Every finding on record at Claremore Skilled Nursing and Therapy

Based on record review and interview, the facility failed to ensure bathing was provided for 3 (#5, 6 and #7) of 3 sampled residents reviewed for activities of daily living.The DON identified 78 residents resided in the facility.Findings: 1. A quarterly assessment for Resident #5, dated 07/20/26, showed the resident required substantial/maximum assist with showers and bathing.A care plan for Resident #5, dated 07/20/26, showed the resident required substantial/maximum assist with showers and bathing.An undated Bathing Schedule showed Resident #5 was to receive baths weekly on Monday and Thursday.Shower Sheets for Resident #5, dated 07/01/26 through 07/31/26, showed the resident received baths on the following dates:a. 07/04/26,b. 07/06/26,c. 07/13/26,d. 07/17/26, ande. 07/31/26,There was no documentation to show Resident #5 had received baths on the following dates:a. 07/09/26,b. 07/20/26,c. 07/23/26, andd. 07/27/26. 2. A quarterly assessment for Resident #6, dated 06/25/26, showed the resident required substantial/maximum assist with showers and bathing.A care plan for Resident #6, dated 06/25/26, showed the resident required substantial/maximum assist with showers and bathing.An undated Bathing Schedule showed Resident #6 was to receive baths weekly on Wednesday and Sunday.Shower Sheets for Resident #6, dated 07/01/26 through 07/31/26, showed the resident received baths on the following dates:a. 07/01/26,b. 07/08/26,c. 07/12/26, andd. 07/26/26.There was no documentation to show Resident #6 had received baths on the following dates:a. 07/05/26,b. 07/15/26,c. 07/19/26,d. 07/22/26, ande. 07/29/26.3.A admission assessment for Resident #7, dated 07/31/26, showed the resident required substantial/maximum assist with showers and bathing.A care plan for Resident #7, dated 07/31/26, showed the resident required substantial/maximum assist with showers and bathing.An undated Bathing Schedule showed Resident #7 was to receive baths weekly on Monday and Thursday.Shower Sheets for Resident #7, dated 07/23/26 through 08/13/26, showed the resident received baths on the following dates:a. 07/23/26,b. 07/27/26,c. 08/03/26, andd. 08/06/26.There was no documentation to show Resident #7 had received baths on the following dates:a. 07/30/26,b. 08/10/26, andc. 08/13/26.On 08/13/26 at 11:03 a.m., CNA #1 stated the facility had a shower aide until about three weeks ago, so they had not given been giving showers as part of their regular tasks. On 08/13/26 at 11:16 a.m., CNA #2 stated they tried to work showers into the day, but it had been difficult to work it in to their schedule. CNA #2 stated they completed a shower sheet and turn it in to the nurse if the resident refused, then documented the refusal in the computer system. CNA #2 stated they didn't always get the paperwork completed.On 08/13/26 at 12:02 p.m., RN #2 stated the aides were to complete the showers and document in the computer as well as turn in a shower sheet into the charge nurse on the hall. RN#2 stated that if the resident refused, the aides were to report to the nurses so they could follow up with the resident but stated it did not happen on a regular basis with all the staff. On 08/13/26 at 1:31p.m. the DON stated residents should receive a bed bath or shower two times a week. The DON stated the documentation was not being consistently completed to allow follow up and interventions if necessary.

Based on observation, record review, and interview, the facility failed to ensure staff: a. served food in a manner to reduce the risk of cross contamination; b. kept the kitchen clean; c. wore hair and beard restraints when in the food preparation area; and d. discarded leftover food per facility policy during 1 of 2 kitchen observations. The dietary manager identified 87 residents received meals prepared by the kitchen. Findings: On 03/01/26 at 10:14 a.m., dietary aide #1 was observed standing by the stove in the kitchen. Dietary aide #1 had a beard and was not wearing a hair restraint or a beard guard. On 03/01/26 at 10:17 a.m., the deep fryer was observed to have dark grease and food particles floating in the grease and piled on the outer edges. On 03/01/26 at 10:22 a.m., a steam table pan labeled sausage was observed in the refrigerator and dated 02/26. On 03/01/26 at 10:28 a.m., there was a thick black substance observed around the wheels of the oven, and a brown substance had dripped down the outside of the stove. A tater tot was observed under the stove. A facility policy titled Dining Services Policies and Procedures, dated 01/01/00, read in part, Hairnets or hair covers must be worn at all times. Facial hair must also be covered with a protective covering. A facility policy titled Dining Services Policy and Procedure, dated 11/28/17, read in part, leftovers will only be kept for 24 hours and then discarded. On 03/01/26 at 10:15 a.m., dietary aide #1 stated they should have worn a hair restraint and beard guard. On 03/01/26 at 10:18 a.m., cook #2 stated the deep fryer was used daily. They stated they thought the deep fryer was last cleaned about three days ago. [NAME] #2 could not provide a cleaning schedule for the deep fryer. On 03/01/26 at 10:23 a.m., cook #2 stated leftovers were to be thrown away after 24 hours. They stated the sausage should have been thrown away. On 03/01/26 at 10:30 a.m., dietary cook #2 stated the black substance around the oven wheels and the brown substance that had dripped down the side of the oven was grease. They stated the tater tot was from the dinner meal served the night before. [NAME] #2 stated the floor area around the oven wheels was cleaned about a month ago. Dietary [NAME] #2 stated they were not aware of a cleaning schedule for 02/2026.

Based on record review and interview, the facility failed to have sufficient staff to meet the needs of the residents for 3 (#9, 11, and #74) of 3 sampled residents reviewed for ADL care.The administrator reported 87 residents who resided in the facility.Findings:1. An admission record, dated 07/25/24, showed Res #9 had diagnoses which included respiratory failure and chronic kidney disease.An admission assessment, dated 12/10/25, showed Res #9 had a BIMS score of 15, which indicated intact cognition. The assessment also showed Res #9 required substantial/maximal assistance with bathing.A care plan, reviewed 12/16/25, showed Res #9 required substantial staff assistance with bathing and was dependent on staff to transfer to the shower.The task portion of Res #9's EHR showed the resident was to receive showers on Monday and Thursday. The EHR also showed that Res #9 had received a shower on 02/17/25. The shower on 02/17/25 was the only shower documented between 02/01/26 and 03/03/26.On 03/03/26 at 1:45 p.m., CNA #4 stated on 03/02/26 they were responsible to give Res #9 a bath, but they did not have enough time to complete that task during their shift.On 03/03/26 at 1:50 p.m., Res #9 stated they did not get a bath yesterday, and they had not had a bath in over a week.2. An annual assessment, dated 02/03/26, showed Res #11 had a BIMS score of 14, which indicated intact cognition. The assessment also showed Res# 11 required partial/moderate assistance with bathing.A Follow Up Question Report, dated 03/03/26, showed Res #11 was scheduled to receive showers on Tuesdays and Sundays. The report showed during the month of February 2026, Res #11 was offered or received a shower on 02/10/26, 02/17/26 and 02/26/26. The report did not show Res# 11 was offered or received a shower on 02/01/26, 02/08/26, 02/15/26, or 02/22/26. Res #11 received three showers out of seven opportunities for February 2026.On 03/01/26 at 10:34 a.m., Res #11 stated they were usually only given one shower a week.3. An annual assessment, dated 01/30/26, showed Res #74 had a BIMS score of 14, which indicated intact cognition. The assessment also showed Res# 74 required substantial/maximal assistance with bathing.A Follow Up Question Report, dated 03/03/26, showed Res #74 was scheduled to receive showers on Monday and Fridays. The report showed during the month of February 2026, Res #74 was given a shower on02/09/26, 02/16/26, and 02/24/26. The report does not show Res #74 was given a shower on 02/02/26, 02/06/26, 02/13/26, 02/20/26 or 02/27/26. Res #74 received three showers out of eight opportunities for the month of February 2026.On 03/01/26 at 11:44 a.m., Res #74 stated showers were not being given as often as they should be.On 03/03/26 at 1:30 p.m., CNA #2 stated residents are supposed to get 2 showers a week, but sometimes they do not because the facility is short staffed.On 03/03/26 at 1:35 p.m., CNA #3 stated sometimes they just don't have enough time in their shift to get all the showers they are assigned given.On 03/04/26 at 7:45 a.m., CNA #5 stated that CNAs are responsible to give showers on their assigned hall, but they are not always able to complete them. They also stated when they worked last Tuesday, they were supposed to give six showers, but they were only able to complete two.On 03/04/26 at 8:35 a.m., LPN #2 stated the charge nurse was responsible to ensure showers were given. They also stated that if a CNA was unable to complete a shower it should be passed on to the night shift.On 03/04/26 at 10:10 a.m., the DON stated they had some issues with staffing, but it was improving. They stated residents should be getting two showers a week.

Based on record review and interview, the facility failed to respond to concerns and recommendations of the resident council.The administrator identified 87 residents who resided at the facility.Findings: A Resident Council Response Form, dated 01/08/26, showed: a. concerns from the resident council regarding the nursing department, including slow call light response. The form directs the department head to respond in writing to the council by 01/22/26. The form does not show a written response from the DON;b. concerns from the resident council regarding the dietary department, including wanting fresh fruit and a varied menu. The form directs the department head to respond in writing to the council by 01/22/26. The form does not show a written response from the dietary department; andc. concerns from the resident council regarding the housekeeping department, including wanting labels for clothes. The form directs the department head to respond in writing to the council by 01/22/26. The form does not show a written response from the housekeeping department.A Resident Council Response Form, dated 02/05/26, showed:a. concerns from the resident council regarding administration, including the exterior doors opening from the outside without a code. The form directs the person responsible to respond in writing by 02/17/26. The form does not show a written response from the administrator; andb. concerns from the resident council regarding housekeeping, including resident rooms not being cleaned. The form directs the department head to respond in writing to the council by 02/17/26. The form does not show a written response from the housekeeping supervisor.On 03/03/26 at 10:42 a.m., the SSD stated that they were responsible for taking the minutes during the resident council meetings. They also stated that they noted the council's concerns on a form and gave the form to the appropriate department head for a written response. They stated that the department heads did not always respond to the concerns of the resident council.On 03/04/26 at 7:55 a.m., the housekeeping supervisor stated that they signed and returned the council response form but did not document a response on the form.On 03/04/26 at 8:30 a.m., the dietary manager stated they did not always respond to the council in writing.

Based on record review and interview, the facility failed to ensure bathing was provided according to the plan of care for 3 (#9, 11, and #74) of 3 sampled residents reviewed for ADL care.The administrator reported 87 residents who resided in the facility.Findings:1. An admission assessment, dated 12/10/25, showed Res #9 had a BIMS score of 15, which indicated intact cognition. The assessment also showed Res #9 required substantial/maximal assistance with bathing.A care plan, reviewed 12/16/25, showed Res #9 required substantial staff assistance with bathing and was dependent on staff to transfer to the shower.The task portion of Res #9's EHR showed the resident was to receive showers on Monday and Thursday. The EHR also showed that Res #9 had received a shower on 02/17/26. The EHR did not show Res #9 was given a shower on 02/02/26, 02/05/26, 02/09/26, 02/12/26, 02/19/26, 02/23/26 or 02/26/26. Res #9 received one shower out of eight opportunities for February 2026.Additional documentation of showers for Res #9 was requested, but none was provided by the end of the survey.On 03/03/26 at 1:45 p.m., CNA #4 stated on 03/02/26 they were responsible to give Res #9 a bath, but they did not have enough time to complete that task during their shift.On 03/03/26 at 1:50 p.m., Res #9 stated they did not get a bath yesterday, and they had not had a bath in over a week.2. An annual assessment, dated 02/03/26, showed Res #11 had a BIMS score of 14, which indicated intact cognition. The assessment also showed Res# 11 required partial/moderate assistance with bathing.A Follow Up Question Report, dated 03/03/26, showed Res #11 was scheduled to receive showers on Tuesdays and Sundays. The report showed during the month of February 2026, Res #11 was offered or received a shower on 02/10/26, 02/17/26 and 02/26/26. The report did not show Res# 11 was offered or received a shower on 02/01/26, 02/08/26, 02/15/26, or 02/22/26. Res #11 received three showers out of seven opportunities for February 2026.On 03/01/26 at 10:34 a.m., Res #11 stated they were usually only given one shower a week.3. An annual assessment, dated 01/30/26, showed Res #74 had a BIMS score of 14, which indicated intact cognition. The assessment also showed Res# 74 required substantial/maximal assistance with bathing.A Follow Up Question Report, dated 03/03/26, showed Res #74 was scheduled to receive showers on Monday and Fridays. The report showed during the month of February 2026, Res #74 was given a shower on02/09/26, 02/16/26, and 02/24/26. The report does not show Res #74 was given a shower on 02/02/26, 02/06/26, 02/13/26, 02/20/26 or 02/27/26. Res #74 received three showers out of eight opportunities for the month of February 2026.On 03/01/26 at 11:44 a.m., Res #74 stated showers were not being given as often as they should be.On 03/03/26 at 1:30 p.m., CNA #2 stated residents are supposed to get 2 showers a week, but sometimes they do not because the facility is short staffed.On 03/03/26 at 1:35 p.m., CNA #3 stated sometimes they just don't have enough time in their shift to get all the showers they are assigned given.On 03/04/26 at 7:45 a.m., CNA #5 stated that CNAs are responsible to give showers on their assigned hall, but they are not always able to complete them. They also stated when they worked last Tuesday, they were supposed to give six showers, but they were only able to complete two.On 03/04/26 at 8:35 a.m., LPN #2 stated the charge nurse was responsible to ensure showers were given. They also stated that if a CNA was unable to complete a shower it should be passed on to the night shift.On 03/04/26 at 10:10 a.m., the DON stated they had some issues with staffing, but it was improving. They stated that residents should be getting two showers a week.

Based on record review and interview, the facility failed to ensure quarterly care plan meetings were held for 1 (#1) of 17 sampled residents reviewed for care plans.The administrator identified 87 residents residing in the facility findings.Findings:An admission assessment, dated 07/03/25, showed Res #1 had been admitted to the facility on [DATE]. It further showed the resident had a BIMS score of 13 which indicated intact cognitive functioning.A review of Res #1's EHR showed a comprehensive care plan meeting had occurred on 07/11/25. No other care-plan meetings notes were found in the resident's EHR.On 03/01/26 at 11:36 a.m., Res #1 stated they did not recall attending any care plan meetings.On 03/03/26 at 10:34 a.m., MDS Coordinator #1 stated they were assigned to conduct the care plan meetings for the long-term care residents at the facility. They stated they had not known they were supposed to have quarterly care plan meetings with the residents or their representatives. They stated the only care plan meeting they found in Res #1's EHR occurred in July 2025.On 03/03/26 at 12:25 p.m., the DON stated the facility did not have a policy and procedure for care planning and just followed CMS guidelines.On 03/04/26 at 9:39 a.m., the DON stated MDS Coordinator #1's supervisor was Corp. Nurse Consult #1.On 03/04/26 at 9:41 a.m., Corp. Nurse Consult #1 stated they were the manager of MDS Coordinator #1. They stated MDS Coordinator #1 had been training on tracking care-plan meetings. They stated MDS Coordinator #1 had turned in a schedule for their care-plan meetings but for some reason those meetings did not occur. They stated they had retrained the employee and will monitor them closely.

On 06/11/25, a past non-compliance situation was determined to exist related to the facility's failure to ensure staff provided supervision to prevent falls from lifts. A facility reported incident, dated 03/26/25, showed Resident #2 fell while being transferred by CNA #4 using a lift. 1. Immediate Action Taken: a. A quality assurance meeting was held to initiate a plan of action. b. all lifts and slings were inspected for wear and tear. 2. Systemic Changes Implemented: a. a schedule of inspection for slings and lifts to ensure all are in good working order. 3. Education and Training: a. All direct care staff were educated on safe use of lifts and slings. An initial incident report, dated 06/03/25, showed certain injuries for Resident #1 as a result of a sling failing during a transfer. 1. Immediate Action Taken: a. A quality assurance meeting was held to initiate a plan of action. b. Inspect all slings b. Discard all old slings and order new slings. 2. Systemic Changes Implemented: a. Method of laundering slings was changed to prevent excess wear by drying. 3. Education and Training: a. Direct care staff were educated on proper method of inspection for slings before use. Based on record review and interviews, the facility failed to ensure staff provided supervision to prevent falls from lifts which resulted in injury for 2 (#1 and #2) of 3 sampled residents who were reviewed for requiring transfers with lifts. The administrator reported 20 residents required the assistance of a lift. Findings: 1. An initial incident report, dated 03/26/25, documented in part .Witnessed fall by staff .Resident sent to ER for evaluation. BIMS of 12. CNA was suspended pending investigation .Upon investigation, it was determined that the sling detached from the lift during transfer. Resident was assessed by facility nurse and EMS called for transport to ER for assessment. ER X-rays showed rib fracture .All direct care staff inserviced on lift use and safety. Maintenance visually inspected all lifts and slings to ensure they were in good working order. Weekly documented checks will be conducted by maintenance to ensure lifts and slings are in working order. A progress note, dated 03/26/25 at 10:45 a.m., showed Res #2 had fallen to the ground while being assisted to a chair in a lift. A purple shower sling was noted hanging from the lift on 3 of the 4 hooks. A final incident report, dated 03/26/25, showed it was determined the sling detached from the lift during transfer and only one staff was operating the Hoyer lift and Resident #2 suffered a rib fracture as a result of the fall. A QAPI report, dated 03/26/25, showed a meeting was held and an action plan was developed. Inservice's were conducted for all direct care staff on safe transfers and the use of two staff when using all lift devices. The report showed compliance rounds to be initiated on 03/27/25. A significant change assessment, dated 04/03/25, showed Resident #2 had a BIMS of 7, which indicated severe cognitive impairment for decision making. The assessment showed the resident was dependent on staff for transfers and bathing. A care plan, dated 04/24/25, showed Resident #2 was dependent on a lift for transfers. On 06/10/25 at 12:38 p.m., Resident #2 stated the lift didn't get hooked properly. They reported there was only one person helping them transfer that day. 2. A significant change assessment, dated 03/24/25, showed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment for decision making. The assessment showed Resident #1 required the use of a lift for transfers. An initial incident report, dated 06/03/25 showed certain injuries for Resident #1 as a result of a sling failing during a transfer. The report showed a fracture to the left arm and hip resulted from the fall. On 06/09/25 at 12:05 p.m., Resident #1 stated they were in the lift and the strap broke. Resident #1 stated they felt safe in the lift and they felt when the strap broke it was a freak accident. On 06/12/25, a review of documentation provided by the facility was conducted and included: 1. Quality assurance meeting held 06/04/25 2. Inservice's for staff conducted on 06/04/25 regarding the safe use and care of slings. 3. Documentation of new slings ordered on 06/04/25. 4. Weekly lift and sling checks. 5. Lift competency checks for CNA#3 and LPN #4 On 06/12/25, five direct care staff were interviewed regarding their prior education and current knowledge of proper and safe use of transfers and slings.

Based on record review and interview, the facility failed to ensure bathing was provided for 2 (#2 and #4) of 4 sampled residents who were reviewed for activities of daily living. The administrator identified 85 residents resided at the facility. Findings: 1. A significant change assessment for Resident #2, dated 04/03/25, showed Resident #2 had a BIMS of 7, which indicated they were moderately impaired for daily decision making. The assessment showed Resident #2 was dependent for showers. Task flow sheets for showers in April, May, and June of 2025 showed Resident #2 was to receive showers twice a week. The flow sheet for April 2025 showed one shower was given on 04/15/25 out of nine opportunities for showers. The flow sheet for May 2025 showed four showers were given on 05/07/25, 05/23/25, 05/28/25, and 05/30/25 out of nine opportunities in the month for showers. The flow sheet for June showed no showers had been given as of 06/10/25. On 06/10/25 at 12:38 p.m., Resident #2 stated they had only get one shower a week. 2. A quarterly assessment, dated 05/13/25, showed Resident #4 had a BIMS score of 15 (which is indicative of intact cognition). The assessment showed Resident #2 was moderately dependent for showers. Task flow sheets for showers in April, May, and June of 2025 showed Resident #4 was to receive showers twice a week. The flow sheet for April 2025 showed four showers were given out of 9 opportunities. The flow sheet showed showers were given on 04/17/25, 04/19/25, 04/24/25, and 04/29/25. The flow sheet for May showed three showers were given out of nine opportunities. The flow sheet showed showers were given on 05/01/25, 05/03/25, and 05/17/25. The flow sheet for June showed one shower had been given on 06/05/25 as of 06/10/25. On 06/11/25 at 10:46 a.m., the regional nurse consultant stated the residents should get the opportunity for two showers a week. On 06/11/25 at 11:02 a.m., the administrator stated residents should get two showers a week.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 (#3) of 3 sampled residents reviewed for abuse. The administrator identifed 85 residents resided in the facility. Findings: A undated facility policy titled Resident Abuse, Neglect and Misappropriation of Property, read in part, The administrator and or facility designee will report all allegations to the QAPI committee. The QA committee will monitor for compliance.A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283 [Oklahoma Department of Health]. An undated Transfer/Discharge Report documented the resident had diagnoses which included major depressive disorder, chronic pain, anxiety disorder, and persistent mood disorders. A discharge return anticipated assessment, dated 12/01/24, did not show a BIMS for the resident. The assessment showed the resident was independent for daily decision making. An OSDH incident report, dated 12/17/24, showed an allegation of abuse for Resident #3. The report showed an allegation that CNA #1 forcefully pushed the resident in their wheelchair away from the nurse station and hit the wall. The facility could not provide statements regarding the incident occurring 12/17/24 from the identified resident or the identified CNA. A quality assurance committee report, dated 12/31/24, did not show abuse was monitored for compliance. On 06/11/25 at 1:47 p.m., the administrator stated there were no documented resident or staff statements regarding the incident on 12/17/24. The administrator stated without statements they did not know if the incident was witnessed by other staff or residents or what time the incident occurred. On 06/11/25 at 2:45 p.m., the administrator stated they could not provide the documentation/investigation to show a thorough investigation was completed. The administrator reviewed the QAPI committee documentation and stated abuse had not been identified after the incident on 12/17/24.

The facility failed to ensure lab work was completed as ordered for two (#39 and #33) of five residents reviewed for unnecessary medications. The administrator reported the census in the facility was 80. Findings: 1. Resident #39 had diagnoses which included diabetes mellitus and hypertension. A physician's order, dated 02/16/24, documented to repeat a lipid level in 3 months, April 2024. A review of Resident #39 records did not document a lipid level had been collected in April of 2024. On 06/27/24 at 2:40 pm, The ADON stated that the lab had not been completed in April of 2024. They also stated the lab had been completed on 06/27/24 and the results had been addressed by the physician. On 06/28/24 at 12:41 pm, The DON stated the ADON was responsible for ensuring lab work was completed as ordered. 30267 2. Resident #33 had diagnoses which included atrial fibrillation and an unspecified coagulation defect. A laboratory report, dated 01.25.24, documented the resident had a critical low potassium level of 2.7 mEq/L (normal range 3.5-5.1 mEq/L). On the laboratory report was a hand written note, dated 01/26/24, which read to administer 40meq of potassium now, to start potassium 20meq daily, and to check the resident's potassium level by redrawing the lab on 01/29/24. There was no documented lab drawn on 01/29/24. A laboratory report, dated 01/30/24, documented the laboratory results of a complete blood count. The laboratory findings for a complete blood count does not measure the resident's potassium level. On 06/28/24 at 9:33 a.m., the resident's laboratory results were reviewed with the DON. The DON stated the redraw was not performed and a laboratory order for a complete blood count was ordered instead by mistake. The DON stated the facility did not have a system in place which would monitor laboratory orders for inaccuracies.

Based on record review and interview, the facility failed to ensure two (#58 and #7) of two residents/representatives reviewed for care plans, were involved in the care planning process. The administrator identified 80 residents who resided at the facility. Findings: 1. Resident #58 admitted with diagnoses which included anxiety. On 06/25/24 at 8:32 a.m., Resident #58 stated they did not know when the care plan meetings were held. Review of progress notes revealed, no notes concerning care plan meetings. On 06/27/24 at 10:41 a.m., the MDS Coordinator stated they conducted the care plan meetings and invited the resident and resident representatives. They stated the invitations were not documented, however the representative for Resident #58 came. The MDS Coordinator stated they did not believe it was documented. On 06/27/24 at 10:59 a.m., the MDS Coordinator returned and stated they did not have anything the representative for Resident #58 had signed to indicate they had attended the care plan meeting. 30267 2. Resident #7 was admitted with diagnoses which included hypertension, depression, and over-active bladder. The care plan, last updated 06/21/24, did not document the resident/representative participated in the care plan process. On 06/25/24 at 09:23 a.m., Resident #7 stated they had not participated in a care plan meeting. On 06/27/24 the resident's clinical record was reviewed. There was no documentation the resident was notified of or participated in the care plan meeting. On 06/27/24 at 11:00 a.m., the MDS Coordinator stated when a resident's care plan was due, they informed the resident/representative of the meeting. They stated they did not document they informed the resident or their representative of the care plan meeting nor documented who participated in it.

Based on observation, record review, and interview, the facility failed to provide showers for four (Resident #7, 21, 33, and Resident #37) of four sampled residents whose clinical records were reviewed for ADL care to dependent residents. The facility Administrator identified 80 residents. Findings: A facility policy, effective date 10/01/01, documented showering was important because it rid the body of surface dirt, eliminated body odors, stimulated circulation, and provided an opportunity to inspect the resident's skin for any abnormalities or breakdown. A quality improvement report, dated 04/01/24, documented the facility identified showers as a problem and suggested they dedicate one to two staff to provide showers. 1. Resident #7 was admitted with diagnoses which included hypertension, depression, and over-active bladder. The care plan, revised 03/25/24, documented the resident required partial/moderate assistance with shower/bathing. The quarterly assessment, dated 06/07/24, documented the resident was mildly impaired in cognition and required partial/moderate assistance with shower/bathing. On 06/25/24 at 9:37 a.m., Resident #7 stated they did not received their showers as scheduled nor received showers when they requested. Resident #7 stated they bathed daily at home and would appreciate a shower daily or every other day. Resident #7 stated they would bathe themselves in the sink because they preferred to stay clean and did not care to be woke in the middle of the night or early morning to make up for a missed shower. On 06/27/24, a review of the clinical record documented Resident #7 received assistance with bathing on 06/02/24, 06/05/24, 06/12/24, 06/16/24, 06/19/24, and 06/26/24. On 06/27/24 at 1:10 p.m., CNA #2 stated the shower assignment list was usually 28 to 30 residents per day. The aide stated some residents require two or more person assistance for transfers and bathing and that required the aide to coordinate care with other staff for the additional help. The aide stated if they were unable to coordinate with staff for the additional help, the resident was left for the other shift to complete. The aide stated the residents requiring the additional help were often left for the other shift. The aide stated they left a list at the nurses station of all the residents who received a shower and the residents who did not receive a shower. The aide stated the following shift was to complete the remainder of the assigned showers. On 06/28/24 at 12:15 p.m., LPN #2 stated the shower aide would report to them when a resident refused their shower but had not reported to them that all assigned showers were not completed. The LPN stated all shower refusals were to be signed by the resident, the aide, and the nurse. On 06/28/24 at 1:15 p.m., the DON stated the facility employed one shower aide through the weekday and one shower aide on the weekends. The DON stated the shower aide may have 12 or more residents listed on the shower list for each weekday. The DON stated if the shower aide was unable to complete the assigned showers for the day, the other aides and shifts were expected to complete the assigned showers. 2. Resident #21 had diagnoses which included chronic pain, Hodgkin's lymphoma, and sarcopenia. The care plan, dated 03/22/24, documented Resident #21 would like a shower once a week. The physician's order, dated 05/07/24, documented Resident #21 was admitted to hospice services. The care plan, dated 05/09/24, documented Resident #21 received bath/showers from hospice. On 06/25/24 at 12:33 p.m., Resident #21 was observed in bed. The resident's hair appeared uncombed and there was dirt and debris under the resident's finger nails. Resident #21 stated they had not received a shower in six weeks. Resident #21 stated they agreed to hospice services because they were promised if they did so, they would receive showers. Resident #21 stated they did not feel clean after they received a bed bath. On 06/28/24, the Resident #21's clinical record was reviewed, including the hospice records related to bathing. The hospice records documented Resident #21 received a bed bath on the following dates: 05/13/24, 05/15/24, 05/21/24, 05/23/24, 05/29/24, 06/17/24, and 06/24/24. On 06/28/24 at 1:15 p.m., the DON stated residents receiving hospice services were bathed by hospice staff. The DON stated a residents' bathing preference should be accommodated by hospice when clinically possible. The DON stated the facility was responsible for the coordination of care for all residents, including ensuring residents received their baths and their choice of bathing preference was respected. 3. Resident #33 had diagnoses which included infection and inflammatory reaction due to indwelling urethral catheter and a stage three pressure ulcer. The quarterly assessment, dated 05/14/24, documented the Resident #33 was cognitively intact and was totally dependent on others for repositioning, transfers, and bathing. On 06/25/24 at 9:57 a.m., Resident #33 was observed in bed with their hair uncombed and gown stained with food. Resident #33 stated they had not received a shower in two weeks. Resident #33 stated when they were admitted , the facility had a shower bed but now they only have shower chairs. Resident #33 stated the shower chair was very uncomfortable and they did not feel they were clean when using the shower chair because they could not lean forward for their back to be washed and could not lift either hip up from the surface of the chair for the aide to wash their buttocks. Resident #33 also stated it was difficult for the aide to reach under the chair to wash the residents perineum. On 06/27/24 at 1:10 p.m., CNA #2 stated the shower assignment list was usually 28 to 30 residents per day. The aide stated Resident #33 required three staff members to assistance with their transfer to and from the shower chair. The CNA stated Resident #33 was in a lot of pain when up in the shower chair even when they padded the chair with multiple bath blankets. The aide stated they had not given the Resident #33 a shower in a few weeks. The aide stated they tried to start the bath schedule with those residents who they missed on their previously scheduled shower day to ensure the resident had at least one shower per week. The aide stated since the Resident #33 required the assistance of two other staff members, the resident was often left for the other shift to complete. The aide stated the residents requiring the additional help were often left for the other shift. The aide stated they left a list at the nurses station of all the residents who received a shower and the residents who did not receive a shower. The aide stated the following shift was to complete the remainder of the assigned showers. On 06/28/24 at 12:15 p.m., LPN #2 stated the shower aide would report to them when a resident refused their shower but had not reported to them that all assigned showers were not completed. The LPN stated all shower refusals were to be signed by the resident, the aide, and the nurse. On 06/28/24 at 1:15 p.m., the DON stated the facility employed one shower aide through the weekday and one shower aide on the weekends. The DON stated the shower aide may have 12 or more residents listed on the shower list for each weekday. The DON stated if the shower aide was unable to complete the assigned showers for the day, the other aides and shifts were expected to complete the assigned showers. 4. Resident #37 had diagnoses which included impulse disorder. The quarterly assessment, dated 06/07/24, documented the resident was cognitively intact, exhibited no behaviors, and required partial/moderate assistance with bathing. The care plan, dated 06/19/24, documented the resident required partial/moderate assistance with bathing and to offer bathing at least twice a week. On 06/25/24 at 1:07 p.m., Resident #37 was in bed. The resident's hair appeared oily and their face unshaven. Resident #37 stated they did not receive their showers, even after asking for a shower. The care plan documented if the resident was to refuse, to try again later, document the refusal, and inform the nurse. On 06/26/24 at 9:00 a.m., the Resident #37's clinical record was reviewed. There was no documentation the resident received a bath in the last 30 days. There was no documentation the resident refused a bath in the last 30 days. On 06/27/24 at 1:10 p.m., CNA #2 stated Resident #37 required the assistance of a male staff member which was not always available. On 06/28/24 at 1:15 p.m., the DON stated the facility employed one shower aide through the weekday and one shower aide on the weekends. The DON stated male staff were assigned to provide the Resident #37 with a shower each week or document when the resident refused.

Based on record review and interview, the facility failed to ensure appropriate communication between the facility and the dialysis provider for one (#16) of one resident reviewed for dialysis. The DON reported two residents received dialysis services. Findings: The Policy and Procedure Guidelines for Dialysis After Care policy, effective 07/11/12, read in part, .Schedule visits to dialysis center and coordinate care accordingly . A care plan intervention, revised on 05/15/24, documented to schedule dialysis every Monday, Wednesday, and Friday and to coordinate care with the dialysis center. A review of Resident #16's medical record did not document a Dialysis Communication Form had been completed for Resident #16 since 05/28/24. On 06/27/24 at 10:13 am, LPN #1 stated that until yesterday they were unaware that they were supposed to be filling out a Dialysis Communication Form and sending the form with the resident to the dialysis center. They also stated they had dropped the ball and from now on they would utilize the form. On 06/27/24 at 10:55 am, the DON stated the nurse on duty was responsible for sending the dialysis form with the resident and putting the information in the computer when the resident returned. On 06/28/24 at 8:33 am, LPN #2 stated that the communication form should be sent to dialysis with the resident and then entered into the computer upon the resident's return from dialysis. LPN #2 also stated the charge nurse was responsible for completing these tasks. On 06/28/24 at 10:40 am, LPN #3 stated nurse assigned to the dialysis residents hall was responsible for sending the dialysis for with the resident and ensuring it was entered into the computer.

Based on record review and interview, the facility failed to ensure the resident and the resident's representative were given a summary of the baseline care plan for one (#7) of two residents whose baseline care plans were reviewed. The administrator reported the census was 80. Findings: 1. Resident #64 had diagnoses which included kidney failure and sleep apnea. On 06/25/24 at 9:23 a.m., Resident #7 stated they did not receive a summary of their baseline care plan. On 06/27/24 the Resident #7's clinical record was reviewed. There was no documentation of a baseline care plan. On 06/28/24 at 9:13 am MDS coordinator #1 stated that they did not give Resident #7 or their representative a copy of their baseline care plan because they were unaware that it was a requirement. On 06/28/24 at 12:41 pm, The DON stated that a summary of the baseline care plan should be given to all residents and their representatives.

Based on observation, record review, and interview, the facility failed to ensure the accuracy of an MDS assessment for one (#31) of five residents reviewed for MDS accuracy. The administrator reported the census was 80. Findings: Resident #31 had diagnoses including acute respiratory failure with hypoxia. A Medicare five-day assessment, dated 06/12/24, indicated the resident had required invasive mechanical ventilation while a resident at the facility. A review of Resident 31's orders did not document they had orders for a ventilator at the facility. On 06/27/24 at 2:19 pm, the DON stated they did not accept residents that required ventilators. On 06/27/24 at 2:30 pm, MDS coordinator #2 stated they had coded that Resident #31 required a ventilator because they required one before admission to the facility.

Based on record review and interview, the facility failed to ensure residents and staff were interviewed as part of a investigation into alleged abuse for one (#1) of four sampled resident reviewed for abuse. A Resident List Report, dated 06/12/24, documented 73 residents resided at the facility. Findings: A Resident Abuse, Neglect, and Misappropriation of Property policy, revised date 11/01/22, read in part, A member of the administrative staff will then conduct a thorough investigation of the incident/allegation to obtain information about the incident and complete ODH-283. An ODH-283, an incident reporting form, documented an allegation of abuse had been received by the DON on 05/24/24. The form documented an investigation had been conducted which included interviews with residents and staff. On 06/12/24 at 10:35 a.m., DON stated they could not recall if they had interviewed any residents about the alleged incident between CNA #1 and Resident #1. They stated they did not recall speaking to the nurse who worked the night of the alleged abuse about the incident itself. They stated they had worked with CNA #1 many times and felt they knew them well. They stated after speaking with CNA #1 about the incident they had no reservations about allowing the staff member to return to work and unsubstantiated the allegation. They stated they believed they had conducted a thorough investigation. On 06/12/24 at 12:48 p.m., DON stated they think they could have investigated the allegation more than they had. They stated they could have spoken with residents in the hall where the alleged incident had occurred. They stated they had not conducted a thorough investigation.

Based on observation, record review, and interviews, the facility failed to have sufficient staff to ensure residents received personal care and services in a timely manner for three (#17, 55, and #34) of three residents sampled for sufficient staffing. The Resident Census and Conditions of Residents report, dated 04/17/23, documented 74 residents resided in the facility. Findings: On 04/17/23 at 12:57 p.m., Resident #17 reported staff did not check on her regularly or at least every two hours. The resident reported she was not able to use her call light and sometimes when her daughter came to visit, the resident's brief would be full. The resident stated she felt the facility didn't have enough staff to check on residents as often as they should. On 04/17/23 at 3:07 p.m., Resident #55 reported the facility did not have enough staff and often worked with only two CNAs in the whole building. The resident stated she had complained and she was starting to see staff members coming out of the offices to assist on the floor. The resident stated she thought they had pulled nurses to the floor instead of filling office jobs. On 04/18/23 at 2:30 p.m., LPN # 1 reported staffing had been a challenge. The LPN reported she worked almost every day. The LPN reported they were currently working with two CNAs for 74 residents and stated this was common. The LPN was asked how many staff in total were currently working and she stated there were two LPNs, three CMAs, and two CNAs working the floor for 74 residents. The LPN stated they had been managing to get resident care completed but the aides were stretched very thin. On 04/20/23 at 8:15 a.m., CNA #3 reported she worked in the business office but was also a CNA. The CNA was observed to answer call lights, assist with resident care, and was asked how often she was pulled to the floor. The CNA stated either the charge nurse or DON would usually ask her to help out and when she did, they would add her to the schedule. The CNA was asked if she was ever scheduled specifically to work the floor, and she stated no, she was only pulled to help out as needed. On 04/20/23 at 10:09 a.m., a family member for resident #34 reported that on more than one occasion, they had found resident #34 drenched with urine. The family member stated sometimes there would be only one or two aides for more than 70 residents. They stated there was one day when the resident's lunch tray was still sitting in the resident's room at 5:00 p.m., and it was their opinion there wasn't enough staff to ensure residents had eaten and trays were picked up in a timely manner. The family member did not express a concern regarding weight loss and the resident's clinical record did not document weight loss. Quality of Care Monthly Reports, dated January, February and March 2023, were reviewed for adequate staffing and documented the following: The January report documented five days with insufficient staffing for the reported resident census. 01/01/23 - 203.07 total direct care staff hours for 76 residents. The facility should have had at least 220.4 hours. 01/21/23 - 229.90 total direct care staff hours for 81 residents and should have had at least 234.9 hours. 01/22/23 - 211.82 total direct care staff hours for 80 residents and should have had at least 232.0 hours. 01/28/23 - 188.33 total direct care staff hours for 79 residents and should have had at least 229.1 hours. 01/29/23 - 184.34 total direct care staff hours for 78 residents and should have had at least 226.2 hours. The February report documented six days with insufficient staffing for the reported resident census. 02/04/23 - 195.44 total direct care staff hours for 80 residents and should have had at least 232.0 hours. 02/05/23 - 180.52 total direct care staff hours for 79 residents and should have had at least 229.1 hours. 02/11/23 - 181.61 total direct care staff hours for 76 residents and should have had at least 220.4 hours. 02/12/23 - 187.75 total direct care staff hours for 75 residents and should have had at least 217.5 hours. 02/25/23 - 177.14 total direct care staff hours for 80 residents and should have had at least 232.0 hours. 02/26/23 - 221.81 total direct care staff hours for 80 residents and should have had at least 232.0 hours. The March report documented four days with insufficient staffing for the reported resident census. 03/05/23 - 217.92 total direct care staff hours for 78 residents and should have had at least 226.2 hours. 03/12/23 - 198.45 total direct care staff hours for 79 residents and should have had at least 229.1 hours. 03/19/23 - 207.31 total direct care staff hours for 73 residents and should have had at least 211.7 hours. 03/26/23 - 219.93 total direct care staff hours for 76 residents and should have had at least 220.4 hours. On 04/20/23 at 11:29 a.m., the DON was interviewed regarding staffing and asked if she thought two CNAs was enough to care for a census of 74 residents. The DON stated the nurses helped out as well and they also used EAs. She stated the EAs could pick up meal tickets, deliver food to residents who did not require assistance, deliver ice, and answer call lights to relay messages to an aide or nurse. The DON stated CMAs were scheduled specifically to pass medications, although they would occasionally help with resident showers when needed. The DON stated they had designated the PRN aides to be shower aides and reported they worked about two days a week, usually 8:00 a.m. to 2:00 p.m. The DON stated she had complaints in the past about call lights but thought it was getting better. She reported she had been able to hire more staff and the facility was much better staffed on the weekend shifts than previous. The DON stated she had worked the floor herself and had worked several overnight shifts. She reported the ADONs had also worked the floor, as well as the business office staff member who was certified and cross-trained. The DON stated she kept a calendar schedule for nurses to help with feeding assistance, as well as assisting to get meal trays passed in a timely manner. On 04/20/23 at 11:30 a.m., hand-written staffing schedules were reviewed at length. It was very difficult to determine exactly how many staff were working on any given shift. The DON was asked to review the schedules and provide specific numbers in regard to how many aides had worked each shift. This information was not provided. On 04/20/23 at 12:03 p.m., the Administrator stated it had been very difficult to get CNAs hired, who would actually show up for work, so he had hired more LPNs and had the weekend shifts covered better than previous. The Administrator mentioned the business office staff member who was cross-trained and certified to help on the floor as needed, as well as the social services and activities staff who were also CNAs.

Based on record review and interview, the facility failed to ensure dependent residents were provided/offered baths for four (#2, #4, #8, and #12) of six sampled residents who were reviewed for ADL assistance. The Resident Census and Conditions of Residents form identified 66 residents who required the assistance of one or two staff members for bathing and 16 residents who were dependent on staff for bathing. Findings: 1. Resident #2 had diagnoses which included hemiplegia of the dominate side and aphasia. The Documentation Survey Report v2 report, dated December 2022, documented the resident was scheduled baths on Mondays and Thursdays. The report documented the resident had been offered/received two baths out of nine opportunities. The Documentation Survey Report v2 report, dated January 2023, documented the resident was scheduled baths on Mondays and Thursdays. The report documented the resident had been offered/received three baths out of nine opportunities. The quarterly assessment, dated 02/02/23, documented the resident required assistance from staff for bathing. The Care Plan, dated 02/08/23, documented the resident resisted care at times and required physical assistance for bathing. The Documentation Survey Report v2 report, dated February 2023, documented the resident was scheduled baths on Mondays and Thursdays. The report documented the resident had been offered/received three baths out of eight opportunities. Review of the EMR did not reveal documentation the resident had refused scheduled baths for December 2022, January 2023, or February 2023. 2. Resident #4 had diagnoses which included malignant neoplasm of the ovary. A 5-day assessment, dated 02/22/23, documented the resident required assistance from staff for bathing. The Care Plan, dated 02/27/23, documented the resident required extensive assistance of one person for bathing. The Documentation Survey Report v2 report, dated February 2023, documented the resident was scheduled baths on Tuesday and Friday. The report documented the resident had not been offered/received baths out of out of four opportunities from 02/17/23 through 02/28/23. Review of the EMR did not reveal documentation the resident had refused scheduled baths for February 2023. 3. Resident #12 had diagnoses which included dementia and rheumatoid arthritis. The Documentation Survey Report v2 report, dated February 2023, documented the resident was scheduled baths on Tuesday and Friday and had been discharged from hospice services on 02/17/23. The report documented the resident had been offered/received one bath in three opportunities from 02/18/23 through 02/28/23. The significant change assessment, dated 02/20/23, documented the resident was cognitively intact for daily decision making. The Care Plan, dated 02/28/23, documented the resident required supervision to set up help to assistance of one and the resident refused bathing at times. Review of the EMR did not reveal the resident had refused baths in February 2023. On 03/02/23 at 1:45 p.m., Resident #12 was asked how often they received baths. They stated they had not received a bath in approximately two weeks. They stated they had spoken to staff about the lack of baths and was notified they were working on a schedule change. 4. Resident #8 had diagnoses which included acute kidney failure. The Documentation Survey Report v2 report, dated February 2023, documented the resident was scheduled baths on Monday and Thursday. The report documented the resident had been offered/received one bath out of three opportunities from 02/20/23 through 02/28/23. The admission assessment, dated 02/26/22, documented the resident required one person physical assistance for bathing and was cognitively intact for daily decision making. On 03/01/23 at 1:15 p.m., Resident #8 was asked how often they received baths. They stated they had received one bath since they had been admitted . On 03/02/23 at 2:35 p.m., the DON was asked how the bath schedule was utilized by staff. The DON stated the schedule has continued to change since the facility had identified a concern with baths in January 2023. The DON stated ensuring baths were provided had been a process and had required several schedule changes. They stated the ADON managed the bath schedule. On 03/02/23 at 2:41 p.m., the ADON was asked how baths were monitored to ensure residents were offered/received showers as scheduled. The ADON stated they reviewed the list of baths that were given and would make sure the residents received at least one per week.

Based on interview and record review, it was determined the facility failed to ensure: a) nursing home employees were tested twice a week for COVID-19 based on the county's positivity rate for eight (#1 through #8) of eight sampled employees who were reviewed for COVID-19 testing; and b) testing was completed when a resident had signs and symptoms consistent with COVID-19 for one (#1) of three sampled residents reviewed for COVID-19. The facility identified 73 staff members who were employed at the facility and 59 residents who resided at the facility. Findings: A CMS (Center's for Medicare and Medicaid) memo, dated 08/26/20, documented: .COVID-19 Testing .Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency . A facility policy for COVID-19 testing, revised 11/23/20, documented: .There are three triggers for testing: symptomatic, outbreak and routine/surveillance. Symptomatic Testing: Test any staff or residents who have signs or symptoms of COVID-19 .Routine Testing: Test all staff based on CMS' published county positivity rate .Facilities should monitor their county positivity rate on the first and third Monday of every month and adjust employee testing frequency accordingly . 1. Per review of CMS COVID-19 Nursing Home Data, archived data documented the county positivity rate was in the red zone since 11/04/20 to 12/10/20. According to the county positivity rates the staff should have been tested twice a week. A review of the eight employees' testing logs documented the employees had not been tested twice a week. A review of the eight employees' punch detail reports for the past two weeks, documented the employees had been working. The employees were not tested two times a week as required according to the county positivity rate. On 11/09/20 at 12:52 p.m., the infection preventionist/(IP) registered nurse (RN) stated the county positivity rate was red and red indicated the staff needed to be tested twice a week. The IP stated the facility had nurses on all shifts who were trained to perform COVID-19 testing. On 11/10/20 at 5:43 a.m., employee #1 stated she had not been tested since 11/30/20 and was not sure why she had not been tested since 11/30/20. At 5:49 a.m., employee #5 stated she had not been tested since 11/30/20. At 6:01 a.m., employee #3 stated she was supposed to be tested two times a week, but had not been tested twice a week. At 6:10 a.m., employee #6 stated she thought she had been tested last week, but was not sure. At 6:14 a.m., employee #4 stated she had not been tested in one or two weeks. The employee stated she had been working the past two weeks and had never tested positive for COVID-19. At 6:23 a.m., employee #7 stated she had not been tested since 11/30/20. The employee stated she had not been told to come in for testing and supplies were not accessible to the staff to be tested . At 6:30 a.m., employee #8 stated she had not been tested twice a week. She stated she had not been told she needed to come in to be tested . At 8:09 a.m., the director of nursing (DON) stated she had provided all of the employee testing logs. The DON stated the facility had enough testing supplies and were using the BD Veritor machine. She stated the county positivity rate indicated the employees were supposed to be tested two times a week. The DON stated she did not have a testing schedule and she did not remind the employees when to come in to be tested . She stated the quality manager was off and usually took care of the testing. When asked about the employee COVID-19 tests for the eight employees, the DON stated some things might have been missed. 2. Resident #1 had [DIAGNOSES REDACTED]. Resident #1's treatment administration record (TAR) documented, .COVID-19 (Coronavirus) Symptom Monitoring: Assess resident for Cough, Fever, Shortness of breath, Chills, Repeated shaking with chills, Muscle pain, Headache, New loss of taste or smell, Diarrhea, Nausea, Vomiting, Sore throat, fatigue, nasal congestion, runny nose, red eyes, new onset confusion. Does the resident have s/s (signs and symptoms) of respiratory infection or COVID-19 that are NEW onset and not from a Chronic Condition: Answer question yes or no. IF YES, CALL PHYSICIAN AND RULE OUT INFLUENZA, every 6 hours for COVID-19 Symptom Monitoring . On 12/05/20 at 2:00 a.m., the TAR documented, Yes the resident had symptoms of COVID-19. The TAR also documented the resident had a temperature of 99.9. The TAR documented the resident had a temperature of 99.7 degrees Fahrenheit at 8:00 a.m. and 99.4 degrees Fahrenheit at 2:00 p.m. The progress notes for resident #1 did not document the physician was notified when the resident had symptoms of COVID-19 and did not document a COVID-19 test was performed. On 12/09/20 at 2:00 p.m., RN #1 stated there was no documentation the physician had been notified when the resident had symptoms of COVID-19. She stated there was no documentation a COVID-19 test had been done when the TAR documented the resident had symptoms of COVID-19. She stated the resident had not had a COVID-19 test since admission on 12/04/20.

Based on observation, interview, and policy review, the facility failed to ensure staff wore gowns as part of the infection control precautions for one of seven residents (Resident (R) 2) that was placed in the 14-day quarantine unit. R2 was placed in the 14-day quarantine unit after being readmitted to the facility. This failed practice had the potential to affect 80 other residents in the facility by increasing the possible spread of infection by allowing the staff to care for residents without proper personal protective equipment (PPE). Findings include: During observation of the facility's quarantine unit on 11/10/20 at 10:30 AM, revealed Staff1 (a laundry aide) was observed in R2's room assisting R2 with a phone. R2 was in bed and Staff1 was touching R2's phone and leaning in near R2's face so that both could view the phone. Staff1 was also observed touching R2's bed rails. Staff1 was not wearing a gown or gloves. A sign on the door noted, Observation/Quarantine.Required PPE.Isolation Gown, Gloves. During an interview on 11/10/20 at 10:35 AM, Staff1 was asked about being in the resident's room without a gown and not [MEDICATION NAME] social distance. Staff1 stated she was not giving direct care to R2 and thought that she did not have to wear a gown or gloves. Staff1 was asked if she knew that R2 was in a 14- day quarantine. Staff1 stated she knew that she had been readmitted for m the hospital and knew R2 was on precautions for the COVID-19 virus. Review of R2's electronic medical record (EMR) indicated an undated Profile which indicated resident had been re-admitted to the facility on [DATE]. During an interview on 11/10/20 at 10:55 AM, the Corporate Infection Preventionist Registered Nurse (IP/RN) stated that Staff1, knew better. The IP/RN stated staff had been in-serviced and instructed when a resident is in quarantine; full PPE was to be worn if staff were going to be up close and touching anything in the residents' room. Review of the facility's undated policy titled, COVID19 Pandemic Plan, indicated, .Personal Protective Equipment (PPE) Gloves. Gloves are used to prevent contamination of healthcare personnel hands when.3. Handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces.Isolation gowns. Isolation gowns are used as specified by Standard and Transmission- Based Precautions, to protect the HCW's (healthcare workers) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident was transferred with two staff members in order to prevent falls for one (#45) of three residents reviewed for falls. The resident experienced three falls while being transferred by one staff member with the third fall resulting in a fracture. The director of nursing determined there were five falls with fractures in the past six months. Findings: Resident #45 was admitted with [DIAGNOSES REDACTED]. A care plan, initiated on 08/17/18, documented: Focus Potential for falls r/t: Deconditioning, Gait/Balance Problems . Goal Staff will evaluate all falls and intervene as needed to reduce the potential of significant injury through the review date . Interventions . Follow Facility Fall Protocol . Anticipate and meet the resident's needs . Keep Pathways clear, clutter free, dry and well lit . Keep personal and frequently used items in reach . Ensure that resident is wearing non-skid footwear before transfers and when up in wheelchair . Ensure that resident is wearing non-skid foot wear before ambulation . Encourage resident to participate in activities that promote physical activity for [MEDICATION NAME] and improved mobility . Call light in reach encourage to use. Date Initiated: 08/17/2018 . Focus (Resident) is at risk for fluctuations in ADL's due to change in independence level Goal Will maintain current level of function through the review date Interventions . Transfer: requires limited x2 (X) staff participation with transfers . An admission assessment, dated 08/23/18, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, dressing, toilet use, bathing, and hygiene; had no impairment in range of motion; was frequently incontinent of bowel and bladder; had one fall with injury except major; and received an antidepressant and a diuretic medication seven days out of the seven day look back period. An incident note, dated 10/28/18 at 8:40 a.m., documented, This nurse called to room by CNA stating that res had sat down in the floor in the bathroom. Upon entering res bathroom res in sitting position facing toilet. CNA stated that she was going to toilet the res and states that her legs felt week (sic), CNA then lowered res to the floor. Res stated, 'I was going to the bathroom and my legs felt weak .Res assisted into W/C with the help of this nurse and two CNA's .Intervention: CNA educated on importance of reading falling star before transferring residents, res is a two person assist for all transfers. An update, initiated on 10/29/18, to the care plan for potential for falls, documented, RESOLVED: fall 10/28 no injury staff education to read/check falling star . An update to the care plan for potential for falls, initiated on 11/15/18, documented: Bolster . Positioning Bars x2 . A revision, dated 12/05/18, to the care plan for fluctuations in ADL's, documented, .Walking does not walk .Toilet Use : Extensive Assist 2(X) person physical assist . An incident note, dated 01/08/19 at 1:32 p.m., documented, This nurse was called to resident's room d/t resident in the floor. CNA stated that during transfer resident was being uncooperative and started sliding so CNA assisted resident down CNA's legs to the floor. Resident stated that her feet slid out from under her. Upon entering room nurse observed resident resting in floor by bed .Intervention: Educate CNAs will follow transfer status that is on the Falling Star (posted in resident's room and at the nurse's station) to prevent falls and for resident's and CNA safety. An update, initiated on 01/08/19, to the care plan for potential for falls, documented, RESOLVED: 1/8/2018 (sic) Fall in room non injury Intervention: Learning circle with staff . A quarterly assessment, dated 02/11/19, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, dressing, toilet use, bathing, and hygiene; had no impairment in range of motion; was frequently incontinent of bowel and bladder; had one fall with injury except major; and received an antidepressant and a diuretic medication seven days out of the seven day look back period. An incident note, dated 03/20/19 at 10:37 a.m., documented, This nurse called to res room. CNA stated that she was assisting res to toilet and res stated that her legs felt week (sic), CNA then eased res to floor. Res stated, 'my legs felt weak and I couldn't stand.' Res assisted into W/C with help of two nurse and three CNA's. Res assessed for injuries, right knee swollen with light bruise to outer knee observed .Pain 5/10 to right knee .New order to obtain X ray to right leg, knee and hip. Intervention: res to be evaluated for therapy. An incident report form, dated 03/20/19, documented, At 1000, resident was observed sitting on the floor in her bathroom. Resident was with CNA at the time assisting resident to the toilet. Resident stated that her legs felt weak and CNA eased resident to the floor .Resident complained of pain to her right knee. Resident assisted to her wheelchair x2 nurse and 3 CNA assist. Pain 5/10 to right knee .Order received to obtain stat xray of right leg, knee and hip. Xray revealed fracture of right lower extremity. Order received to send resident to ER . An update, initiated on 03/21/19, to the care plan for the potential for falls, documented, 3/21/2019 Fall broke R lower ext Intervention: part b/transferred to hospital clarification fall date 3/20/19 . A quarterly assessment, dated 05/09/19, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene; had no impairment in range of motion; was frequently incontinent of bowel and bladder; had one fall with injury except major; and received an antidepressant and a diuretic medication seven days out of the seven day look back period. On 06/20/19 at 8:45 a.m., the resident was observed in bed. The resident was asked if she remembered having falls. She stated she knew she had fallen but she could not remember anything about them. On 06/20/19 at 9:45 a.m., an undated copy of the falling star form was observed in the resident's room. The form documented the resident was a two person assist for ADLs. On 06/20/19 at 1:45 p.m., CNA #1 was asked if she was familiar with the residents care. She stated yes. She was asked to describe what assistance was required for the resident. She stated the resident had recently fallen and required a Hoyer lift to transfer. She stated the resident had been a two person assist. On 06/24/19 at 9:08 a.m., LPN #4 was asked if she remembered the falls of this resident. She stated yes, some of them. She was asked how the staff would know what interventions to use for transfers and toileting. She stated it would be on the falling star form on the closet door. She was asked what interventions were in place for transfers for this resident. She stated the resident was a two person assist at all times. At 9:13 am, the DON was asked how the staff would know what interventions should be done regarding resident transfers. She stated the falling star document. She was asked who ensured the falling star was current. She stated the staff did the falling star updates. She stated the falling star would be posted in the residents' room and in a book. The DON was asked how the resident should have been being transferred. She stated she should have been a two person assist and staff should have done that. At 10:16 a.m., the resident was observed in her bed. She was asked if she was going to get out of bed today. She stated she had just gotten back to bed. At 1:43 p.m., CNA #2 was asked if she had been with the resident when a fall occurred. She stated yes. She was asked to describe what occurred. She stated she knew she was supposed to look at the falling star, but she had listened to the other CNAs who were familiar with the resident and she had been told the resident could be transferred by one person. She was asked if she knew what her falling star documented at the time the fall occurred. She stated she was pretty sure the resident was a two person. She was asked where the falling star protocol was located. She stated on the resident's closet door.

On 02/16/16, an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to provide supervision to prevent falls and to implement interventions to aid in the prevention of falls. Resident #9 fell on [DATE] with interventions initiated to prevent future falls. The interventions were not consistently implemented and the resident fell again on 01/31/16 and sustained a fractured right femur that required surgery. The facility was currently not consistently implementing the interventions that had been identified. In addition the facility failed to prevent accident hazards in the residents environment. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 5:09 p.m., the administrator, the DON, the corporate LPN consultant, and the regional corporate consultant were informed of the IJ regarding falls and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 5:48 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Plan of removal 02/16/16 Resident identified will be assessed for appropriate interventions for falls immediately by the DON and documented 02/16/16 All residents with falling star in place will be assessed by nurses/nurse managers for appropriate interventions and ensure interventions are in place and documented by 12:00am 2/16/16 All charge nurses will be in serviced on assessing monitoring and intervening appropriately when a fall occurs. Staff currently in building will in-serviced immediately. All other nursing staff we cannot get in the building will be in-service (sic) via phone by 12:00am then before working a shift to ensure understanding. 2/16/16 All nursing staff will be in serviced on the fall policy and the importance of reporting falls to charge nurse, charge nurse then reports to on call nursing manager and/or administrator to ensure appropriate interventions have been put in place by 12:00am 2/16/16 Administrator and or designee will monitor every two hours for 24 hours then every shift continuously to ensure resident appropriate interventions are in place. On 02/17/16 at 9:13 a.m., the administrator provided an addendum to the plan of removal. The addendum documented: Addendum to the Plan of Removal 02/17/16 Employee (name deleted) CNA (PRN) was unavailable for In Service of Plan of Removal. After several attempts to contact on or before midnight of 02/16/16 employee was terminated. Staff were interviewed on 02/17/16 in regards to their knowledge of the fall inservice; to ensure their understanding of all aspects of the plan of removal. The IJ was removed effective 02/17/16 at 7:22 a.m., when all components of the plan of removal and addendum had been completed. The deficient practice remained at actual harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to: ~ provide supervision to prevent falls and to consistently identify and implement interventions to aid in the prevention of falls for three (#4, #8, and #9) of eight sampled residents who had experienced falls; and ~ ensure the environment was free of accident hazards for one (#9) of eight sampled residents who had experienced falls. Resident #9 fell on [DATE] with interventions initiated to prevent future falls. The interventions were not consistently implemented and the resident fell again on 01/31/16 and sustained a fractured right femur that required surgery. The facility was currently not consistently implementing the interventions that had been identified. In addition the facility failed to ensure accident hazards were not present in the residents environment. The facility identified 84 residents who were at high risk for falls. Findings: A fall awareness program policy documented, .The fall risk assessment will be completed on all admissions, readmission, falls, and significant changes .develop care plan based on interventions used. Review quarterly and as needed .Assess resident for injuries, provide appropriate medical attention, and notify physician and family. Obtain orders for X-ray as indicated. Complete incident report .Complete additional fall risk assessment tool .assess current pain management and effectiveness .Consider factors regarding the fall . Develop care plan using appropriate interventions . 1. Resident #9 had [DIAGNOSES REDACTED]. A significant change assessment, dated 12/16/15, documented the resident had a BIMS score of five. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent with transfers, was frequently incontinent, and had not experienced any falls. A fall care plan, dated 01/04/16, documented, Focus: .high risk for falls r/t a hx of falls .Goal: .will be free of falls through the review date .Interventions: Anticipate and meet (resident's) needs .Be sure (resident's) call light is in reach and encourage her to use it for assistance as needed .(Resident) needs prompt response to all requests for assistance .Concave mattress to bed .Hoyer lift to be used at all times .keep frequently used items within reach .Keep pathways clear, dry, clutter free and well lit .appropriate non-skid footware (sic) . An incident report, dated 01/14/16, documented, .This nurse notified that resident had fallen out of her bed and was on floor. This nurse observed Resident on floor on her back. Staff had placed pillow under her head. Resident AAOx2. Resident stated I tried to get out of bed to put some things in a box. I put one leg off the bed, then the other, then my body just followed and fell to the floor Resident stated I didn't hit my head and I didn't break any bones. Resident reports pain to bilat knees. Immediate action taken: Resident assessed for injuries with none noted at this time. Res assisted to her bed via hoyer lift and staff .Res reports bilat knee pain, med aide notified to administer pain medication. Resident unable to state pain level. Intervention of safety floor mat at bedside initiated .a wedge cushion on bed placed to prevent resident from rolling out of bed . Updates to the fall care plan, dated 01/14/16, documented, Focus: Fall Non Injury .Goal: .will be free of falls through the review date .Interventions: Provide a wedge cushion and a safety mat next to her bed when in bed. An incident report, dated 01/31/16, documented, .This nurse was informed by aide that resident had feel (sic) out of bed last night, also heard while aide was doing care for resident, Resident stated fell out of bed .Immediate action taken: VS taken, neuro initiated, pain meds given .No Injuries Observed Post Incident. Level of Pain: (Blank) . A radiology report, dated 01/31/16 at 3:29 p.m., documented, .there is a nondisplaced fracture of the distal femur . A nurse's note, dated 01/31/16 at 4:07 p.m., documented, It was reported to this nurse that resident had a fall out of bed last night. VS taken resident assessed .Resident c/o pain in right knee there was some inflammation, when family notified of this asked about x-ray also .PA ordered one due to pain, during day a bruise to the right side of chin appeared will continue to monitor .X Ray results came back and PA .Stated due to results to send resident out to (hospital, name deleted) for further evaluation . A nurse's note, dated 01/31/16 at 7:31 p.m., documented, We are doing a Learning circle/Inservice on proper setting for weight of resident who sleeps on an airloss mattress. A learning circle inservice, dated 01/31/16, documented, .Air loss mattress must be set to weight, there is a setting on the end of the bed, push (up) or (down) to adjust setting .If a light weight person is in a bed set on a firm setting it may roll them out of bed. Please check settings when put residents into bed. If you need residents weight ask your nurse . Updates to the fall care plan, dated 01/31/16, documented, Focus: Fall with injury .Goal: .will be free of falls through the review date .Interventions: Learning circle for correct operation of bed. An undated final state reported incident report, documented, .Incident Date 01/30/16 .Resident was observed laying on the floor in front of her bed. Focused assessment completed. Resident complained of pain in R knee and a bruise to R chin. No other injuries were noted .Resident sent to .Hospital .for further evaluation .Resident has safety/fall precautions in place .The facility completed an initial investigation by interviewing the resident .family .staff members .involved, and by completing a focused assessment on the resident .resident sent to ER .Upon completion of the investigation, the facility determined the resident rolled off the bed, landing on her fall mat. A fracture to her R distal femur and a small bruise to her R chin were noted. No other injuries were noted. Resident returned to the facility following surgery on her R femur. Pain orders in place. The facility has updated the resident's plan of care to include the appropriate safety/fall precautions. The facility has also educated .appropriate staff members of the safety/fall risks, transfer status and devices in place . The fall care plan, updated 02/01/16, did not address any new fall interventions to prevent further falls. An inservice by the ADON, dated 02/03/16, documented, .what a CNA should do when a resident falls . There were 14 staff signatures on the inservice. There was no documentation of what information was provided to staff at the inservice. An inservice by the ADON, dated 02/03/16, documented, .Charting after a fall - Assessing/Neuros/IR . There were six staff nurses' signatures on the inservice. There was no documentation of what information was provided to staff at the inservice. A fall risk assessment, dated 02/04/16, documented the resident had a fall risk score of 55. This score indicated the resident was at high risk for falls. On 02/16/16 at 2:00 p.m., the resident was observed in bed in her room. The fall mat was not beside the bed and the wedge cushion was not in use. The wedge cushion was in a chair and had not been placed under the resident. The mechanical lift had been left approximately one to two feet to the side of the resident's bed. The bed had not been lowered and remained approximately three feet up from the floor. At 2:40 p.m., the DON and corporate LPN#1 were asked about the falls and the fracture the resident sustained [REDACTED].>They were asked what had occurred when the resident fell on [DATE]. The DON stated, An aide told another aide and that's how I found out. She stated the aides had put the resident back to bed and not reported the fall to anyone when it occurred. She stated the air loss mattress may have been set too firm and the resident had fallen out of bed. She stated they did a learning circle inservice regarding reporting falls and what to do when a fall occurred. The DON was asked if the wedge cushion was in place when the fall occurred. She stated, As far as I know she did not have a wedge cushion in place on the bed. She was asked why it was not in place. She stated, Excellent question, I don't have an answer. The DON stated the resident was sent out to the hospital after she had experienced pain and it was determined she had a fracture. She stated the resident had surgery and was readmitted to the facility. She was asked if the resident was assessed for the cause of the fall or for pain the day after the fall when staff became aware she had fallen. She stated since the resident was admitted to the hospital after they discovered the fracture she did not have a fall assessment done until her return to the facility after surgery. She stated the only pain assessment completed would be on the e-mar when she was medicated for pain. The e-mar on 01/31/16 documented the resident had a follow up pain scale of zero and the medication was effective. There was no other documentation a pain assessment had been completed. They were informed of the observation of the resident regarding the wedge cushion and fall mat not in place, the bed not being lowered, and the mechanical lift being left next to the bed. No comment was made. They were asked if the staff were implementing the fall interventions that had been care planned. The DON stated, That's an excellent question and I can't really answer. The DON was asked why the resident was put back to bed by the aides and they did not report the fall to the nurse. She stated she did not find out until the next day. She stated the whole fall was very upsetting and she felt it was a one time thing, not the normal. The DON and corporate LPN #1 were asked if an investigation was conducted regarding the resident's fall. The DON stated she interviewed the resident and staff, and they had concluded the air loss mattress was set too high and the resident had fallen out of bed. She was asked for the investigation. She stated she did not have any interviews or other documentation except for the state reported incident report. She stated she did not keep the interviews or document them and did not have any other documentation other than the inservices about what to do if someone falls and the air loss mattress settings. The DON was asked how they determined what interventions to put in place if they did not do a thorough investigation. She stated, After we find out through deduction we decide on interventions. The DON was asked if any new interventions had been put in place since the resident returned to the facility after having surgery to repair her fractured leg. She stated she would have to look and see. She was informed there were no new interventions on the care plan. No comment was made. On 02/17/16 at 10:10 a.m., CNA #9 was asked if she was aware of what happened when the resident had fallen out of bed. She stated she was told the resident had fallen, the aides had assisted her back to bed, and it was not reported to a nurse until the next day. She stated they attended an inservice regarding reporting to a nurse if a resident fell and not moving the resident until assessed by the nurse. At 10:20 a.m., CNA #10 was asked if she was aware of what happened when the resident had fallen out of bed. She stated, I was told she was in the hospital because she fell and a charge nurse did an inservice to turn it in and not move patient until a nurse sees them. At 1:33 p.m., CNA #11 was asked if she was aware of what happened when the resident had fallen out of bed. She stated, Yes. I was told I do not pick them up. I get my nurse and she has to come do an assessment but I do not pick them up. At 2:55 p.m., LPN #7 was asked what had happened when the resident had fallen out of bed. She stated, It was reported to me that she had fell the previous night. She stated, I assessed her and she was having pain in leg, knee, and swelling on 01/31/16. She stated it occurred on a weekend and they got an X-ray and sent her out to the hospital. The LPN was asked how she was notified of the fall. She stated, I was not told in report she had fallen. It was passed on between aides and she was hurting too much to get up so we gave her her prn pain medicines. She was asked if any assessments had been done. She stated, I asked her if she was hurting and she told me her knee, leg. She was asked if there were any other assessments completed. She stated, No. She stated neuros and the fall risk assessment were completed. She stated there was no post fall assessment, that they no longer fill out the fall scene investigation because they no longer use those through Grace Living Center. She stated, and it was all hearsay so I wouldn't have been able to since it had already happened. The LPN stated, The resident went out and they fixed the fracture site and she had a lot of staples in it. The LPN was asked if anyone took a statement from her on what had occurred. She stated, No. She stated we found out the bed was set up too high and I did an inservice for the CNAs and to report any falls to the nurse and have the nurse assess before moving the resident. On 02/18/16 at 3:10 p.m., the DON and the care plan coordinator were asked why there were not any new interventions put in place to prevent further falls. The DON stated they should have them in place. They were informed of the observations of the resident without the bed in the low position, without the wedge cushion in place, without the fall mat next to the bed, and with the mechanical lift placed close to the bed. They were asked if staff were implementing the fall interventions in place for the resident. No comment was made. 2. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. A fall care plan, dated 07/17/15, documented, Focus: I am at risk for future falls with injury due to I am unsteady and require assistance with transfers, toileting and mobility .incontinent of bowel and bladder, require the use of a w/c for locomotion and require mood altering medications .Interventions: Scoop mattress .Placed on red star program .Notice my red falling star and check on me to be sure I am safe .provide me with a pressure alarm and personal alarm as indicated .provide me with non skid socks and the assistance I need to put them on .Staff education on safety checks . A quarterly assessment, dated 09/29/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with bed mobility, transfers, locomotion, dressing, and toilet use, had experienced frequent moderate pain, had no falls since admission or prior assessment, and had received antianxiety and antidepressant medications in the past seven days. An incident report, dated 10/28/15, documented, .Incident Description: Called to res room via LPN .Res noted on floor at bedside. States 'I didn't think I would fall.' Left elbow with a pea sized skin tear .Immediate Action Taken: Head to toe assessment completed. Assisted res back to bed via 2 person assist. V/S obtained .Left elbow cleansed with NS and steri strip applied. Tol well . An incident report, dated 11/25/15, documented, .Incident Description: Res noted on bathroom floor in front of toilet sitting on buttocks by CNA .Immediate Action Taken: Res assessed for injuries then assisted out of floor back into w/c. No noted injuries or c/o pain at this time. Neuro checks initiated due to unwitnessed fall .New intervention is: Res will not be left alone in bathroom when toileting. CNAs educated . The fall care plan, updated 12/24/15, documented, Focus: 10/28/15 Fall ST to left elbow .11/25/15 Fall no injuries .Interventions: changed out bed .Staff to ensure alarms is in working order .Keep frequently used items within reach .make sure resident has appropriate non-skid footware (sic) .provide (name deleted) a pressure mat alarm . The fall care plan had not been updated to address the intervention to stay with the resident while in the bathroom. A quarterly assessment, dated 12/30/15, did not document the resident's cognitive status, mood, and pain. The assessment documented the resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene; required limited assistance with locomotion; had experienced two falls with no injury since the prior assessment; and had received antianxiety and antidepressant medications in the past seven days. A state reportable incident report, dated 01/03/16, documented, .At 00:00 (midnight), resident was observed sitting on the floor in front of her floor mat. Focused assessment completed. A dime sized abrasion to the back of her head was noted. No other injuries were noted. Abrasion site was cleansed with normal saline and triple antibiotic ointment applied. ROM within normal limits for this resident. Neuro checks initiated .Resident observed at nurse's station for any complication from fall .The facility completed an initial investigation by interviewing resident, family, and staff members involved, and by completing a focused assessment on the resident, an evaluation of her medication, foot ware (sic), incident history, and environmental .Upon completion of the investigation, the facility determined that the resident lost her balance, fell backwards, and hit her head on the floor. A focused assessment was completed. A small dime size abrasion to the back of her head was noted. No other injuries noted Abrasion monitored until healed. The facility has updated the resident's plan of care to include the appropriate safety/fall precautions. Intervention will be to assist with toileting while in bed and not to leave resident alone while on the toilet. Resident provided non-skid socks . The incident report did not address any new fall interventions to prevent further falls. The fall care plan, updated 01/05/16, documented, Focus: 1/3/16 Fall no injuries .Interventions: .1/3/16 Prompted toileting q2 while in bed . The fall care plan had not been updated to address the abrasion to the back of the resident's head and to not leave the resident alone while in the bathroom. An incident report, dated 01/15/16, documented, .Incident description: resident observed sitting on floor near safety mat on buttocks, alert oriented to person, denies pain and ROM WNL for resident x 4 ext .Resident description: I wanted to get up and I went down .Immediate Action Taken: Frequent checks on resident initiated. Neuros initiated, assisted to WC, ensured pressure alrm (sic) in place. After investigating fall, resident was noted to not have a safety mat beside bed. A safety mat was placed next to bed while resident is in bed . The fall care plan, updated 01/18/16, documented, Focus: .1/15/2016 Fall None Injury .Interventions: .1/15/2016 Provide safety fall mat next to bed when she is in it and pressure alarm at all times . The fall care plan had not been updated to address new fall interventions to prevent further falls. On 02/18/16 at 3:15 p.m., the MDS/care plan coordinator, ADON, and DON were asked what interventions were put in place to prevent further falls. The MDS/care plan coordinator stated, I don't know. They were asked if fall mats and alarms prevent falls. The MDS/care plan coordinator stated, No. The MDS/care plan coordinator was asked what new interventions were put in place to prevent further falls. She stated, I'd have to look at it. The DON was asked why no appropriate new interventions were put in place after each fall. She stated, We should be. 3. Resident #8 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/14/15, documented the resident had a short/long term memory problem and had modified independence in cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with transfers, did not ambulate, used a wheelchair for mobility, was always incontinent, and had not experienced any falls. A monthly physician's orders [REDACTED].Bed mat alarm in bed while res in bed .Chair mat alarm in wheelchair while res up . An incident report, dated 01/05/16, documented, .This nurse was called to resident's room, resident was sitting on the floor by bathroom door. No injuries were found at this time .Immediate action taken: resident was assisted to w/c and dressed by aide, lap buddy in place at this time .No injuries observed . A fall care plan, dated 01/11/16, documented, Focus: .has a history of falls and now require the use of a lap buddy to help him to prevent future falls .Goal: .will be free of from complications related to my use of a lap buddy through the review date .Interventions: Assess need for lap buddy q month. Chair mat alarm and bed alarm as ordered by physician .clip alarm at all times .low bed .appropriate non-skid footwear .has two staff members present during transfers .monitor .for decline in mobility .ability to release his lap buddy .remove .lap buddy at meal times and every 2 hours for care and PRN . An incident report, dated 02/01/16, documented, .Res found sitting on floor in front of bathroom .Immediate action taken: Head to toe assessment, placed res in wheelchair .No injuries observed . A fall care plan, updated 02/01/16, documented, Focus: Fall with no injury. Goal: .will be free of from complications related to my use of a lap buddy through the review date .Interventions: Bed mat alarm in bed at all times. There were no new fall interventions addressed or implemented to prevent further falls. An incident report, dated 02/09/16, documented, .Res found sitting in the floor outside his room .Immediate action taken: Head-to-toe ass't, placed res in his wheelchair .No injuries observed . A fall care plan, updated 02/09/16, documented, Focus: Fall non injury. Goal: .will be free of from complications related to my use of a lap buddy through the review date .Interventions: Staff to get resident up at 5 am. On 02/18/16 at 2:40 p.m., the DON and the care plan coordinator were informed of the falls and asked if a bed alarm that was already on the care plan was an appropriate intervention to prevent further falls. No comment was made. They were asked if getting the resident up every morning at 5:00 a.m. was an appropriate intervention when the resident had fallen once at 6:14 a.m. They stated, No. They were asked why there were no new/appropriate fall interventions developed to prevent further falls. No comment was made. They were asked if there should have been new/appropriate interventions developed after each fall. They both stated, Yes.

Based on record review, observation, and interview, it was determined the facility failed to prevent severe/significant weight loss and consistently implement interventions to aid in the prevention of weight loss in a timely manner for six (#1, #3, #13, #16, #20, and #21) of nine sampled residents reviewed for weight loss. Resident #13 experienced a severe weight loss of 37.2 pounds (26.46%) in six months, a severe weight loss of 23 pounds (16.36%) in three months, a severe weight loss of 14.2 pounds (12.07%) in three months, a severe weight loss of 16.3 pounds (11.6%) in one month, and a severe weight loss of 9.6 pounds (8.3%) in one month. The resident developed multiple Stage III pressure ulcers. The facility identified 22 residents with severe/significant weight loss. Findings: A facility policy, titled Weight loss risk assessment, documented: .It is the goal of Grace Living Centers to identify those residents who may be at risk for weight loss and provide intervention to help prevent weight loss .Procedure: .the information to complete the form will be obtained from the resident's medical record, interview the resident, resident's family and or staff .assess changes in appetite, digestive problems, and or swallowing problems .Is the resident on a restrictive diet: ex. 1600 ADA diet, 2gm NA Renal diet, or a mechanically altered diet (pureed, ground meat, etc.) .any wounds stage II or greater regardless of cause: pressure, stasis, diabetic .does the resident require any assistance with their meal: cueing, encouragement to eat, or does resident have to be fed .Upon completion of the assessment if the resident is considered to be: at risk residents (score of 15 or below) consult with the dietary manager for interventions such as nourishments, super cereal, or a referral to the registered dietician. The frequency of the nourishments may depend upon the level of risk, current weight .Nursing may weigh the resident at least bi-monthly or more frequently if ordered by the doctor .Develop and or update the care plan with the resident being at risk for weight loss and the interventions to prevent the loss . 1. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Facility weight records documented the resident weighed 140.6 pounds on 08/10/15 and on 09/01/15 documented the resident weighed 124.3 pounds. This was a severe weight loss of 16.3 pounds (11.6%) in one month. A nutritional care plan, dated 09/25/15, documented, Focus: requires a regular diet, pureed texture, Nectar thick liquids .Interventions: Provide .the consistency as ordered for my doctor .provide .the diet her doctor has ordered . The care plan did not address the recent weight loss and there were no new dietary recommendations for the resident to prevent further weight loss. A significant change assessment, dated 09/28/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with eating, had a weight of 121 pounds, had experienced a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, received a mechanically altered diet, did not receive a PEG tube feeding, was at high risk for pressure ulcers, and had one unhealed stage II pressure ulcer. An RD note, dated 09/28/15, documented, Wt on 9/22 was 119.6#, -10.8% since 9/14, -16.9% since 6/29, -14.2% since 6/8. Weights have varied past few weeks. Hospital from 9/9 to 9/14. Diet reg. pureed, NTL. Meal intake is frequently less than 50%. Receives multi-vit c min and calcium c vit D. Plan .appetite stimulant .house shake c meals . Facility weight records documented the resident weighed 119.2 pounds on 10/08/15. This was a weight loss of 5.1 pounds (4.1%) in one month, from the weight of 124.3 pounds on 09/01/15. A care plan for GERD, dated 10/17/15, documented, Focus: .[MEDICAL CONDITION]/6/15 wt on 9/22 was 119.6lbs, -10.8% since 9/14, -16.9% since 6/29, -14.2% since 6/8. Weight loss may be related to recent hospital stay from 9/9 to 9/14, meal intake us(sic) frequently <50% .Interventions: administer calcium-vit D as per physicians orders .administer Certa Plus as per physicians orders . The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendation for an appetite stimulant and house shakes with meals. An RD nutritional progress note, dated 10/26/15, documented, Wt 115.64#, -17.8% since 8/10, -17.0% since 6/8; .Unstageable PU to R foot, .5cm x 1cm x .1cm, unstageable PU to R foot, 1.1cm x .6cm x .1cm; Diet is reg diet, pureed, NTL; house shake tid; Multi-vit c min, Ca-VitD; [MEDICATION NAME] 15mg; usual meal intake 25-50% .Plan .Med pass 2.0 bid .VitC 500mg bid .[MEDICATION NAME] 1 pk bid . The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendations for Med pass 2.0 twice a day, the Vit C 500mg twice a day, or the [MEDICATION NAME] twice a day. A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . The October 2015 meal percentages did not document if the resident received her supplement for the month. There were 64 times the resident ate 50% or less of her meals. There was no documentation for the house supplements for the month of October 2015. Facility weight records documented the resident weighed 117.6 pounds on 11/17/15. This was a severe weight loss of 23 pounds (16.36%) in three months (08/10/15 through 11/17/15). A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 1 tablet by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . An RD nutritional progress note, dated 11/23/15, documented, Wt 117.6#, -7.8% since 11/3, -12.2% since 9/14, -15.6% since 6/8; stage 3 PU to R foot, 1.1cm x .6cm, stage 3 PU to L buttocks, 1.4cm x .5cm, stage 2 PU to upper back .4cm x .4cm, diet is reg, pureed, NTL; house shake tid; 2.0 cal 120cc bid; multi-vit c min; VitC 500mg bid; Ca-VitD; [MEDICATION NAME] 15mg; [MEDICATION NAME]; meal intake often <50% .Plan .change house shake order to mighty shake plus tid . A physician's orders [REDACTED]. The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendations to change the house shake to the mighty shake plus three times a day and did not address the med pass 2.0, the [MEDICATION NAME], and the [MEDICATION NAME]. The November 2015 meal percentages did not document if the resident received her supplement for the month. There were 58 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake supplements for the month of November 2015. Facility weight records documented the resident weighed 115.8 on 12/01/15. This was a weight loss of 8.5 pounds (6.84%) in three months (09/01/15 through 12/01/15). A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .Mighty shake plus three times a day related to abnormal weight loss; pressure ulcer of left buttock, stage 2; pressure ulcer of left buttock, stage 3 .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 500 mg by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . A terminal prognosis care plan, updated on 12/11/15, documented, Focus: .has a terminal prognosis .11/20/2015 .continues to have anticipated weight loss related to her terminal dx. No new intervention reqested (sic). Previous interventions to continue .11/25/2015 New order for mighty shake pluse (sic) 3 times a day .Interventions: Provide mighty shakes as ordered per physician . An RD nutritional progress note, dated 12/22/15, documented, Wt 108#, -8.2% since 11/17, -9.7% since 9/22, -25.5% since 6/22 .stage 3 PU to R foot, 2.7cm x 2.7cm x .2cm, stage 3 PU to L buttocks, .8cm x .7cm, stage 3 PU to [MEDICATION NAME] upper back, 1.1cm x (sic) diet is reg, pureed, ntl; mighty shake plus tid, 2.0 cal bid med pass, house supplement tid, VitC 500mg bid; [MEDICATION NAME] bid; multi-vit c min, Ca-VitD; [MEDICATION NAME] 15mg, avg meal intake 25-50% .Plan .Super cereal . [MEDICAL CONDITION] plan, updated 12/28/15, documented, Focus: 12/24/15 n/o for super cereal .Interventions: Administer super cereal as ordered by physician . The nutritional care plan, [MEDICAL CONDITION], and the terminal [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/29/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident required extensive assistance with eating, had a weight of 103 pounds, had experienced a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, received a mechanically altered diet, did not receive a PEG tube feeding, was at high risk for pressure ulcers, and had three unhealed and worsening stage III pressure ulcers. The December 2015 meal percentages did not document if the resident received her supplement for the month. There were 57 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake plus supplements for the month of December 2015. Facility weight records documented the resident weighed 106.2 pounds on 01/05/16. This was a severe weight loss of 9.6 pounds (8.29%) in one month (12/01/15 through 01/05/16) and a severe weight loss of 13 pounds (10.9%) in three months (10/01/15 through 01/05/16). A monthly physician's orders [REDACTED].Regular diet mechanical soft texture, nectar thick liquids consistency, One time a day resident to eat mechanical-soft meal PRN @ lunch or dinner only with supervision from CNA or nurse for pleasure meal .Regular diet pureed texture, nectar thick liquids consistency .Mighty shake plus three times a day related to abnormal weight loss; pressure ulcer of left buttock, stage 2; pressure ulcer of left buttock, stage 3 .Super cereal one time a day for weight loss .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 500 mg by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . [MEDICAL CONDITION] plan, updated 01/14/15, documented, Focus: 1/11/2016 New order for house supplement to change to Mighty shake .Interventions: .administer Mighty shake as ordered for weight loss . An RD nutritional progress note, dated 01/19/16, documented, Wt 99.26#, -8.1% since 12/15, -14.2% since 10/20, -29.4% since 8/10 .stage 3 pu to R foot, 2.5 cm x 1.8cm; stage 3 pu to midline [MEDICATION NAME] upper back, 1.8cm x 1.4cm x .3cm c necrotic tissue; diet is reg, pureed tex, ntl; and one meal q d mech soft, ntl for lunch or dinner only and while supervised by CNA or nurse; super cereal, mighty shake plus tid, [MEDICATION NAME] bid; multi-vit c min; VitC 500mg bid; Ca-VitD; 2.0 cal bid; [MEDICATION NAME] 15mg; inconsistent meal intake with avg ~25-50%, often refuses supplements; interventions in place to aid wound healing .Plan .Appetite stimulant . No new interventions were addressed to prevent further weight loss. The nutritional care plan, [MEDICAL CONDITION] plan, and the terminal [DIAGNOSES REDACTED]. The January 2016 meal percentages documented the resident drank 50% or less of her supplement 39 times. There were 57 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake plus supplements for the first ten days for the month of January 2016. There was no documentation for the super cereal for the month of January 2016. Facility weight records documented the resident weighed 103.4 pounds on 02/02/16. This was a severe weight loss of 14.2 pounds (12.07%) in three months (11/17/15 through 02/02/16) and a severe weight loss of 37.2 pounds (26.46%) in six months (08/10/15 through 02/02/16). The meal percentages for 02/01/16 through 02/10/16 documented the resident drank 50% or less of her mighty shake plus supplement 19 times. The super cereal was not documented for four of the ten days and the resident refused the super cereal on one day. There were 12 times the resident ate 50% or less of her meals. On 02/09/16 at 12:18 p.m., the resident was observed during the lunch meal. She was served pureed fish, cottage cheese, chocolate pudding, a mighty shake, and a soda. The resident was observed being fed by staff two bites of the pureed fish, 100% of the cottage cheese and soda, no chocolate pudding, and the staff never opened the mighty shake or offered it to the resident. The resident was not served the pureed french fries, pureed vegetables, or pureed hushpuppies. At 1:58 p.m., the meal percentage records documented the resident drank 76%-100% of the mighty shake plus with the lunch meal and ate 51%-75% of her meal. At 4:41 p.m., the resident was observed during the dinner meal. She was served cottage cheese, pureed vegetables, pureed bologna, pureed bread, and soda. The resident was observed to eat 100% of the cottage cheese but not eat anything else. A family member requested eggs for the resident and fed the resident 100% of the eggs. No mighty shake plus was served with the meal or offered to the resident. At 6:32 p.m., the meal percentage records documented the resident drank 51%-75% of her mighty shake plus with the dinner meal and ate 26%-50% of her meal. On 02/10/16 at 5:09 p.m., the resident was observed during the dinner meal. The resident was served pureed chili, pureed salad, chocolate pudding, nectar thick consistent juice, and a mighty shake plus. The resident was observed to eat 100% of her salad and several sips of juice, 0% of the chili, and 0% of the pudding. The mighty shake plus container was opened. The CNA did not offer the mighty shake plus or encourage the resident to drink the shake. At 6:40 p.m., the meal percentage records documented the resident refused the mighty shake with the dinner meal and ate76%-100% of her meal. On 02/11/16 at 2:00 p.m., the DON and the corporate LPN were asked to provide copies of the meal percentages and supplement percentages for the months of October 2015 through February 2016. At 2:20 p.m., the corporate LPN stated, There is no documentation for October, November, and December for house shakes and mighty shakes. At 4:58 p.m., the resident was observed during the dinner meal. The resident was served cottage cheese, jello, hot cereal, chocolate pudding, and soda. The resident was observed to eat 100% of the cottage cheese, jello, and soda. She ate 50% of hot cereal and 0% of the pudding. No mighty shake was served with the meal or offered to the resident. The resident's sister was sitting at the table assisting the resident with her meal. On 02/18/16 at 2:55 p.m., the dietary manager was asked why the resident did not receive the mighty shake plus as ordered. She stated, I don't know. She was asked who was responsible for monitoring that residents received the mighty shakes as ordered. She stated, Myself, unless I'm not here. She was asked if she had monitored the supplements were provided. She stated, No. I haven't been out on the line. The dietary manager was asked who documented the meal and supplement percentages. She stated, CNA's document the hall trays, dietary documents the big dining room. She was informed of the inaccurate documentation for the percentage of meals and supplements, she was asked how the dietician would know if her interventions were really working or not. She stated, She wouldn't know. The care plan coordinator was asked why the weight loss was not updated on the nutritional care plan. She stated, I don't know. She was asked if the weight loss should have been updated on the nutritional care plan. She stated, Yes. 2. Resident #1 had [DIAGNOSES REDACTED]. On 08/06/15, the resident's weight was documented as 192.4 pounds. A significant change assessment, dated 08/14/15, documented the resident had a BIMS score of 13. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident required limited assistance with eating, and had not experienced any weight loss. On 09/10/15, the resident's weight was documented as 186.5 pounds. A notice of significant weight change, dated 10/16/15, documented, .weight 173.7 Date: 10/6/2015 .weight loss/gain time span .1 month .current diet NAS, ground meat .possible factors contributing to wt. loss/gain .inconsistent intake .Date Physician contacted 10/16/2015 .new orders/interventions 2.0 cal 120cc's tid, weekly weight . On 10/30/15, the resident's weight was documented as 173.5 pounds. A monthly physician's orders [REDACTED].NAS (No Added Salt) diet ground meat texture .2.0 cal three times a day for weight loss give 120cc's . A quarterly assessment, dated 11/14/15, documented the resident had a BIMS score of nine. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident required limited assistance with eating, and had experienced a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. A nutritional progress note, dated 11/23/15, documented, .Wt 178.01#, -10.6% since 6/9 .diet is nas, gr meat tex; 2.0 cal 120cc tid .meal intake varies, usual intake 25-75% .notify Dr of wt loss, -10.6% since 6/9 .[MEDICATION NAME] 1 scoop c meals . A notice of significant weight change, dated 11/24/15, documented, .weight 178.01 Date: 11/20/2015 .weight loss/gain time span 3 months .current diet nas, gr meat tex; 2.0 cal 120cc tid .meal intake varies, usual intake 25-75% .possible factors contributing to wt. loss/gain .failure to thrive .Date Physician Contacted 11/24/2015 .no new orders . A weight loss care plan, dated 11/24/15, documented, Focus: .is at risk for .weight loss .required a regular mechanical soft diet, due to difficulty swallowing .new order for [MEDICATION NAME] with meals .Goals: .will be free of complications related to nutrition and kept comfortable through next review date .Interventions: .administer [MEDICATION NAME] per physicians orders .assist me with my meals as needed .monitor and record my intake daily .provide me with the diet my doctor has ordered . On 11/27/15, the resident's weight was documented as 180.1 pounds. This was a weight loss of 7.3% in three months. A monthly physician's orders [REDACTED].NAS (No Added Salt) diet ground meat texture .[MEDICATION NAME] with meals 1 scoop with meals .2.0 cal three times a day for weight loss give 120cc's . A notice of significant weight change, dated 12/18/15, documented, .weight 176.04 Date: 12/11/2015 .weight loss/gain time span 6 months .current diet NAS ground meat .possible factors contributing to wt. loss/gain depression, [MEDICAL CONDITION], inconsistent intake .Date Physician Contacted 12/18/2015 .new orders/interventions .mighty shakes tid with meals . A nutritional progress note, dated 12/21/15, documented, .Wt 173.1#, -11.1% since 6/22 .diet is NAS, gr meat, mighty shake c meals, [MEDICATION NAME] 1 scoop c meals, 2.0 cal tid .avg meal intake 50-75% .interventions in place r/t wt loss .notify Dr of wt loss, -11.1% since 6/22 . On 12/25/15, the resident's weight was documented as 179.4 pounds. A monthly physician's orders [REDACTED].NAS (No Added Salt) diet ground meat texture .thin liquids consistency .[MEDICATION NAME] with meals 1 scoop with meals .Mighty shake three times a day .2.0 cal three times a day for weight loss give 120cc's . A notice of significant weight change, dated 01/17/16, documented, .weight 170.3 Date: 1/15/16 .weight loss/gain time span 1 month .current diet Reg NAS with ground meat, mighty shakes tid, 2.0 cal, 120 ml with med pass .possible factors contributing to wt. loss/gain inconsistent intake .physician notified .new orders/interventions .double desserts with lunch and dinner . A weight loss care plan, updated 01/18/16, documented, . new order for double deserts (sic) with lunch and dinner .Goals: .will be free of complications related to nutrition and kept comfortable through next review date .Interventions: .administer [MEDICATION NAME] per physicians orders .assist me with my meals as needed .monitor and record my intake daily .provide me with the diet my doctor has ordered . On 01/29/16, the resident's weight was documented as 171.0 pounds. A monthly physician's orders [REDACTED].NAS (No Added Salt) diet regular with ground meat texture .thin liquids consistency, give double desserts with lunch and dinner .Mighty shake three times a day .Protein Supplement/Shake three times a day related to abnormal weight loss .120ml with meals .2.0 cal three times a day for weight loss give 120cc's . On 02/02/16, the resident's weight was documented as 167.0 pounds. The resident had experienced a severe weight loss of 13.2% in six months (August, 2015 through February, 2016). On 02/08/16 at 11:40 a.m., the resident was observed sitting in a geriatric chair in the dining room at the assisted feeding table. At 11:50 a.m., the resident's plate was served. No assistance was provided for the resident. At 12:27 p.m., a CNA sat down and began assisting the resident with her meal. At 12:45 p.m., the resident was observed being taken out of the dining room by the CNA. The resident ate approximately 75% of her stuffed potato, 50% of the beans, 50% of the bread, 100% of the applesauce, and 100% of the mighty shake. She did not receive double desserts with lunch, or the scoop of [MEDICATION NAME] powder with meals as ordered by her physician for weight loss. At 2:30 p.m., the meal/supplement sheet documented the resident had received double desserts with lunch. At 4:45 p.m., the resident was observed sitting in a geriatric chair in the dining room at the assisted feeding table. At 5:00 p.m., she received her plate of food. No mighty shake was provided for the resident, or the scoop of [MEDICATION NAME] powder with meals as ordered by her physician for weight loss, or the double desserts. At 5:00 p.m., the meal/supplement sheet documented the resident had received double desserts with dinner. At 6:57 p.m., the meal/supplement sheet documented the resident had received a mighty shake with dinner. On 02/09/16 at 11:15 a.m., the resident was observed sitting in a geriatric chair in the dining room at the assisted feeding table. A CNA was observed feeding the resident a grilled cheese sandwich. She ate approximately 25% of the grilled cheese sandwich. She drank 100% of her mighty shake. The resident did not receive double desserts, or any dessert with lunch, or the scoop of [MEDICATION NAME] powder with meals as ordered by her physician for weight loss. Various staff were observed pushing the dessert cart through the dining room during the noon meal. They were observed to ask random residents if they wanted dessert. They were not observed checking meal tickets for any special diet orders pertaining to the desserts being offered. At 12:00 p.m., the meal/supplement sheet documented the resident had received double desserts with lunch. The mighty shake meal/supplement sheet for breakfast and lunch were blank. At 4:30 p.m,, the resident was observed sitting in a geriatric chair in the dining room at the assisted feeding table. No staff were observed assisting the resident with her meal. The resident ate approximately 50% of the chopped bologna sandwich, a few bites of cucumber salad, and a few bites of macaroni salad. She did not receive a health shake, double servings of dessert or any dessert, or the scoop of [MEDICATION NAME] powder with meals as ordered by her physician for weight loss. Various staff were observed pushing the dessert cart through the dining room during the meal. They were observed to ask random residents if they wanted dessert. They were not observed checking meal tickets for any special diet orders pertaining to the desserts being offered. At 5:00 p.m., the meal/supplement sheet documented the resident had received double desserts with dinner. At 6:32 p.m., the meal/supplement sheet documented the resident had received a mighty shake with dinner. On 02/11/16 at 2:05 p.m., the dietary manager was asked if she had been using the [MEDICATION NAME] powder. She stated she had it but residents don't like it. She stated she had been using protein plus drink. She was asked when she stopped using the protein powder. She stated she had stopped using the protein powder approximately a month ago. She was asked if she had obtained an order to change from [MEDICATION NAME] powder to protein plus drink. She stated, No. On 02/16/16 at 2:40 p.m., a medical records staff person, who was observed passing desserts during several of the meals observed throughout the survey, was asked how she knew what types of desserts to offer residents with special diet orders. She stated the diet orders were transferred to the residents' meal tickets from the diet cards in the kitchen. She stated the meal tickets were to be placed on the table when the residents had been given their meals. She was asked if she looked at each meal ticket before giving a resident a dessert. She stated, Yes. She was informed of the observation of her passing desserts to random residents at different meals throughout the survey. She was informed the resident had been observed during meal times not being asked if she wanted a dessert and she had not received a double dessert. She was asked why the resident had not been given double desserts during the meals. She stated, I should have read the meal ticket. I must have missed it. She was asked if the resident had received her diet as ordered by her physician if she had not received double desserts with the lunch and dinner meals. She stated, No. On 02/18/16 at 2:33 p.m., the DON, ADON, corporate LPN, and MDS coordinator were asked who documented the supplements. The DON stated, That would be dietary. They were asked how they would know what specific diet/supplement orders the residents were to receive. The DON stated, It's on the care plan to be implemented. She was asked why supplements and specific diet orders were not being followed. She stated she did not know. She was asked if the specific diet orders and supplement orders should have been monitored. She stated, Yes. She was asked if the residents with care plan interventions for [MEDICATION NAME] powder with their meals, should have been getting the [MEDICATION NAME] powder with their meals. She stated, Yes. At 2:48 p.m., the dietary manager was asked who was responsible to ensure the dietary supplements were given out as ordered by the physician. She stated, Myself. I haven't been able to be out on the line for awhile. I have had to be in the back doing dishes. When I'm on the line the cooks go by their diet cards and supplement orders. She was asked who documented the meal percentages. She stated the dietary staff documented the meal percentages in the large and small dining rooms, and the CNAs documented the meal percentages for the hall trays. She was asked, if the meal percentages were documented with inaccurate amounts, how would the dietitian know that the nutritional interventions were working. She stated, She wouldn't know. 3. Resident #20 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 08/31/15, documented the resident had a BIMS score of 10. This score indicated the resident was moderately impaired with cognitive skills for daily decision making. The assessment also documented the resident required limited assistance with eating, and had a weight loss of 5% or more in the last month or loss of 10% or more in six months. On 09/18/15, the resident's weight was documented as 160.3 pounds. A physician's orders [REDACTED].Give 120cc's po A physician's orders [REDACTED]. A monthly physician's orders [REDACTED].regular diet mechanical soft texture .thin liquids consistency, offer finger foods .2.0 cal three times a day related to loss of weight give 120 cc's po .mighty shake plus with meals . The supplement documentation, dated October 2015, documented the resident had not been offered any supplements for the month. On 10/15/15, the resident's weight was documented as 162.6 pounds. A nutritional progress note, dated 10/26/15, documented, .Wt 162.56#, -15.7% since 4/22 .Diet is reg, mech soft .finger foods, Mighty shake plus c meals; 2.0 cal tid .usual meal intake 50-100%; current wt stable, expect current meal intake plus supplements to meet needs .notify Dr of wt loss, -15.7% since 4/22 . A monthly physician's orders [REDACTED].regular diet mechanical soft texture .thin liquids consistency, offer finger foods .2.0 cal three times a day related to loss of weight give 120 cc's po .mighty shake plus with meals . The supplement documentation, dated November 2015, documented the resident had not been offered any supplements for the month. There were no nutritional progress notes for November 2015. On 11/03/15, the resident's weight was documented as 165.2 pounds. A monthly physician's orders [REDACTED].regular diet mechanical soft texture .thin liquids consistency, offer finger foods .2.0 cal three times a day related to loss of weight give 120 cc's po .mighty shake plus with meals . The supplement documentation, dated December 2015, documented the resident had not been offered any supplements for the month. A significan

Based on record review, observation, and interview, it was determined the facility failed to provide interventions to aid in the prevention of pressure ulcers, to promote the healing of pressure ulcers, and to prevent the worsening of pressure ulcers for two (#13 and #14) of four sampled residents with new and/or worsening pressure ulcers. The facility failed to provide nutritional supplements to residents with pressure ulcers, provide pressure relieving devices, float heels, reposition the resident to redistribute pressure at least every two hours, update the care plan for pressure ulcers as needed, apply coverings or cushioning devices, and failed to provide monitoring to ensure care and nutritional supplements were provided. Resident #13 developed multiple stage III pressure ulcers and developed a wound infection in one stage III pressure ulcer. The facility identified five residents with pressure ulcers. Findings: Skin integrity/wound care guidelines, documented, Purpose: .to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and developing interventions .Guidelines for pressure ulcers .Avoid all pressure over pressure ulcer as much as possible. If unable to position off pressure ulcer, a pressure reduction/pressure relief surface will be required .major position changes at least every two (2) hours while in bed. A 30 (degree) side lying position as recommended .position off affected area . weight shifts (reposition according to care plan) . 1. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 06/09/15, documented the resident had no pressure ulcers. Facility weight records documented the resident weighed 140.6 pounds on 08/10/15 and on 09/01/15 documented the resident weighed 124.3 pounds. This was a severe weight loss of 16.3 pounds (11.6%) in one month. A nutritional care plan, dated 09/25/15, documented, Focus: requires a regular diet, pureed texture, Nectar thick liquids .Interventions: Provide .the consistency as ordered for my doctor .provide .the diet her doctor has ordered . The care plan did not address the recent weight loss and there were no new dietary recommendations for the resident to prevent further weight loss. A significant change assessment, dated 09/28/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent on staff for assistance with transfers, locomotion on the unit, dressing, and toilet use; required extensive assistance with bed mobility and eating. The assessment documented the resident had a weight of 121 pounds, had experienced a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, received a mechanically altered diet, did not receive a PEG tube feeding, was at high risk for pressure ulcers, and had one unhealed stage II pressure ulcer. An RD note, dated 09/28/15, documented, Wt on 9/22 was 119.6#, -10.8% since 9/14, -16.9% since 6/29, -14.2% since 6/8. Weights have varied past few weeks. Hospital from 9/9 to 9/14. Diet reg. pureed, NTL. Meal intake is frequently less than 50%. Receives multi-vit c min and calcium c vit D. Plan .appetite stimulant .house shake c meals . A wound care specialist evaluation, dated 10/01/15, documented, .wound of the right foot .duration: > 1 days .wound size (LxWxD): 0.5 x 1 x not measurable cm .Granulation tissue: 100% .Blister: Blood filled .Assessment & Plan: wound of the right foot - initial evaluation .continue: skin prep - twice daily . A physician's orders [REDACTED]. Facility weight records documented the resident weighed 119.2 pounds on 10/08/15. This was a weight loss of 5.1 pounds (4.1%) in one month, from the weight of 124.3 pounds on 09/01/15. A wound care specialist evaluation, dated 10/15/15, documented, .Wound of the right foot .Duration >14 days .wound size (LxWxD): 1.1 x 0.6 x not measurable cm .thick adherent devitalized necrotic tissue: 100% .Blister: blood filled .Wound progress: Deteriorated .Findings that indicate deterioration: Generalized decline of patient .Assessment & Plan: Wound of the right foot - Deteriorated due to generalized decline of patient: change dressing -procedure: Surgical excisional debridement of subcutaneous tissue .Discontinue: skin prep- twice daily .Continue: Hydrogel - once daily, dry protective dressing - once daily . A care plan for GERD, dated 10/17/15, documented, Focus: .[MEDICAL CONDITION]/6/15 wt on 9/22 was 119.6lbs, -10.8% since 9/14, -16.9% since 6/29, -14.2% since 6/8. Weight loss may be related to recent hospital stay from 9/9 to 9/14, meal intake us(sic) frequently <50% .Interventions: administer calcium-vit D as per physicians orders .administer Certa Plus as per physicians orders . The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendation for an appetite stimulant and house shakes with meals. A care plan, dated 10/18/15, documented: Right foot wound (Resident) has a stage 3 to her Right foot . Goal To resolve without complications through next review date . There were no interventions for 10/18/15 listed. An RD nutritional progress note, dated 10/26/15, documented, Wt 115.64#, -17.8% since 8/10 .unstageable PU to R foot, .5cm x 1 cm x .1cm, unstageable PU to R foot, 1.1cm x .6cm x .1cm; Diet is reg diet, pureed, NTL; house shake tid; Multi-vit c min, Ca-VitD; [MEDICATION NAME] 15mg; usual intake 25-50% .Plan .Vit C 500mg bid .[MEDICATION NAME] 1 pk bid . An RD nutritional progress note, dated 10/26/15, documented, Wt 115.64#, -17.8% since 8/10, -17.0% since 6/8; .Unstageable PU to R foot, .5cm x 1cm x .1cm, unstageable PU to R foot, 1.1cm x .6cm x .1cm; Diet is reg diet, pureed, NTL; house shake tid; Multi-vit c min, Ca-VitD; [MEDICATION NAME] 15mg; usual meal intake 25-50% .Plan .Med pass 2.0 bid .VitC 500mg bid .[MEDICATION NAME] 1 pk bid . The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendations for Med pass 2.0 twice a day, the Vit C 500mg twice a day, or the [MEDICATION NAME] twice a day. A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . A physician's orders [REDACTED]. The October 2015 meal percentages did not document if the resident received her supplement for the month. There were 64 times the resident ate 50% or less of her meals. There was no documentation for the house supplements for the month of October 2015. A wound care specialist evaluation, dated 11/19/15, documented, .Wound of the right foot .duration: >48 days .wound size (L x W x D): 3 x 2.1 x 0.3 cm .Thick adherent devitalized necrotic tissue: 30% .Granulation tissue: 70% .Blister: Blood filled .Wound progress: Improved .Dressing: [MEDICATION NAME] Blue - Once daily, dry protective dressing - once daily .Stage 2 pressure wound of the left, midline thorcici upper back .etiology: pressure .MDS 3.0 stage: 2 .Duration: >9days .wound size ( L x W xD): 0.3 x 0.5 x not measurable cm .wound progress: No change .Dressing: skin prep - twice daily . Updates to the right foot wound care plan, dated 11/19/15, documented, .Goal To have decreased wound size with in the next review date .Interventions: consult with wound consultant as needed .refer to physician as needed .screen for pain and treat with pain medication as ordered as needed . The care plan did not address new interventions to promote wound healing or prevent further break down. A wound care plan, dated 11/19/15, documented, Focus: midline thorcic upper back wound, stage 3 .Goal: to have active wound healing with in the next review date .Interventions: consult with wound consultant as needed .refer to physician as needed .screen for pain and treat with pain medication as ordered as needed . The care plan did not address new interventions to promote wound healing or prevent further break down. A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 1 tablet by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . An RD nutritional progress note, dated 11/23/15, documented, Wt 117.6#, -7.8% since 11/3, -12.2% since 9/14, -15.6% since 6/8; stage 3 PU to R foot, 1.1cm x .6cm, stage 3 PU to L buttocks, 1.4cm x .5cm, stage 2 PU to upper back .4cm x .4cm, diet is reg, pureed, NTL; house shake tid; 2.0 cal 120cc bid; multi-vit c min; VitC 500mg bid; Ca-VitD; [MEDICATION NAME] 15mg; [MEDICATION NAME]; meal intake often <50% .Plan .change house shake order to mighty shake plus tid . A physician's orders [REDACTED].;Pressure ulcer of left buttock, Stage 2 .;Pressure ulcer of Left buttock, Stage 3 . The nutritional care plan and [MEDICAL CONDITION] plans were not updated to address the dietician's recommendations to change the house shake to the mighty shake plus three times a day and did not address the med pass 2.0, the [MEDICATION NAME], and the [MEDICATION NAME]. The November 2015 meal percentages did not document if the resident received her supplement for the month. There were 58 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake supplements for the month of November 2015. Facility weight records documented the resident weighed 115.8 on 12/01/15. This was a weight loss of 8.5 pounds (6.84%) in three months (09/01/15 through 12/01/15). A wound care specialist evaluation, dated 12/03/15, documented, .Wound of the right foot .duration >61 days .wound size (L x W x D): 2.7 x 2.8 x 0.2 cm .granulation tissue: 100% .Blister: Blood filled Epiboly present within the wound margins .wound progress: improved .Stage 3 pressure wound of the left, midline thorcici upper back .Duration: >22 days .wound size (L x W x D): 1.1 x 1 x not measurable cm .thick adherent devitalized necrotic tissue: 100% .wound progress: Deteriorated .Dressing: Silver hydrogel - twice daily . A monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .House supplement three times a day for weight loss 120 cc's .Mighty shake plus three times a day related to abnormal weight loss; pressure ulcer of left buttock, stage 2; pressure ulcer of left buttock, stage 3 .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 500 mg by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . A terminal prognosis care plan, updated on 12/11/15, documented, Focus: .has a terminal prognosis .11/20/2015 .continues to have anticipated weight loss related to her terminal dx. No new intervention reqested (sic). Previous interventions to continue .11/25/2015 New order for mighty shake pluse (sic) 3 times a day .Interventions: Provide mighty shakes as ordered per physician . An RD nutritional progress note, dated 12/22/15, documented, Wt 108#, -8.2% since 11/17, -9.7% since 9/22, -25.5% since 6/22 .stage 3 PU to R foot, 2.7cm x 2.7cm x .2cm, stage 3 PU to L buttocks, .8cm x .7cm, stage 3 PU to [MEDICATION NAME] upper back, 1.1cm x (sic) diet is reg, pureed, ntl; mighty shake plus tid, 2.0 cal bid med pass, house supplement tid, VitC 500mg bid; [MEDICATION NAME] bid; multi-vit c min, Ca-VitD; [MEDICATION NAME] 15mg, avg meal intake 25-50% .Plan .Super cereal . [MEDICAL CONDITION] plan, updated 12/28/15, documented, Focus: 12/24/15 n/o for super cereal .Interventions: Administer super cereal as ordered by physician . The nutritional care plan, [MEDICAL CONDITION], and the terminal [DIAGNOSES REDACTED]. A quarterly assessment, dated 12/29/15, documented the resident had a BIMS score of three. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent on staff for assistance with transfers, dressing, and toilet use; required extensive assistance with bed mobility and eating; had a weight of 103 pounds, had experienced a loss of 5% or more in the last month or loss of 10% or more in the last 6 months, received a mechanically altered diet, did not receive a PEG tube feeding, was at high risk for pressure ulcers, and had three unhealed and worsening stage III pressure ulcers. The December 2015 meal percentages did not document if the resident received her supplement for the month. There were 57 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake plus supplements for the month of December 2015. Facility weight records documented the resident weighed 106.2 pounds on 01/05/16. This was a severe weight loss of 9.6 pounds (8.29%) in one month (12/01/15 through 01/05/16) and a severe weight loss of 13 pounds (10.9%) in three months (10/01/15 through 01/05/16). A wound care specialist evaluation, dated 01/06/16, documented, .Wound of the right foot .duration: >94 days .wound size (L xW x D): 3 x 2 x not measurable cm .granulation tissue: 100% .wound progress: No change .Stage 3 pressure wound of the left, midline thorcici upper back .duration: >55 days .wound size (L x W x D): 1.8 x 1.4 x not measurable cm .thick adherent devitalized necrotic tissue: 80% .granulation tissue: 20% .wound progress: deteriorated .findings that indicate deterioration: infection .Other Diagnosis: [REDACTED].Treatment: Keflex 500mg po bid x 14 days Rifampn 300mg po bid x 14 days . A physician's orders [REDACTED]. Updates to the right foot wound care plan, dated 01/08/16, documented, .Interventions: consult wound doctor as needed .float heels .multivitamin with minerals daily .turn and reposition q 2 and PRN .Vitamin c 500mg daily . Updates to the care plan for the Midline [MEDICATION NAME] upper back wound, dated 01/08/16, documented, multivitamin with minerals daily .Vitamin C 500mg daily . Monthly physician's orders [REDACTED].Regular diet pureed texture, nectar thick liquids consistency .Mighty shake plus three times a day related to abnormal weight loss; pressure ulcer of left buttock, stage 2; pressure ulcer of left buttock, stage 3 .Super cereal one time a day for weight loss .2.0 cal supplement BID with med pass two times a day for supplement 120cc of 2.0 supplement to be given PO with med pass .weight weekly on tuesdays every day shift every Tue .[MEDICATION NAME] tablet give 500 mg by mouth two times a day for supplement .[MEDICATION NAME] tablet 15 mg ([MEDICATION NAME]) give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], recurrent, unspecified . [MEDICAL CONDITION] plan, updated 01/14/15, documented, Focus: 1/11/2016 New order for house supplement to change to Mighty shake .Interventions: .administer Mighty shake as ordered for weight loss . An RD nutritional progress note, dated 01/19/16, documented, Wt 99.26#, -8.1% since 12/15, -14.2% since 10/20, -29.4% since 8/10 .stage 3 pu to R foot, 2.5 cm x 1.8cm; stage 3 pu to midline [MEDICATION NAME] upper back, 1.8cm x 1.4cm x .3cm c necrotic tissue; diet is reg, pureed tex, ntl; super cereal, mighty shake plus tid, [MEDICATION NAME] bid; multi-vit c min; VitC 500mg bid; Ca-VitD; 2.0 cal bid; [MEDICATION NAME] 15mg; inconsistent meal intake with avg ~25-50%, often refuses supplements; interventions in place to aid wound healing .Plan .Appetite stimulant . No new interventions were addressed to prevent further weight loss. The nutritional care plan, [MEDICAL CONDITION] plan, and the terminal [DIAGNOSES REDACTED]. A wound care specialist evaluation, dated 01/20/16, documented, .Wound of the right foot .duration: >107 days .wound size (L x W x D): 1.8 x 2 x not measureable cm .yellow necrotic: 20% .granulation tissue: 80% .Blister: dry .wound progress: improved .Wound debrided via surgical excision and muscle removed along with necrotic tissue .Stage 3 pressure wound of the left, midline thorcici upper back .duration: >68 days .wound size (L x W x D): 2.3 x 2.5 x 0.1 cm .thick adherent divitalized necrotic tissue: 100% . wound progress: deteriorated .wound debrided via surgical excision and muscle removed along with necrotic tissue . Updates to the midline thorcic upper back wound care plan, dated 01/22/16, documented, .Interventions: cleanse with anacep, pat dry, apply/pack with acquacel (sic) and cover . The care plan had not been updated to address nutritional interventions or pressure relieving interventions while up in the broda chair and in the bed to prevent further breakdown and promote wound healing. The January 2016 meal percentages documented the resident drank 50% or less of her supplement 39 times. There were 57 times the resident ate 50% or less of her meals. There was no documentation for the mighty shake plus supplements for the first ten days for the month of January 2016. There was no documentation for the super cereal for the month of January 2016. Facility weight records documented the resident weighed 103.4 pounds on 02/02/16. This was a severe weight loss of 14.2 pounds (12.07%) in three months (11/17/15 through 02/02/16) and a severe weight loss of 37.2 pounds (26.46%) in six months (08/10/15 through 02/02/16). Updates to the right foot wound care plan, dated 02/08/16, documented, .Interventions: cleanse with anacep, pat dry, apply with acquacel (sic) and cover . The care plan had not been updated to address nutritional interventions to prevent further breakdown and promote wound healing. On 02/09/16 at 12:18 p.m., the resident was observed during the lunch meal. She was served pureed fish, cottage cheese, chocolate pudding, a mighty shake, and a soda. The resident was observed being fed by staff two bites of the pureed fish, 100% of the cottage cheese and soda, no chocolate pudding, and the staff never opened the mighty shake or offered it to the resident. The resident was not served the pureed french fries, pureed vegetables, or pureed hushpuppies. At 1:58 p.m., the meal percentage records documented the resident drank 76%-100% of the mighty shake plus with the lunch meal and ate 51%-75% of her meal. At 4:41 p.m., the resident was observed during the dinner meal. She was served cottage cheese, pureed vegetables, pureed bologna, pureed bread, and soda. The resident was observed to eat 100% of the cottage cheese but not eat anything else. A family member requested eggs for the resident and fed the resident 100% of the eggs. No mighty shake plus was served with the meal or offered to the resident. At 6:32 p.m., the meal percentage records documented the resident drank 51%-75% of her mighty shake plus with the dinner meal and ate 26%-50% of her meal. The meal percentages for 02/01/16 through 02/10/16 documented the resident drank 50% or less of her mighty shake plus supplement 19 times. The super cereal was not documented for four of the ten days and the resident refused the super cereal on one day. There were 12 times the resident ate 50% or less of her meals. On 02/10/16 at 8:51 a.m., the resident was observed lying on her left side in bed. No turn schedule was observed posted in her room. At 9:31 a.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 10:28 a.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 2:28 p.m., the resident was observed sitting in her broda chair in her room. No pressure relieving devices for her back were observed in her broda chair. At 3:11 p.m., the resident was observed in bed lying on her back. Her heels were not floated. At 4:06 p.m., the resident was observed in bed laying on her back. Her heels were not floated. At 4:53 p.m., the resident was observed in her broda chair being wheeled to the dining room. No pressure relieving devices for her back were observed in her broda chair. At 5:09 p.m., the resident was observed during the dinner meal. The resident was served pureed chili, pureed salad, chocolate pudding, nectar thick consistent juice, and a mighty shake plus. The resident was observed to eat 100% of her salad and several sips of juice, 0% of the chili, and 0% of the pudding. The mighty shake plus container was opened. The CNA did not offer the mighty shake plus or encourage the resident to drink the shake. At 6:40 p.m., the meal percentage records documented the resident refused the mighty shake with the dinner meal and ate76%-100% of her meal. On 02/11/16, at 8:46 a.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 10:42 a.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 11:42 a.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 1:31 p.m., staff were observed leaving the resident's room with a lift. The resident was observed in bed on her right side with her heels not floated. At 2:00 p.m., the DON and the corporate LPN were asked to provide copies of the meal percentages and supplement percentages for the months of October 2015 through February 2016. At 2:20 p.m., the corporate LPN stated, There is no documentation for October, November, and December for house shakes and mighty shakes. At 3:41 p.m., the resident was observed lying on her back in bed with her heels not floated. At 4:36 p.m., the resident was observed sitting in her broda chair in the lobby. No pressure relieving devices for her back were observed in her broda chair. At 4:58 p.m., the resident was observed during the dinner meal. The resident was served cottage cheese, jello, hot cereal, chocolate pudding, and soda. The resident was observed to eat 100% of the cottage cheese, jello, and soda. She ate 50% of hot cereal and 0% of the pudding. No mighty shake was served with the meal or offered to the resident. The resident's sister was sitting at the table assisting the resident with her meal. At 5:41 p.m., the resident was observed sitting in her broda chair in the dining room. No pressure relieving devices for her back were observed in her broda chair. Monthly physician's orders [REDACTED].Mighty Shake Plus three times day related to abnormal weight loss .Pressure ulcer of left buttock, stage 2 .pressure ulcer of left buttock, stage 3 . On 02/18/16 at 2:45 p.m., LPN #6 and the DON were informed of the resident's position not being changed every two hours as the care plan had documented. LPN #6 was asked why the resident was not repositioned every two hours. She stated, She should have been. She was informed of the resident's heels not being floated while in bed as the care plan had documented. She was asked if she knew why it was not done. She stated, No. She was asked if the heels should have been floated. She stated, Yes. LPN #6 was asked why turning and repositioning was not an intervention for the wound on her midline back. She stated, She had not been updated for skin at risk care plan. Turn and reposition is usually on the skin at risk. The DON was asked who monitored the turning and repositioning. She stated, No specific person. She was asked what system was in place for turning and repositioning. She stated, CNA's do that. She was asked if they had a turning schedule. She stated, No, just verbal report. At 2:55 p.m., the dietary manager was asked why the resident had not received the mighty shake plus as ordered. She stated, I don't know. She was asked who was responsible for monitoring that residents received the mighty shakes as ordered. She stated, Myself, unless I'm not here. She was asked if she had monitored the residents to ensure they received their mighty shakes. She stated, No. I haven't been out on the line. The dietary manager was asked who documented the meal and supplement percentages. She stated, CNA's document the hall trays, dietary documents the big dining room. She was informed of the inaccurate documentation for the percentage of meals and supplements, she was asked how the dietician would know if her interventions were really working or not. She stated, She wouldn't know. The care plan coordinator was asked why the weight loss was not updated on the nutritional care plan. She stated, I don't know. She was asked if the weight loss should have been updated on the nutritional care plan. She stated, Yes. 2. Resident #14 had [DIAGNOSES REDACTED]. A monthly physician's orders [REDACTED].place O2 cannula to back of head so tubing does not rest on ears. every shift .to prevent breakdown behind ears .Protein Powder TID with meals .TAO to top of both ears one time a day for pressure sores . There was no documentation the resident had received protein powder three times a day with meals for the month of September 2015. A monthly physician's orders [REDACTED].protein powder tid with meals .place O2 cannula to back of head so tubing does not rest on ears. every shift .to prevent breakdown behind ears .TAO to top of both ears one time a day for pressure sores . There was no documentation the resident had received protein powder three times a day with meals for the month of October 2015. A monthly physician's orders [REDACTED].protein powder tid with meals .place O2 cannula to back of head so tubing does not rest on ears. every shift .to prevent breakdown behind ears . There was no documentation the resident had received protein powder three times a day with meals for the month of November 2015. A quarterly assessment, dated 11/27/15, documented the resident had long and short term memory problems and was moderately impaired with cognitive skills for daily decision making. The assessment documented the resident had no pressure ulcers, and no pressure ulcers were present on the prior assessment. A monthly physician's orders [REDACTED].protein powder tid with meals .place O2 cannula to back of head so tubing does not rest on ears. every shift .to prevent breakdown behind ears . There was no documentation the resident had received protein powder three times a day with meals for the month of December 2015. A monthly physician's orders [REDACTED].protein powder tid with meals .place O2 cannula to back of head so tubing does not rest on ears. every shift .to prevent breakdown behind ears . There was no documentation the resident had received protein powder three times a day with meals for the month of January 2016. A telephone order, dated 01/19/16, documented, .padding to O2 lining at all times. every shift for pressure points .[MEDICATION NAME] ointment 500 unit/gm apply to right ear topically every shift for shear cleanse with NS, pat dry and apply . A pressure ulcer care plan, dated 01/25/16, documented, Focus: .has a stage II for the right ear .Goal: .will have wound healing through the review date .Interventions: .[MEDICATION NAME] q shift, cleanse with NS, pat dry, apply and cover with a 4X4 gauze .cannula ear covers to bilateral ears @ all times .monitor wound weekly . Wound nurse documentation, dated 01/25/16, documented, .location right ear .onset date 01/25/16 .developed in-house .0.8cm x 0.2cm x 0cm .stage 2 .current tx/order: [MEDICATION NAME], cleanse(sic) with NS, pat dry, apply .4x4 gauze in crease of ear .pink granulation tissue noted light drainage .cannula ear covers placed .surrounding skin is clear . A telephone order, dated 01/25/16 at 11:32 a.m., documented, .[MEDICATION NAME] ointment 500 unit/gm apply to right ear topically every shift related to pressure ulcer of other site, stage 2 .cleanse with NS, pat dry apply and place 4x4 gauze in crease of ear . A monthly physician's orders [REDACTED].protein supplement/shake three times a day for wound healing give 120ml .change O2 tubing, place padding by wrapping with [MEDICATION NAME] and covering in omnifix every day shift every Fri . A skin/wound note, dated 02/01/16, documented, .wound to the right ear 0.3cm x 0.2cm with slightly pink area noted around wound bed, no warmth light drainage noted, res encouraged to place 02 tubing to back of head and keep off of ear creases. padding placed on tubing if res is non compliant or forgets to place tubing back when self transfers are made . There was no documentation the resident received protein powder three times a day with his meals for 02/08/16 through 02/10/16. On 02/10/16 at 3:35 p.m., the resident was in his room, sitting in his recliner. No gauze was observed under the right or left ear cannula tubing. No covers were observed on the right or left cannula tubing. At 4:20 p.m., the resident was observed in his room, sitting in his recliner. No gauze was observed under the right or left ear cannula tubing. No covers were observed on the right or left cannula tubing. At 4:22 p.m., the DON was observed to enter the resident's room and walked to his roommate's bed. She came out of the room and asked a CMA, who was down the hall, if she knew what the resident wanted. The CMA stated she didn't know but staff had been in the room several times to assist him. The CMA and the DON returned to the resident's room for approximately five minutes. They left the room without replacing the gauze under the right ear cannula tubing or placing covers on the right and left cannula tubing. At 4:40 p.m., the resident was observed in his room, sitting in his recliner. No gauze was observed under the right or left ear cannula tubing. No covers were observed on the right or left cannula tubing. At 5:00 p.m., the resident was observed in his room, sitting in his recliner e

Based on observation, interview, and record review, it was determined the facility failed to assess, monitor, and intervene in a timely manner for one (#9) of eight sampled residents who had experienced falls. Resident #9 fell on [DATE]. The fall was not reported by staff to the charge nurse until the next day. There was no assessment, monitoring or interventions for this resident until the afternoon of the following day. The resident sustained [REDACTED]. The facility identified 84 residents who were at high risk for falls. Findings: A fall awareness program policy documented, .The fall risk assessment will be completed on all admissions, readmission, falls, and significant changes .develop care plan based on interventions used. Review quarterly and as needed .Assess resident for injuries, provide appropriate medical attention, and notify physician and family. Obtain orders for X-ray as indicated. Complete incident report .Complete additional fall risk assessment tool .assess current pain management and effectiveness .Consider factors regarding the fall .Develop care plan using appropriate interventions . Resident #9 had [DIAGNOSES REDACTED]. A significant change assessment, dated 12/16/15, documented the resident had a BIMS score of five. This score indicated the resident was severely impaired with cognitive skills for daily decision making. The assessment documented the resident was totally dependent with transfers, was frequently incontinent, and had not experienced any falls. A care plan, dated 01/04/16, documented, Focus: .high risk for falls r/t a hx of falls .Goal: .will be free of falls through the review date .Interventions: Anticipate and meet .needs .call light is in reach and encourage her to use it for assistance as needed .needs prompt response to all requests for assistance .Concave mattress to bed .Hoyer lift to be used at all times .keep frequently used items within reach .Keep pathways clear, dry, clutter free and well lit .appropriate non-skid footware (sic) . A fall care plan, updated 01/14/16, documented, Focus: Fall Non Injury .Goal: .will be free of falls through the review date .Interventions: Provide a wedge cushion and a safety mat next to her bed when in bed. An incident report, dated 01/31/16, documented, .This nurse was informed by aide that resident had feel (sic) out of bed last night, also heard while aide was doing care for resident, Resident stated fell out of bed .Immediate action taken: VS taken, neuro initiated, pain meds given .No Injuries Observed Post Incident. Level of Pain: (Blank) . A radiology report, dated 01/31/16 at 3:29 p.m., documented, .there is a nondisplaced [MEDICAL CONDITION] femur . A nurse's note, dated 01/31/16 at 4:07 p.m., documented, It was reported to this nurse that resident had a fall out of bed last night. VS taken resident assessed .Resident c/o pain in right knee there was some inflammation, when family notified of this asked about x-ray also .PA ordered one due to pain, during day a bruise to the right side of chin appeared will continue to monitor .X Ray results came back and PA .Stated due to results to send resident out to (hospital, name deleted) for further evaluation . An undated final state reported incident report, documented, .Incident Date 01/30/16 .Resident was observed laying on the floor in front of her bed. Focused assessment completed. Resident complained of pain in R knee and a bruise to R chin. No other injuries were noted .Resident sent to .Hospital .for further evaluation .Resident has safety/fall precautions in place .The facility completed an initial investigation by interviewing the resident .family .staff members .involved, and by completing a focused assessment on the resident .resident sent to ER .Upon completion of the investigation, the facility determined the resident rolled off the bed, landing on her fall mat. A fracture to her R distal femur and a small bruise to her R chin were noted. No other injuries were noted. Resident returned to the facility following surgery on her R femur. Pain orders in place. The facility has updated the resident's plan of care to include the appropriate safety/fall precautions. The facility has also educated .appropriate staff members of the safety/fall risks, transfer status and devices in place . An inservice by the ADON, dated 02/03/16, documented, .what a CNA should do when a resident falls . There were 14 staff signatures on the inservice. There was no documentation of what information was provided to the staff at the inservice. An inservice by the ADON, dated 02/03/16, documented, .Charting after a fall - Assessing/Neuros/IR . There were six staff nurses' signatures on the inservice. There was no documentation of what information was provided to the staff at the inservice. A fall risk assessment, dated 02/04/16, documented the resident had a fall risk score of 55. This score indicated the resident was at high risk for falls. On 02/16/16 at 2:00 p.m., the resident was observed in bed in her room. The fall mat was not beside the bed and the wedge cushion was not in use. The wedge cushion was in a chair and had not been placed under the resident. The mechanical lift had been left approximately one to two feet to the side of the resident's bed. The bed had not been lowered and remained approximately three feet up from the floor. At 2:40 p.m., the DON and corporate LPN#1 were asked about the falls and the fracture the resident sustained [REDACTED].>They were asked what had occurred when the resident fell on [DATE]. The DON stated, An aide told another aide and that's how I found out. She stated the aides had put the resident back to bed and not reported the fall to anyone when it occurred. She stated the air loss mattress may have been set too firm and the resident had fallen out of bed. She stated they did a learning circle inservice regarding reporting falls and what to do when a fall occurred. The DON was asked if the wedge cushion was in place when the fall occurred. She stated, As far as I know she did not have a wedge cushion in place on the bed. She was asked why it was not in place. She stated, Excellent question, I don't have an answer. The DON stated the resident was sent out to the hospital after she had experienced pain and it was determined she had a fracture. She stated the resident had surgery and was readmitted to the facility. She was asked if the resident was assessed for the cause of the fall or for pain the day after the fall when staff became aware she had fallen. She stated since the resident was admitted to the hospital after they discovered the fracture she did not have a fall assessment done until her return to the facility after surgery. She stated the only pain assessment completed would be on the e-mar when she was medicated for pain. The e-mar on 01/31/16 documented the resident had a follow up pain scale of zero and the medication was effective. There was no other documentation a pain assessment had been completed. The DON was asked why the resident was put back to bed by the aides and they did not report the fall to the nurse. She stated she did not find out until the next day. The DON and corporate LPN #1 were asked if an investigation was conducted regarding the resident's fall. The DON stated she interviewed the resident and staff, and they had concluded the air loss mattress was set too high and the resident had fallen out of bed. On 02/17/16 at 10:10 a.m., CNA #9 was asked if she was aware of what happened when the resident fell . She stated she was told the resident had fallen, the aides had assisted her back to bed, and it was not reported to a nurse until the next day. She stated they attended an inservice regarding reporting to a nurse if a resident fell and not moving the resident until assessed by the nurse. At 10:20 a.m., CNA #10 was asked if she was aware of what happened when the resident had fallen. She stated, I was told she was in the hospital because she fell and a charge nurse did an inservice to turn it in and not move patient until a nurse sees them. At 1:33 p.m., CNA #11 was asked if she was aware of what happened when the resident had fallen. She stated, Yes. I was told I do not pick them up. I get my nurse and she has to come do an assessment but I do not pick them up. At 2:55 p.m., LPN #7 was asked what had happened when the resident had fallen. She stated, It was reported to me that she had fell the previous night. She stated, I assessed her and she was having pain in leg, knee, and swelling on 01/31/16. She stated it occurred on a weekend and they got an X-ray and sent her out to the hospital. The LPN was asked how she was notified of the fall. She stated, I was not told in report she had fallen. It was passed on between aides and she was hurting too much to get up so we gave her her prn pain medicines. She was asked if any assessments had been done. She stated, I asked her if she was hurting and she told me her knee, leg. She was asked if there were any other assessments completed. She stated, No. She stated neuros and the fall risk assessment were completed. She stated there was no post fall assessment, that they no longer fill out the fall scene investigation because they no longer use those through Grace Living Center. She stated, and it was all hearsay so I wouldn't have been able to since it had already happened. The LPN stated, The resident went out and they fixed the fracture site and she had a lot of staples in it.

Based on record review and interview, it was determined the facility failed to ensure a resident did not develop pressure sores for one (#1) of five sampled residents reviewed for pressure sores or at risk for developing pressure sores. The facility failed to: a) consistently assess the resident's skin integrity. b) implement measures to prevent the development of pressure sores. c) notify the physician of changes in the resident's pressure sore. Resident #1 developed a stage IV pressure sore on the coccyx which did not improve resulting in excessive odorous drainage. The facility identified four residents currently living at the facility had pressure sores. Findings: The facility pressure ulcer prevention policy documented prevention interventions which included implementing a written turning schedule, changing the resident's position at least every 2 hours while in bed or in a chair, place pressure reduction devices on the bed, chair or wheelchair if indicated, and inspect the skin at least daily. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The admission assessment, dated 08/06/14, documented the resident had moderate cognitive impairment, required limited assistance of one staff for bed mobility and transfers, and used a wheelchair for mobility. The assessment documented the resident was at risk for development of pressure sores but did not currently have pressure sores. The assessment documented the resident had a surgical wound and a venous/arterial ulcer. The assessment documented the resident was on a turning/repositioning program but did not use pressure relieving devices for the bed or chair. The care plan, dated 08/15/14, documented the resident had a venous ulcer on the inner left ankle, was at risk for poor healing, and was in isolation for [MEDICAL CONDITION] in the wound. The care plan documented the resident was at risk for pressure ulcers related to bowel and bladder incontinence, needing assistance with mobility, and the use of a wheelchair. The care plan interventions included to check on the resident for comfort through out the day, float heels as ordered when the resident was in bed, monitor the condition of the skin and report findings, provide incontinent care every two hours and as needed, and provide pressure relieving devices if indicated. A nursing progress note, dated 08/23/14, documented the resident was admitted to the hospital for chest pain and returned on 08/24/14. A Medicare nursing evaluation, dated 08/24/14, documented the resident did not have a pressure sore and did not have pressure relieving devices for the bed or chair. The facility did not provide a complete skin assessment completed at the time the resident returned from the hospital. A nursing progress note, dated 08/26/14 at 11:45 a.m., documented, "pt (patient) refuses to get up for lunch, states his L (left) heel feels fine when he's in bed but hurts when he gets up..." The nursing progress notes prior to 08/26/14 did not document resident complaints of pain in the heel. The facility did not provide skin/wound assessments completed related to the resident being identified at high risk for developing pressure sores prior to 08/26/14. A facility decubitus/pressure ulcer report, dated 08/26/14, documented an unstageable pressure ulcer on the left heel that measured 5.0 cm (centimeters) x 3.0 cm with black necrotic tissue present. The wound specialist report, dated 08/26/14, documented an unstageable pressure sore to the left heel, of greater than one day duration, that was covered 100% by thick adherent black necrotic tissue. The pressure sore measured 2.5 cm x 2.9 cm. A nursing progress note, dated 08/26/14 at 12:21 p.m., documented the resident was seen by the wound care specialist for a "new injury" to the left heel. The note documented the physician and the resident's daughter were notified. Twenty-six Medicare nurse evaluation notes from 08/26/14 through 09/22/14 documented the resident did not have a pressure sore. The notes did not consistently document the use of pressure relieving devices for the bed and chair and turning and repositioning for the resident. The notes did not consistently document the resident's refusal of care. The facility decubitus/pressure ulcer report, dated 09/23/14, documented the pressure sore on the heel had resolved. The facility did not provide skin/wound assessments completed related to the resident being identified at high risk for developing pressure sores prior to 09/26/14. A nursing progress note, dated 09/26/14 at 2:27 a.m., documented the nurse was called to the resident's room to assess a spot on the resident's buttocks. The note documented a stage II pressure sore was identified. The note documented the pressure sore was cleaned and dressed. A facility decubitus/pressure ulcer report, dated 09/26/14, documented the resident had a stage II pressure sore on the right buttock which measured 3.0 cm x 1.5 cm with no drainage. The treatment record for September 2014 documented the resident's wound on the right buttock had been treated with hydrogel covered with a foam dressing on 09/26/14, 09/29/14, and 09/30/14. The treatment record was blank for 09/27/14 and 09/28/14. The facility could not provide the physician's orders [REDACTED]. Nine Medicare nurse evaluations from 09/26/14 through 10/06/14 (ending of skilled services) documented the resident did not have a pressure sore. The notes did not consistently document the use of pressure relieving devices for the bed and chair and turning and repositioning for the resident. The notes did not consistently document the resident's refusal of care. A care plan meeting report, dated 09/29/14, documented the resident's daughter had been present and the stage II pressure sore to the resident's coccyx had been discussed. A nursing progress note, dated 09/29/14 at 4:02 p.m., documented the resident's daughter had been informed the wound specialist would see the resident the next day. A wound specialist consult, dated 09/30/14, documented an unstageable pressure sore on the resident right upper buttock which measured 3.5 cm x 3.0 cm with light serous drainage, of greater than four days duration, that was covered 100% by thick adherent black necrotic tissue. The report documented the physician performed a surgical debridement of the area and the wound was then classified as a stage III. The care plan, updated 09/30/14, documented the resident had an unstageable pressure sore on the right upper buttock and could be at risk for worsening and infection related to refusal to allow staff to turn and reposition the resident. The care plan interventions included to assist with repositioning every two hours, explain importance of repositioning, encourage resident to rest in bed and avoid prolonged sitting in the wheelchair, provide with pressure relieving devices if indicated, record wound healing progress weekly, and redirect with refusals to turn and reposition. The physician's orders [REDACTED]. A nursing progress note, dated 10/03/14 at 11:59 a.m., documented the resident "insisted on staying up in the chair regardless of numerous attempts to assist pt (patient) to bed to alleviate pressure to coccyx, he states well you've told me and I understand you want me to lie down but Im (sic) telling you I dont (sic) want to..." The treatment record for October 2014 documented the Santyl treatment was blank on 10/05/14. A nursing progress note, dated 10/07/14 at 9:03 a.m., documented the wound care specialist had surgically debrided the pressure sore on the buttock and the wound was classified as a stage IV pressure sore. A facility decubitus/pressure ulcer report, dated 10/07/14, documented the resident had a stage IV pressure sore on the right buttock which measured 3.5 cm x 4.0 cm with moderate drainage (type of drainage not identified) and 100% necrosis. A wound specialist consult, dated 10/07/14, documented a stage IV pressure sore on the resident's right upper buttock which measured 3.5 cm x 4.0 cm with moderate serous drainage of greater than ten days duration that was covered 100% by thick adherent black necrotic tissue. The report documented the wound had deteriorated. The report documented the surrounding tissue was purple/maroon with the appearance of surrounding deep tissue injury. The report documented the physician ordered the treatment be changed to Santyl with calcium alginate covered with a foam dressing daily. A nursing progress note, dated 10/07/14 at 6:45 p.m., documented the resident had a notable change in cognition related to confusion and refusal of medications. Nursing progress notes from 10/07/14 through 10/30/14 intermittently documented the resident's refusal of medications and participation in the restorative program but did not consistently identify the resident's refusal for staff assistance with repositioning. A late entry nursing progress note, dated 10/08/14 at 9:09 a.m., documented the resident's daughter requested the current wound care specialist not see the resident any longer related to another wound care specialist had been contacted. A physician's orders [REDACTED]. The treatment record for October 2014 documented the treatment order was not changed until 10/11/14. The record was blank for 10/13/14 and 10/16/14. The facility did not provide a pressure sore assessment for 10/14/14. The facility decubitus/pressure ulcer report, dated 10/22/14, documented the resident had a stage IV pressure sore on the right buttock which measured 5.0 cm x 4.5 cm x 2.0 cm with no drainage and 100% necrotic tissue. A nursing progress note, dated 10/22/14 at 12:29 p.m., documented the nurse had contacted the resident's daughter with concerns related to the resident's pressure sore not improving. The note documented the daughter was planning to discharge the resident in a few days and was planning for the resident to be seen by a wound care physician after discharge. A nursing progress note, dated 10/25/14 at 5:57 p.m., documented the resident was confused and had a stage II pressure sore. The facility decubitus/pressure ulcer report, dated 10/28/14, documented the resident had a stage IV pressure sore on the right buttock which measured 5.8 cm x 6.4 cm x 1.7 cm with 2.3 cm tunneling with 100% necrotic tissue. The report did not document an odorous drainage was present. A nursing progress note, dated 10/29/14 at 5:57 p.m., documented the resident was confused and had a stage II pressure sore to the coccyx. A nursing progress note, dated 10/31/14 at 3:00 p.m., documented the resident was discharged from the facility to home with home health services. The note did not identify the resident's condition at the time of the discharge. The resident was not in the facility at the time of the investigation. On 11/17/18 at 3:04 p.m., a family interview was conducted regarding the development of the pressure sore on the resident's buttock. The family stated the resident had developed a reddened area on his bottom approximately 5 weeks before discharge from the facility. The family stated the facility called approximately 2 weeks before the resident's discharge and was informed the resident's pressure sore was getting worse. The family stated the resident could not move independently and was always in the wheelchair but was not repositioned. The family stated the resident had gone out of the facility for an appointment with a wound care specialist in another town on 10/30/14. The family stated the wound was very odorous at the time of the resident's appointment. The family stated another family member had reported the wound smelling "bad" while the resident was in the nursing home. The family stated the resident was discharged to home on 10/31/14 and was going to be evaluated for home health services after returning home. The family stated the home health nurse immediately felt it necessary to order a wound vac because of the excessive amount of malodorous drainage from the pressure sore on the resident's buttock. On 11/18/14 at 10:25 a.m., licensed practical nurse (LPN) #3 was asked when skin assessments were completed for the residents. The LPN stated skin checks, including a head to toe assessment, were completed every shift for each resident receiving skilled services, daily for diabetics, and weekly for diuretic evaluations. The LPN stated she thought the actual skin assessments were completed by the night shift weekly. On 11/18/14 at 10:30 a.m., certified nurse aide (CNA) #1 was interviewed regarding the resident's care. The CNA stated the resident could not independently change positions in the wheelchair and sometimes the resident refused to go to bed preferring to sit up in the wheelchair. The CNA stated the CNAs were supposed to report any skin problems or changes observed during incontinent care or showers to the charge nurse. The CNA stated the resident did not have a special mattress on his bed and did not have anything in his wheelchair. On 11/18/14 at 10:40 a.m., the director of nurses (DON) was interviewed regarding the resident's pressure sore. The DON stated the resident had developed a pressure sore on the heel because the resident kept his foot on the floor and the resident stated his shoe hurt his foot. The DON stated the resident's footwear was changed and heel pads were used. The DON stated the resident developed a "bad" pressure sore on the iliac crest (same as on buttock) which was debrided by the wound specialist on two different occasions. The DON was asked what had been done to prevent the development of the pressure sore. The DON replied the staff tried to keep the resident positioned off of the area but the resident frequently would not allow staff to reposition him. The DON was asked when skin assessments were completed. The DON stated assessments were completed weekly on those residents identified with a problem but routine skin assessments were not being done on residents identified at risk for developing a pressure sore. On 11/18/14 at 2:30 p.m., LPN #1 was interviewed regarding the pressure sore. The LPN stated she had been assigned to do wound assessments and treatments in September. The LPN was asked if the physician had been notified for a treatment order for the pressure sore on the resident's buttock. The LPN stated the physician had been notified and an order had been received but she could not find the order. The LPN stated she probably forgot to document the order but if it was in the computer there had to be an order. The LPN was asked if the physician was called when a pressure sore developed. The LPN stated usually the physician or nurse practitioner were notified at the time they came in to do their weekly visits. The LPN stated sometimes she "just wrote an order for [REDACTED]. On 11/18/14 at 3:15 p.m., the wound care specialist was interviewed regarding the development of the resident's pressure sore. The physician stated the primary care physician had ordered a consult when the resident was admitted to the facility with the arterial wound on his ankle and surgical wound on the leg. The physician stated the resident had developed a pressure sore on the heel which resolved and then developed a pressure sore on the buttock. The physician stated the resident had a low air loss mattress but was uncertain of the date of placement. The physician stated she was unsure about a cushion in the wheelchair. On 11/18/14 at 3:45 p.m., the primary care physician was interviewed regarding the development of the pressure sore on the resident's buttock. The physician stated he had been notified of the pressure sore but was uncertain of the exact time. The physician stated the resident had a low air loss mattress on his bed from admission but was uncertain when the chair cushion had been implemented. The physician stated he had not actually seen the pressure sore on the resident's sacral coccyx (same as one on right buttock). The physician stated the facility notified him regularly of changes in the residents' conditions. The physician stated he had not been notified of the family's dismissal of the wound physician.

Based on interview and record review, it was determined the facility failed to provide care and services to ensure a resident's highest level of well-being for one (#1) of four residents sampled for resident well-being. The facility failed to assess and monitor a resident after a medication error. A nurse's note documented the resident's blood pressure was 63 over 38, the resident complained of weakness, and a tingling sensation. The note documented the physician was notified and an order was received to transfer the resident to the hospital by ambulance. A hospital electrocardiogram documented the resident's heart rate was 67 and the rhythm was [MEDICAL CONDITION]. A hospital physician's note documented the resident's blood pressure was 77 over 45. The note documented an exacerbating factor for the [MEDICAL CONDITION] (low blood pressure) was the administration of the [MEDICATION NAME] 20 mg. The facility census was 97. Findings: The facility policy, titled New Medication orders, documented the nurse receiving a new order was responsible for the following information: the resident's name, the name of the medication, and the directions for administration. The facility policy, titled Medication Incident Report Procedure, documented the resident's clinical record would include the medication error, notification of the physician, the physician's subsequent orders, and the resident's response and condition. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital discharge record, dated 11/22/13, documented the resident's blood pressure was 110 over 56. A hospital prescription, dated 11/22/13, documented [MEDICATION NAME] 20 milligrams (mg) oral tablet one each day. The last name on the prescription was the same as resident #1. The first name and birth date were not the same as resident #1. The prescription was with the medical records received by the facility at the time the resident was admitted . A Medication Administration Record, [REDACTED]. A nurse's note, dated 11/23/13 at 10:45 a.m., documented the prescription for the [MEDICATION NAME] 20 mg was not for resident #1 and the resident had been administered the [MEDICATION NAME] 20 mg. The note documented the resident's family and the physician were notified. The note documented physician's orders [REDACTED]. The note documented the resident's blood pressure was 105 over 59. A medication error report, dated 11/23/13, documented the resident was administered [MEDICATION NAME] 20 mg at 9:00 a.m. The report documented the medication error was reported to the physician. The physician documentation on the report stated the medication error should have very little effect due to the length of time before the onset of the medication's action. A nurse's note, dated 11/23/13 at 5:47 p.m., documented the resident was seated on the side of the bed, complained of numbness and tingling in his feet, the family was at the bedside, the resident's speech was clear, he was able to answer questions appropriately, and the blood pressure was low. A nurse's note, dated 11/23/13 at 6:00 p.m., documented the resident's blood pressure was 63 over 38, the resident complained of weakness, and a tingling sensation. The note documented the physician was notified and an order was received to transfer the resident to the hospital by ambulance. A hospital electrocardiogram, dated 11/23/13 at 7:31 p.m., documented the resident's heart rate was 67 and the rhythm was [MEDICAL CONDITION]. A hospital physician's note, dated 11/23/13 at 7:51 p.m., documented the resident's blood pressure was 77 over 45. The note documented an exacerbating factor for the [MEDICAL CONDITION] (low blood pressure) was the administration of the [MEDICATION NAME] 20 mg. The note documented the risk factors for the [MEDICAL CONDITION] were a recent thoracotomy with ordered valve replacement, mitral valve repair, and single-vessel bypass. Laboratory results, dated 11/23/13 at 8:30 p.m., documented the resident's red blood cell count, the hemoglobin, the Hematocrit, the platelets, the blood urea [MEDICATION NAME], the Creatinine, the sodium, the chloride, the [MEDICATION NAME], and the calcium level were all below normal. A hospital progress note, dated 11/27/13, documented the resident was discharged with family. On 12/04/13 at 3:40 p.m., the physician who cared for the resident while the resident was in the facility was interviewed. The physician stated he was notified regarding the medication error. The physician stated the medication error (the [MEDICATION NAME] 20 mg) would not have caused the resident to decline. The physician stated it takes an extended time to build up a level of [MEDICATION NAME] to obtain the full effect of the medication. On 12/04/13 at 4:00 p.m., the assistant director of nursing was asked for the resident's documented hourly blood pressure measurements for 11/23/13 at 10:45 a.m. through 11/23/13 at 6:00 p.m. On 12/04/13 at 4:30 p.m., the ADON stated she had contacted the licensed practical nurse (LPN) who was on duty on 11/23/13. The ADON stated the LPN had assigned a certified nurse aide (CNA) to perform the hourly blood pressures and the CNA had not completed the blood pressure measurements. The ADON stated the LPN had not followed up to assure the blood pressure measurements had been completed. The ADON stated the ordered blood pressure measurements had not been completed. On 12/12/13 at 11:10 a.m., the facility administrator was interviewed regarding the blood pressure measurements which were not completed. The administrator stated the facility's personnel policy had been followed regarding the staff who did not complete the blood pressure measurements. The administrator stated the staff involved in the medication error and the blood pressure not monitored were suspended, counseled, and reported to the appropriate state boards.

Based on interview and record review, it was determine the facility failed to ensure a resident was not administered a wrong medication for one (#1) of four sampled residents. The facility failed to identify a medication prescription received from a hospital was not for the resident who was admitted to the facility. The facility census was 97. Findings: The facility policy, titled New Medication orders, documented the nurse receiving a new order was responsible for the following information: the resident's name, the name of the medication, and the directions for administration. The facility policy, titled Medication Incident Report Procedure, documented the resident's clinical record would include the medication error, notification of the physician, the physician's subsequent orders, and the resident's response and condition. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A hospital prescription, dated 11/22/13, documented [MEDICATION NAME] 20 milligrams (mg) oral tablet one each day. The last name on the prescription was the same as resident #1. The first name and birth date were not the same as resident #1. The prescription was with the medical records received by the facility at the time the resident was admitted . A Medication Administration Record, [REDACTED]. A nurse's note, dated 11/23/13 at 10:45 a.m., documented the prescription for the [MEDICATION NAME] 20 mg was not for resident #1 and the resident had been administered the [MEDICATION NAME] 20 mg. The note documented the resident's family and the physician were notified. The note documented physician's orders [REDACTED]. The note documented the resident's blood pressure was 105 over 59. A medication error report, dated 11/23/13, documented the resident was administered [MEDICATION NAME] 20 mg at 9:00 a.m. The report documented the medication error was reported to the physician. On 12/04/13 at 3:20 p.m., the director of nursing (DON) was asked for the facility medication error reports. The DON had one report on her desk. The report was for resident #1 and the administration of [MEDICATION NAME] 20 mg without a physician's orders [REDACTED]. The surveyor asked the DON why the resident received the [MEDICATION NAME] without a a physician's orders [REDACTED]. The prescription was for a person with the same last name, but a different first name and a different birth date. The DON stated the error was not discovered until after the resident had been administered one dose of the [MEDICATION NAME].

Based on observation, record review, and interview, it was determined the facility failed to ensure residents maintained acceptable body weight for three (#2, #3, and #4) of five sampled residents reviewed for weight loss. The facility failed to: a) accurately and consistently assess a resident's nutritional status as needed. b) identify a resident at nutritional risk and address risk factors for impaired nutritional status. c) identify, implement, monitor, and modify interventions consistent with the resident's assessed needs and current standards of practice to maintain acceptable parameters of nutritional status. d) notify the physician in evaluating and managing causes of the resident's nutritional risks and impaired nutritional status. e) identify and apply relevant approaches to maintain acceptable parameters of residents' nutritional status. f) accurately obtain weights and notify the physician of changes. g) have a policy for prevention and management of weight loss. h) seek guidance from the medical director when the attending physicians failed to respond to repeated recommendations made by the dietitian. Resident #2 had a severe weight loss of 30 pounds in four months. The resident developed a pressure sore after admission which deteriorated to a stage III within one month of admission. Resident #3 had a severe weight loss of 41.6 pounds in six months. The facility census and condition identified 17 residents had unplanned significant weight loss. Findings: The facility did not have a policy for prevention and management of unplanned weight loss. The facility policy for dietary supplements documented, if a resident consumes less than 50% of meal an alternate meal will be offered. If the resident does not consume the alternate meal a supplement will be offered based on lab results, weight loss and/or poor intake. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's orders, dated 05/23/13, documented a daily weight was to be obtained every day while the resident received skilled services or therapy. The admission comprehensive assessment, dated 05/30/13, documented the resident's cognition was moderately impaired for daily decision making and the resident had difficulty focusing her attention. The assessment documented the resident resisted care 1-3 days during the assessment period. The assessment documented the resident required extensive assistance with activities of daily living (ADLs). The assessment documented the resident was always incontinent of urine and frequently incontinent of bowels. The assessment documented the resident's height was 60 inches and weight was 137 pounds (lbs). The assessment documented the resident was at risk for development of pressure sores but did not have pressure sores at that time. The care area assessment summary documented the urinary incontinence, nutritional status, and pressure ulcer (risk) would be addressed in the care plan. The monthly weight record documented the resident was weighed on 05/23/13, 05/25/13, 05/26/13, and 05/30/13. The record did not document a weight for 05/24/13, 05/27/13, 05/28/13, 05/29/13, 05/31/13, and 06/01/13. The record documented the resident's weight was 138.24 lbs in the geri-chair on 05/30/13 and 173.4 lbs in the geri-chair on 06/02/13. The record did not document the resident had been re-weighed when the discrepancy was noted until the next day and the weight was 133.28 (06/03/13) in the geri-chair. The nutritional evaluation, dated 06/05/13, documented the resident was on a mechanical soft diet with ground meat and nectar thick liquids. The evaluation documented the resident was not receiving supplements. The evaluation documented the resident's kilocalorie needs were 1400 and the protein needs were 43 grams. The evaluation documented no dietary recommendations would be made at that time but the nutritional status of the resident would be monitored by the dietitian. The weight record documented on 06/06/13 at 7:14 a.m. the resident weighed 173.23 lbs in the geri-chair and at 12:47 p.m. the resident weighed 172.82 lbs in the geri-chair. The resident continued to weigh 171.62 to 173.22 lbs through 06/09/13. The record documented on 06/12/13 at 3:08 p.m. the resident's weight was 132.04 lbs in the wheelchair and on 06/13/13 at 5:27 p.m. the resident's weight was 129.14 lbs in the geri-chair. The record documented the resident weighed 145 lbs in the geri-chair on 06/18/13. The record documented the resident weighed 121.68 lbs in the geri-chair on 06/28/13 at 2:06 p.m. The record documented the resident had consistently lost weight greater than 5% in 30 days. The comprehensive care plan, dated 06/12/13, documented the resident required a mechanical soft diet with nectar thick liquids and was at risk for weight loss due to refusing meals, replacements, and supplements. The care plan did not identify additional nutritional risk factors. The interventions included to assist the resident with meals as needed, encourage the resident to take a meal replacement or supplement if 50% or less of the meal was consumed, monitor the resident's weight, provide the resident with the diet and fluid consistency ordered by the physician, and record and monitor meal percentages. The care plan did not include specific measures to prevent weight loss. The care plan was not updated with new interventions after the weight loss developed. A dietary note from the dietitian, dated 06/29/13, documented, "Resident reported to have stage II lt (left) butt and stage III in crease of buttocks. Rec (recommend) Multiplevit/min (multiple vitamin/minerals) one daily, Vit C 500 mg (milligrams) bid (twice daily), Zinc Sulfate 220 mg daily x 14 days and [MEDICATION NAME] 1 pkt (packet) bid x 14 days." A dietary note from the dietitian, dated 07/27/13, documented, "Wt. (weight) ??123.9# (pounds). Intake has been very inconsistent. Labs: 7/5/13-Alb ([MEDICATION NAME]) 3.3, HGBA1C (blood sugar monitoring test) 5.7H (high). Area on lt butt resolved. Stage III to midline coccyx reported to be stable. No response noted to previous rec for multivit/min, Vit C, Zinc or [MEDICATION NAME]. Will re-rec except will rec [MEDICATION NAME] Extra 1 carton bid instead of [MEDICATION NAME]. Also rec checking [MEDICATION NAME]." The monthly weight record documented the resident's weight was 128.56 lbs in the geri-chair on 07/30/13 at 5:15 p.m. The record documented the resident weighed 118.2 lbs in the geri-chair on 08/13/13. The record documented the resident weighed 130 lbs on 09/20/13. A physician's progress note, dated 08/25/13, documented the resident weighed 118 lbs. The note did not document new orders had been given related to the weight loss. A dietary note from the dietitian, dated 08/29/13, documented, "Wt. 118#, down 5.9#. Intake remains very inconsistent. Diet upgraded to regular with thin liquids on 8/27. This may help improve residents po (oral) intake. No new nutritionally significant labs available. Stage III wound to midline coccyx improving according to wound Dr. Still no response to previous rec for [MEDICATION NAME] Extra, Vit C, Zinc, multivi/min or [MEDICATION NAME]. Will f/u (follow-up) with DON (director of nurses)." A dietary note from the dietitian, dated 09/29/13, documented, "Wt. 130#? Wts last mo (month) varied from 118-123.6#. Intake appears fair to poor overall. [MEDICATION NAME] on 09/27/13 was 18 WNL (within normal limits). Continues with stage III wound to butt crease. No response yet noted to previous rec for [MEDICATION NAME] Extra, Multivit/min, Vit C or Zinc. Will f/u with DON." The monthly meal percentage sheet for September 2013 identified 58 meals which documented the resident had refused the meal or consumed less than 50% of the meal and a supplement was offered but refused by the resident. A telephone order, dated 10/01/13, documented an order for [REDACTED].o. bid, Zinc Sulfate 220 mg p.o. daily, and Multivitamin (with) minerals p.o. daily. The treatment administration record (TAR) for October 2013 documented the resident received the above orders beginning 10/02/13 (first recommended by the dietitian 06/29/13). The monthly meal percentage sheet for October 2013 documented the resident refused the meal or consumed less than 50% from 10/01/13 through 10/09/13 ten times. The report documented the resident was offered a supplement and refused ten times. On 10/08/13 at 12:10 p.m., the resident was observed in the dining room in the geri-chair. The resident was assisted with the meal by a certified nurse aide (CNA). The resident consumed approximately 40% of the meal. The resident was not offered a supplement before being removed from the dining room. The meal percentage sheet documented the resident had consumed 51-75 % of the meal and a supplement was not required. On 10/09/13 at 11:30 a.m., the resident was observed in the dining room in the geri-chair. The resident was assisted by a CNA. The resident consumed approximately 30% of the meal and was not offered a supplement prior to being removed to the lobby. The meal percentage sheet documented the resident had consumed 51-75 % of the meal and a supplement was not required. On 10/09/13 at 2:40 p.m., the director of nurses (DON) was asked how the dietitian's recommendations were communicated to the physician. The DON stated the recommendation was faxed to the physician and a response was usually received within 7-10 days. The DON was asked how she knew the physician had received the faxed recommendations. The DON stated she did not have any way of knowing for sure the physician had received the recommendations. The DON was interviewed about the dietitian's recommendations for Multivitamin/mineral daily, Vitamin C 500 mg BID, Zinc Sulfate 220 mg, and [MEDICATION NAME]. The DON stated the recommended vitamins and supplements had been missed and the resident had started receiving the vitamins recommended by the dietitian she thought in October. When asked why the repeated recommendations were not acknowledged until October the DON stated the physician did not respond to the recommendations. The DON was asked if the medical director had been contacted to assist with the physician's inattention to the dietary recommendations and the resident's severe weight loss. The DON stated she had not contacted the medical director. The DON stated it was not the usual practice to contact the medical director if another physician did not respond to dietary recommendations or other concerns. The DON stated the facility waited for the attending physician to respond to the recommendations. The DON was asked when replacement dietary supplements were given. The DON stated supplements were only given if the physician ordered them for the residents. On 10/09/13 at 3:10 p.m., the registered dietitian was interviewed regarding the dietary recommendations sent to the physician. The dietitian stated the physician's response to dietary recommendations should be addressed immediately. The dietitian stated it had been too long from the time the recommendations had been made until the physician responded and agreed with the recommendations. The dietitian stated she knew the physician did not have to agree with any recommendations but was not sure what could be done if the physician did not respond to the dietary recommendations. On 10/09/13 at 3:30 p.m., the certified dietary manager (CDM) was asked how dietary changes were communicated between the nursing and dietary departments. The CDM stated a communication form was given to the dietary department from the nursing department and also a flag would come up in the computer if changes were made. The CDM stated she would look to see if any communication had occurred between nursing and dietary to indicate changes had been made related to the resident's nutritional status. On 10/09/13 at 4:10 p.m., the CDM returned and stated she did not have any communication from the nursing department related to the resident's nutritional status. On 10/09/13 at 4:45 p.m., the assistant director of nurses (ADON) was asked who obtained the weights for the residents. The ADON stated the weights were obtained by whatever CNA was assigned to the hall. The ADON stated the weights were not obtained by a certain person at a certain time. The ADON was asked about her role in the dietary recommendations. The ADON stated she did not get the dietary recommendations. The ADON stated an inservice had been conducted at the first of September related to weighing the residents correctly. The ADON stated at that time the CNAs were shown the proper way to weigh the residents in the wheelchair and geri-chair. The ADON stated weight inconsistencies continued after the inservice. On 10/09/13 at 5:10 p.m., the maintenance man was asked about the log for the calibration of the scales. The maintenance man stated a log was not available because the scales had not been calibrated. On 10/10/13 at 9:50 a.m., CNA #3 weighed the resident in the presence of the surveyor. The resident's weight was 107.24 lbs (a loss of 30 lbs since admission). On 10/10/13 at 10:05 a.m., the administrator stated he was unable to locate a policy for the prevention and management of weight loss. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. The physician's note, dated 03/06/13, documented the resident was a new admit and resident's weight on 03/05/13 was 164.9 pounds. The admission assessment, dated 03/11/13, documented the resident was severely impaired for daily decision making and required assistance with activities of daily living (ADLs). The physician's note, dated 03/20/13, documented on 03/20/13 the resident's weight was 147.8 pounds. The care plan, dated 03/22/13, documented the resident had [MEDICAL CONDITION] and needed assistance with ADLs. The care plan documented the resident refused meals occasionally and the resident was considered overweight. The care plan documented the resident was at risk for continued meal refusals. Interventions included the resident's meal intake was to be monitored, the resident was to be redirected when meals were refused, and to provide the resident with house supplements as ordered and encourage the resident to drink the supplements. The consolidated orders dated March 2013 documented daily weights while the resident received skilled services. The consolidated orders dated April 2013 documented the resident was to receive a house supplement with meals. The care plan, updated 06/24/13, documented the resident had no weight change. The intervention was to monitor the resident's weight. The consolidated orders dated July 2013 documented the resident was to receive a house supplement with meals and three times a day between meals. The physician's note, dated 08/04/2013, documented the resident's weight was 129.9 pounds. The care plan, updated 09/24/13, documented the resident had significant weight loss since the last assessment. The care plan did not identify new interventions for the weight loss. On 10/10/13, the resident was weighed in the presence of the surveyor. The resident's weight was 130.08 pounds. On 10/08/13 at 11:30 a.m., the resident was taken to the dining room by staff. At 11:33 a.m., the resident wheeled herself out of the dining room. The resident was redirected by staff and returned to the dining room. The resident attempted to leave the dining room two more times before family arrived to assist the resident with the meal. On 10/09/13 at 12:15 p.m., the dietary manager (DM) was interviewed regarding house supplements. The DM stated that residents would receive supplements if they ate less than 50% of the meal. The DM stated that if the resident had an order for [REDACTED]. 3. Resident #4 was admitted to the facility on 03/22/06 with [DIAGNOSES REDACTED]. The comprehensive annual assessment, dated 11/08/12, documented the resident was severely impaired for daily decision making and required moderate to total assistance with eating and other ADLs. The assessment documented the resident weighed 143 pounds. The assessment documented the resident had an open lesion on her foot and received interventions to prevent pressure ulcers. The resident's care plan, dated 11/26/12, documented the resident had [MEDICAL CONDITION] reflux disease (GERD) with [MEDICAL CONDITION] spasms and the staff was to monitor the resident for pain, abdominal discomfort, coughing, or choking. The care plan did not identify possible weight loss as a problem, did not document interventions to prevent weight loss, and did not document how the staff was to monitor the weight or when to notify the physician. The resident's weight record documented the resident's weight was 149.2 pounds in November 2012 and 137.5 pounds in January 2013. The resident had lost 11.7 pounds in two months. The physician's progress note, dated 01/19/13, documented the resident's condition was stable. The notes showed no documentation regarding the resident's weight loss or reference to the RD's recommendations. The registered dietitian's (RD) progress notes, dated 01/31/13, documented the resident's appetite was fair to poor. The note documented the resident received multivitamins with minerals and calcium with vitamin D. The notes documented there was no pre-[MEDICATION NAME] test result to review as per RD recommendation. The physician's progress note, dated 02/16/13 documented the resident was doing well. The notes showed no documentation regarding the resident's weight loss, nutritional status, or dietary recommendations. The RD's progress note, dated 02/28/13, documented the resident had inconsistent meal intake. The note documented there was no pre-[MEDICATION NAME] test result as per the RD's recommendation. The nutritional evaluation, dated 03/27/13, documented the resident's appetite was inconsistent and the resident had chewing and swallowing problems. The evaluation documented the resident required 1574 calories per day, 62 grams of protein per day, and 1545 milliliters of fluid per day. The evaluation documented the resident had a new stage II pressure ulcer to the right buttocks. The RD recommended the resident receive vitamin C 500 milligrams (mg) twice daily, zinc 220 mg once daily for 14 days, and [MEDICATION NAME] one package twice daily for 14 days. The physician's orders for March 2013 and April 2013 were reviewed. The physician's orders did not document orders for vitamin C, zinc or [MEDICATION NAME]. The weight record, dated 04/06/13, documented the resident's weight was 127.3 pounds. The resident had lost 10.2 pounds in three months which reflected a 7.41% weight loss. A 7.5% weight loss in three months indicated a significant weight loss. The RD's progress note, dated 04/27/13, documented the resident's weight loss and the resident's skin ulceration. The RD recommended the resident receive a diabetic house supplement three times a day with meals and to obtain a serum pre-[MEDICATION NAME] level. The physician's progress note, dated 05/18/13, documented the resident had a runny nose and allergies [REDACTED]. The RD progress notes, dated 05/31/13, documented there was no response from the previous recommendations to the physician. In June 2013 the resident was admitted to the hospital and treated for [REDACTED]. The weight record, dated 06/09/13, documented the resident weighed 117.0 pounds. The RD's progress note, dated 06/29/13, documented the resident's meal intake continued to be inconsistent and there had been no physician response for the recommendations to check a pre-[MEDICATION NAME] level or begin a house supplement three times a day. The physician's progress note, dated 07/20/13, documented the resident was doing well. The notes documented the resident's weight was 117 pounds. The notes documented the plan was to continue present care and medications. The notes showed no documentation regarding the dietary recommendations for a diabetic house supplement or checking the resident's pre-[MEDICATION NAME] level to monitor nutritional status. The RD's progress note, dated 07/28/13, documented there was no physician response regarding the dietary recommendations documented in June 2013. The physician's orders for August 2013 documented an order for [REDACTED]. The orders documented the resident received a multivitamin with minerals and oyster calcium with vitamin D once daily. The weight record, date 08/04/13 documented the resident's weight was 128.2 pounds. The quarterly assessment, dated 08/11/13, documented the resident was severely impaired for daily decision making and required moderate to total assistance with eating and other ADLs. The assessment documented the resident weighed 128 pounds and had a stage II pressure ulcer. The care plan, dated 08/23/13, documented the resident'[MEDICAL CONDITIONS] spasms continued to be a problem. The care plan did not document the resident's weight loss or interventions to prevent weight loss. The RD's progress note, dated 08/29/13, documented the resident's meal intake was inconsistent. The notes documented there was no physician response regarding the dietary recommendations made by the RD in July 2013. The telephone order's dated 08/29/13, documented an order for [REDACTED]. The physician's orders for September 2013 documented an order for [REDACTED]. The orders documented the resident received a multivitamin with minerals and oyster calcium with vitamin D once daily. The physician's progress note, dated 09/08/13, documented the resident's blood glucose level was high and the plan was to increase the resident's insulin. The notes did not show documentation regarding the resident's weight loss. The notes showed no documentation regarding the dietary recommendations or plan for checking the resident's pre-[MEDICATION NAME] level to monitor nutritional status. The weight record, dated 09/20/13, documented the resident's weight was 132.0 pounds. A telephone order, dated 09/26/13, documented a pre-[MEDICATION NAME] level was to be drawn due to weight loss per dietitian's nutritional recommendation. The telephone order was unsigned by the physician. The meal intake records for June 2013 through October 2013 documented the resident ate 25 to 100% of her meals. The record documented the resident was offered a meal replacement supplement when the meal intake was less than 50%. The record documented the resident refused the house supplement on all but two occasions. The record did not provide documentation regarding the diabetic house supplement the resident was to receive three times a day with meals. On 10/08/13 at 12:20 p.m., the resident was seated in her wheelchair at the feeding assist table in the dining room. The resident received a pureed diet with thickened juice. The resident required feeding and ate approximately 60 percent of the meal. No meal replacement was offered. No diabetic house supplement was provided to the resident with the meal. On 10/09/13 at 2:45 p.m., the DON was interviewed regarding the process for dietary recommendations. The DON stated the dietitian would fill out a recommendation sheet, submit the recommendation to the DON, and the recommendation would be faxed to the physician. The DON stated the documentation should be made in the nurses notes. The DON stated the process usually took seven to ten days from the time the recommendation was received until the recommendation was implemented. The DON stated the resident's physician did not respond to the dietary recommendations from January 2013 through August 2013. The DON stated she would not notify the medical director when a resident's physician did not respond to dietary recommendations. The DON stated any issues regarding a resident would be discussed with the physician during the physician's routine visits. The DON was not aware when the resident had last seen the physician. On 10/09/13 at 3:00 p.m., the RD was interviewed regarding weight loss procedures. The RD stated residents who received tube feeding, had wounds, received skilled nursing services or had weight loss were reviewed monthly. The RD stated the dietary recommendations were monitored by checking the physician's orders monthly. The dietitian stated the resident's weight fluctuated and it was the weight management policy to offer the resident a meal replacement supplement when a resident did not eat greater than 50 percent of a meal. The RD was asked why she recommended the physician obtain a pre-[MEDICATION NAME] level for the resident. The RD stated the pre-[MEDICATION NAME] was necessary when a resident's weight fluctuated in order to determine true weight loss. The RD stated nine months was an excessive amount of time to pass before receiving an order or response from the physician for dietary recommendations. The RD was asked whose responsibility it was to ensure the residents received the dietary supplements which were ordered. The RD stated it was the responsibility of both the nursing and dietary departments. The RD stated a resident would be re-weighed if there was a significant difference between the resident's monthly weights. On 10/09/13 at 3:45 p.m., the dietary manager was interviewed regarding the residents' weights. The dietary manager stated the ADON would notify her when a resident had a weight loss issue and the weight program on the computer would flag a resident when there was a significant weight loss. The dietary manager stated there had not been a weight loss meeting in several months. On 10/09/13 at 4:45 p.m., the ADON was interviewed regarding the monthly weights. The ADON stated there were multiple inconsistencies regarding the residents' weights. The ADON stated there was an in-service completed for the nursing staff in September 2013. The in-service consisted of the procedure to zero the scale, center the resident on the scale, must remove excessive items, have the resident's feet off the ground, must subtract the weight of the geri-chair or wheelchair, and to compare weights from week to week or month to month. The staff was instructed to reweigh a resident when there was a significant change in weight. On 10/09/13 at 5:05 p.m., the maintenance manager was interviewed regarding the calibration of the scale. The manager stated there were no facility records for the scale calibrations. The maintenance manager stated he did not know how to calibrate the scale and he would need to acquire the calibration instructions from the manufacturer. On 10/10/13 at 10:05 a.m., the resident was weighed in the presence of the surveyor. The resident's weight was 128.24 lbs. On 10/11/13 at 8:30 a.m., the resident was in her wheelchair at the feeding assist table. The resident was served scrambled eggs, sausage and gravy, biscuits and gravy, and honey thick juice. The resident ate approximately 50 percent of the meal. A licensed practical nurse checked the resident's meal card. The resident was not offered a meal replacement supplement. The resident was not provided with the diabetic house supplement which was to be served to the resident with meals.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident's environment remained as free of accident hazards as possible. The facility failed to follow the its fall risk program for 1 (#7) of 3 sampled residents who were reviewed to have had falls. Resident #7 had a fall which resulted in a fracture of the skull with air trapped in the brain. The director of nursing (DON) identified 47 residents who had falls in the previous 3 months. Ninety-nine residents resided at the facility. Findings: The facility's fall risk program documented the following: "All residents with one or more falls in a month will be put on the Falls-Risk Program until the risk is decreased or eliminated. 1. All residents are assessed upon admission, every three months and on an as needed basis. 2. This assessment will be reviewed at the residents' care plan meetings and measures will be implemented to prevent or diminish the risk of future falls. 3. Residents' medications will be reviewed with the pharmacist with suggestions to the physician which may be offered as to the adjustments of medications when the side effects of the medication may predispose the resident to falls. 4. If a resident continues to have a series of falls, the procedures in the restraints policy will be followed. 5. Residents who have proven a series of falls, but restraints are inappropriate for use will be placed on the Falling Stars program. A star will be placed outside of the resident's room, on their chairs and geri-chairs to alert staff to look in on that resident to check for safety whenever they go past." The facility's restraints policy documented the following: "To protect the resident that is at risk for falls. . . .To prevent residents from injuring themselves or others. . . .If resident is found to have a series of falls, they will be assessed for need of safety restraining devices which include . . .Personal alarms - Attached to resident and bed, chair, or wheelchair to remind resident to use their call light or to alert staff." 1. Resident #7 had [DIAGNOSES REDACTED]. A significant change in status assessment, dated 01-04-11, documented the resident was cognitively moderately impaired, was not oriented to year or month, was independent with activities of daily living, and had falls. A fall risk assessment, dated 11-2010, documented the resident had a high risk for falls. The resident's care plan, dated 01-05-11, documented the resident had long and short term memory loss, had a history of [REDACTED]. The care plan documented to keep the call light in reach, monitor the resident's gait, keep the resident's room clutter free, remind the resident to take time when walking, make sure the resident's shoes fit properly, keep the resident clean and dry, and encourage the resident to attend exercise classes daily. The care plan documented the resident had falls on 01-31-11, 02-11-11, 02-27-11, 03-02-11, 03-17-11, and 03-19-11. The resident's fall care plan was last updated on 04-04-11 and stated, "No recent falls." The resident's clinical record had documentation of pharmacy drug regimen reviews with no recommendations for the months of 12-2010, 01-2011, and 02-2011. An incident report, dated 01-31-11, documented the resident was found on the floor of the shower room and was attempting to use the bathroom. The report documented the corrective measures were to ask the resident to use the bathroom in his room as the shower room floors were wet. This intervention was not documented on the resident's care plan. A fall risk assessment, dated 02-2011, documented the resident was a high risk for falls. An incident report, dated 02-11-11, documented the resident was observed sitting on the floor next to his bed. The report documented the resident stated he had stumbled and fell . The report documented the resident was encouraged to use his cane and the resident stated he did not need a cane. This intervention was not documented on the resident's care plan. An incident report, dated 02-27-11, documented the resident was observed sitting on the floor of his room in a puddle of urine. The report documented the resident was encouraged to call staff to empty his urinal after he used the urinal. This intervention was not documented on the resident's care plan. The resident's current physician's orders [REDACTED]. Lanoxin 0.25 mg one tab daily for [DIAGNOSES REDACTED]and congestive heart failure, originally dated 02-20-09; Lasix 40 mg one tab daily for congestive heart failure, originally dated 02-20-09; Zestril 10 mg one tab daily for essential hypertension, originally dated 02-20-09; Coreg 6.25 mg one tab twice a day for coronary atherosclerosis native coronary artery, originally dated 04-02-09; Atarax 25 milligram (mg) one tablet (tab) twice a day for pruritic disorder, originally dated 02-02-10; Coumadin 4 mg one tab daily for atrial fibrillation, originally dated 04-29-10; Glipizide XR 10 mg one tab daily for diabetes mellitus, originally dated 10-20-10; and Metformin XR 500 one tab twice a day for diabetes mellitus, originally dated 11-17-10. Mosby's Nursing Drug Reference. Publisher - Mosby, Inc. an affiliate of Elsevier Inc., (Lanoxin) p 379, (Lasix) p 520,(Zestril) p 653, (Coreg) p 239, (Atarax) p 565, (Coumadin) p 1131, (Glipizide) p 537, and (Metformin) p 694 documented the following potential side effects for the resident's medications: a. Lanoxin - drowsiness and fatigue; b. Lasix - fatigue and weakness; c. Zestril - vertigo, fatigue, and dizziness; d. Coreg - dizziness, fatigue, weakness, vertigo, and postural hypertension; e. Atarax - dizziness, drowsiness, and fatigue; f. Coumadin - dizziness, fatigue, and lethargy; g. Glipizide - weakness and dizziness; and h. Metformin - weakness, dizziness, drowsiness, and vertigo. An incident report, dated 03-02-11, documented the resident fell in the dining room. The report documented the resident stated he got dizzy when he turned around. The report documented the resident was told to turn slower and not to make sudden moves. The report documented the resident was encouraged to allow a staff member to walk with him to and from the dining room. These interventions were not documented on the resident's care plan. A rehabilitation screening form, dated and signed 03-03-11, documented, "Referred to PT (physical therapy) s/p (status [REDACTED]." An entry, dated 03-24-11, documented, "Pt refused eval x 3, requesting 'speech therapy', will monitor progress = ST (speech therapy) services and attempt to eval as appropriate pt refused to attempt use of walker." An incident report, dated 03-17-11, documented the resident had fallen while out of the facility with a family member. The report documented that physical therapy would evaluate the resident. This intervention was not documented on the resident's care plan. An incident report, dated 03-19-11, documented the resident was found on his knees and was not sure if he fell or not. The report documented there was spilled aftershave on the floor. The report documented the resident was informed not to shave unless a staff member was in the room for standby. This intervention was not documented on the resident's care plan. An incident report, dated 04-16-11, documented the resident was observed sitting on the floor of his room. The report documented the resident was encouraged to ask for help when needed. This fall had not been addressed on the resident's care plan. An incident report, dated 04-22-11, documented the resident was observed sitting on the floor of his room. The report documented the resident was encouraged to use his cane. This intervention was not documented on the resident's care plan. This fall had not been addressed on the resident's care plan. An incident report, dated 04-26-11, documented the resident was observed sitting on the floor of his room, bleeding from his head, with water on the floor. The report documented the resident was sent to a local hospital emergency room . A nurse's note, dated 04-26-11 at 5:15 p.m., documented a call had been received from the hospital. The note documented the resident's CT (computerized tomography) Scan showed a fracture of the skull with air trapped in the brain. On 05-03-11 at 12:25 p.m., the resident's room was observed. No yellow star was observed outside the resident's room by the door. On 05-03-11 at 12:35 p.m., the director of nursing (DON) was asked if the pharmacist had reviewed the resident's medications after the resident had falls. The DON stated no. Then the assistant director of nursing (ADON) entered the room. The DON asked the ADON if the pharmacist had reviewed the resident's medications after the resident had falls. The ADON stated she would check. On 05-03-11 at 2:00 p.m., the resident's physician, medical doctor (MD) #1 was interviewed by phone. The physician was asked if he thought the resident's falls were avoidable to unavoidable. The physician stated he thought the resident's falls were unavoidable as the resident was non-compliant, had refused therapy, and had an unsteady gait. He stated he did not think the resident had any hypotension. The MD was asked if he thought the facility had done everything they could do to prevent the resident's falls. He stated yes. The physician stated he did not know what else the facility could have done as the resident refused to ask for assistance. On 05-03-11 at 2:45 p.m., the consultant pharmacist was interviewed by phone. The pharmacist was asked if he had reviewed the resident's medications specifically as related to falls from January 2011 to April 2011. He stated no. On 05-03-11 at 3:30 p.m., certified nurse aide (CNA) #3, when asked, stated he had worked at the facility 6-7 months as a CNA. The CNA, when asked, stated the resident was a fall risk. The CNA was asked what was the falling star program. He stated that meant that the resident had a star on their room door. He was asked what the star meant. He stated he guessed the star meant that the resident was continent, could get up, and walk. On 05-03-11 at 4:00 p.m., CNA #4, when asked, stated she had worked at the facility since 10-2010. The CNA was asked what was the falling star program. She had no response. The CNA was asked what the yellow stars on the residents' room doors meant. She stated, "I don't know." On 05-03-11 at 4:10 p.m., the DON was asked what steps the facility had put in place after the resident had falls to prevent him from falling again. The DON stated the facility had attempted to pinpoint the cause of the resident's falls. She stated they could not find a cause. She stated the resident was encouraged to use a cane and walker and he could never use them. She stated he refused to use a wheelchair. She stated a physical therapy consultant was attempted and the resident refused therapy. She stated speech therapy had worked with the resident and could not find a cognitive reason for the resident refusing. She stated the resident did not feel like he needed a cane or walker. The DON was asked if the resident was on the fall risk program. The DON stated he was on fall risk precautions. The DON was asked what did fall risk precautions mean. She stated the resident was checked every two hours, offered assistance, assisted to bathroom, and encouraged to call for assistance. The DON was asked again if the resident was put on the fall risk program. The DON stated the resident was put on the fall risk "just by the care plan." The DON was asked again if the resident had been put on the fall risk program. The DON stated she would have to check with licensed practical nurse (LPN) #2 to see if a star had been put up for the resident. The DON was asked if the resident should have been put on the fall risk program. She stated, "He should have been." The DON was asked if the procedures in the facility's restraint policy were followed for the resident. She stated, "We never got past him using a cane." The DON was asked if a personal alarm had been attempted on the resident. She stated the resident would not be the kind to leave it on as he ambulated. The DON was asked if the resident had been placed on the falling star program. She stated she would have to check. The DON was asked how staff was made aware of the facility's falling star program. She stated LPN #2 went over the information during staff orientation. The DON was asked if the resident's risk for falls was on the activities of daily living sheets. She reviewed the resident's clinical record and stated no for the 03-2011. On 05-03-11 at 4:53 p.m., LPN #2 was asked for documentation of orientation related to the falling star program for CNAs #3 and #4. She stated she did not know if the falling star program was documented on the employees' orientation forms. The LPN returned with the employees' orientation forms. The falling star program was not documented on the forms. The LPN stated the resident had not been placed on the facility's falling star program. On 05-03-11 at 5:30 p.m., the resident's fall care plan was reviewed with the DON. The DON was asked if the interventions developed after the resident's falls should have been on the care plan. The DON stated yes. The DON was shown the lack of updates to the care plan after the resident's fall on 04-2011. She stated she would check with the assistant director of nursing. The DON did not return to the surveyor with any information related to the resident's care plan prior to exit.