and assessed the situation. The resident was lying in bed. She had a bruise above her right eyebrow that could have been potentially old. The nurses present noted a small amount of blood in the resident's left nostril. The local police responded and took pictures to send to the Coroner, Physician II, who declined to assess the resident stating that the pictures of injuries they sent him did not warrant a coroner review and requested that the resident's primary physician sign the death certificate. The facility's Complaint Investigation signed on [DATE] revealed CMA R did not follow R1's care plan related to transfers on [DATE]. Included in the [DATE] facility investigation was a follow-up with CMA R on [DATE] in which CMA R stated he believed the resident may have hit her head on his collar bone and name tag and that her legs may have hit the wheelchair pedals during the failed transfer to the wheelchair and that is what could have caused her injuries. CMA R denied the resident falling and stated he had lowered her to the ground. After the resident was sitting on the floor CMA R asked Certified Nurse Aide (CNA) M to assist with transferring the resident from the floor to the wheelchair. Neither notified LN G prior to transferring the resident. Once the resident was in the wheelchair CNA M notified LN G. When the nurse entered the room, the resident was slouched in her chair and unresponsive. CNA M went to obtain the vital sign machine and by time they returned the resident had passed. The facility's Complaint Investigation included Administrative Nurse D began immediate re-education of staff on Abuse, Neglect and Exploitation (ANE) and following plans of care, initiated on [DATE]. CMA R was terminated from employment at the facility. On [DATE] at 08:10 AM CNA I stated she was educated on abuse and knew she was a mandatory reporter. CNA I would inform her nurse immediately if she saw anything she felt needed reported. She stated she has not had a resident report any form of abuse to her. She stated she did not witness any abuse from staff to any resident. She confirmed she did not work the night the resident died . On [DATE] at 08:45 AM CMA S stated she would report any allegations of abuse immediately. She stated she did not work the night of R1's death but was aware she needed two staff with any mechanical lift use and she would use the resident's care plan to find out how to care for the residents. On [DATE] at 10:10 AM Administrative Staff A reported LN H contacted her regarding not thinking everything was right with R1's recent transfer by CMA R. The resident had injuries, which included a bruise to the right eye, blood from the left nostril, and abrasion to her right shin. Administrative Staff A and Administrative Nurse D came to the facility, went to the resident's room, and observed the resident. The police were called to investigate, and CMA R admitted to attempting to transfer the resident by himself without the care planned mechanical lift and second staff member. He knew he was to use the mechanical lift, but thought he was big enough to transfer her to the wheelchair and realized he could not and lowered the resident to the floor. CMA R insisted the resident did not fall. The resident was sitting on the floor with back against night table, so he grabbed another aide (CNA M) to help lift her to a wheelchair. The resident was non-responsive, and CNA M went to get the nurse. The resident remained non-responsive and later expired. Administrative Nurse D called the Police, and they came out and took pictures to send to the coroner. The coroner replied back to the police department, noting that the injuries did not appear substantial enough to cause death and the officers left the facility after talking to staff. On [DATE] at 10:20 AM LN J stated she was educated on abuse and would immediately remove the alleged perpetrator away from the victim if something was reported to her. She would then update her supervisor and assist any way she could. LN J expected her staff to know to look at the care plan for the care of residents and stated staff should always use two staff with the use of mechanical lifts. On [DATE] at 10:40 AM Police Officer KK reported there was an autopsy done on the resident due to injuries to the body. The autopsy noted the resident had two ankle fractures and bruising. The resident also had blunt force trauma to her head, with an abrasion on her forehead, and no fractures to her skull. Officer KK further reported the resident had blunt force trauma to the torso with bruising noted. The Police Department would continue to investigate and determine if charges would be filed. An interview with Coroner II on [DATE] at 10:59 AM revealed she could not provide a copy of the autopsy to the surveyor, but confirmed the injuries identified by Police Officer KK. Attempts made to contact CMA R on [DATE] at 01:10 PM, [DATE] at 08:18 AM and [DATE] at 01:30 PM, with no answer. Review of the facility policy named Safe Lifting and Movement of Residents dated ,d+[DATE] revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Review of the facility policy named Abuse, Neglect and Exploitation Prevention and Prohibition dated 2022 revealed residents have the right to be free from abuse. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of the investigation will also be reported. The facility will educate all employees upon hire and at least annually on this policy. The facility failed to provide a safe environment free of injury/falls when Certified Medication Aide (CMA) R failed to follow the plan of care developed for Resident (R) 1 and transferred the resident without the assistance of another staff member and the use of a mechanical lift. CMA R lowered the resident to the floor and R1 sustained injuries which included a bruise to her right eye, blood from her left nostril, and an abrasion to the right shin. An autopsy noted R1 had blunt force trauma to her head and torso and two fractured ankles. The failure of CMA R to follow R1's plan of care and properly transfer placed R1 in immediate jeopardy. This citation was considered to be past non-compliance, when the facility corrected the deficient practice, with implementation and then completion of the following items, on [DATE] at 07:00 PM. 1. On [DATE] at 01:00 PM, staff education and competencies started immediately regarding abuse, neglect, and exploitation. This was ongoing, and by [DATE] at 01:20 PM, most of the staff had been re-educated. Staff not allowed to work until completion of the education/competency evaluation. 2. Nursing leadership to provide re-education to nursing staff on transfers and following plan of care for resident specific transfer requirements, and not to move a resident following a potential fall without prior nursing assessment of the resident. 3. All new hires will have the ANE (abuse, Neglect, exploitation) policy reviewed during orientation. 4. Nursing leadership audits began the week of [DATE], after staff training/competency completed. 5. Audit results to QAPI for review.

The facility census totaled 113 residents, with 31 residents that required the full lift with a sling for transfers. Based on observation, interview, and record review the facility failed to ensure the CNAs (Certified Nurse Aides) employed by the facility received adequate training and demonstrated competency for safe full lift transfers and correct use of slings. During a full lift transfer, Resident (R)3 fell three feet to the floor from the full lift due to CNA D incorrectly securing the sling to the lift. R3 required first aid for a 5 centimeters (cm) by 3 cm skin tear to her left forearm and needed Emergency Medical Services (EMS) response for transfer to a local emergency room . The resident remained on the floor across the legs of the lift for about 30 minutes while awaiting EMS arrival. A fall from a lift at this height can likely cause serious injury or harm to vulnerable residents who require lift transfers. This deficient practice placed the 31 residents in the facility that required full lift transfers in Immediate Jeopardy. Findings included: - Resident (R) 3's pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/01/20 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 12, indicating moderately impaired cognition. The resident required total dependence of two staff for transfers. No falls documented in the assessment for the review period. The 12/01/20 ADL [Activities of Daily Living] Care Area Assessment (CAA) revealed R3 required the full mechanic lift with two staff assistance for transfers. The 12/01/20 Falls CAA revealed R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 had no falls in the past six months. The 08/17/21 Quarterly MDS revealed a BIMS of 10, indicating moderately impaired cognition. She required two staff assistance for transfers and had two or more non-injury falls during the review period. The 07/17/18 Comprehensive Care Plan revealed R3 was at risk for falls. She required two staff assistance with the full lift for transfers, and she did not ambulate. The 08/23/21 and 10/28/21 Fall Risk Assessments revealed R3 was at moderate risk for falls. The 11/04/21 Fall Investigation revealed at approximately 04:08 PM, CNA C and CNA D transferred R3 with the full mechanical lift, but failed to crisscross the sling straps and secure the sling correctly to the lift, resulting in R3 falling on her bottom approximately three feet from the sling, on top of the full lift legs. She complained of left shoulder and neck pain and was sent to the emergency room . A chronic (old) cervical (neck) fracture (broken bone) was noted on diagnostic imaging, a skin tear to her left forearm measuring five centimeters (cm) by three cm that required steri-strips and ecchymosis (bruising) to her left knee. The 11/04/21 pain scale for R3 noted pain rated four out of ten upon return from the hospital. The 11/05/21 at 03:26 PM Nursing Interdisciplinary Team Note revealed a root cause that CNA D was not competent to independently use the lift and failed to properly secure the sling. The 2012 Attaching the Sling to the Lift general guidelines revealed [when staff] attached the leg straps- [they must] be sure these straps were crisscrossed, then attached to the hooks. Observation of R3 on 11/08/21 at 03:15 PM revealed the resident in her room, lying in bed listening to classical music, and did not appear to be in any distress. Further observation revealed steri-strips to her left forearm with scabbing, and yellow/purple bruising noted. No observation of transfer of R3, as she did not want to get up when asked by staff. Observation of full lift use on 11/09/21 at 08:58 AM revealed CNA L and CNA M in room with R5 for a full lift transfer from wheelchair to the bed and secured the sling attached to the lift hooks correctly. Interview with CNA C on 11/08/21 at 01:47 PM revealed she and CNA D got R3 up for dinner. She stated I was working the full lift controls, and [CNA D] was at the foot of the resident. She secured the top two sling straps and [CNA D] secured the two leg straps to the full lift. Both were secured, CNA C thought, but [CNA D] did not crisscross the straps through the resident's legs, and so the resident slid out from the bottom. CNA C said she grabbed R3's shoulders as she fell to the floor, but R3 landed on her bottom. CNA D did not know the leg straps of the sling were supposed to be crossed and CNA C did not look to ensure the straps were correctly placed and secured. Interview with CNA E on 11/08/21 at 02:08 PM revealed the facility had not completed a full lift competency training for her prior to the 11/04/21 incident or with orientation. Interview with CNA L and CNA M on 11/09/21 at 09:02 AM revealed there were five residents on the unit that required the full lift. Interview with CNA O on 11/09/21 at 09:52 AM revealed he had never been checked for full lift transfer competency and he worked at the facility four years. Interview with CNA P on 11/09/21 at 03:22 PM revealed she had never been checked for full lift transfer competency and she has worked at the facility two years. Interview with CNA Q on 11/09/21 at 03:25 PM revealed she had never been checked for full lift transfer competency and she has worked at the facility four months. Interview with CNA D on 11/09/21 at 03:30 PM revealed she was a brand-new CNA, this was her first job, and had training for full lift transfers during her schooling in March 2021. She never received full lift transfers competency training during orientation at the facility, but [CNA L] was her mentor and showed her what to do. She and CNA C were getting ready to get R3 up for dinner, but she failed to secure the crisscross sling straps between the resident's legs. As CNA C lifted R3 up in the mechanical full lift, the resident fell to the floor. CNA D noted R3 had a bruise and a cut on her left arm. CNA D said since this incident, all staff received training on the full lifts/slings and placement. Interview with LN N on 11/09/21 at 07:14 PM revealed when she entered the resident's room, R3 laid by her bed on the full lift legs. The sling the staff used had to be crisscrossed between the resident's legs and they had not completed that. R3 would not allow vital signs, she was agitated, but she did complain of left shoulder pain, a skin tear on her left forearm and bruising to her left knee. LN N said the facility sent R3 to the emergency room for evaluation. Interview with Administrative Nurse K on 11/09/21 at 11:10 AM revealed CNA C and CNA D did not crisscross the sling leg straps between the resident's legs resulting in the resident sliding out the bottom of the sling, falling to the floor, and landing between the lift legs with her legs over one side and head over the other. Interview with Administrative Nurse B on 11/08/21 at 03:34 PM revealed CNA C and CNA D placed R3 in a sling that can be crossed between the legs or under them, but they placed the sling straps straight to the lift instead. Administrative Nurse B said the slings that required crisscrossing between the resident's legs were shaped different and had longer straps to ensure the staff can crisscross them. The facility started re-training staff for full lifts/sling transfers after this incident. In the training, different slings were discussed, and all staff completed a competency checkoff. Interview with Administrative Nurse B on 11/09/21 at 01:34 PM revealed she talked with Director of Therapy J about what the orientation transfer training included, and the training did not include full lift/sling transfer training. She continued to say no training for full lifts/sling transfers for staff before the incident happened. Prior to the incident, the nursing staff oversaw the direct care staff for transfers. There were always two staff using the full lifts, and they should check each other Interview with Therapy Staff J on 11/09/21 at 02:03 PM revealed she trained the new orientation employees for all transfers that did not include the lifts/slings. The 07/2017 Lifting Machine, Using a Mechanical policy revealed lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. On 11/09/21 at 03:42 PM, Administrative staff A and Administrative Nurse B were provided with the IJ template by email and notified that the facility failed to ;ensure full lift competency training was completed for CNA D and this deficient practice was likely to cause serious harm, injury or death. Staff failed to prevent injury to R3 when on 11/04/21 CNA C and CNA D performed an unsafe transfer for cognitively impaired R3 in a full mechanical lift with sling, without securing the sling to the lift correctly. Due to the lack of competency training to the nursing staff, R3 fell out of the lift to the floor, with the resident landing on the lift legs, and resulted in a skin tear to her left forearm which required steri-strips and evaluation at a local emergency room . The failure to ensure nursing staff were competently trained in lift/sling usage constituted immediate jeopardy at F726. The facility identified and corrected the deficient practice on 11/04/21 after 04:08 PM when the facility implemented the following: 1. All education/competencies started immediately. 2. Nursing leadership to provide re-education to nursing staff on correct sling usage, including: facility policy/procedures regarding mechanical lifts, how to securely fasten slings to lifts, properly positioning of residents in the sling and how to safely operate mechanical lifts. 3. Nursing leadership will provide education to direct care staff on correct procedures for lifts by giving demonstrations along with having staff return demonstrate competency for lift use prior to allowing staff to work their next scheduled shift. 4. Staff will not be allowed to work and will be taken off the schedule until all education/competency has been given and have proven their competency. 5. Education and competencies will continue until all nursing staff have been educated. 6. All new nursing staff will have the same information reviewed with them at orientation. 7. Nursing leadership will begin randomly auditing three to five mechanical lift transfers each day Monday thru Friday to ensure staff are following facility policy and demonstrating competency starting 11/9/21. Due to the facilities actions to identify and correct the deficient practice on 11/04/21, it was deemed past non-compliance at a scope and severity of K.

The facility census totaled 113 residents, 8 residents who required full mechanical lift with sling for transfers with 3 residents sampled. Based on observation, interview, and record review the facility failed to provide appropriate assistance for a safe full lift transfer for Resident (R) 2. On 10/30/21, Certified Nurse Aide (CNA) E attempted to transfer R2 with use of a full mechanical lift, which required two staff to safely operate. R2 fell out of the lift and sustained a right tibia/fibula (bones of the lower leg) fracture (broken bone) and a [CONDITION(S)], which required emergency transport and five staples to her scalp. This failure placed R2 in immediate jeopardy. Findings included: - Resident (R) 2's pertinent diagnoses from the Physician Progress Note in the Electronic Medical Record (EMR) dated 11/03/21 revealed dementia (a progressive mental disorder characterized by failing memory, confusion) and a fall on 10/30/21 from the full lift after the sling came off hook resulting in left side of [CONDITION(S)] with staples, swelling/bruising to her right ankle, right knee with obvious deformity and complaints of pain the night of 11/02/21. The 05/12/21 Significant Change Minimum Data Set (MDS) revealed short and long-term memory problems with severely impaired decision-making skills. The resident required total dependence of two staff for transfers, had range of motion impairment to one side of her upper and lower extremities, and experienced no falls since the last review. The 05/12/21 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed R2 could not carry on a conversation and could not always make her needs known. The 05/12/21 Falls CAA revealed R2 was at low risk for falls and did not have any falls in the past six months. The 08/09/21 Quarterly MDS revealed R2 with short and long-term memory problems and severely impaired decision-making skills, with fluctuating inattention and altered level of consciousness. She required total dependence of two staff for transfers and had impairment to both sides of her upper extremities and one side of her lower extremities. She had no falls in the review period. The 05/14/20 Comprehensive Care Plan revealed a revision on 11/16/20 noting the resident required total assistance by two staff and a full lift for safe transfers. R2 was at risk for falls as evidenced by a history of falls, medications, and her medical diagnosis. The 08/09/21 and 11/02/21 Fall Risk Assessments revealed the resident was a low fall risk. The 11/08/21 CP [Complaint Investigation] revealed on 10/30/21 at approximately 04:25 PM CNA E notified Licensed Nurse (LN) R that R2 fell in her room from the full lift while she attempted to transfer the resident alone. R2 received a [CONDITION(S)], which required five staples at a local emergency room . R2's pain scales from 10/30/21 to 11/03/21 increased up to four out of ten. A few days later, staff noticed the resident had bruising, swelling and discoloration to her right ankle, a deformity to her right knee, and grimacing when touched. The 11/03/21 x-ray (a photographic or digital image of the internal composition of the body) revealed a fractured right tibia and fibula. The 11/05/21 at 02:33 PM Nursing Fall Interdisciplinary Team Note revealed the sling came off of the full lift and R2 ended up on the floor. The root cause identified CNA E did not follow the resident's care plan, which included two staff assistance while using the full mechanical lift, and also failed to properly secure the sling to the lift, prior to use. The 11/05/21 Direct Supply maintenance on full lifts revealed both full lifts on the unit had four missing hook safety clips (secures sling to lift). Upon further review and observation of the other full lifts in the facility, five out of nine full lifts were missing one to six hook safety clips and the 01/01/21 to 11/09/21 Work Orders revealed eleven work orders for full lifts. The undated Full Lift Transferring From lifting preparation instructions revealed, when [resident] is elevated a few inches off the surface being transferred from and before moving the patient, check [the transport sling] again to ensure that the sling is properly connected to the attachment points. Observation of R2 on 11/08/21 at 03:25 PM revealed she laid in bed and looked out the window. She had a dressing with an ace wrap noted to her right ankle but did not respond to questions. She did not grimace or display any signs or symptoms of distress or pain at the time of observation. The resident did not want to get out of bed, therefore, no observation of a resident transfer occurred. Interview with alert and oriented R4 on 11/09/21 at 02:50 PM revealed he required a full lift for transfers. He stated there have been times that only one staff transferred him with the full lift. Staff would say it was quicker and that the other staff were busy. Interview with CNA E on 11/08/21 at 02:08 PM revealed she was getting R2 up for dinner and stated she knew the full lift required two staff to operate but decided to get R2 up with the full lift by herself. She secured the four sling loops to the lift, but the loop slipped off the hook near the resident's right foot. She then stated I thought I had the sling loop secured to the hook, but two safety clips were missing, and the resident fell to the floor, hitting the legs of the lift. She had blood on the back of her head too. Interview with CNA F on 11/09/21 at 08:21 AM revealed full lift transfers required two staff assistance. She worked at the facility for three years, and the full lifts had missing safety clips that were needed to secure the sling to the lift. Without the safety clips, staff must ensure the sling did not come off the lift hook. Staff put in work orders with the nurse for these to be fixed. Interview with CNA L and CNA M on 11/09/21 at 09:02 AM revealed full lift transfers required two staff to ensure resident safety. Both indicated that some of the full lifts in the facility had missing safety clips on the hooks for the last year, and the whole purpose of the safety clips was to ensure the sling did not slip off the lift hook. When asked if the lift could be used without the safety clips, they stated the lift can be used even if the safety clips were missing, but staff had to ensure the sling did not slip off the lift hook. Interview with LN G on 11/09/21 at 10:52 AM revealed two staff were required to use the full lift for resident transfers, but she never noticed the safety clips missing. The safety clips function to keep the sling secured to the lift, and she stated the lift could be used without them, but staff must be very aware. Interview with Administrative Nurse K on 11/09/21 at 11:10 AM revealed the function of the safety clips on the full lift hooks were to secure the sling to the lift and the lift could be used without these safety clips, but staff would have to be very aware of the potential outcome of them not being secured. Interview with Administrative Nurse B on 11/08/21 at 03:34 PM revealed CNA E did not get the sling secured to the lift hook. R2 went to the emergency room and required staples for a [CONDITION(S)]. She then stated R2 was non-verbal and did not complain of pain. She had no injuries once she returned 10/30/21, and then on 11/03/21, it was noted that R2's right ankle was swollen. The x-ray showed acute (new) fractures. Interview with Physician H on 11/08/21 at 04:37 PM revealed staff notified his office immediately that R2 fell from the full lift during a transfer because she had a [CONDITION(S)] after the fall. He then stated, the facility transfers residents by full lift daily, something went horribly wrong. Interview with Administrative Staff A by email on 11/09/21 at 10:19 AM revealed maintenance did not complete lift safety checks and there was no indication in the lifts owner's manual that missing safety clips would increase the risk of unsafe transfers. He further stated, I do not believe the presence of the missing clips would have prevented the fall. Interview with Administrative Nurse B on 11/09/21 at 01:34 PM revealed there was no training or competencies completed for full lifts/sling transfers for any staff before the incident happened. Prior to the incident, the nursing staff oversaw the direct care staff for transfers. There were always two staff using the full lifts, and they should check each other. Interview with Director of Plant Operations I on 11/09/21 at 10:20 AM revealed before last week's falls from the full lifts, staff would put work orders in when something was wrong with the lifts. He then stated we do yearly maintenance to clean wheels and inspected the entire lift at that time. Now, we have an automated work order system and it sends us a monthly inspection sheets to complete. The full lifts should have the safety clips on the hooks, those have all been ordered to get them placed. They can still be used without these clips as long as staff ensure the sling is connected correctly. When asked why the safety clips were missing, even though maintenance had checked them earlier in the year, he responded the full lifts were checked earlier this year and the facility should have ordered new safety clips then. The safety clips must have come off since then. The 07/2017 Lifting Machine, Using a Mechanical policy revealed at least two nursing assistants are needed to safely move a resident with a mechanical lift. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Make sure the sling is securely attached to the clips and that it is properly balanced. Before the resident is lifted, double check the security of the sling attachment. Examine all hooks, clips or fasteners. The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. The facility failed to prevent major injury to cognitively impaired R2 on 10/30/21, when CNA E performed an unsafe transfer with a full mechanical lift, without a second staff member to safely operate the lift. The sling came unhooked due to missing safety clips on the full lift hooks, which resulted in a fall to the floor. R2 received a [CONDITION(S)], which required five staples and four days later an x-ray revealed R2 had a right tibia/fibula fracture and misalignment of the femur and tibia. The facility identified and corrected the deficient practice on 11/04/21 after 04:08 PM when the facility implemented the following: 1. All education/competencies started immediately. 2. Nursing leadership to provide re-education to nursing staff on correct sling usage, including: facility policy/procedures regarding mechanical lifts, how to securely fasten slings to lifts, properly positioning of residents in the sling and how to safely operate mechanical lifts. 3. Nursing leadership will provide education to direct care staff on correct procedures for lifts by giving demonstrations along with having staff return demonstrate competency for lift use prior to allowing staff to work their next scheduled shift. 4. Staff will not be allowed to work and will be taken off the schedule until all education/competency has been given and have proven their competency. 5. Education and competencies will continue until all nursing staff have been educated. 6. All new nursing staff will have the same information reviewed with them at orientation. 7. Nursing leadership will begin randomly auditing three to five mechanical lift transfers each day Monday thru Friday to ensure staff are following facility policy and demonstrating competency starting 11/9/21. Due to the facilities actions to identify and correct the deficient practice on 11/04/21, it was deemed past non-compliance at a scope and severity of J.

The facility census totaled 149 residents, with 28 residents on the locked Dementia Care Unit (DCU). Based on observation, interview, and record review, the facility failed to provide appropriate supervision to cognitively impaired Resident (R)1, identified by the facility as at risk for wandering and who exhibited exit seeking behaviors. R1 eloped (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without staff knowledge) on 09/24/20 through a window in the south dining room of the locked DCU. R1 was out of the facility between 08:30 PM and 08:42 PM (12 minutes) at the end of which time facility staff noted him missing. The staff located R1 at 08:42 PM, approximately 75-100 feet away from the window, holding onto a fire hydrant, surrounded by large fist-sized rocks (as part of the landscaping). This area was approximately 0.7 miles/3696 feet away from a bustling road and intersection with 40 miles per hour speed limits and the facility parking lot. These failures placed R1 in immediate jeopardy and placed the twelve other residents, identified by the facility as cognitively impaired and independently mobile, at risk for elopement. Findings included: - R1's pertinent [DIAGNOSES REDACTED]. deficit. Review of the 08/17/20 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of six, indicating severely impaired cognition. The MDS indicated no wandering during the seven-day review period. The resident's gaitnoted as unsteady, and he used of a walker for mobility. R1 required limited assistance of one staff for walking in the corridor and locomotion on the unit, and set-up only for locomotion off of the unit. R1 had limitations in range of motion to bilateral (both left and right side) upper and lower limbs. He had no falls reported since admission to the facility. Review of the 08/17/20 Cognitive Care Area Assessment (CAA) revealed R1 triggered for confusion, disorientation, forgetfulness, and severely impaired cognition. Review of the 08/17/20 Activities of Daily Living (ADL) CAA revealed R1 had limited mobility related to his conditions and required staff assistance. Review of the 08/17/20 Fall CAA revealed R1 at low risk for falls. Review of the 08/14/20 Elopement Risk Assessment completed by staff indicated R1 as a high risk for elopement. Review of the 09/25/20 Elopement Risk Assessment revealed R1 fully ambulatory, wandered aimlessly, voiced desires to leave the facility, attempted elopement one or more times noted with difficulty redirecting, and at risk for elopement. Review of the 08/12/20 ADL Care Plan revealed R1 needed assistance with ADL care. Revision dated 08/13/20 revealed R1 required limited assistance of one staff to walk in his room, and he did not walk in the corridor/on the unit/off the unit during the review period; used a four-wheeled walker (FWW) for mobility. Review of 08/12/20 Fall Care Plan revealed R1's potential for falls increased related to recent admission to the community. Review of 08/12/20 Cognitive loss/Dementia Care Plan with revision dated 08/21/20 revealed staff provided R1 cues and reminders for orientation. Revision dated 09/25/20 revealed R1 was at risk for wandering/elopement. R1's had a Wander Guard (a bracelet that sets off an alarm when residents were wearing one attempt to exit the building without an escort) and he resided on a locked unit. Staff distracted the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, and companionship. Staff identified patterns of wandering and assessed/documented if the wandering was purposeful, aimless, escapist, or an indicator for more exercise. Staff reminded R1 of the location of his room when he needed help to prevent him from wandering into other resident's rooms. The facility kept R1's picture at the front desk on the neighborhood units and made staff aware of his elopement risk. He also enjoyed looking at picture books and allowed supervised time outside for fresh air in the courtyard. On 09/24/20, R1 exited through a window in the dining room and was found in the parking lot. Staff redirected R1 back inside the building and assessed for injuries; none found. Staff offered the resident an as-needed (PRN) beer, offered toileting, and 1:1 conversation. R1 was placed on 15-minute visual checks for 72 hours after elopement. Review of 08/12/20 at 05:04 PM Progress Note revealed R1 arrived at the facility from the hospital following an ischemic (restriction in blood supply to tissues, causing a shortage of oxygen) stroke with orientation noted to self and time; with intermittent confusion noted. He did not have any overt (plainly or readily apparent) weaknesses, but reported slight left-sided foot drag. Review of 08/13/20 at 12:34 AM Progress Note revealed R1 was up in the room several times before bedtime with an unsteady gait noted and weakness to lower left extremity (LLE). Review of 08/15/20 at 02:30 AM Progress Note revealed R1 remained oriented to self and time with confusion. He was up throughout the beginning of the shift, wandered outside of his room without using his walker, and wandered into another residents room at one time. R1 stated, I am ready to go home, I need to lock up the house, my wife should be coming, and is there a porch light outside. Wander Guard was in place and functioned correctly. Review of 08/20/20 at 04:00 PM Progress Note revealed R1 attempted several phone calls to arrange for a taxi to pick him up and attempted several times to go through exit doors. He believed he needed to go home today. Review of 08/21/20 at 12:10 AM Progress Note revealed R1 remained oriented mainly to self, unaware of time, place, or circumstances. He strolled with slightly shuffled steps. R1 stated, It is almost time to leave and attempted to wander through the exit doorway to another unit. Review of 08/26/20 at 11:25 AM Progress Note revealed R1 moved from an unlocked unit to the locked DCU. Review of 08/27/20 at 08:39 AM Progress Note revealed R1 was up ad-lib (as desired) with a walker on the unit and needed to be redirected several times from the exit door. Review of 09/04/20 at 05:37 PM Progress Note revealed R1 frequently exhibited exit seeking behaviors during the shift. Review of 09/06/20 at 03:01 AM Progress Note revealed the resident exhibited exit seeking behaviors earlier in the shift, tried to open a window near the kitchen area with a butter knife, and knocked the screen off onto the outside when staff attempted to redirect the resident asking what he was doing. R1 stated, I'm trying to get out so I can go to the liquor store. Staff attempted redirection by offering a snack and watching television, and the resident was difficult to redirect. Review of 09/25/20 at 01:33 AM Progress Note revealed Licensed Nurse (LN) G noticed Certified Nurse Aide (CNA) D passed by with a walker and called out for R1 at 08:35 PM. The resident roamed around hall B (south hall dining room) dining area when last seen by LN G. Staff could not find R1 after searching his room. Staff noticed the (south) dining area window that faced the parking lot wide open, and subsequently R1 brought back into the unit through the main entrance. R1's Wander Guard functioned, but did not alarm due to the exit used. Review of 09/30/20 at 04:05 PM Progress Note revealed on 9/29/20, a significant change MDS completed with R1. He scored a BIMS of 13, which indicated intact cognition; however, R1's memory comes and goes, and he stood at the door this AM and looked for the train to come to pick him up so he could get to plant #1. Review of 09/01/20 to 10/01/20 Treatment Administration Record (TAR) revealed R1's behavior issues on 09/16/20 included resident trying to get out to go down the block, and on 09/22/20 exit seeking noted. Review of signed 09/30/20 Facility Investigation for the 09/24/20 elopement revealed R1 exited the facility out of a window in the (south hall) dining room of the DCU on 09/24/20 and was last seen by CNA D at 08:30 PM. Per surveillance cameras, R1 waited for CNA D to leave the common area, checked another common area, and then walked towards the window. At 08:35 PM, CNA D noted his walker left by the dining room table. She then went to the resident's room. CNAs D and E notified LN G that they could not locate R1. At approximately 08:39 PM, CNA D returned to the (south hall dining) window and saw the disheveled blinds. At 08:42 PM, CNA D and CNA E walked out to the parking lot of the DCU and found R1 (by the fire hydrant per witness statement from CNA C on 09/29/20). During that time, LN H proceeded outside and attempted to redirect R1 back into the facility. Eventually, staff assisted R1 back into the facility and back into the secured DCU at 09:32 PM. LN G assessed R1's skin and did not find any external signs of injury. The Wander Guard to his right ankle functioned correctly. Observation on 10/01/20 at 10:35 AM of the area R1 traversed on 09/24/20 included a grassy area from the window to the sidewalk, and a fire hydrant noted approximately 75-100 feet away, large fist sized rocks around the hydrant. About 1200 feet from the parking lot was a busy intersection, and the busy east-west street was approximately 400 feet from the elopement window. Observation of R1 on 10/01/20 at 11:13 PM revealed the resident in the west common area for a socially distanced group activity. At 11:19 AM, R1 ambulated from the west dining room to the south dining room and sat down at a table. He ambulated to his room with a walker, and while his gait was unsteady and slow, he was able to manage it with the walker. His demeanor was pleasant, receptive to conversation, but confused. Interview with R1 on 10/01/20 at 11:26 AM revealed when asked why he left the building through a window he stated, I guess between that girl and the other and made remarks and gestures, and I just got tired of it, but could not explain. He then stated, So, I elevated to the window and went out. He indicated that the staff tried to talk him into coming inside the facility, but he did not want to and held on to the fire hydrant. He then stated, they invited me to the fire station, and I stayed at the fire station all night. He indicated that he wanted to leave the building because he is tired of all the people here. R1 stated, staff treated him well, and he loves where he is. Noted to be pleasantly confused, and while talking, his thoughts wandered to unrelated topics. When asked if he wore a Wander Guard, he responded, I do not have a Wander Guard because I do not need one. The resident then lifted his right pant leg and showed the Wander Guard and reported it worked when he wanted to use it and it kept him safe. Interview with CNA C on 10/01/20 at 10:21 AM revealed on 09/24/20 at approximately 08:30 PM to 09:00 PM staff could not find R1. She noted the broken pull string on the blinds in the south dining area. She stated she heard a story that he tried to get out of his bedroom window previously about a month ago. The large window that he eloped from in south dining moved side to side. She indicated the stop gap being too wide, which allowed R1 to elope easily. R1 walked around the unit usually, socialized, and from time to time, he wandered, pushed on the doors, and asked where to go to leave. He exhibited confusion during a conversation, and he often stated comments not related to the conversation. His unsteady gait/balance due to a stroke indicated the need for a walker, and for safety, staff watched him closely. She then indicated that R1 could have been hit by a car in the parking lot, or that busy road by the facility. She told interventions in place before he eloped included a Wander Guard, but no extra visual checks until after he eloped. Interview with CNA J on 10/05/20 at 10:20 AM revealed R1 walked down the halls a lot. He tried to go out of the exit doors frequently, and the staff redirected him. Interview with Licensed Nurse (LN) G on 10/01/20 at 10:43 AM revealed R1 had exit seeking, set off alarms, while continuously wandering. R1's exhibited confusion and walked with a walker due to his gait. Before the elopement, R1's interventions included his information in the elopement book. She indicated before the elopement, he mentioned he would take off one of these days, and he was looking for a liquor store at times. The Wander Guard on his ankle that nurses checked every shift functioned correctly. She then indicated that R1 tried to elope in the past, setting alarms off, and R1 mentioned he wanted to escape. Per LN G, appropriate interventions for R1 with wandering/exit seeking included distraction with conversation and more frequent checks. Interview with LN K on 10/01/20 at 04:17 PM revealed on 09/06/20 he attempted to get the window open in the south dining hall, on the south side of the dining room, to the facility's front. (The same window he eloped out of). Interview with Administrative Nurse B on 09/30/20 at 03:13 PM revealed the DCU south dining room windows had a 12-inch stop-gap, which allowed the window to open too wide and enabled R1 to exit the unit. When he eloped, R1 wore a short-sleeved black shirt, long black pants, tennis shoes, and a wristwatch. Interview with Administrative Maintenance I on 09/30/20 at 03:03 PM revealed window inspections for stop gaps had not been completed for a couple of years before R1's 09/24/20 elopement. He indicated concern for the 12-inch stop gaps on windows in the DCU's common areas never came up because there was more staff observation in those areas, but that thought was incorrect. A review of the undated Wandering, Unsafe Resident policy revealed the facility strived to prevent unsafe wandering while maintaining the least restrictive environment for residents at risk for elopement. The facility failed to provide adequate/appropriate supervision for a cognitively impaired and independently mobile R1, which allowed him to leave the facility through a window without staff knowledge. R1 traversed a busy parking lot, near a heavily trafficked road and intersection. This failure placed R1 in immediate jeopardy and placed twelve facility identified cognitively impaired independently mobile residents at risk for elopement.

The facility census totaled 162 residents with 3 residents reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to develop and implement timely and effective interventions to prevent the development of pressure ulcers for 2 of 3 residents sampled for pressure ulcers. (#10, #4). Resident #4 developed 3 avoidable pressure ulcers, a stage 3 (full-thickness loss of skin, including some of the subcutaneous tissue) pressure ulcer to the left buttock, a stage 2 (partial-thickness loss of dermis) to the right buttocks, and a stage 2 pressure ulcer to the right ankle. Resident #10 developed 2 avoidable stage 2 pressure ulcers to the gluteal area and 1 avoidable deep tissue injury (DTI- intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister) on the right heel. Findings included: - Review of resident #4's signed physician orders dated 10/2/17 revealed the following Diagnoses: [REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 indicating normal cognition. The resident required extensive assistance of 1 staff for bed mobility and toilet use. The resident required total assistance of two staff for transfers, was non-ambulatory, did not leave his/her room, and had no locomotion in the corridors. The resident had an indwelling Foley catheter and was always incontinent of bowel. The resident was at risk for pressure ulcers (PU) with no pressure ulcers present at the time of admission. The resident had a pressure relieving device to his/her bed. The MDS lacked documentation that the resident was on a turning or repositioning plan. Review of the 30 day MDS dated [DATE] revealed the resident had no change in cognition, (activities of daily living) ADL functions, or continence since the admission MDS dated [DATE]. The resident was at risk for pressure ulcers and developed 2 stage 2 pressure ulcers (partial thickness loss of skin presenting as a shallow open ulcer, with a red pink wound bed, without slough (dead tissue, usually cream or yellow in color)), and 1 stage 3 pressure ulcer first documented on 10/10/17). The stage 3 ulcer (full thickness tissue loss.) measured 4.9 centimeters (cm) x 4.0 cm x 0.1 cm deep. The MDS recorded the resident had pressure reducing devices to bed and chair, and received pressure ulcer care, and dressing changes. The MDS did not include that the resident was on a turning/repositioning plan. The Braden scale (an assessment to determine the risk for pressure ulcers) score on 9/25/17 was 14, which indicated a moderate risk for development of pressure sores due to: the resident's skin was occasionally moist and required an extra linen change every day. The resident was chair fast (non-ambulatory) with very limited mobility, and made occasional slight changes in his/her body or extremity position. The resident had a history of [REDACTED]. Staff could not lift the resident's body completely without sliding against the sheets. The Braden scale score remained a 14 on 10/2/17. Review of the care area assessment (CAA) dated 10/2/17 revealed; Activities of daily living (ADL) CAA - The facility admitted the resident to skilled nursing following a hospitalization for a [MEDICAL CONDITION] infarction. The resident required extensive assistance of two staff for bed mobility and toileting. The resident required extensive assistance of 1 staff for hygiene and bathing. The resident required a total lift with 2 staff assistance for transfers. The resident had an indwelling Foley catheter in place and was incontinent of bowel. The resident had moisture associated tissue damage area to his/her buttock with maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces, or wounds for extended periods), and received Z-guard (moisture barrier ointment) in place per treatment administration record (TAR). The resident did not get out of bed, except to sit in a recliner in his/her room due to low blood pressure. Nutrition CAA- The resident was at risk for weight loss related to his/her disease process, medications, weakness, and altered diet. The resident received a diabetic diet and required set up assist for meal intake. Pressure ulcer CAA- The resident was at risk for development of skin breakdown related to disease processes, weakness, and decreased mobility. The resident had a pressure relieving mattress in place. The resident required extensive staff assist for bed mobility and needed staff to offer/assist with repositioning at least every 2 hours and as needed. Review of the comprehensive care plan with a date of 9/25/17 revealed: The resident needed assistance with daily ADL care. Approaches included- The resident required total assistance of two staff with transfers using a total lift. The resident needed extensive assistance of one staff with mobility with use of a wheelchair. The resident needed extensive assistance of 2 staff with bed mobility. The resident had a Foley catheter in place. The resident needed extensive assistance of two staff with toileting and was incontinent of bowel. The resident had altered elimination due to disease process and weakness. Approaches included- assess and report signs of impaired skin integrity or breakdown. The resident was incontinent of bowel and had a Foley catheter in place. The resident required extensive assist of two staff for toileting needs. The resident needed staff to assist with toileting at least every 2 hours and as needed. The resident was at risk for skin breakdown as determined on admission on 9/25/17. The resident needed a complete Braden Scale. Keep bed linens wrinkle free and do not use excess pads- 9/25/17 Inspect skin for signs and symptoms of breakdown-9/25/17 The care plan lacked interventions to address the risk factors for development of a pressure ulcer, which included: disease processes and weakness. The care plan lacked a turning/repositioning program on admission. Updates added to the care plan on 10/10/17 (after the wound clinic discovered a stage 3 and a stage 2 pressure ulcer to the resident's buttocks and a stage 2 to the ankle) included: The resident had a pressure relieving mattress and wheelchair cushion in place-10/10/17. The resident required extensive assist from staff for bed mobility and needed assist with repositioning at least every 2 hours and as needed. 10/10/17. Review of the skin evaluation record on admitted d 9/26/17 revealed the resident had multiple bruises and scabs present on his/her body. No pressure ulcers were present on the admission skin assessment completed by the admitting nurse. Review of the nurse's notes dated 9/27/17 at 8:39 p.m. revealed the resident had sores on his/her bottom and needed turned side to side to avoid continued breakdown of skin. Review of the nurse's notes 9/25/17 through 10/10/17 revealed no documentation of the newly developed pressure ulcers on the right and left buttock and right ankle. Review of the physician wound clinic notes dated 10/10/17 revealed the resident had a stage 2 pressure ulcer to right buttock measuring 1.5 cm x 4.0 cm x 0.1 cm and a stage 3 pressure ulcer to the left buttock measuring 4.9 cm x 4.0 cm x 0.1 cm. The physician at the wound clinic documented the pressure ulcers on 10/10/17 as new ulcers. The resident had a newly developed stage 2 pressure ulcer on right ankle. Treatment consisted of Bioguard (sterile packing strips) and Sorbact (antimicrobial) dressing for the right ankle and both buttock pressure sores and secured with tape. ABD (thick padded) dressings over all pressure points. Review of the physician orders dated 10/11/17 revealed an order for [REDACTED]. Review of the nurse's notes dated 10/11/17 at 3:50 p.m. revealed physician orders for: 1. Bioguard and Sorbact dressing for right ankle and both buttocks. Cover with gauze for right ankle and both buttock. Secure with tape. Change every other day. 2. Off-load pressure from wounds with ABDs over all pressure points daily. 3. Promote venous return to treat/prevent swelling related [MEDICAL CONDITION] (swelling caused by accumulation of lymph) in bilateral lower extremities (BLE) - Change every other day. 4. Rehabilitation therapy at the facility was to change dressings 5. Activity as tolerated. Review of the physician documentation dated 10/24/17 from wound clinic revealed a stage 2 PU on right buttock measured 1.5 cm x 4.2 cm x 0.1 cm with moderate drainage. The left buttock measured 5.5 cm x 3.6 cm x 0.1 cm medium amount of drainage and red tissue. Area covered with a dressing with border. The facility to change dressing 2-3 times a week. The right ankle wound measured 0.6 cm x 0.4 cm with 100% eschar (dead tissue). No open wound, apply ABD for padding. Review on 12/4/17 of the direct care staff daily charting for October 2017 revealed sporadic charting for the resident's bed mobility ability. The charting did not include the resident needed turned every 2 hours as ordered by physician on 9/26/17 admission orders [REDACTED] Interview on 12/4/17 at 11:03 a.m. direct care staff D reported the resident came in with an area on his/her bottom. He/she did not know if it was open or not, but it got a lot worse. The resident utilized a full body lift for transfers when transferred to a gurney to go to the wound clinic. The resident had low blood pressure and if it was too low, he/she could not get up. Staff was to turn the resident every 2 hours or when uncomfortable. Staff D reported staff did not chart or document turning the resident every 2 hours. The resident had a Foley catheter and was incontinent of bowel. He/she was alert and could tell staff what he/she needed. Interview on 12/4/17 at 10:30 a.m. licensed nurse E reported the resident required total assist except with eating. The staff was to turn the resident every 2 hours per physician orders. Interview on 12/4/17 at 10:45 a.m. social service staff G reported when the resident admitted to the facility he/she had both legs wrapped, and required a trapeze for bed mobility. The resident needed repositioning for pressure ulcers on his/her backside. Interview on 12/4/17 at 1:30 p.m. administrative nurse H, reported he/she did not add a specific treatment plan to the care plan with the discovery of the pressure ulcers. Nurse H stated the charge nurse or unit manager was responsible for updating the treatment plan and included it on the plan of care. He/she acknowledged when the resident admitted to the facility there were bruises and scabs on various areas of his/her body but the resident had no pressure ulcers present. The order for repositioning was not the care plan on admission. The unit manager updated the care plan on 10/10/17 when the resident was found to have the pressure ulcers. Interview on 12/4/17 at 11:15 a.m. physician extender A reported the resident had a lot of co-morbidities, some being Diabetes, vascular disease and low blood pressure. The resident remained in bed much of the time due to his/her low blood pressure. That is not saying he/she should not have been turned while in bed. The resident went to the wound clinic for treatment of [REDACTED]. Review of the facility policy named Pressure Injury Treatment dated 11/2017 revealed nurses were to review the care plan to assess for special needs. They were to review the current Braden Scale. The pressure injury treatment program should focus on the following strategies: Evaluate the resident and the status of the pressure injury. Observe currently used support surfaces and/or pressure relieving devices and initiate as needed. Resolution of current pressure injuries and prevention of additional pressure injuries. Managing and preventing bacterial colonization and infection. Identification of additional nutritional needs to aide in wound healing and education. The facility failed to develop and implement interventions to prevent the development of 3 avoidable pressure ulcers for resident #4. - Review of resident #10's [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE], discharged on [DATE], and did not return to the facility. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 13, indicating no cognitive impairment. Resident #10 required extensive assist from 2 staff members for transfers, bed mobility, and toileting. He/she was at risk for the development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) although he/she did not have any at that time. The facility implemented a pressure reduction device for his/her bed and wheelchair. Review of the activities of daily living (ADL) care area assessment (CAA) dated 10/19/17 revealed the resident admitted to the facility for skilled nursing (a type of intermediate care) after a fall which had resulted in a [MEDICAL CONDITION]. On 10/16/17, the facility noted an open area to his/her coccyx (a small, triangular bone at the base of the spinal column) and a reddened area to his/her right heel. The facility implemented topical dressings for the areas. Review of the skin integrity CAA dated 10/19/17 revealed the resident was at risk for the development of skin integrity issues related to his/her disease process and weakness. The facility implemented a pressure reduction mattress for his/her bed and wheelchair. Staff were to assist the resident with repositioning every 2 hours and as needed (PRN). The resident was occasionally incontinent of bladder and bowel and received a no added salt or fat diet. On 10/6/17, the facility completed a Braden assessment (a standardized tool to identify residents at risk for pressure ulcers) and identified a moderate risk with a score of 14 (residents with a total score of 16 or less are considered to be at risk of developing pressure ulcers-15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk).The facility revaluated the resident's Braden assessment on 10/20/17 and identified him/her at high risk for the development of pressure ulcers with a score of 12. Review of the resident plan of care revealed on 10/6/17, the resident required set up assistance of 1 staff with eating. He/she required maximum assistance of 2 staff for transfers, bed mobility and utilized a wheelchair for mobility with the maximum assistance of 1 staff member. The resident was incontinent of bowel and bladder and required maximum assist of 2 staff for toileting. The care plan instructed staff to complete the Braden tool for the determination of the resident's pressure ulcer risk and inspect his/her skin for signs and symptoms of breakdown. Staff were to keep the bed linens wrinkle free and not to utilize excess bed pads. The facility revised the care plan on 10/26/17 to assess and report signs of impaired skin integrity and/or breakdown. He/she required extensive assistance of 2 staff for toileting and needed assistance to toilet at least every 2 hours and as needed (PRN). The resident had an open area on his/her coccyx, noted on 10/16/17, with a skin protectant paste ordered and applied per the treatment administration record (TAR). He/she had an open area to his/her right heel with physician ordered treatment. The resident had a pressure reduction mattress and wheelchair cushion in place and staff needed to reposition the resident every 2 hours and PRN. On 11/2/17, the updated care plan reported the resident had memory problems, impaired decision-making, and impaired comprehension Resident #10's care plan did not identify any further pressure reduction interventions. The resident's admission skin assessment, dated 10/7/17, noted the resident had a glued right hip surgical incision well approximated (close together) with bruises around the incision. The skin assessments did not identify any areas of concern to the resident's heels and/or coccyx. A nurse's note dated 10/16/17 revealed the resident complained of pain with dorsiflexion (flexion of the foot upward) and sharp pain when he/she attempted to bear weight on the right ankle. The resident's right lower leg was larger and warmer than his/her left leg and no redness noted. The licensed nursing staff contacted the physician extender and obtained orders for diagnostic images. Review of skin assessments dated 10/16/17 revealed staff documented a 6 centimeters (CM) x 3 CM partial thickness pressure ulcer to the right heel. Staff documented the pressure ulcer was [MEDICATION NAME] tissue (new skin growing in a superficial wound) and was blanchable (to press on a person's skin to push blood away and wait for return to determine blood circulation). Staff applied Skin Prep (a liquid film-forming dressing that formed a protective film to help reduce friction during removal of tapes and films) to the heel. Documentation showed a partial thickness wound on the residents left lower coccyx. The wound measured 2.5 CM x 1 CM and was described as a red opened area. Staff applied a protective skin paste over the coccyx wound and contacted the physician extender for orders. Review of skin assessments, dated 10/19/17, revealed a stage II (The National Pressure Ulcer Advisory Panel definition is a shallow, open ulcer with red-pink wound bed) pressure ulcer to the gluteal (pertaining to the buttocks or buttocks muscles) crease. The wound measured 1.2 CM x 0.8 CM with [MEDICATION NAME] tissue noted. Staff continued with the protective skin paste treatment 2 times daily and PRN. The facility's staff documented another stage II pressure ulcer to the right upper buttocks, which measured 1.5 CM x 2 CM with [MEDICATION NAME] tissue noted. Staff applied the protective skin paste over the wound 2 times daily and PRN. Staff documented an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) on the residents right heel. The wound measured 4.5 CM x 4.5 CM and staff obtained an order from the physician to cover the area with a foam dressing and change every 3 days. The skin assessment's dated 10/23/17 revealed the same information from the 10/19/17 skin assessments. Review of a 11/3/17 nurses note revealed the resident's family expressed concern about the resident's right heel wound. The licensed staff changed the dressing and documented the wound had opened with black eschar (dead tissue cast off from the skin) to the right heel. Staff documented they would continue to monitor and report to oncoming nurse. On 11/4/17, a review of a nurse's note revealed the resident's family requested the resident to be transferred to a hospital emergency room for evaluation and treatment of [REDACTED]. The resident transferred to a local hospital and per the physician's admission history and physical documentation on 11/4/17, admitted for wound care and intravenous antibiotics. The physician documented there was a pressure wound to the right heel, which was eschar, and he/she did not see bone. The physician did not observe the resident's coccyx. Interview with direct care staff D on 12/4/17 at 11:03 AM revealed the resident's heels were always covered when he/she worked with the resident and did not know about any pressure ulcers. Interview with licensed nursing staff E on 12/4/17 at 10:30 AM revealed he/she did not remember the resident having any open skin areas. He/she remembered applying skin prep but he/she did not see the resident before he/she was discharged . Interview with administrative nursing staff H on 12/4/17 at 1:42 PM revealed he/she could not state what interventions were in place, other than the pressure reduction mattress and wheelchair cushion, prior to the development of the pressure ulcers. Interview with physician extender A on 12/4/17 at 11:20 AM revealed he/she had not seen the pressure ulcers due to the treatments being completed during the night time. He/she relied upon the information provided by staff to determine and approve treatment orders. He/she believed the resident sat in a recliner a lot which could have contributed to the development of the heel ulcer. Review of the policy entitled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 12/2016, revealed the physician would help identify medical interventions related to wound management, evaluate and document wound healing, and assist staff with the review and modification of the care plan. Review of the procedure entitled Procedure: Pressure Injury Treatment, revised 11/2017, revealed staff were to review the resident's care plan to assess for special care needs and review the current Braden Assessment. The treatment program needed to include evaluation of the pressure injury and the use of support surfaces and/or pressure relieving devices. The facility failed to develop and implement interventions to prevent resident #10, dependent on staff for mobility and identified at risk for developing pressure ulcers, from developing 2 stage II pressure ulcers to the coccyx area and 1 unstageable pressure ulcer to the right heel.

The facility reported a census of 157 residents with 26 residents sampled for review of advance directives (a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions) and cardiopulmonary resuscitation (CPR- an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs when the heart has stopped pumping on its own) status. Based on interview and record review, the facility failed to provide CPR for approximately 20 minutes for 1 of 26 residents (#1) whose closed records (records of residents who died in the facility) were reviewed for advance directives and the resident expired when he/she experienced a [MEDICAL CONDITION] (the heart suddenly and unexpectedly stops beating). The resident's medical record indicated his/her durable power of attorney (DPOA- an agent, such as a trusted relative or friend, appointed to handle specific health, legal and financial responsibilities) desired him/her to have full code (begin CPR immediately) status. The facility's failure to honor the expressed wishes of the resident's DPOA for the resident to have CPR initiated placed the resident in immediate jeopardy. The facility also failed to have a signed advance directive for DNR for resident #2 whose CPR status was changed to DNR less than 24 hours prior to his/her death, display resident wishes for CPR/DNR prominently in the resident's medical record according to his/her advanced directive for resident's #6, #8, and #22, ensure CPR certified staff worked on every shift which had potential to affect all 157 residents in the facility Findings included: - Review of resident #1's unsigned physician visit form dated [DATE] revealed the resident's [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] revealed the resident admitted directly from the hospital. He/she had difficulty communicating and had a regular heart rate and rhythm. The resident's admission Minimum Data Set (MDS) assessment was incomplete due his/her recent admission and death less than 24 hours later. Review of the resident's care plan dated [DATE] directed staff to: Verify advanced directives on admission Review code status with the resident and/or responsible party at admission Confirm code status with the physician Review of the undated summary face sheet revealed the resident had full code status to receive cardiopulmonary resuscitation (CPR- an emergency procedure in which the heart and lungs are made to work by compressing the chest overlying the heart and forcing air into the lungs when the heart has stopped pumping on its own) if needed. Review of the resident's pre-admission hospital record revealed a resuscitation status note signed by the physician dated [DATE] that stated the resident's family desired he/she be full code status. In the event the resident coded (experienced [MEDICAL CONDITION]), his/her family wanted staff to attempt shocks (an electrical shock to restore normal heart rhythm), chest compressions and intubation (insertion of a breathing tube) regardless of the high likelihood he/she would have a poor functional outcome. The physician discussed these matters with the resident's durable power of attorney (DPOA- an agent, such as a trusted relative or friend, appointed to handle specific health, legal and financial responsibilities) and the resident remained full code status: the note further stated the resident's family understood that his/her recovery might be limited and regardless wanted full medical intervention (shocks, chest compressions, intubation and, intravenous blood pressure medications) for the resident if needed. The resident remained a full code following the physician's discussion with his/her family. Review of the resident's pre-admission hospital record revealed a neurology note dated [DATE] in which the physician discussed the resident's prognosis with his/her family and the family again indicted they understood the situation and wished for all medical measures to be done and the resident remained a full code. Review of the Admission Nurse's Note dated [DATE] at 2:31 PM revealed the resident arrived in the facility transported by emergency medical services (EMS) from the hospital. He/she was lethargic (drowsy, sluggish, apathetic), nonverbal and needed total assistance of two staff assistance with ADLs (activities of daily living). He/she received no supplemental oxygen and slept. Staff measured the resident's blood pressure at ,[DATE] (normal less than ,[DATE]), oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) at 94% (normal ,[DATE]%), temperature at 99.1 degrees Fahrenheit (normal ,[DATE] degrees Fahrenheit), and respirations at 16 (normal ,[DATE] breaths per minute) per minute. Review of the nurse's note on [DATE] revealed at approximately 9:30 AM direct care staff K requested urgent assistance in the resident's room. Licensed nurse H entered the room and observed the resident laying in bed. He/she had pale skin, his/her toes were blue and he/she was not breathing with no response to verbal or touch stimulation or sternal rubs (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli). He/she had no pulse and no breath sounds. The nurse requested staff K to grab the crash cart (a code cart used for transportation and dispensing of emergency medication and equipment at site of a medical or surgical emergency). Staff H asked the direct care staff to find a red CPR tag to deflate the resident's mattress to prepare for CPR. Licensed nurse C called physician extender staff O. Staff O told staff C to call the doctor after staff C explained the situation. Staff C then handed the phone to staff H and he/she explained the situation to staff O then staff O told staff H to call physician E. Staff H contacted physician E and notified him/her of the situation and Physician E advised that coding the resident would not be beneficial. Review of the Huddle Tool - Initiation of CPR (document that verified facility provided staff training for initiating CPR ) dated [DATE] revealed CPR training occurred at the facility for all staff (18 months prior to the resident's [MEDICAL CONDITION] on [DATE]). During an interview on [DATE] at 10:44 AM direct care staff B reported he/she checked the resident on [DATE] at about 7 AM. The resident had his/her eyes open and breathed normally. Staff B stated he/she entered the resident's room with direct care staff K about 9:30 AM and found the resident laying on his/her back with his/her mouth open and frothy saliva in it. Staff B stated both aides spoke to the resident and he/she did not respond and staff K said, I don't think he/she is breathing. Both staff checked for a pulse and staff K felt a light pulse then went and got the nurse. The nurse arrived and direct care staff D (certified to administer medications) arrived and all but staff B stayed with the resident. During an interview on [DATE] at 7:50 PM direct care staff K reported the day the resident died he/she lay awake in his/her room with his/her eyes open at 7:00 AM and staff K could see him/her breathing and he/she blinked his/her eyes. Staff K stated he/she checked the resident at 9:30 AM and the resident was not breathing then he/she checked for a pulse and felt a faint pulse in the resident's left wrist at 9:30 AM and told direct care staff B to stay with the resident while he/she went to get the nurse. Staff K stated he/she told licensed nurse H that he/she needed to go to the resident's room right away it was an emergency. Staff K stated he/she told the nurse he/she felt for a pulse and the resident had a faint pulse. Staff K stated direct care staff D took the code book to the nurse and the nurse verified the resident was a code. Staff H asked staff K to put a pulse oximeter on the resident's finger but it had no reading. Staff K stated staff D followed licensed nurse H in with the blood pressure machine and staff H sent him/her out to get the crash cart. Licensed nurse C from another unit arrived and licensed nurse H called the doctor. Staff K did not remember the time staff H called the doctor and stated no one kept track of the time but all staff involved were aware the resident was a full code and no one performed CPR. Staff K stated he/she had CPR certification but did not perform CPR. Staff K stated that nurse H talked on the phone with the doctor and reported the doctor said performing CPR would not benefit the resident so no one performed CPR. During an interview on [DATE] at 8:15 PM direct care staff D reported on the day the resident died he/she took his/her roommate medications and saw the resident's eyes were open and he/she breathed normally. Staff D stated he/she followed the nurse into the room but did not know the exact time the resident passed away and his/her skin was warm to the touch and he/she had no rigor (the stiffening of the joints and muscles of a body after death). Staff D stated he/she had CPR certification and did not notice the time and did not observe anyone performing CPR. During an interview on [DATE] at 11:34 AM direct care staff M reported he/she walked by the resident's room and saw his/her feet moving on [DATE] between 9:00 AM and 9:15 AM. Staff M stated direct care staff K came out of the resident's room and said the resident needed a nurse and gave him/her a stethoscope and blood pressure machine to take in the room then told another licensed nurse C that staff in the resident's room needed him/her. Staff M stated he/she got certified for CPR last month and he/she answered call lights on the morning the resident coded. Interview on [DATE] at 12:09 PM with licensed nurse H revealed if he/she found a resident in [MEDICAL CONDITION] he/she would assess the resident for breathing, responsiveness, heartbeat, and if a full code would start CPR and call 911. Staff H stated he/she came in at 7:30 AM on [DATE] to work on the resident's unit the day he/she died but that was not his/her normal unit to work. Staff H stated staff who worked on the unit that day included staff H him/herself, staff F, direct care staff D, direct care staff K, and direct care staff B. When he/she went into the resident's room the resident's face was white. Staff H stated he/she listened for a heartbeat and also felt for a radial pulse on his/her left side and the resident had no pulse or respirations and his/her toes on the left foot were blue. Staff H stated he/she did not recall what time this occurred. Staff H stated he/she carried an oximeter (machine used to measure how much oxygen the blood carried as a percentage of the maximum it could carry) in his/her pocket and placed it on the resident's right hand and the oximeter had no oxygen saturation reading. Staff H stated he/she asked one the direct care staff to get the vitals machine. Staff K left the room and staff B stayed in the room. Staff K stated staff placed a blood pressure cuff on the resident's left arm and it measured no blood pressure. Staff H stated he/she looked at the clock at the same time she called the doctor and it was 9:50 AM (approximately 20 minutes after direct care staff B and direct care staff K found the resident unresponsive). Staff H stated he/she thought the resident already passed when he/she got in the room because the resident just had a look like he/she was already gone. Staff H stated he/she asked the direct care staff to get the code book, the crash cart, vitals machine and get nurse C from another unit. Staff H stated he/she verified the resident was a code and suctioned foam from his/her mouth and asked staff in the room to deflate the resident's air mattress by pulling the tag so the staff could start CPR. Staff C was on the phone with physician extender staff O and staff C gave staff H the phone. Staff C stated physician extender staff O told him/her to call physician E. Staff H stated he/she called physician E and the first attempt it went to voice mail so he/she re-dialed and physician E picked up on the first ring of the second call then he/she explained to physician E the resident admitted the previous day and today staff walked into the resident's room and found him/her unresponsive, pale white, with no respirations, and no heartbeat or pulse and the resident was a full code. Staff H stated he/she explained to the physician E at 9:15 AM staff D went in the room to give the resident's roommate medications and resident #1's eyes were open and he/she wiggled his/her toes and seemed OK. Then at 9:30- 9:35 AM staff K and staff B went in the resident's room and found the resident not right and staff K felt for a pulse and thought he/she felt a very faint pulse. Staff H stated he/she reported to physician E what had occurred and he/she felt for a pulse and did not feel anything and also listened for a heartbeat and did not hear anything and re-checked for a radial pulse and still did not feel anything. During an interview [DATE] at 10:20 AM licensed nurse C reported if a resident was a full code he/she would do CPR. The day the resident died staff C was the charge nurse on another unit when a direct care staff came to him/her and stated, Hey, hey they need you on the other side. Staff C stated he/she went to the resident's unit and when he/she walked into the resident's room licensed nurse H was assembling suction and asked where the cord was that pulled the resident's mattress down and staff C told staff to turn the air off. Staff C stated he/she did not know if licensed nurse H nurse or the two direct care staff in the room had taken any vital signs. Staff C stated he/she felt for the resident's pulse and he/she had no pulse, no movement, no breathing and appeared lifeless. Staff C reported he/she stated to the other staff in the room, I think he/she is dead, and told staff H he/she thought they needed to call the doctor because, he/she's dead. Staff C stated staff H suctioned the resident and he/she called the doctor but since he/she was not in charge staff H actually talked to the doctor. Staff C stated staff H told him/her the doctor said if the resident was dead already not to do CPR and staff H told staff ,we're not going to do CPR, after he/she talked to the doctor because the resident was already dead. During an interview on [DATE] at 3:32 PM administrative nursing staff J reported if staff found a resident unresponsive they should establish what the resident's code status was then begin CPR unless the resident had a do not resuscitate (DNR) status. During an interview on [DATE] at 3:41 PM administrative nursing staff I reported staff would start CPR depending on if resident was a DNR or full code. If staff found a resident unresponsive the staff needed to check to see if the resident had respirations and a pulse. Unless there were actual signs of death like rigor mortis (the stiffening of the joints and muscles of a body after death) he/she would expect staff to start CPR if the resident was not a DNR, notify the doctor and call 911. During an interview on [DATE] at 11:10 AM physician E reported the staff called him/her on [DATE] but he/she had no record of the time the call came in because he/she just cleared out his/her phone of the old data. Physician E stated licensed nurse H reported a direct care staff thought there was a thready pulse (a scarcely perceptible and commonly rapid pulse) and when the nurse checked the resident there was no pulse and no vital signs so there was nothing there to code. Physician E stated he/she thought the direct care staff may have felt his/her own pulse but if there truly was a pulse a code should be done. Review of facility policy Emergency Procedure - Cardiopulmonary Resuscitation last revised ,[DATE] revealed General Guidelines - F: if a resident was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS (Basic Life Support) should initiate CPR unless it was known that a Do Not Resuscitate order prohibited CPR or there were obvious signs of irreversible death (e.g. rigor mortis). Emergency Procedure - F: All rescuers, trained or not, should provide chest compressions to victims of [MEDICAL CONDITION]. Trained rescuers should also provide ventilations (Forcing air or oxygen into the lungs when a patient has stopped breathing) with a compression to ventilation ratio of 30:2. The facility failed to provide CPR for resident #1 who had full code status which placed him/her in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 11:03 AM by implementing the following measures: 1. Provide education for Emergency Procedure Cardiopulmonary Resuscitation for clinical staff to include re-education of Cardiopulmonary Resuscitation Policy to current staff and during new hire orientation. 2. Audited to determine status of CPR/BLS certification of current licensed staff. 3. Conduct monthly Mock Code Drills rotating neighborhoods and shifts each month 4. Confirm at least one CPR/BLS certified staff is scheduled per shift. 5. Conduct a monthly audit to monitor compliance of licensed staff with CPR certification per facility policy and report during monthly QAPI (Quality Assurance and Performance Improvement) meeting. 6. In-service newly hired staff during orientation on CPR policy and procedures, prior to providing direct resident care. 7. Monitor in-service logs weekly for 4 weeks for staff review of Education Procedure: Cardiopulmonary Resuscitation, then monthly for 3 months and report during QAPI meeting. 8. Monitor staffing sheets prior to distribution to the neighborhoods weekly for 4 weeks to ensure staff knows about CPR certified individuals scheduled. The deficient practice remained at a scope and severity of a G. - Review of resident #2's signed physician progress notes [REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a resident brief interview for mental status (BIMS) score 15 indicating intact cognition. Review of the significant change MDS dated [DATE] revealed a BIMS score 13, which also indicated intact cognition. Review of the resident's care area assessments (CAAs) dated [DATE] revealed CAAs that triggered for further assessment included: Activities of Daily Living (ADL)/Functional: The resident readmitted to the facility [DATE] after an acute hospital stay for a wound infection. According to the hospital history and physical and progress notes, the resident had a personal history of CAD. He/she could express his/her needs to staff. Review of the resident's care plan dated [DATE] directed staff to: Review the code status and/or responsible party on admission. Apply the appropriate code status. Confirm the code status with the physician. Review of a Do not Resuscitate (DNR) directive signed by the resident and printed on [DATE] revealed the resident revoked and withdrew a DNR declaration. The revocation had Full Code handwritten in the top right corner. Review of the advance directives acknowledgement dated [DATE] signed by the resident and a witness revealed the resident checked the box on the form to indicate he/she chose not to formulate or issue any Advance Directives and wanted efforts made to prolong his/her life and wanted life-sustaining treatment to be provided. Review of a nurses note dated [DATE] at 11:36 AM revealed the nurse assessed the resident's respirations had become more labored with apnea (an absence of breathing) up to 45 seconds. A hospice nurse was present at the time and the resident's respirations eased at 6:04 PM and he/she had no apical pulse (located at the apex of the heart). Review of a social work note dated [DATE] at 10:43 AM revealed the social worker was informed the resident showed signs of decline and the nursing manager was in contact with the resident's family and submitted referral for hospice services the same day. The social work note further stated he/she was informed the resident's Durable Power of Attorney (DPOA) no longer wished for the resident to be a full code. The social worker completed a DNR form and nursing management informed him/her the resident's DPOA would come to the facility to sign the DNR form. Review of resident #2's hospice admission agreement dated [DATE] revealed the agreement was signed by the resident's DPOA and physician indicating the resident's code status was DNR. The resident's medical record lacked an actual DNR signed by the resident's DPOA. During an interview on [DATE] at 11:40 AM administrative staff N reported the resident signed a DNR but the facility could not locate it. Staff N provided a copy of the resident's hospice record indicating the resident was a DNR. Staff N stated the resident's DPOA agreed to a DNR only a few hours before the resident's passed and the facility had no record the DPOA had signed a DNR. During an interview on [DATE] at 2:53 PM the resident's DPOA reported the resident passed away on [DATE]. The resident's DPOA stated hospice was involved but just barely and hospice services started the same day the resident died and saw the resident only once. The DPOA stated he/she signed authorization for hospice and was sure he/she had signed a DNR but the resident declined so fast there was no time to say whether or not his/her end of life wishes were honored because he/she died within 2 hours and no measures of resuscitation were attempted. The facility called him/her to see if he/she wanted the resident sent to the hospital when the resident deteriorated and he/she told the facility the resident was DNR. During an interview on [DATE] at 5:53 PM administrative staff N reported the facility contacted hospice and hospice had no DNR record for the resident. During an interview on [DATE] at 7:34 AM social work staff A reported the resident was very direct about what he/she wanted and originally did not want a DNR but declined very rapidly on the day he/she died . Staff A stated a nurse manager referred the resident to hospice and he/she passed away the next day. Staff A stated the resident was cognitive a month before he/she died but the day before he/she passed away he/she would just open his/her eyes when questioned but could not converse. Staff A stated everything happened so fast on the day the resident passed away that his/her DPOA may not have signed the DNR the facility had prepared. Review of the facility policy Advance Directives last revised ,[DATE] revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Changes or revocations of a directive must be submitted in writing to the administrator. The facility failed to have a signed advance directive for DNR for resident #2 whose CPR status was changed to DNR less than 24 hours prior to his/her death. - Review of 26 closed records (residents who expired) revealed 4 resident's code status on the electronic record and/or in the code notebook (a quick reference for staff to know a resident's CPR status) on each unit did not always match the resident's advance directive as follows: Resident #6's code status in the code notebook did not match his/her advance directive. Resident #8 and resident #22's code status was not listed on face sheet of the resident's electronic record. Social work staff A could not access resident #14's advanced directive on the facility's current electronic record system. During an interview on [DATE] at 2:01 PM social work staff A reported it was the social worker's responsibility to make sure a resident's code status matched in both the electronic record and the code notebook. Staff A stated staff had not updated the electronic records for residents #6, #8, and #22. Review of the facility policy Advance Directives last revised ,[DATE] revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Changes or revocations of a directive must be submitted in writing to the administrator. - Review of the roster of licensed nurses who worked in the facility revealed 9 licensed nurses had not provided proof of a current cardiopulmonary certification (J, U, V, W, X, Y, Z, AA, and BB). During an interview on [DATE] at 3:41 PM administrative nursing staff I reported the facility required licensed nurses to have CPR certification when hired and new hires had 30 days to produce proof of CPR certification. During an interview on [DATE] at 1:45 PM administrative nursing staff I reported the facility did not have proof of CPR certification for administrative nurse J and licensed nurses U, V, W, X, Y, Z, AA, and BB. During an interview on [DATE] at 8:20 AM administrative nursing staff I reported the facility planned to conduct an audit to confirm if CPR certified staff were available on all shifts. Staff I stated there was no way to know that CPR certified staff worked on all shifts due to not having verified all licensed nurses had valid CPR certification. Review of facility's position description for licensed nurses revealed licensed nurses were required to have CPR certification or obtain CPR certification within thirty (30) days of employment The facility failed to ensure CPR certified staff worked on every shift which had potential to affect all 157 residents in the facility.

The facility census totaled 157 with 3 residents sampled for accidents. Based on observation, interview, and record review the facility failed to toilet resident #1 as planned during the night and the resident fell in the bathroom resulting in hospitalization with a subdural hemorrhage (collection of blood on the surface of the brain) and a laceration that required staples. Findings included: - Review of the electronically signed hospital discharge record for resident #1 dated 4/28/17 revealed the resident had [DIAGNOSES REDACTED]. Review of the admission minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 7 indicating severe cognitive impairment. The resident had no signs of delirium and no behaviors with a mood score of 5 indicating mild depression. The resident required extensive assistance of 1 staff with transfers, walking, and toileting; and could not balance self during transitions without staff assistance. The resident had occasional urinary incontinence and was on a toileting program. The resident had falls prior to admission but did not have any since admission. Review of the fall care area assessment (CAA) dated 1/25/17 revealed staff identified the resident at risk for falls related to disease process, medications, weakness and history of falls. The resident received medications that could cause orthostatic hypotension (blood pressure dropping with change of position) which could cause falls. The resident worked with physical and occupational therapies to increase his/her strength which should help to prevent falls. Review of the cognitive loss CAA dated 1/25/17 revealed the resident had a [DIAGNOSES REDACTED]. Review of the activities of daily living (ADL) functional CAA dated 1/25/17 revealed the resident required extensive assistance of 1 staff with transfers, toileting, and walking and used a wheelchair and walker. Review of urinary incontinence CAA dated 1/25/17 revealed staff needed to offer/assist the resident with toileting at least every 2 hours and as needed (PRN). Review of the quarterly MDS dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. The resident required limited assistance of 1 staff with transfers and toileting; and supervision/set up assistance with walking. The resident could balance self without staff assistance during transitions and used a walker and wheelchair. The resident had 1 non-injury fall since the prior MDS. Review of the fall risk assessments revealed the following: 4/26/17 revealed a score of 29 indicating at risk for falls (a score greater than 14 indicated at risk). 5/3/17 revealed a score of 32 indicating at risk for falls. Review of the care plan effective 4/28/17 revealed staff identified the resident at risk for falls related to disease process, medication use, and weakness. Interventions included: The resident worked with therapies to increase his/her strength which should help prevent falls. Staff needed to assist the resident with toileting at approximately 2:00 AM, 8:30 AM, 10:30 AM 4:30 PM, 9:20 PM and 11:00 PM, as well as before and after each meal and activity. 4/15/17 - Staff needed to remind the resident to use his/her walker and wear his/her glasses for safety. 5/3/17 - Upon return from the hospital staff changed the type of call light to a Bulb call light for safety purposes. Review of the facility's fall investigation dated 4/26/17 at 4:30 am revealed staff found the resident in the bathroom lying on the floor with his/her head against the wall. The resident had blood at the back of his/her head and staff applied a towel with pressure to stop the bleeding. The resident had 2 obvious hematomas and a laceration. The resident answered questions appropriately and was alert and oriented. The resident had on gripper socks and skippers, the bathroom light was on, and the walker was nearby with his/her glasses on the floor. Staff assisted the resident into his/her wheelchair and continued to monitor. The resident stated he/she tried to put on her underwear and fell . The resident did not turn on his/her call light for assistance. The intervention implemented was to toilet the resident every 2 hours and PRN (as needed) with visual checks every 30 minutes. Review of the nurse's notes revealed the following: 4/26/17 at 4:54 PM revealed the resident yelled for help around 4:30 AM and staff found the resident on the floor in the bathroom with his/her head under the sink. The resident did not have on pants or a brief. The resident had a scalp laceration and 2 hematomas. Staff notified the physician and received an order to send the resident to the emergency room for evaluation via emergency medical services (EMS). 5/1/17 at 4:35 PM - The resident returned from the hospital at 4:00 PM via EMS. 5/2/17 at 2:29 AM - The resident had increased confusion and staff made visual checks every thirty minutes. 5/2/17 - at 5:48 PM - Staff placed a Bulb call light in place for safety and to be kept within the residents reach. Staff initiated fifteen minute visual checks at midnight for safety, and family planned to stay overnight. Staff continued to evaluate toileting needs and family pushed the call light at 3:30 AM for staff to assist the resident with toileting needs. Observation on 5/8/17 at 2:50 PM the resident sat in a recliner in the TV area holding hands with his/her family member with feet on the floor and eyes closed. The family member sat in a wheelchair, no walker or other wheelchair in the area. Observation of the resident's room revealed there were no non-skid strips in front of the resident's bed, chair or toilet. Observation on 5/9/17 at 10:57 AM licensed nursing staff A removed the staples from the back of the resident's head and when finished, handed the resident his/her call light and left the room. Observation on 5/9/17 at 11:46 am direct care staff B assisted the resident to sit on the side of the bed, put a gait belt on the resident, and provided minimal assistance to help the resident stand using the walker. Staff B assisted the resident to walk to the bathroom using the gait belt and walker. The resident leaned to the left but stood straight when staff provided direction. The resident held onto the grab bar to transfer on and off the toilet. Observation revealed the resident had been incontinent of urine prior to sitting on the toilet. During an interview on 5/8/17 at 2:49 PM a family member stated the resident had fallen and it seemed to involve using the bathroom. The family member stated staff told them they planned to take the resident to the bathroom more frequently. During an interview on 5/9/17 at 11:28 AM direct care staff B reported the resident required assistance of 1 staff and used the call light when he/she needed assistance to go to the bathroom. Staff stated the resident had more confusion since returning from the hospital. The resident walked with a walker and staff assistance. Staff B reported before going to the hospital the resident walked by him/herself and would change his/her own brief when needed. During an interview on 5/9/17 at 11:36 am direct care staff C stated he/she worked the night the resident fell last week and had to go to the hospital. Staff stated the night shift checked and changed the resident for incontinence during the night but did not have much incontinence during the night. During an interview on 5/9/17 at 12:18 PM licensed nursing staff A reported the direct care staff checked and changed the resident every 2 hours prior to the fall. Staff A said the resident woke up at night and get up and look for his/her family. Staff A stated the last fall the resident got up to the bathroom and fell in the bathroom. During an interview on 5/9/17 at 2:33 PM licensed nursing staff A reported staff now takes the resident to the bathroom at 1:00 AM, 4:00 AM, and 6:00 AM. Staff A reviewed the medical record and the documentation only identified it the resident voided or not and did not identify the time the resident voided or staff took the resident to the bathroom. During an interview on 5/9/17 at 3:10 PM administrative nursing staff D reported he/she reviewed what the nurses documented related to the fall and then determined the most likely cause and start an intervention to prevent further falls. Staff D stated before the fall on 4/26/17 direct care staff offered to toilet the resident at 12:00 AM, 1:00 AM, 2:00 AM, 4:00 AM and 6:00 AM. Staff D reported the direct care staff only documented in the record when the resident got up and voided, not when they offered to take him/her to the bathroom. Staff D agreed the resident accepted toileting assistance at 12:00 AM and staff last visualized the resident at 3:45 AM before he/she fell at 4:30 AM. During an interview on 5/9/17 at 4:45 PM administrative nursing staff E reported the care plan prior to the fall directed staff to assist the resident to the toilet at 2:00 AM and did not address not disturbing the resident during the scheduled toileting time when he/she was asleep. During an interview on 5/9/17 at 4:06 PM physician F reported there were potentially many factors that caused the resident to fall such as the need to void or pain and he/she did not know if it could have been prevented or not. Review of the Care Plan policy dated 4/16/15 revealed daily care and documentation must be consistent with the resident's care plan. The facility failed to toilet resident #1 at 2:00 AM as planned and staff found the resident on the floor in the bathroom which resulted in hospitalization for subdural hemorrhage and scalp laceration.

The facility had a census of 158 residents with 3 residents sampled. Based on interview and record review, the facility failed to follow the advanced directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) for 1 of 3 sampled residents. Resident #1 expressed a desire for cardiopulmonary resuscitation (CPR) (chest compression to pump blood through body) in the event he/she experienced a lack of pulse/respirations. Staff entered the resident ' s room and found the resident unresponsive and without respirations. Staff failed to initiate CPR as desired by the resident ' s advanced directives. The resident expired. The facility ' s failure to honor resident #1 ' s preferences for cardiopulmonary resuscitation placed the resident in immediate jeopardy. Findings included: - Resident #1 ' s electronic clinical record included a section which noted admission to the facility on [DATE] from the hospital. The Resident Info section included advanced directives of Full Code-indicating the resident requested CPR. The clinical admission/readmission assessment dated [DATE] identified the resident as alert, oriented to person, place and time with clear speech and able to make his/her needs known. The resident transferred independently but required assistance of 1 staff to ambulate. The facility identified the Resident Care Summary Assessment as the temporary care plan. Review of resident #1 ' s Resident Care Summary assessment dated [DATE] included directions to staff regarding general care needs of the resident. Staff failed to complete the section on Code Status. The inter-agency transfer record signed by the physician on [DATE] included an order for [REDACTED].>Review of the interdisciplinary progress notes revealed an entry on [DATE] and timed 8:23 am At approximately 0725 (7:25 am), OT (occupational therapy) notified this nurse that the patient was unresponsive. This nurse entered the room to assess patient. Patient had a blue, gray tint and was cold. This nurse was unable to arouse patient with verbal or physical stimuli. (sic) No pulse and patient was not breathing at this time. The nurse wrote that he/she reviewed the resident ' s chart for code status and initiated CPR (video showed 19 minutes later) .RN (registered nurse), notified 911 (emergency services). At approximately 0750 (7:50 am), EMS (emergency medical services) arrived and started CPR. EMS pronounced the resident dead. Review of the facility ' s video monitoring revealed on [DATE] at 7:26 am therapy staff C entered the resident ' s room. A few seconds later direct care staff A entered and both staff exited a minute later and went to the nurses ' charting area 2 doors down from the resident ' s room. The staffed talked for a few seconds then therapy staff C left the unit, direct care staff A went back to the resident ' s room and licensed nurse D passed by the room looked in from the doorway and continued to the nurses ' station. At almost 7:29 am direct care staff A exited the room and went to the nurses ' station. A few seconds later direct care staff A and direct care staff B exited the nurses ' station and entered the resident ' s room. A few seconds later both staff A & B exited the room, approached licensed nurse D in the hallway near the nutrition center and talked with the nurse. There is no evidence of any staff being hurried or in emergency response mode. At 7:30 am licensed nurse D entered the resident ' s room, exited 45 seconds later and went to the nurses ' station. The nurse does not appear to be in a hurry and does not alert any of the staff in the area of an emergency situation. At 7:43 am licensed nurse D and licensed nurse E stand outside the resident ' s room talking and neither staff members facial expression showed concern or need for emergency response. At 7:45 am (19 minutes after staff reported the resident as unresponsive) licensed nurse F and administrative staff G approached the resident ' s room and began to give directions to staff. Nurse D and direct care staff A entered the resident ' s room, Nurse E and nurse F arrive seconds later with the emergency rescue equipment and entered the room. The video footage did not show the actions within the resident ' s room but as listed above the nurses E and F entered the room with rescue equipment 19 minutes after nurse D received notification of the resident ' s unresponsiveness. Administrative staff G reported nurse D and direct care staff B started CPR at that time following his/her directions. Interview on [DATE] at 12:10 pm with therapy staff C revealed he/she went to the resident ' s room around 7:20 am (but did not know exact time) to see if he/she could work with the resident on dressing and grooming. Therapy staff C reported he/she stood at the partial open privacy curtain, called out the resident ' s name a couple times with no response and he/she could see that the resident ' s blankets were not rising and falling with respiration. Therapy staff C said direct care staff A had entered to tend to the resident ' s roommate and staff C asked him/her to check the resident. Then therapy staff C went to tell the nurse and left the area. Therapy staff C reported he/she is not an employee of the facility and not authorized to perform CPR. Interview on [DATE] at 11:18 am with direct care staff B revealed he/she reported that on [DATE] around 7:30 am he/she went to the resident ' s room after a co-worker told him/her of the resident ' s condition. Direct care staff B reported he/she went to licensed nurse D immediately to report the resident ' s condition and get directions. He/she described the resident as on his/her back with arms up by shoulders, eyes closed, mouth closed and skin pale. Direct care staff B said he/she could tell the resident was not breathing but the resident felt warm to the touch when he/she touched the resident. During a telephone interview on [DATE] at 1:08 pm licensed nurse D said he/she received report from the off-going shift around 6:00 am and he/she remained at the nurses ' station when therapy staff C approached and reported the resident did not respond when therapy staff C tried to wake the resident. Licensed nurse D said he/she went to the room to evaluate the resident. She reported not knowing the resident ' s code status, he/she found conflicting information in the record that the hospital transfer sheet indicated the resident did not want CPR but the electronic resident information page indicated the resident wanted CPR. Nurse D reported he/she attempted to contact a supervisor for directions. Nurse D said he/she did not know what to do in this situation because he/she thought the resident may have been dead for a while by blue/grayish skin color. Licensed nurse D said he/she had CPR training in the past but his/her certificate had expired. Review of licensed nurse D personnel file revealed the CPR certification expired [DATE]. On [DATE] at 2:33 pm licensed nurse J reported he/she would start CPR immediately upon finding a resident without a pulse, call out for help and direct someone to check code status and call 911. Nurse J reported the code status is in the resident record when you click on a resident and also have a notebook in the nurses ' station with the information. On [DATE] at 2:42 pm per telephone interview licensed nurse K said he/she would start CPR immediately and call for help. Nurse K reported the code status can be verified in the resident safety notebook in nurses ' station, in the electronic record and on the nurse aide touch screen. On [DATE] at 3:00 pm administrative nurse H reported licensed nurse D failed to immediately go to the resident, evaluate the resident ' s condition and initiate CPR for resident #1 when staff found the resident unresponsive. Nurse H stated staff had multiple places to verify the code status of residents, including the resident safety book located in the nurses ' station on the chart rack, the electronic record in the resident information section, and the nurse aide electronic touch screen. The facility ' s policy titled, Cardiopulmonary Resuscitation (CPR) dated [DATE] directed staff the purpose was to allow resident ' s choice about advanced directives and that the resident ' s wishes would be carried out. CPR should be initiated when a resident exhibited signs and symptoms of [MEDICAL CONDITION] (the heart stops beating suddenly) and the resident had requested CPR in their advanced directives or had not formulated an advanced directive. First responder associates/staff should immediately contact appropriate emergency medical services and a CPR certified associate(s) should initiate CPR as soon as possible. The facility failed to implement the advanced directives of resident #1 in regards to CPR in the event he/she stopped breathing and did not have a pulse on [DATE] at 7:26 am, the facility failed to initiate CPR for 19 minutes after first discovery of unresponsiveness. The resident expired. The facility ' s failure to honor resident #1 ' s preferences for CPR placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 6:00 pm by implementation of the following measures: the facility provided re-education on Initiation of CPR (cardiopulmonary resuscitation), staff completed an audit of CPR certifications and any identified associates who do not have a current certification must obtain certification before provision of direct care. This deficiency remains at the scope and severity of a G.

The facility had a census of 158 residents with 3 residents sampled. Based on interview and record review, the facility failed to follow the advanced directive (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) for 1 of 3 sampled residents. Resident #1 expressed a desire for cardiopulmonary resuscitation (CPR) (chest compression to pump blood through body) in the event he/she experienced a lack of pulse/respirations. Staff entered the resident ' s room and found the resident unresponsive and without respirations. Staff failed to initiate CPR as desired by the resident ' s advanced directives. The resident expired. The facility ' s failure to honor resident #1 ' s preferences for cardiopulmonary resuscitation placed the resident in immediate jeopardy. Findings included: - Resident #1 ' s electronic clinical record included a section which noted admission to the facility on [DATE] from the hospital. The Resident Info section included advanced directives of Full Code-indicating the resident requested CPR. The clinical admission/readmission assessment dated [DATE] identified the resident as alert, oriented to person, place and time with clear speech and able to make his/her needs known. The resident transferred independently but required assistance of 1 staff to ambulate. The facility identified the Resident Care Summary Assessment as the temporary care plan. Review of resident #1 ' s Resident Care Summary assessment dated [DATE] included directions to staff regarding general care needs of the resident. Staff failed to complete the section on Code Status. The inter-agency transfer record signed by the physician on [DATE] included an order for [REDACTED].>Review of the interdisciplinary progress notes revealed an entry on [DATE] and timed 8:23 am At approximately 0725 (7:25 am), OT (occupational therapy) notified this nurse that the patient was unresponsive. This nurse entered the room to assess patient. Patient had a blue, gray tint and was cold. This nurse was unable to arouse patient with verbal or physical stimuli. (sic) No pulse and patient was not breathing at this time. The nurse wrote that he/she reviewed the resident ' s chart for code status and initiated CPR (video showed 19 minutes later) .RN (registered nurse), notified 911 (emergency services). At approximately 0750 (7:50 am), EMS (emergency medical services) arrived and started CPR. EMS pronounced the resident dead. Review of the facility ' s video monitoring revealed on [DATE] at 7:26 am therapy staff C entered the resident ' s room. A few seconds later direct care staff A entered and both staff exited a minute later and went to the nurses ' charting area 2 doors down from the resident ' s room. The staffed talked for a few seconds then therapy staff C left the unit, direct care staff A went back to the resident ' s room and licensed nurse D passed by the room looked in from the doorway and continued to the nurses ' station. At almost 7:29 am direct care staff A exited the room and went to the nurses ' station. A few seconds later direct care staff A and direct care staff B exited the nurses ' station and entered the resident ' s room. A few seconds later both staff A & B exited the room, approached licensed nurse D in the hallway near the nutrition center and talked with the nurse. There is no evidence of any staff being hurried or in emergency response mode. At 7:30 am licensed nurse D entered the resident ' s room, exited 45 seconds later and went to the nurses ' station. The nurse does not appear to be in a hurry and does not alert any of the staff in the area of an emergency situation. At 7:43 am licensed nurse D and licensed nurse E stand outside the resident ' s room talking and neither staff members facial expression showed concern or need for emergency response. At 7:45 am (19 minutes after staff reported the resident as unresponsive) licensed nurse F and administrative staff G approached the resident ' s room and began to give directions to staff. Nurse D and direct care staff A entered the resident ' s room, Nurse E and nurse F arrive seconds later with the emergency rescue equipment and entered the room. The video footage did not show the actions within the resident ' s room but as listed above the nurses E and F entered the room with rescue equipment 19 minutes after nurse D received notification of the resident ' s unresponsiveness. Administrative staff G reported nurse D and direct care staff B started CPR at that time following his/her directions. Interview on [DATE] at 12:10 pm with therapy staff C revealed he/she went to the resident ' s room around 7:20 am (but did not know exact time) to see if he/she could work with the resident on dressing and grooming. Therapy staff C reported he/she stood at the partial open privacy curtain, called out the resident ' s name a couple times with no response and he/she could see that the resident ' s blankets were not rising and falling with respiration. Therapy staff C said direct care staff A had entered to tend to the resident ' s roommate and staff C asked him/her to check the resident. Then therapy staff C went to tell the nurse and left the area. Therapy staff C reported he/she is not an employee of the facility and not authorized to perform CPR. Interview on [DATE] at 11:18 am with direct care staff B revealed he/she reported that on [DATE] around 7:30 am he/she went to the resident ' s room after a co-worker told him/her of the resident ' s condition. Direct care staff B reported he/she went to licensed nurse D immediately to report the resident ' s condition and get directions. He/she described the resident as on his/her back with arms up by shoulders, eyes closed, mouth closed and skin pale. Direct care staff B said he/she could tell the resident was not breathing but the resident felt warm to the touch when he/she touched the resident. During a telephone interview on [DATE] at 1:08 pm licensed nurse D said he/she received report from the off-going shift around 6:00 am and he/she remained at the nurses ' station when therapy staff C approached and reported the resident did not respond when therapy staff C tried to wake the resident. Licensed nurse D said he/she went to the room to evaluate the resident. She reported not knowing the resident ' s code status, he/she found conflicting information in the record that the hospital transfer sheet indicated the resident did not want CPR but the electronic resident information page indicated the resident wanted CPR. Nurse D reported he/she attempted to contact a supervisor for directions. Nurse D said he/she did not know what to do in this situation because he/she thought the resident may have been dead for a while by blue/grayish skin color. Licensed nurse D said he/she had CPR training in the past but his/her certificate had expired. Review of licensed nurse D personnel file revealed the CPR certification expired [DATE]. On [DATE] at 2:33 pm licensed nurse J reported he/she would start CPR immediately upon finding a resident without a pulse, call out for help and direct someone to check code status and call 911. Nurse J reported the code status is in the resident record when you click on a resident and also have a notebook in the nurses ' station with the information. On [DATE] at 2:42 pm per telephone interview licensed nurse K said he/she would start CPR immediately and call for help. Nurse K reported the code status can be verified in the resident safety notebook in nurses ' station, in the electronic record and on the nurse aide touch screen. On [DATE] at 3:00 pm administrative nurse H reported licensed nurse D failed to immediately go to the resident, evaluate the resident ' s condition and initiate CPR for resident #1 when staff found the resident unresponsive. Nurse H stated staff had multiple places to verify the code status of residents, including the resident safety book located in the nurses ' station on the chart rack, the electronic record in the resident information section, and the nurse aide electronic touch screen. The facility ' s policy titled, Cardiopulmonary Resuscitation (CPR) dated [DATE] directed staff the purpose was to allow resident ' s choice about advanced directives and that the resident ' s wishes would be carried out. CPR should be initiated when a resident exhibited signs and symptoms of [MEDICAL CONDITION] (the heart stops beating suddenly) and the resident had requested CPR in their advanced directives or had not formulated an advanced directive. First responder associates/staff should immediately contact appropriate emergency medical services and a CPR certified associate(s) should initiate CPR as soon as possible. The facility failed to implement the advanced directives of resident #1 in regards to CPR in the event he/she stopped breathing and did not have a pulse on [DATE] at 7:26 am, the facility failed to initiate CPR for 19 minutes after first discovery of unresponsiveness. The resident expired. The facility ' s failure to honor resident #1 ' s preferences for CPR placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 6:00 pm by implementation of the following measures: the facility provided re-education on Initiation of CPR (cardiopulmonary resuscitation), staff completed an audit of CPR certifications and any identified associates who do not have a current certification must obtain certification before provision of direct care. This deficiency remains at the scope and severity of a G.

The facility census totaled 176 residents with 3 residents included in the sample for a change in condition. Based on interview and record review the facility failed to provide the necessary care and services for a resident who experienced a significant change in health. The resident had a steady decline in condition throughout the evening of [DATE] and early morning of [DATE]. The resident's physician was not notified to get orders for emegent care. This placed the resident in immediate jeopardy and resulted in the death of resident #3. Findings included: - Review of resident #3 ' s signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 12, indicating moderately impaired cognition. The resident had minimal depression. The resident required extensive assistance of two staff with bed mobility, transfers, toileting, was non-ambulatory and required extensive assistance of one with locomotion on and off the unit. The resident had frequent urinary incontinence. The resident received O2 (oxygen) on a continuous basis. The resident received antianxiety, antidepressant and antibiotic medications daily during the 7 day look-back period. The resident received Speech therapy (ST), Occupational therapy (OT), and Physical therapy (PT) 5 times a week for rehabilitation. Review of the care plan dated [DATE] revealed: Functional status- Resident required extensive assistance of ,[DATE] staff for bed mobility, transfers, and mobility using a wheelchair, dressing and toilet needs. Resident #3 received oxygen to maintain his/her blood oxygen saturations due to [MEDICAL CONDITION]. The resident received ST, OT and PT 5 days a week for rehabilitation. Review of the physician visit progress notes revealed: On [DATE] physician, E examined the resident after admission to the facility. It stated that the resident was to continue admission medications including [MEDICATION NAME] 17 GM (gram) daily for constipation along with [MEDICATION NAME] ,[DATE] mg as needed for pain. Review of the physician progress notes [REDACTED]. Review of the nursing notes dated [DATE] at 1:29 p.m. revealed new orders from physician extender F for the resident ' s last skilled day of [DATE], discharging home on [DATE] with PT/OT and nursing with home health, with the resident to continue current medications. Review of the nursing notes dated [DATE] at 3:30 p.m. revealed new orders to give MOM 30 cc at that time for constipation. Review of the nurse's notes [DATE] at 5:30 p.m. revealed the resident rested in bed most of the day. The resident refused to eat breakfast or lunch. The resident consumed less than 25% of supper. The resident had a distended abdomen but said he/she did have a bowel movement the previous day. At 10:30 a.m., the resident received MOM for constipation with no report of a bowel movement up to 5:30 p.m. The resident's family members were in the room with him/her. Review of the nurse's notes dated [DATE] at 3:17 a.m. revealed the resident lay in bed resting. The resident was lethargic and had labored breathing. The resident was able to answer questions. The resident had a firm distended abdomen, and labored breathing. The vital signs revealed: blood pressure (b/p) ,[DATE] (normal ,[DATE]), pulse-119 Normal ,[DATE]), respirations- 28 (normal ,[DATE]) O2 saturation 92% (normal ,[DATE]) at 2L/min (2 liters per minute). The record lacked evidence of physician notification of the resident's decline. Review of the nurse's notes on [DATE] at 3:25 a.m. revealed Nurse I went to the resident's room to check on him/her and noticed the resident was not breathing. The resident did not have an apical pulse or peripheral pulse. Nurse I contacted the family members by phone. Nurse's note dated [DATE] at 7:00 a.m. revealed physician extender F gave orders to release resident #3's body to the mortuary. Review of the facility investigation of the resident's death revealed that on [DATE] at approximately 4:00 p.m. CMA (certified medication aide) G observed the resident wasmore lethargic, with a pulse of 102 and had difficulty taking medications. The CMA reported to nurse X on duty that then assessed the resident. Nurse X reported the resident had a bowel movement on [DATE] with loose and hard formed consistency. The resident was awake, alert, responded to questions and took his/her scheduled medication without difficulty. Physician extender F saw the resident on [DATE] before noon and noted some abdominal distention and ordered a laxative for the resident. He/she confirmed it was not uncommon for a person of that stature to have distention due to gas or constipation (difficulty passing stool). The resident had active bowel sounds. On [DATE] at around 8 p.m. - 9 p.m. licensed nurse I administered the resident's medication and assessed the resident to be lethargic but able to answer questions. The resident's abdomen at that time remained distended and firm. On [DATE] at approximately 10:30 p.m. while conducting shift-to-shift rounds direct care staff J observed the resident to be less talkative, with a distended abdomen, a blood pressure of ,[DATE] and a 02 sat of 92. Staff J reported his/her concern to licensed nurse H who immediately assessed the resident. The resident was lethargic, slow to respond and observed the resident's respirations to be 30, and blood pressure ,[DATE]. The resident had a distended abdomen and hypoactive bowel sounds. Nurse H reported the concerns to licensed nurse I (the nurse caring for the resident that shift). Further review of the facility investigation revealed nurse I assessed the resident shortly after nurse H assessed him/her. Nurse I took the resident's vital signs, kept resident comfortable, turned him/her frequently and concluded that there was no acute change in the resident ' s condition and the resident displayed symptoms consistent with someone actively dying. At approximately 3:30 a.m. on [DATE] nurse I asked nurse H to accompany him/her to the resident's room to confirm the resident had passed away. Nurse I assessed the resident and the resident had no apical pulse or respirations. Nurse I notified the family at 3:35 a.m. then contacted the physician at an unknown time. Review of the witness statement dated [DATE] direct care staff G reported on day shift (,[DATE]) the resident had problems taking his/her medications. Staff G gathered the resident's vital signs and noted the resident's pulse was higher than normal so he/she contacted licensed nurse X that the resident was not eating much food and had a hard time with medications. Review of the witness statement dated [DATE] revealed direct care staff J was doing rounds and taking vital signs of the residents. When staff J saw the resident, he/she was not acting like him/herself. The residents b/p was low, O2 saturation was low and the resident was not talking as he/she normally did. Staff J notified licensed nurse H due to nurse I being busy with another resident. Staff G then spoke to direct care staff D and he/she reported the resident had been like that during his/her shift (,[DATE]). Staff G retook the resident's vital signs and asked Nurse I to look at the resident. Nurse I assisted staff G to reposition the resident then told staff G the resident was a DNR (Do Not Resuscitate) and just to keep him/her comfortable and both of us kept monitoring the resident and sometime between 3:00 a.m. and 3:30 a.m. nurse I told staff G the resident had passed away. Review of the witness statement on [DATE] revealed that about 10:30 p.m. staff G reported to nurse H that he/she was concerned about the resident's vital signs and that the resident's primary nurse was with another resident. Nurse H went to the resident's room and observed the resident ' s respirations were up to about 30 per minute, the b/p was low ,[DATE] and the resident was lethargic and slow to respond. His/her lung sounds had crackles and the resident's abdomen was distended. The resident had hypoactive bowel sounds. Nurse H told staff G he/she would report to the primary nurse concerns for the resident. Nurse H reported telling nurse I about the resident and nurse I reported he/she would go check the resident and headed toward the resident's room and nurse H went back to his/her assigned hall and residents. Review of the witness statement dated [DATE] revealed licensed nurse I received report from the day shift nurse between 6:00 p.m. and 7:00 p.m. that the resident had not been eating much and his/her abdomen was distended. and firm that day. The resident had been seen by physician extender F earlier in the day. Nurse I reported the resident had been in bed much of the day. Between 8:00 p.m. and 9:oo p.m. the nurse administered scheduled medications to the resident and at that time the resident was lethargic and the abdomen was distended and firm which the nurse reported what he/she expected after getting report. Vital signs were taken and showed the b/p and pulse were not within the normal ranges and the respirations were consistent with someone who is in the dying process. Nurse I reported he/she took into consideration the resident ' s medical [DIAGNOSES REDACTED]. Nurse I concluded that there were no acute changes but a slow and steady decline so his/her plan was to make the resident comfortable until the nurse extender could see the resident in the morning. Nurse I also checked the chart and found a DNR form signed. A few minutes before nurse I was going to fill out a fax to the physician and the nurse extender the resident had no breathing or pulse. Review of a witness statement dated [DATE], physician extender F reported the resident was planning his/her discharge to home with family and home health. At the time of his/her visit on [DATE] morning the resident was awake, and alert. Physician extender F was discussing his/her discharge and how anxious the resident was to be going home. The resident was stable with a b/p of ,[DATE] and breathing at his/her normal baseline. The resident did have some abdominal distention, a slight increase from the previous day but was soft and non-tender with active bowel sounds. Physician extender F reported it was not uncommon for the resident to be distended and had been intermittently since admission. After a discussion, the resident requested MOM to be given. That was the last communication the physician extender had about the resident until [DATE] when the day shift nurse called for an order to release the body. During an interview on [DATE] at 3:35 p.m., direct care staff D reported he/she worked with the resident on the second shift (,[DATE] p.m.) the evening before he/she died , when he/she acted lethargic and did not respond normally. The resident would not eat and staff D tried to give him/her some Ensure (nutritional supplement). The next shift came in and took the residents vital signs and the resident had a low b/p. Staff D reported he/she reported the resident condition to nurse I and thought the nurse would take care of the resident. During an interview on [DATE] at 4:00 p.m., licensed nurse C reported on [DATE] at about 8:30 p.m. in the evening licensed nurse I called him/her to report about resident #3 and his/her condition briefly. Nurse C reported nurse I did not ask for help and with the way nurse I talked about resident #3, it seemed like he/she had taken care of him/her. When nurse C came to work the next morning and found out the resident had passed he/she started asking questions and went to Administrative nurse A and requested a full investigation on the unexpected death. During an interview on [DATE] at 3:00 p.m. administrative nurse A reported that the two nurses on duty that night were put on suspension. After taking statements from all staff involved nurse I was terminated and nurse H given written counseling. Nurse H chose to terminate his/her employment at the facility. During an interview on [DATE] at 3:30 p.m. consultant nurse K reported after the investigation he/she felt both nurses practiced outside their scope of practice by the failure to contact the physician when the resident's vital signs and level of alertness declined significantly, stating they did not contact the physician because the resident had a DNR (do not resuscitate). Consultant K reported the facility pursued disciplinary action against nurse I and H. During an interview on [DATE] at 4:10 p.m., physician E reported he/she knew physician extender F (who worked with the physician) examined the resident on [DATE]. The resident was in good spirits and talkative. Physician E did not hear anything else until getting a phone call around 4:00 a.m. from nurse I about the resident passing. Physician E asked the nurse what had happened and why staff did not notify him/her and nurse I replied the resident was a DNR. The physician reported telling nurse I there was a huge difference between DNR and do not treat and informed nurse I he/she should have contacted the physician for treatment orders. Review of the policy named Change in Residents Condition or status dated [DATE] revealed: Associates shall promptly notify the resident, his/her attending physician, and legal representative of significant changes in the resident's condition and/or status. The facility failed to provide the necessary care and services for a resident who experienced a significant change in condition. The resident had a steady decline in health. The resident had a steady decline in condition throughout the evening of [DATE] and early morning of [DATE]. Two licensed nurses assessed the resident but neither nurse notifiyed the physician for treatment orders. This placed the resident in immediate jeopardy and resulted in the death of resident #3. The facility abated the immediate jeopardy on [DATE] by implementing the following measures: 1) Education was provided to the nursing staff to re-educate on the policy and protocol for reporting a resident's change in condition. Further education would be provided to all licensed staff on Advanced Directives with an emphasis on DNR education. 2) A mandatory in-service for all nursing staff will take place on [DATE] and be offered on all shifts. All staff will attend this mandatory in-service 3) A thorough review of the nurse mentoring program that is initiated after general orientation to include a complete review of the physician standing orders. The deficiency still remains at a scope and severity of a 'G'

The facility census totaled 169 with 20 residents included in the sample. The sample included review of weight loss for 3 residents. Based on observation, interview and record review, the facility failed to ensure that 1 of 3 residents did not experience avoidable weight loss. One resident (#21) experienced a severe weight loss of 12.1% in 90 days, and the facility failed to implement appropriate interventions as care planned, recommended and ordered by the dietician and the physician for a period of 90 days. Findings included: - Review of resident #21's signed physician orders dated 2/27/15 revealed the following Diagnoses: [REDACTED]. Review of the admission MDS (minimum data set) dated 10/6/14 revealed a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident had a total mood severity score of 1, indicating minimal depression. The staff assessment for resident preferences indicated it was important for the resident to have snacks between meals. The resident required extensive assistance of one staff for transfers, limited assistance of one staff for walking in the room and corridor, and ate independently with setup help only. The resident did not have swallowing disorders, loss of weight , or have any nutritional approaches Review of the CAAs (care area assessment) for the 10/7/14 MDS assessment revealed the nutritional status and Dental Care CAAs did not trigger. Review of the ADL (activities of daily living) Functional/Rehabilitation Potential CAA dated 10/7/14 revealed the resident required limited set up assistance with meal intake. The resident did not wear glasses, and had impaired vision. The resident worked with OT (occupational therapy) to improve his/her activity tolerance and independence with ADLs. Review of the significant change MDS dated [DATE] revealed a BIMS score of 0, indicating severe cognitive impairment. The resident had a total mood severity score of 11, indicating moderate depression. The resident indicated it was not very important to have snacks available between meals. The resident had supervision with setup help only for eating. The resident lost 5% of his/her body weight in the past month or 10% or more in the past 6 months and was not on a physician prescribed weight loss program. The resident did not have any special nutritional approaches and no swallowing or oral/dental problems identified. Review of the Nutritional Status CAA dated 1/1/15 revealed the resident required extensive assistance with ADLs. It was difficult for the resident to communicate with staff and to hear staff when they talked to the resident due to the resident being very hard of hearing. The resident also had [MEDICATION NAME] degeneration, but did not wear glasses. The resident received [MEDICATION NAME] (antidepressant) for depression. The resident had been losing weight and the resident was on the YFP (yellow flag program-a program for residents who have lost and includes giving the resident fortified foods at mealtimes) and had a supplement ordered. The resident needed staff assistance with eating at times. The resident had a poor appetite. Review of the resident's temporary admission care plan dated 9/29/14 revealed the resident had nutrition problems due to an acute illness episode and recent admission to the SNF. Interventions directed staff to provide a regular diet, weigh weekly, and allow the resident to eat independently at meals. Review of the resident ' s care plan, on 1/8/15, revealed the resident received multivitamin with minerals. He/she received a regular diet. The resident started on YFP. The resident received a diet supplement daily for added nutrition. Magic cups (nutritional supplement) BID (twice a day) for calories. He/she had ensure plus PRN (as needed) and offered by staff. The resident required set up assistance with meal intake. Sometimes staff needed to help him/her. The care plan did not include weight monitoring and how often staff should obtain weights. Weights: 10/5/14- 141 pounds 10/12/14- 142 pounds 10/19/14- 133 pounds (6.34% weight loss in 1 week) 10/26/14- No weights documented, even though the care plan instructed staff to obtain weights weekly) . 11/06/14- 132 pounds 11/06/14-12/03/14- No weights obtained for a period of 27 days. 12/03/14- 126 pounds 12/23/14- 125 pounds 01/04/15- 124 pounds (a 12.1% weight loss in 90 days) Review of a nutrition assessment dated [DATE] by dietary consultant BB revealed the resident weighed 134.8 pounds, had a regular diet, no feeding problems, needed 1533 calories per day, 61 grams of protein per day, and 1533 cc (cubic centimeters) of fluid per day. The resident had a good appetite, consuming 76-100% of meals per meal intake documentation. The resident was already receiving a multivitamin with minerals for general nutrition. The resident's current weight was above IBW (ideal body weight) range for the resident. dietary consultant BB recommended that staff offer Ensure Plus 120cc BID for additional calories and protein. Continue current diet order of Regular. Monitor weight monthly and meal intake daily. Review of a dietician/ physician faxed communication dated 10/9/14 revealed the dietician recommended to offer vitamin C 500 mg po (oral) daily. Offer Ensure Plus 120 cc BID for additional calories and protein. Physician replied "above ok". Review of a nutrition services progress note dated 10/28/14 revealed the reason for the assessment was admission. The resident had a good appetite and ate 51-75% of his/her meals. No weight loss was identified on the assessment even though the resident had lost 5.6% since admission. Review of a fax to the physician dated 11/5/14 revealed the resident lost 8 pounds in one month. The physician replied, "noted". Review of a fax to the physician dated 11/6/14 revealed the resident had marked decrease in appetite, not eating well during meals. Nursing requested an order to switch [MEDICATION NAME] to [MEDICATION NAME]. Physician replied "will check on visit and discuss with his/her family member". Review of a fax to the physician from the dietician dated 11/19/14 revealed Due to trending weight loss; recommend starting YFP - fortified foods. Continue Regular diet order, and Magic Cup BID. The resident triggered for an 8 pound weight loss in 30d. The weight loss committee discussed the resident's weight in the monthly weight meeting. It was decided to offer a Magic Cup BID between meals for additional calories and protein. The physician ' s response was ok with above". Review of a nurse/physician faxed communication dated 12/10/14 revealed the resident had lost 5.3% in one month. The physician returned a reply of "noted". Review of a quarterly nutrition services progress note dated 1/6/15 revealed the resident had a fair appetite and ate approximately 26-50% of his/her meals. The dietician was not notified of the resident ' s weight of 124 pounds even though the resident had already lost 12% of his/her body weight. The nutritional progress notes did not identify any weight loss. Review of a nutrition assessment by the dietician dated 1/26/15 revealed: Referred for significant change assessment. The resident triggered for a significant weight loss of 17 pounds (12.1%) in 90 days, a 2 pound weight loss in 30 days. The resident received YFP with fortified foods last month. The resident continued to receive Magic Cups BID for additional protein/calories, as well as received [MEDICATION NAME] which may help to stimulate appetite. The resident consumed 51-75% of meals. Current body weight remained within IBW range. Continue current POC (plan of care). Continue with Regular, YFP diet order. Continue to offer Magic Cups BID for additional calories/protein. Monitor weight monthly and meal intake daily. IBW 104-126 and the resident's weight was 124 lbs. Calorie needs around 1410 kcals, Protein needs 56 grams, and fluid needs 1410 cc. The dietician did not recommend anything new, even though the resident continued to lose weight since 11/19/14 when the resident started on the YFP and magic cup BID. Review of the resident's meal intake: 9/29/14-9/30/14- average meal intake of 69%. October 2014- average meal intake of 57%. November 2014- average meal intake of 58%. December 2014- average meal intake of 33%. January 2015- average meal intake of 49%. February 2015- average meal intake of 53%. The meal documentation was not consistent, some days without any intake charted, other days with only 1 or 2 meals charted. Review of the March 2015 MAR (medication administration record) on 3/17/15 at 9:42 AM revealed an entry for magic cups BID between meals. The resident refused magic cup on 3/2/15 one time due to not feeling well. Not initialed at all on 3/1/15 or 3/13/15 for either time. There was another entry for ensure plus supplement PRN when the resident ate less than 50% of his/her meal without any evidence a supplement was offered/given. Observation on 03/16/2015 at 8:08 AM revealed the resident ate a mixed fruit cup, raisin bran with milk. water to drink. The resident ate 100% of his/her food and fed him/herself. No dietary supplements/ fortified foods were served. Observation on 03/16/2015 at 12:36 PM revealed the resident received 2 chicken legs, rice, mixed vegetables, and a dinner roll. The resident received soda and water to drink. The resident fed him/herself after staff removed the chicken meat from the bone for the resident. The resident ate everything except for 50% of the rice. No supplement/fortified foods given. Interview with direct care staff R on 3/16/15 at 4:24 PM revealed the resident's appetite varied. The resident fed him/herself and staff offered him/her a supplement if he/she did not eat more than 50% of his/her meal. Interview with direct care staff Q on 3/17/15 at 9:44 AM revealed the initials on the MAR (medication administration review) for the supplement meant the resident consumed all of it. Interview with administrative nursing staff J on 3/17/15 at 4:38 PM revealed staff put the resident on the yellow flag program, which meant he/she needed higher calories, and on Magic Cup BID. The resident was depressed and we started him/her on [MEDICATION NAME] and that helped. Staff was expected to document meal intake for every meal. There was no medical reason other than depression, for the resident to lose weight. During an interview on 3/19/15 at 8:18 AM, physician O was aware of the resident ' s weight loss but was not aware of the staff not giving the resident fortified foods and supplements of magic cups BID and Ensure as needed. He/she felt the resident would not have continued with a severe weight loss had those things been done. During an interview on 3/19/15 at 11:00 AM consultant U reported the resident was on a Yellow Flag Alert diet for the severe weight loss and should have been getting fortified foods with magic cups or other supplements offered for the weight loss. Staff was aware of what the yellow flag alert program was and should have offered the fortified portions of the meals served. Review of the facility policy for the Yellow Flag Alert Program , last revised 04/27/2010, revealed it is the policy of the facility to provide appropriate nutritional interventions to residents who have been identified at risk for nutritional problems. 1. Residents on the yellow flag program were to receive special assistance and encouragement to consume as much as possible. 3. Yellow flag resident should be weighed weekly. 4. Yellow flag alert resident should be provided a fortified diet (certain foods with extra ingredients added to increase calorie and nutritional value such as butter, cream, cheese, etc. Review of the Policy for Nutritional Supplements revised on 4/27/10 revealed supplements should be provided for residents at nutritional risk, by resident request or as ordered by the physician The facility failed to ensure resident #21 did not experience severe avoidable weight loss by failing to Implement appropriate interventions as care planned, recommended and ordered by the dietician and the physician. Resident #21 lost 12.1% in a 90 day period.

The facility census totaled 165 residents with 7 included in the sample. Of those, 4 residents were reviewed for pressure ulcers. Based on observation, interview and record review the facility failed to develop and implement interventions to ensure a resident who entered the facility without pressure ulcers did not develop avoidable pressure ulcers after admission. Resident #6 developed 2 stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) avoidable pressure ulcers after admission to the facility. The facility also failed to develop and implement interventions to promote healing after the pressure ulcers developed. Findings included: - Review of resident #6's signed physician orders [REDACTED]. Review of the significant change MDS (minimum data set) dated 7/23/14, (completed due to the development of pressure ulcers) revealed the resident was not cognitively able to complete a BIMS (brief interview for mental status). The resident had poor memory and severely impaired decision making ability. The resident was dependent on 1 staff for daily care and assistance of 2 staff for transfers and mobility. The resident was incontinent of bowel and bladder and had a stage 3 pressure ulcer measuring 3.0 cm (centimeter) x 2.6 cm x 0.5 cm deep. The wound had pink granulation tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). The resident required a pressure relieving device for the bed and chair, repositioning program, nutritional approaches and application of non-surgical dressing changes. Review of the pressure ulcer CAA (care area assessment) dated 7/23/14 revealed the following: The resident had a stage 3 ulcer to his/her left hip, he/she grimaced and tried to reach down to his/her hip or tried to roll to his/her back while staff changed the dressing. The resident responded well to soft calming voice and rubbing his/her back to help calm the resident during the dressing changes. The resident was always incontinent of both bladder and bowel. The resident wore incontinent briefs and had a toileting schedule developed specifically for him/her. Review of the quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. The resident required extensive assist with bed positioning and total assist of 1 to 2 staff for all daily care. The resident was incontinent at all times. The resident had a stage 3 pressure ulcer measuring 1.8 cm x 1.3 cm x 0.5 cm deep. The wound had improved over the last assessment. Treatment included pressure reducing devices for the bed and the chair, repositioning, nutritional approaches, and pressure ulcer care. Review of the care plan with a date of 3/17/14 directed staff to reposition the resident every 2 to 3 hours (during toileting) to prevent skin breakdown. - Juven (high protein supplement) taken daily to prevent skin breakdown. -Resident was to have skin monitored during baths. Direct care staff notified the licensed nurse with any new skin issues. -Foot checks were to be performed by nursing weekly due to disease process. -Use pillows to help position resident while in bed, to off-load pressure points on his/her body. -Please, keep spenco (pressure reducing) boots on while in bed to prevent pressure to heels. -Low pressure air mattress on bed to assist with wound healing. -Check and change toileting plan every 2 hours and wears briefs as the resident was always incontinent. -Total care needed with toileting and can be combative, please talk to the resident when providing care. The care plan failed to address the resident's wounds or interventions for wound care and monitoring of the wound. Review of the care plan with a date of 11/3/14 directed staff to reposition the resident every 2 to 3 hours (during toileting) to prevent skin breakdown. - Juven (high protein supplement) taken daily to prevent skin breakdown. -Resident was to have skin monitored during baths. Direct care staff notified the licensed nurse with any new skin issues. -Foot checks were to be performed by nursing weekly due to disease process. -Use pillows to help position resident while in bed, to off-load pressure points on his/her body. -Please, keep spenco (pressure reducing) boots on while in bed to prevent pressure to heels. -Low pressure air mattress on bed to assist with wound healing. -Check and change toileting plan every 2 hours and wears briefs as the resident was always incontinent. -Total care needed with toileting and can be combative, please talk to the resident when providing care. The care plan lacked documentation of wound care and monitoring of the wound. Review of the nurse's notes dated 5/22/14 revealed: direct care staff reported to the nurse that the resident had reddened areas on bilateral hips. Right hip had reddened area measuring 4.5 x 3.0 cm. Left hip reddened area measured 4.0 x 7.5 cm. Left hip had two open areas. Area #1 measured 0.4 x 0.9 cm and #2 measured 0.3 x 0.4 cm. Duoderm (wound dressing) applied to both sides. Nursing changed the dressing every 3 days and as needed. Notification sent to Consultant physician via fax. On 5/23/14, nursing received faxed communication regarding red areas on resident's hips. Consultant C stated to closely watch and if the wounds worsened let him/her know. On 5/27/14, review of the previous noted wounds revealed the right hip reddened area remained. Red area with open areas noted on left hip with measurements same as on 5/22/14. Appeared to be related to pressure. Air mattress was returned to the resident's bed after being discontinued when Hospice withdrew from resident's care in March 2014. Staff re-educated about resident's turning schedule. On 6/17/14, a new treatment for [REDACTED]. On 7/1/14 the wound to the resident's left hip assessed today by consulting physician C noted the wound bed was pink with very little drainage (approximately 15% along the edge of the wound). There appeared to be some undermining at approximately 6-7 o'clock the wound measured 4.2 cm X 2.0 cm X 0.4 cm. Consultant C stated that the treatment would remain the same at this time with Calcium Alginate (dressing material placed in the wound) covered with [MEDICATION NAME] and change daily. Redness noted to the right hip and covered with Duoderm. An order from physician for hip protectors received. On 7/30/14, nursing received a faxed communication regarding change in the pressure ulcer treatment order. 1) Every 3 days: cleanse left hip wound with NS (normal saline) or wound cleaner, pat dry, apply skin prep to periwound, gently pack undermining and wound bed with DACC packing strips per instructions. 2) Cover with non-bordered foam and secure with tape, change BID (twice a day). On 8/14/14, Consultant physician C looked at the wound on the resident's hip. Consultant C gave orders to continue current treatment. During an unscheduled physician visit on 9/3/14 Consultant physician C examined an open area on the left hip. The wound was clean, open to subdermal (layer of tissue below skin level) area with tunneling to superior (higher) side measuring less than 8 millimeters. On 9/17/14 the resident's wound on the left hip measured 2.5 cm X 1.7 cm X 0.5 cm with undermining at 12 o'clock of 0.2 cm, 7 o'clock was 1.9 cm and 12 o'clock was 2.2 cm. The wound bed continued to be red with no odor noted. On 10/3/14 staff assessed the resident's left hip wound and found to be 2.6 cm X 1.9 cm with undermining at 12 o'clock 0.1 cm, 3 o'clock 0.1 cm 6 o'clock 0.3 cm 7 o'clock 2.5 cm and 9 o'clock 0.7 cm. The wound bed appeared to be dark red, with no odor noted. The dressing had a moderate amount of drainage. Staff contacted Consultant physician C and requested and received orders to change DACC (antibacterial wound dressing) dressing daily and outer dressing changed from foam covering to DACC dressing. On 11/14/14 staff assessed the resident's wound and measured 1.8 cm X 1.3 cm X 0.9 cm with tunneling at 12 o'clock 0.5 cm, 3 o'clock 0 cm, 6 o' clock 0.3 cm, 7 o'clock 2.8 cm and 9 o'clock 3 cm. There was no odor noted, some drainage noted. The wound bed looked pink and moist. On the afternoon of 12/16/14 licensed nurse D assessed the wound on the left hip as 1 cm X 0.8 cm X 0.5 cm with tunneling at 12 o'clock 1 cm, 3 o'clock 0, 6 o'clock 1.2 cm, 9 o'clock 2 cm, 7 o'clock 2.5 cm and at 10 o'clock 1 cm. There was very little drainage, no odor and, no slough (shedding of tissue from a wound). Tissue appeared pink in the wound bed. Current order was to pack the wound with Collagen and apply wound tape daily and cover with foam dressing and "pink" tape. Review of the Braden Scale dated 10/15/14 revealed a score of 13 indicating moderate risk for skin breakdown. Review of the clinical record lacked any lab work pertinent to skin and healing. Observation on 12/22/14 at 11:37 a.m. revealed direct care staff E entered the resident's room and uncovered the resident. The staff removed the resident's hip protector brief revealing a dressing to the left hip. Staff E turned the resident to his/her left side and removed a soiled brief. On the right hip a large red area that had an area of redness approximately 5-6 cm that was unblanchable (had no change in color when pressure applied caused by pressure). With clean gloves, the staff placed a clean brief on the resident and redressed the resident. At that time direct care staff J entered the room with a total body lift and assisted staff E with transfer of the resident to a wheelchair with a cushion in the seat. Observation on 12/22/14 at 12:00 p.m. revealed the resident sat at the dining table in a wheelchair. The resident had a plate of pureed baked chicken, cheesy rice, mixed vegetables and a hot roll. Staff used regular eating utensils and assisted the resident with his/her meal. The resident ate 100% of the meal and was returned to his/her room at 1:15 p.m. Staff E and J transferred the resident from the wheelchair to bed with the use of a total body lift. The resident's brief was dry and staff positioned the resident on the right side with pillows for support. The resident continued to wear hip protectors. Observation on 12/22/14 from 1:30 p.m. till 3:15 p.m. the resident was on his/her right side in bed with pants removed and hip protectors put on. Pillows were between his/her knees and a pillow in front of the resident. Observation on 12/22/14 at 3:30 p.m. revealed direct care staff F entered the resident's room and checked the incontinent brief. The brief was dry and staff repositioned the resident to his/her back. Observation on 12/23/14 at 7:15 a.m. revealed direct care staff E and G, in the resident's room. The resident had a soiled brief, and staff proceeded to change the resident's brief after removing the hip protectors. The staff proceeded to get the resident dressed for the day and took the resident to the dining room for the breakfast meal. At 7:50 a.m. staff served the resident a bowl of hot cereal, a plate with pureed eggs, pureed sausage and glasses of juice, water and milk. The resident required staff to assist him/her. Further observation at 8:30 a.m. revealed the resident consumed all the cereal, sausage and approximately 75% of the eggs. The resident drank most liquids at the meal. During an interview on 12/22/14 at 11:40 a.m. direct care staff E reported he/she turned the resident every 2 to 3 hours. The resident wore the hip protector pad due to a sore on the left hip. Direct care staff E reported the resident had no other skin issues. On 12/22/14 at 4:20 p.m. direct care staff F reported the resident was a 2 person transfer with a lift. The resident wore spenco boots while in bed and staff turned him/her about every 2 hours with a pressure sore on the left hip and a red spot on the right hip. The resident wore hip protectors with pads on both hips. The resident was on a check and change toileting program. During an interview on 12/23/14 at 11:23 a.m. licensed nurse I reported the resident had the wound to his/her hip for months now but had no idea how the resident got the wound. During an interview on 12/23/14 at 11:25 a.m. licensed nurse H reported the resident used to be on hospice but the resident improved and hospice discharged him/her this last March. When hospice left, they took their air mattress the resident had and the facility put the resident on a regular mattress. The nurse acknowledged the nursing staff should have monitored the resident's skin due to the mattress change but that staff had not assessed the resident after the regular mattress was put on. During an interview on 12/23/14 at 11:40 a.m. licensed nurse D reported the resident did not have skin issues until Hospice removed the air bed and the resident had the facility's regular mattress. The nurse reported he/she felt the wound could have been avoided if staff would have monitored the resident once Hospice removed the air mattress. He/she felt like the wound developing and getting worse could have been prevented with staff intervention. During an interview on 12/23/14 at 2:54 p.m. Administrative nurse G confirmed wound care for this resident should have been included on the care plan. During an interview on 12/23/14 at 2:37 p.m. Consultant physician C reported the resident was in a weakened state of health. The physician reported he/she expected the staff to turn the resident at least every 2 hours and for the hips to have attention and close monitoring by staff with one broke down and a reddened area to the other. The facility failed to ensure a resident who entered the facility without pressure ulcers did not develop avoidable pressure ulcers after admission. Resident #6 developed 2 avoidable pressure ulcers after admission to the facility. The facility also failed to develop and implement interventions to promote healing after the pressure ulcers developed.

The facility reported a census of 170 residents. The sample was 27 residents of which 4 residents were reviewed for nutrition. Based on observation, record review and interview, the facility failed to meet the nutritional needs of resident #108 which resulted in a 15.6 percent body weight loss in 5 weeks. Findings included: - The physician's orders [REDACTED]., [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness and hopelessness), Diabetes Mellitus (when the body can not use glucose, there is not enough insulin made or the body can not respond to the insulin), paranoid [MEDICAL CONDITION] ([MEDICAL CONDITION] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought, perception and emotional reaction). The admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 which indicated the resident was cognitively intact. The resident was independent with set up assistance with eating, had no chewing or swallowing problems, and had no weight loss or gain in the last 6 months. The Care Area Assessment (CAA) dated 6/25/13 identified the resident with skin issues because the resident was noted to have a stage II pressure ulcer to his/her coccyx on admission and was at risk for [MEDICAL CONDITION] related to his/her need for additional calories and protein for wound healing. The nutritional status was to be included on the care plan. The undated admission care plan did not identify nutrition as a problem. On 6/16/13 the resident weighed 147 pounds (#). On 6/20/13 the registered dietician Y recommended the resident should continue on a regular diet, receive Magic Cup twice a day for protein and calories, Vitamin C 500 milligrams daily by mouth to aid in wound healing and offer a multivitamin with minerals daily for general nutrition. Reviewed laboratory results from 6/10/13 the [MEDICATION NAME] level was 1.9 gram per deciliter (g/dl) which indicated a severe protein depletion and low iron. The normal value for [MEDICATION NAME] was 3.4 to 5.4 g/dl. The current order of a regular diet was appropriate at that time. The resident should receive 1363 calories per day, 71 grams of protein and 1363 cubic centimeter (cc) of fluid per day. On 6/23/13 the resident weighed 145#. On 6/24/13 the physician ordered [MEDICATION NAME] 15 milligram daily by mouth for appetite stimulant and depression. On 6/29/13 the physician ordered Vitamin C 500 milligrams daily by mouth, Theragram daily by mouth and Magic Cup supplement twice a day on 6/29/13. On 6/30/13 the resident weighed 132#. On 7/7/13 the resident weighed 128#. On 7/14/13 the resident weighed 126#. On 7/21/13 the resident weighed 125#. On 7/28/13 the resident weighed 124# consisting of a 15.6 percent or 23# weight loss in 5 weeks. The clinical record lacked evidence the facility notified the physician or the dietician about the continued weight loss in July. The 7/13 meal consumption revealed the resident ate 25 percent of meals 25 times, 50 percent of meals 16 times, 75 percent of meals 21 times and 100 percent of meals 31 times. When the resident consumed 50 percent of the meal or less the staff inconsistantly offered the resident a substitute. The clinical record lacked evidence on the consumption of magic cups. Observation on 11/20/13 at 8:10 A.M. the resident sat in the wheelchair at the dining room table and the staff served her egg on toast, cheerios, orange juice, coffee, and milk. Observation on 11/20/13 at 8:45 A.M. the resident consumed 99% toast, egg, cheerios and beverages. The resident fed him/herself. Observation on 11/21/13 at 12:20 P.M. the resident was in the dining room, feed self and consumed 90% of the meal. Interview on 11/20/13 at 11:20 A.M. direct care staff GG stated the resident ate independently. Interview on 11/21/13 at 10:50 A.M. direct care staff HH stated the resident was able to feed him/herself. Interview on 11/21/13 at 2:47 P.M. licensed staff K stated during the monthly weight meeting the staff looked at the residents that had lost 5% in a month and see what preventative interventions could be put into place. If weight loss occurered, we would do more frequent weights and reweigh if there was a drastic difference. If there was continued weight loss while on weekly weights the dietician should be contacted. Licensed staff K stated the dietician was not contacted between 6/29 or 6/30 and 8/9 for this resident. Licensed staff K stated staff should document magic cup intake in the nurses notes. He/she stated it would have been in the clinical notes about intake of magic cups. He/she stated the order for the magic cups was on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on 11/21/13 at 3:08 P.M. with dietary staff P stated the yellow dot at the top of the resident dietary card indicated the resident recieved a regular diet. Interview on 11/21/13 at 4:34 P.M. licensed staff T confirmed the clinical record lacked documentation for this resident from 6/29/13 or 6/30/13 to 8/9/13 from the dietician while the resident was located on the Post Acute Care Center (PACC). Interview on 11/25/13 at 11:40 A.M. dietician staff Y acknowledged the resident had weight loss. The staff stated the care team met once a month on the second Monday of the month to review the previous month's weight trends. The weight loss trends for 30, 60 and 90 days were also discussed. A reweight could be requested if the weight variance was more than 5 to 10 pounds and attempt to evaluate if the weight was done with or without a brace, splint or wheelchair. The percent of meal consumed was reviewed and the consumption of supplements were not monitored but were correlated to weight loss or gain. Interview on 11/25/13 at 11:30 A.M. physician U acknowledged the resident had weight loss. He/she expected the facility or dietician to notify him/her of 10% weight loss within a month or 5% in a 3 month period. The policy provided by the facility dated 12/27/12 revealed a significant weight change was identified as a weight loss or gain of 5 percent in 1 month, 7.5 percent in 3 months or 10 percent in 6 months. The facility failed to reassess and provide appropriate interventions for this resident with a weight loss of 15.6 percent in 5 weeks.

The facility identified a census of 170 residents. The sample was 27 residents of which 4 were reviewed for pressure sores. Based of observation, record review, and interview, the facility failed to ensure that 3 (#260, #256 and #287) residents received the necessary treatment and services to promote healing of and prevent new pressure ulcers from developing. Findings included: - The July 2013 physician's orders [REDACTED]. The 14 day Minimum Data Set 3.0 ((MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 13 (13 to 15 indicated intact cognition). The resident required limited assistance of one person for transfers and extensive assistance of one person for bed mobility. It documented the resident was at risk of developing a pressure ulcer and had a stage 2 pressure ulcer that was present on admission. Skin and ulcer treatment included a pressure reducing device for chair and bed, pressure ulcer care, and application of ointments. The Admission Care Area Assessment (CAA) dated 7/3/13 for pressure ulcers noted the resident experienced weakness and fatigue. He/she required staff assistance with all Activities of Daily Living (ADL's). The resident had a cushion in the seat of the wheelchair and an air mattress on the bed to prevent further skin breakdown. The undated care plan for skin breakdown noted staff used a special mattress and cushion, assisted to reposition, provided wound treatment and assessment per protocol, monitored for pain, encouraged the resident to reposition, and used a cushion in the wheelchair. It failed to document how often to reposition this resident. The care plan lacked evidence the resident refused to be repositioned. The skin assessment dated [DATE] noted an open area to left buttock which measured 0.1 by 0.2 (no indication of centimeters (cm) or millimeters (mm)). A physician's progress note dated 7/8/13 noted the sore on the resident's buttock was more clean and dry. A physician's orders [REDACTED].. The skin assessment dated [DATE] noted pressure ulcers, one to each buttock; the left measured 1 by 1 by 0.1 cm and the right measured 1 by 2 by 0.1 cm. The skin assessment dated [DATE] noted pressure ulcers, one to each buttock; the left measured 4 by 1.5 by 0.1 cm and the right measured 3 by 2 by 0.2 cm. The clinical record lacked evidence of physician notification of the second pressure ulcer and the worsening of both pressure ulcers. The Braden Skin Risk assessment dated [DATE] noted a score of 19 (greater than 15 indicated a low risk for skin breakdown). The nutrition evaluation dated 7/13/13 by the registered dietician noted the resident was on a low concentrated sweets diet and recommended the resident to continue on the current diet order, offer Horseshoes (a liquid meal supplement) for additional protein and calories, consider an iron supplement, and to monitor the resident's weight monthly and meal intake daily. The clinical record lacked evidence the facility followed up on the dietician's recommendations. Interview on 11/21/13 at 12:04 P.M. direct care staff R stated he/she repositioned a resident every 2 hours and used pillows to aid in repositioning. He/she said if a resident refused to be repositioned, he/she reported it to the nurse. Interview on 11/21/13 at 12:00 P.M. licensed nursing staff S stated physical therapy and occupational therapy assessed the resident for mobility to know if the resident was at risk for skin breakdown. He/she encouraged the resident to reposition self or would reposition the resident. He/she used an air mattress, air booties, and barrier cream to the buttocks if the resident was incontinent (involuntary loss of urine or stool) to prevent or heal pressure ulcers. He/she stated there should be an ongoing assessment of skin breakdown potential. He/she expected a resident to be repositioned every 2 hours. Interview on 11/21/13 at 12:52 P.M. licensed nursing staff T stated this resident was incontinent, determined to lay on his/her back and refused to be repositioned. He/she said he/she educated this resident on the importance of repositioning. This resident had a low air loss mattress, wound treatments, repositioning, and frequent checks. Dietary communications were emailed to the unit manager and then the unit manager faxed them to the physician. He/she stated the clinical record lacked evidence of the education given to the resident. Interview on 11/21/13 at 3:03 P.M. administrative nursing staff A stated a skin assessment was completed at admission. He/she expected staff to use a low air loss mattress, reposition the resident every 2 hours or as needed, use a wheelchair cushion, and heel protectors. Nurses should notify the physician and the family if a pressure ulcer worsened, and also should evaluate the current interventions and treatment. He/she expected staff to reposition a resident with impaired bed mobility at least every 2 hours. Interview on 11/22/13 at 7:30 A.M. physician U stated he/she thought this resident's pressure ulcers were stable and were caused by the resident requiring bed rest and being incontinent. He/she expected staff to turn this resident, transfer him/her to a chair, and evaluate his/her nutritional needs. He/she said this resident was at risk for skin breakdown due to incontinence, noncompliance, and the current diagnoses. The facility policy "Risk Assessment Screening" revised 4/20/10 noted residents were screened upon admission and every 48 hours for the risk of skin breakdown. The facility policy "Prevention Protocol" revised 4/20/10 documented the following interventions were followed if a resident was at risk for skin breakdown: assess the resident daily for reddening areas, reposition the resident every 1 hour when in a chair, assess nutritional status and dietary history, and document in the nurses' notes a summary of the interventions and compliance. The facility policy "Skin Care Protocol" revised 4/28/10 revealed a "Braden Skin Risk Assessment" was completed upon admission, quarterly, and with significant change. The clinical record lacked evidence the facility assessed the resident for potential for skin breakdown. The clinical record lacked evidence the facility provided effective and timely interventions to heal and prevent the development of an additional pressure sore. - The November 2013 physician's orders [REDACTED]. It noted the resident received a multivitamin and Vitamin C daily. The 30 day MDS dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 12 (8 to 12 indicated moderately impaired cognition). The resident required extensive assistance of two persons for bed mobility and transfers and the resident had one stage 2 pressure ulcer. Skin and ulcer treatments included a pressure reducing device for bed and chair, nutrition or hydration measures, pressure ulcer care, and application of non-surgical dressings. The Admission Care Area Assessment (CAA) dated 9/23/13 for cognition noted this resident had some trouble remembering names. He/she needed occasional reminders throughout the day. He/she asked for information appropriately if he/she did not know something. The CAA for pressure ulcer dated 9/23/13 documented this resident was at risk for pressure ulcers due to limited mobility. The care plan dated 10/1/13 for cognition noted the resident had trouble remembering names and used a calendar to help with dates. Staff to assist the resident with reminders and verbal cues when needed. The care plan for skin documented the resident was at risk for skin breakdown due to decreased mobility. Staff to report any changes in skin condition to the nurse or the doctor. The skin assessment dated [DATE] noted the resident had a closed, dark area to the left heel which measured 2 centimeters (cm) by 0.8 cm. A physician's orders [REDACTED]. The skin assessment dated [DATE] noted this area was unchanged. The skin assessment dated [DATE] noted this area measured 0.7 cm by 1.7 cm. The clinical record lacked a skin assessment that documented the Stage 2 pressure sore noted on the MDS. It also lacked skin assessments prior to 10/25/13. The Braden Skin Risk assessment dated [DATE] noted a score of 14 (13 to 14 indicated a moderate risk for skin breakdown). A nutrition assessment dated [DATE] by the registered dietician noted the resident was about 22 pounds heavier than when discharged from this facility a few months ago. Weight gain possibly due to the resident retained fluid. The resident received a no added fat and no added salt diet. It documented the resident already received a multivitamin with minerals. Recommendations were to 1) discontinue the no added fat portion of the diet and offer 500 milligrams (mg) of Vitamin C once daily to aid in wound healing, and monitor weight monthly and meal intake daily. The clinical record lacked any other nutrition assessment. A nurse's note dated 10/25/13 at 3:08 P.M. noted the physician was sent a fax about the new area on this resident's left heel. A nurse's note dated 10/28/13 at 6:23 P.M. documented the return of the fax from the doctor with new orders for the area on the resident's left heel. Observation on 11/20/13 at 10:00 A.M. revealed a pressure reducing air mattress on the bed and a cushion in the recliner. Observation on 11/20/13 at 10:30 A.M., 10:45 A.M. 11:00 A.M., 11:15 A.M., 11:30 A.M. 11:45 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M., 12:45 P.M., 1:00 P.M., 1:15 P.M., 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M. and 2:30 P.M. the resident sat in a recliner with the leg rest up with no change in position. The resident's heels dangled over the edge of the leg rest. Observation on 11/20/13 at 8:45 A.M. the resident was served 1/2 cup cream of wheat, 3 slices of bacon and 4 ounces (oz) of milk. He/she ate and fed himself/herself everything without difficulty. Observation on 11/20/13 at 12:30 P.M. the resident was served Spanish Swiss steak, mashed potatoes and gravy, mixed vegetables, a roll, peach cobbler, and water. He/she ate and fed himself/herself everything without difficulty. Observation on 11/20/13 2:45 P.M., 3:00 P.M., 3:15 P.M., 3:45 P.M., 4:00 P.M., 4:15 P.M., 4:30 P.M., 4:45 P.M. and 5:00 P.M. the resident sat in a recliner with the leg rest up with no change in position. The resident's heels dangled over the edge of the leg rest. Observation on 11/21/13 at 8:45 A.M. revealed a darkened area approx 2 cm in diameter on the resident's outer aspect of the left heel on the bottom of the foot. Interview on 11/21/13 at 12:04 P.M. direct care staff R stated he/she repositioned the resident every 2 hours and used pillows to aid in repositioning. He/she said if a resident refused to be repositioned, he/she reported it to the nurse. Interview on 11/21/13 at 12:00 P.M. licensed nursing staff S stated physical therapy and occupational therapy assessed the resident for mobility to know if the resident was at risk for skin breakdown. He/she encouraged the resident to reposition self or would reposition the resident. He/she used an air mattress, air booties, and barrier cream to the buttocks if the resident was incontinent (involuntary loss of urine or stool) to prevent or heal pressure ulcers. He/she stated there should be an ongoing assessment of skin breakdown potential. He/she expected a resident to be repositioned every 2 hours. He/she stated he/she was unsure why the resident had not been repositioned. Interview on 11/21/13 at 12:10 P.M. licensed nursing staff MM stated the information on the MDS about the Stage 2 pressure ulcer referred to a pressure ulcer on the inside of the resident's buttocks, which has since healed. The area on the resident's heel developed here. The area was not boggy, felt like regular heel tissue and was not open. He/she stated the resident exhibited a lack of motivation with getting out of the recliner. Current interventions for this resident were an air flow mattress, a cushion in the wheelchair, turning and repositioning. He/she stated staff should reposition the resident every 2 hours or earlier if needed. He/she discovered resident refused to move from the recliner. He/she held a care plan meeting with the resident's son and the resident, and discussed the importance of repositioning. Interview on 11/21/13 at 3:03 P.M. administrative nursing staff A stated a skin assessment was completed at admission. He/she expected staff to use a low air loss mattress, reposition the resident every 2 hours or as needed, use a wheelchair cushion, and heel protectors. Nurses should notify the physician and the family if a pressure ulcer worsened, and should evaluate the current interventions and treatment. He/she expected a resident with impaired bed mobility to be repositioned at least every 2 hours. Interview on 11/22/13 at 7:30 A.M. physician U stated the area on this resident's left heel was covered with eschar (a scab). The current treatment order was used to protect this area from infection. He/she stated this area was a pressure ulcer covered with eschar. The facility policy "Risk Assessment Screening" revised 4/20/10 noted residents were screened upon admission and every 48 hours for the risk of skin breakdown. The facility policy "Prevention Protocol" revised 4/20/10 documented the following interventions were followed if a resident was at risk for skin breakdown: assess the resident daily for reddened areas, reposition the resident every 1 hour when in a chair, assess nutritional status and dietary history, and document in the nurses' notes a summary of the interventions and compliance. The facility policy "Skin Care Protocol" revised 4/28/10 revealed a "Braden Skin Risk Assessment" was completed upon admission, quarterly, and with significant change. The facility failed to prevent the development of the avoidable unstageable pressure ulcer and failed to timely reposition this resident after the development of the pressure ulcer, and to prevent the development of additional pressure ulcers for a resident at risk. - Review of the physician's orders [REDACTED]. The resident was admitted with a healing stage IV pressure ulcer on 10/18/13. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) scored of 3 which indicated the resident had severe cognitive impairment. The resident exhibited verbal behavior towards others and [MEDICAL CONDITION] and rejected care daily in the seven day look back period. The resident required extensive assist of 2 staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene. The resident was totally dependent for bathing, mobility was by wheelchair and the resident was frequently incontinent of bladder and bowel. The resident had one Stage lV pressure ulcer identified on admission which measured 5.3 centimeters (cm) x 3.5cm with slough and no depth recorded on admission. The resident had a pressure reducing device for the bed and chair, and was on a turning and repositioning program, nutrition program and pressure ulcer care. The Care Area Assessment (CAA) dated 10/24/13 for urinary incontinence identified frequent urinary and bowel incontinence for the resident. He/she wore adult briefs at all times and required extensive assistance with toileting. The resident was not able at times to tell staff when he/she needed to use the toilet. He/she was on a 2 hour check and change with toileting. The resident had a stage IV pressure ulcer to the coccyx area that required nursing treatment twice a day. He/she used a wheelchair as his/her primary mode of locomotion. Review of the CAA dated 10/24/13 for nutritional status identified the resident was on a regular diet with thin liquids. He/she needed extensive help with eating. He/she denied any pain or discomfort with eating or swallowing. Per staff interview he/she usually ate between 51-75 percent of meals. The resident had a stage 4 pressure ulcer to the coccyx that was treated by staff at this time. Review of the CAA dated 10/24/13 for pressure ulcer identified the resident had a stage 4 pressure ulcer on the coccyx area that measured 5.3 cm x 3.5 cm with slough noted. The nursing staff treated the wound every Monday, Wednesday and Friday. The resident was incontinent of bowel and bladder and was unable to inform staff of needs. He/she wore adult briefs at that time. He/she had a gel cushion in the seat of the wheelchair and an air mattress on the bed to prevent further skin breakdown. The resident needed extensive assistance with all Activities of Daily Living (ADL) and received vitamin C for wound healing. The undated admission care plan identified the resident had a pressure ulcer and the goal was to have the wound decrease in size and show signs of healing measured by granulation tissue, pink wound bed with approximated edges and no signs of infection within 90 days. Interventions were to include a special cushion, special mattress, assist to reposition, wound treatment and assessment per the facility protocol, monitor for pain, and cushion to wheelchair. The care plan dated 10/31/13 revealed the resident had skin issues and identified the resident was admitted with a healing stage IV pressure ulcer to his/her right buttock/coccyx area. The staff should repositioned the resident to his/her right side and back every 2 to 3 hours. The resident used a low air loss mattress and a cushion in the wheelchair to relieve pressure. The incomplete Braden assessment dated [DATE] revealed a score of 16, the risk factor was marked as high. The mobility evaluation was not graded. The initial skin assessment completed by licensed staff F on admitted d 10/18/13 documented the pressure ulcer measurement of 5.3 centimeter (cm) x 3.5 cm and the wound appearance was red. On 10/18/13 a physician's orders [REDACTED]. The weekly pressure ulcer report completed by license staff G revealed measurements and assessment of the pressure ulcer on admitted d 10/18/13 classified the pressure ulcer as a healing stage IV, the measurements were 6.5 cm x 3 cm with granulation. The wound appearance identified the skin was intact. The periwound (the skin around the wound) appearance was [DIAGNOSES REDACTED] (red), no drainage or pain was noted and the response to treatment was healing. The weekly pressure ulcer report dated 10/28/13 classified the pressure ulcer as a healing stage IV, measurements were 6.5 cm x 3 cm, the tissue appearance was described as dark purple inside, the periwound appearance was [DIAGNOSES REDACTED], no drainage or pain noted, and the treatment was changed. The weekly pressure ulcer report lacked an assessment the week of 11/4/13. The clinical note dated 11/11/13 at 5:41 P.M. identified the resident's pressure ulcer appeared purplish in color, initiated turn schedule of right and back every 2 hours and the dressing was changed from [MEDICATION NAME] to Excuderm. No drainage noted. The treatment administration record dated 11/12/13 cleanse the site, pack with calcium alginate and cover with [MEDICATION NAME] twice a day. The weekly pressure ulcer report dated 11/13/13 classified the pressure ulcer as a healing stage IV, the area was open, measured 3.9 cm x 1.8 cm, tissue appearance identified slough, wound appearance documented not applicable, periwound appearance was [DIAGNOSES REDACTED], no drainage or pain noted, and the treatment was changed. The clinical note dated 11/13/13 at 6:22 P.M. revealed the facility notified the physician the pressure ulcer had reopened. The weekly pressure ulcer report dated 11/20/13 identified the healing stage IV as open and measured 2.4. cm x 2.4 cm, wound depth measured at 0.1 cm, periwound appearance was [DIAGNOSES REDACTED], no drainage or pain noted. The nutritional assessment dated [DATE] recorded the resident's admission weight of 153.5 pounds (#) with a healing stage IV on the buttocks. The resident's nutritional needs were 1745 kilocalories per day, 70 grams of protein per day and 1754 cubic centimeters (cc) of fluid per day. The resident had a good intake of 51 to 75 percent per meal intake. The resident was on [MEDICATION NAME] which may stimulate the appetite. The resident requests to eat in their room. The resident was to receive Vitamin C to aid in wound healing. The plan was to continue a regular diet and to monitor the resident's weight monthly and meal intake daily. The resident weight on 11/8/13 was 145 # which was a 5 percent decline in body weight in 21 days. The laboratory results dated [DATE] revealed a low protein level of 5.8 grams per deciliter (g/dl) the normal range was 6.2- 8.1 g/dl. Observation on 11/20/13 at 9:35 A.M. the resident rested in their bed on his/her back. A low air loss mattress was on the bed and a pressure relieving cushion was in the wheelchair. Observation on 11/20/13 at 9:50 A.M., 10:05 A.M., 10:20 A.M., 10:30 A.M., 10:35 A.M., 10:50 A.M. staff did not reposition the resident. Observation on 11/20/13 at 11:05 A.M. licensed staff C and licenced staff G entered the resident's room and asked if they could change the dressing to his/her buttocks. The resident was turned to the right side and his/her brief was removed, the resident was incontinent of urine and feces. Pericare was provided. The dressing was removed from the pressure ulcer. The wound was approximately quarter size, the wound bed was pink and granulation tissue was noted. The wound was cleansed with SAF-? AF Dermal Wound Cleanse (a wound cleansing solution) then patted dry. The calcium alginate (absorbant wound dressing) was applied on the wound bed and the wound was covered with an [MEDICATION NAME] dressing. Satff applied a clean brief and the resident was positioned on his/her left side. Observation on 11/21/13 at 1:50 P.M. the staff transferred the resident from the wheelchair to the bed by 2 person maximum assistance. The resident was incontinent and staff changed his/her brief. The dressing to the left buttocks was intact. The staff positioned the resident on his/her right side with the support of a pillow behind the resident's back. Continued observation on 11/21/13 at 2:05 P.M., 2:20 P.M., 2:35 P.M., 2:50 P.M., 3:05 P.M., 3:20 P.M., 3:25 P.M., 3:33 P.M., 3:35 PM staff did not reposition the resident. Observation on 11/21/13 at 3:50 P.M. the resident called out, staff entered the room and the resident had spilled the fresh pitcher of water on his/herself in the bed. The staff transfered the resident to the wheelchair by maximum assistance. The staff did not check the resident's brief to determine if he/she had been incontinent of bowel or bladder. Interview on 11/20/13 at 4:41 P.M. direct care staff D stated the resident could be very anxious with visual and verbal checks but stated he/she checked the resident's brief about every 45 minutes due to a sore on his/her bottom that was very deep. When the resident was in bed the staff attempted to position him/her on his/her side with pillows but the resident found a way to get on his/her back. The resident was always incontinent and would hit and kick when turned for pericare. Interview on 11/21/13 at 1:55 P.M. direct care staff Z stated the resident yelled and screamed with cares. Staff attempt to tilt the resident on his/her side when the staff were in the room and at least every 2 hours since he/she has a pressure sore. Interview on 11/20/13 licensed staff G stated he/she made rounds with the charge nurses to look at the resident's wound. The wound was measured and documented on the resident's weekly pressure ulcer report located in the Treatment Administration Record (TAR). The measurement was done weekly but not on a specific day of the week. Interview on 11/21/13 at 11:25 A.M. licensed staff G stated the pressure ulcer was intact with granulation tissue and the area was red. The documentation of a healing stage IV was used because it was known to be a stage IV prior to admission. The pressure sore reopened on 11/11/13 and the doctor was notified. Interview on 11/21/13 at 11:48 A.M. licence staff NN stated the MDS pressure ulcer measurements were documented on the weekly skin assessment done by licensed staff F on 10/18/13. Licensed staff NN stated she did not visualize the wound and agreed there were 2 different measurements of the pressure ulcer on the same day. The facility policy "Risk Assessment Screening" revised 4/20/10 noted residents were screened upon admission and every 48 hours for the risk of skin breakdown. The facility policy "Skin Care Protocol" revised 4/28/10 revealed a "Braden Skin Risk Assessment" was completed upon admission, quarterly, and with significant change. The facility policy "Prevention Protocol" revised 4/20/10 documented the following interventions were followed if a resident was at risk for skin breakdown: assess the resident daily for reddened areas, reposition the resident every 2 hours while in bed and every 1 hour when in a chair, assess nutritional status and dietary history, and document in the nurses' notes a summary of the interventions and compliance. Update the care plan prevention interventions as needed. The facility failed to provide effective interventions to prevent the redevelopment of an avoidable pressure ulcer.