Every finding on record at Community Hospital Onaga Ltcu

The facility identified a census of 23 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to fully complete the Comprehensive Minimum Data Set (MDS) for Resident (R) 3 when staff did not complete an analysis for triggered Care Area Assessments (CAA). This placed this resident at risk for an inaccurate plan of care and unidentified care needs. Findings included: - R3's Electronic Medical Record (EMR) documented diagnoses of mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), dementia (a progressive mental disorder characterized by failing memory and confusion), weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hemiplegia (paralysis of one side of the body), hypertension (HTN-elevated blood pressure), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). R3's Quarterly MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of zero which indicated a severely impaired cognition. R3 had impairment on both sides of his upper and lower extremities. R3 required the use of a Broda chair (specialized wheelchair with the ability to tilt and recline) for mobility. R3 was dependent on staff for all functional abilities. R3 was always incontinent of bowel and bladder. R3 required enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). R3's Care Area Assessment (CAA) dated 01/20/24 triggered for cognitive loss/dementia, communication, urinary incontinence, psychotropic (alerts mood or thought) drug use, visual function, dehydration/fluid maintenance, feeding tube (tube for introducing high-calorie fluids into the stomach), pressure ulcer, pain, nutritional status, and dental care. All triggered CAA lacked completion with analysis of findings. R3's Care Plan revised on 04/17/23 documented that staff would provide care to R3 to maintain appearance, hygiene, and skin integrity. R3's plan of care documented R3 received meals via percutaneous endoscope gastrostomy (PEG-a tube inserted through the wall of the abdomen directly into the stomach). R3's plan of care documented she was incontinent of bowel and bladder. On 10/30/24 at 09:34 AM R3 was reclined in her Broda chair, with her eyes shut. On 10/31/24 at 12:08 PM Administrative Nurse D stated she was unaware the CAA needed to be filled out. She stated she was told they were optional and only needed to be filled out if she needed to use them for the care plan. She stated she had been doing the MDS for three years and had just received training. She stated she had learned each triggered CAA needed resident analysis documentation. The updated facility Comprehensive Assessment policy reviewed 02/2019 documented the facility would conduct initial and periodic comprehensive, accurate, standardized, reproducible assessments of each resident's function capacity. The assessment process would include direct observation and communication with the resident and responsible party and family, as well as communication with licensed and non-licensed direct care staff members from all departments on all shifts. The resident assessment instrument (RAI) system developed by the federal government would be used as the basis for the assessment, care planning, and documentation system. The facility failed to ensure staff fully completed the Comprehensive MDS for R3 when staff did not complete the triggered CAA. This placed R3 at risk for an inaccurate plan of care and unidentified care needs.

The facility identified a census of 23 residents. The sample included 12 residents with six residents reviewed for falls and accidents. Based on observation, record review, and interviews, the facility failed to consistently implement interventions to prevent falls for Resident (R)19 who had multiple falls. This deficient practice placed R19 at risk for further falls and related injuries. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented restlessness and agitation, frontotemporal neurocognitive disorder (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost), and pain. The Quarterly Minimum Data Set (MDS) for R19 dated 09/07/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R19 had two falls since admission with no evidence of injury and two falls with injury, skin tears, abrasions, and bruising. The MDS documented that R19 was dependent on staff for bathing, toileting, and dressing. R19's Falls Care Area assessment dated [DATE] documented that staff were to monitor R19's wandering and assist him with walking. Staff were to walk alongside him in times of wandering. Staff were to accompany R19 to all areas and ensure his needs were met. Nursing was to implement fall precautions and follow facility fall protocol. R19's Care Plan dated 03/14/24 documented R19 was a fall risk related to his wandering and stated a goal that he would not sustain serious injury throughout his stay. Staff were to ensure R19's call light was always near him, while he was in his room. Staff was to provide a low-stimulation environment, follow facility fall protocol, and keep the tray table away from R19's path when staff were not supervising. R19's plan of care dated 07/15/24 documented R19's family and hospice provider agreed to stop doing neurological assessments and vital sign checks after falls, related to R19's increased agitations. R19's plan of care dated 09/09/24 documented that staff were to be one-to-one with R19 when he was walking. Staff were to ensure a fall-hazard-free environment, adequate lighting, and proper footwear. The plan directed to make sure there were no trip hazards, ensure the floor was clean and dry, and ensure R19's blankets were not wrapped tightly around his lower extremities while he was in bed. R19's EMR under Nursing Notes documented non-injury falls on 08/26/24, 09/02/24, 09/08/24, 09/14/24, 09/26, 10/15, and 10/18/24. R19's EMR under Nursing Note dated 9/02/24 documented that a nurse was assisting R19 in his room, and R19 was settled sitting back on his bed. The nurse left the room to complete a treatment across the hall, as they exited the treatment room, the resident was heard groaning. The nurse entered the room to find the resident lying on the floor with his head on the trash can. R19 had a blanket and shoes on, his call light was within reach. R19 did not have a visible injury. Staff lifted R19 and put him back on the bed. R19's clinical record lacked evidence an intervention was implemented in response to the 09/02/24 fall. R19's EMR under Nursing Note dated 9/05/24 documented that R19 was found on the floor. He was relaxed and appeared to have no signs of pain or distress. He was wearing blankets around his back and was resting his back against the wall and headboard. Staff used a Hoyer (total body mechanical lift) to lift R19 into the bed. R19 had been aggressive during position changes due to advanced dementia. R19 also demonstrated poor awareness. Due to R19's dementia, the resident was unable to communicate complex thoughts, though he showed his expressions well, and when he was frustrated, he became visibly agitated and aggressive to staff. R19's family requested orders not to attempt to obtain vital signs if the resident was agitated or aggressive. R19's clinical record lacked evidence an intervention was implemented in response to the 09/05/24 fall. R19's EMR under Nursing Note dated 9/14/24 documented that R19 was found on the floor. He was sitting on the floor in front of his chair, had his left arm bent behind him, his back leaning against the right front of the chair, with his left back against the chair. The resident did not show any signs of distress. The Certified Nurse Aide (CNA) suggested that he slid off the chair and stated R19 was sitting in the chair before his fall. Staff performed range of motion with no apparent signs of pain. Staff assisted R19 to a standing position and he did not show any signs of pain with weight bearing. R19's clinical record lacked evidence an intervention was implemented in response to the 09/12/24 fall. R19's EMR under Nursing Note dated 9/26/24 documented R19 was found lying on his left side in front of his recliner in his room. The CNA staff reported they had assisted R19 with incontinence care as he had a bowel movement. R19 was resistive during care, at some point, he got himself up from his bed and fell . An initial assessment showed no signs of major injury other than a 0.5-centimeter (cm) skin tear to the left elbow. R19 did not want to sit after his fall so he was assisted to sit out on the patio with staff and was taken for a short walk. R19's clinical record lacked evidence an intervention was implemented in response to the 09/26/24 fall. R19's EMR under Nursing Notes dated 10/15/24 documented that R19 had an unwitnessed fall in his room. He was sitting upright in front of the closet door. Staff assessed and noted there were no signs of injury. Staff obtained R19's vital signs, and all vital signs were within his normal baseline. The note documented staff spoke to the hospice nurse concerning the fall. R19's clinical record lacked evidence an intervention was implemented in response to the 10/15/24 fall. R19's EMR under Nursing Notes dated 10/18/24 documented the nurse was called to R19's room. The CNA staff reported that they heard R19 yelling and upon entering R19's room, he was on the floor. R19 lay on his left side, with his head angled towards the window and closet corner. His feet were in the direction of the door. Staff provided comfort and R19 was not yelling when the nurse entered his room. Staff assisted R19 to stand and he became agitated, which was his baseline. The note documented R19 was more agitated than usual, likely from generalized pain from the fall and the need for the nurse to approximate skin tears. R19 seemed to want to wander; he was assisted to his wheelchair and staff wheeled him around, which tended to provide R19 some comfort. R19's clinical record lacked evidence an intervention was implemented in response to the 10/18/24 fall. On 10/29/24 at 09:07 AM R19 sat in the chair in his room with a pillow behind him, covered with a blanket. On 10/30/24 at 09:42 AM R19 sat in the chair in his room. His breakfast tray sat on the TV stand in front of him. On 10/31/24 at 11:24 AM Licensed Nurse (LN) G stated an intervention was put in place anytime a resident had a fall. She stated if an intervention was not put in at the time of the fall, staff would add one after stand-up or after a team huddle. On 10/31/24 at 11:53 AM, CNA M stated fall interventions could be viewed on the resident's care plan. She stated the CNA and the nurses would have a team huddle after a resident fell and decide on an intervention as a team. On 10/31/24 at 12:08 PM Administrative Nurse D stated the nurse on duty should implement a fall intervention after a team huddle. She stated if the nurse was unsure what intervention should be implemented, the nurse should add to the care plan that they would call the director for ideas. On 10/31/24 at 12:11 PM Administrative Nurse A stated the facility had been working on interventions for R19's falls. Administrative Nurse A stated the facility had a performance improvement project (PIP) dated 09/09/24 started. Administrative Nurse A stated the facility would continue working with family and staff on fall interventions. The facility's Accident and Incident Documentation documented that when an elder experiences an incident or accident, the nurses caring for the elder would record the elder's response for at least 72 hours or until the elder's condition was stabilized. The elder's physician or designated physician would be informed of the incident or accident. The information provided to the physician would be recorded in the interdisciplinary notes. The facility failed to identify and implement interventions to prevent further falls for R19. This deficient practice placed R19 at risk for further falls and related injuries.

The facility identified a census of 23 residents. The sample included 12 residents with one resident reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R) 19. This deficient practice placed R19 at risk for impaired end-of-life care. Findings Included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of documented restlessness and agitation, frontotemporal neurocognitive disorder (a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost), and pain. The Quarterly Minimum Data Set (MDS) for R19 dated 09/07/24 recorded a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented R19 was dependent on staff for bathing, toileting, and dressing. The MDS documented that R19 received hospice services during the observation period. R19's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/13/24 documented the resident was on hospice, related to cognitive loss and dementia (a progressive mental disorder characterized by failing memory and confusion). The CAA documented that R19's plan of care would include ways to provide support and comfort to R19, decrease his agitation and anxiety, and provide comforting activities that the resident enjoys. R19 was unable to answer assessment questions appropriately. R19 becomes easily agitated and cannot follow prompts for answers related to advanced dementia. R19's Care Plan dated 03/12/24 documented R19 had a terminal prognosis related to dementia and was receiving hospice services. Staff were to administer medications for anxiety and comfort as ordered. Staff were to allow R19 and his family to share worries, concerns, and feelings. The facility would arrange time for spiritual and religious practice. Staff were to contact hospice and family upon observed changes. Staff was to encourage visitors and encourage R19 to interact with visitors and other residents as much as possible. Hospice was to provide bathing, oral care, peri-care, companionship, and family support. Staff was to observe R19 closely for signs of pain, administer pain medications as ordered, and notify the physician immediately if there is breakthrough pain. Staff were to see the hospice calendar in R19's binder at the nurse's station for the hospice visit schedule. Nursing was to contact hospice if R19 needed additional visits or supplies. The care plan lacked contact information for the hospice provider and lacked information regarding the frequency of visits, the supplies, equipment, and medications provided by the hospice. A review of the hospice-provided binder revealed that R19 was admitted to hospice services on 03/05/24. On 10/29/24 at 09:07 AM R19 sat in the chair in his room, with a pillow behind him, covered with a blanket. On 10/31/24 at 11:24 AM Licensed Nurse (LN) G stated there should be collaboration of care between the facility and hospice and said staff should be able to open the resident's care plan and know what the hospice provider provides for the resident, and what the facility provides for the resident. On 10/31/24 at 11:53 AM Certified Nursing Aide (CNA) M stated if she needed to know when the nurse or aide for a resident on hospice was going to be at the facility, she would find that information in the resident's hospice binder. She stated she was unsure what supplies the hospice provided, or what equipment. CNA M stated she would ask her charge nurse. On 10/31/24 at 12:08 PM Administrated Nurse D stated that administrative staff know what equipment each hospice resident has. She stated if the resident ran out of hospice supplies, the resident would just use the facility's supplies. Administrative Nurse D said she was unsure what medications should be part of the care plan. The facility's Hospice Services policy documents each resident will receive, and this facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility provides continuity of care to provide residents who are terminally ill with the opportunity to receive comprehensive, interdisciplinary care that recognizes their spiritual needs and to assist residents, family members, and friends to live as fully and completely as possible with meaning and dignity. Residents and family members and friends may be offered hospice care upon request of the resident and families and or guardians to meet care and services needs which is consistent with the expressed preferences of the resident's family members and or guardians. The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for R19. This deficient practice placed R19 at risk for impaired end-of-life care.

The facility had a census of 19 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered intervention for behaviors for one sampled resident, Resident (R) 19. This placed the resident at risk for injury and unmet needs. Findings included: - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had severely impaired cognition and required supervision and set up assistance for dressing, toileting, and independent with bed mobility, transfers, ambulation, eating, and personal hygiene. The assessment further documented R19 wandered four to six days, had no behaviors, and did not take any medications. The Quarterly MDS, dated [DATE], documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, directed staff to encourage R19 to participate in group activities, spend one on one time in the [NAME] to provide reorientation and comfort; administer medication as ordered. The plan directed to offer R19 puzzle or books appropriate to her cognition level, and take outside for a walk or to the patio when she felt anxious. The care plan lacked interventions to address specific behaviors, fears and/or triggers and lacked resident specific interventions to address those items. The Physician's Order, dated 04/21/23, directed staff to administer fluoxetine hci ,(an antidepressant medication) 20 milligrams (mg), by mouth, daily for depression. The medication was discontinued on 05/17/23. The Physician's Order, dated 05/07/23, directed staff to administer Xanax, (an antianxiety medication), by mouth every eight hours, three times per day, for the diagnosis of anxiety. The medication was discontinued on 05/09/23. The Physician's Order, dated 05/09/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice a day, as needed, for the diagnosis of anxiety. The medication was discontinued on 05/30/23. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Nurse's Note, dated 04/19/23 at 10:30 PM, documented R19 packed up some belongings and tried to leave out of the south door. The note further documented a Wanderguard (a monitoring device used to help ensure safety) was placed on her right wrist. The Nurse's Note, dated 04/25/23 at 12:30 AM, documented R19 stated that there were men threatening to kill people and staff reassured the resident that the doors to the facility were locked. The Nurse's Note, dated 05/02/23 at 09:30 AM, documented R19 would not answer to her name and told staff she had a different name, and she was little. The Nurse's Note, dated 05/03/23 at 08:07 PM, documented R19 was tearful, and did not to shower. The note further documented R19 cried throughout the shower and became aggressive with the Certified Nurse Aide (CNA) who tried to get her dressed. R19 stated she would not put clothes on because the CNA took her clothes off and swung at the resident. Staff offered R19 reassurance. The Nurse's Note, dated 05/13/23 at 09:39 AM, documented R19 reported she was in lockdown because there dangerous people in the facility. The resident used derogatory racial slurs as well. in the facility who was eating his own children. Reassurance given by staff. The Nurse's Note, dated 05/13/23 at 08:01 PM, documented staff heard the resident crying in her room and found her squatted down on her hands and feet, underneath her bedside table. The note further documented R19 tried to pick up a bucket of candy that fell to the floor and asked the nurse for assistance. While the nurse attempted to assist her, R19 grabbed the nurse's arm, dug her fingernails in the arm, scraping and breaking the skin. The note documented the nurse was able to remove her arm from the resident's grasp, finish cleaning up the candy, and sat in a chair across the room from R19. R19, who was still on the floor with her back against the bed began to scream for help. R19 screamed at the nurse and as the nurse tried to explain what happened, R19 called the nurse a liar and proceeded to try to slam her walker into the nurse. R19 threw two shoes, a bottle of lotion, a book and her hose at the nurse. R19 stated, As soon as I find my gun, I will shoot you! The nurse attempted to reorient R19 and tried to redirect her without success and refused to allow the nurse to assist her off the floor. The note documented the nurse left the room and returned with another staff member to assist R19 off the floor. As staff attempted to transfer R19 to her bed, she was extremely combative , hit, scratched, and pinched staff. The note documented staff checked on R19 multiple times over the next half hour and as staff checked on her, she would move her walker to the door and not allow anyone in. Staff had to go through another resident's room, through the bathroom to R19's room, to check on the resident. The Nurse's Note, dated 05/13/23 at 09:11 PM, documented R19 continued to barricade herself in her room and not allow anyone to enter. The note further documented R19 would curse and shout at someone she saw in her room that was not there. Staff would check on the resident through the bathroom door and she stated a black man tried to kill her. The Nurse's Note, dated 05/16/23 at 01:55 AM, documented R19 self-barricaded herself in her room and would not let the staff enter her room. The note documented staff went through another resident's room, through the bathroom, so they could check on the resident. The nurse went back to R19's room after 30 minutes, knocked on her room door and asked R19 if she could come in. R19 let the nurse in and started to talk about the big black man and that the sheriff was looking for him. The nurse told R19 that she thought the sheriff had caught the man and was able to assist R19 to bed. The Nurse's Note, dated 05/17/23 at 08:41 AM, documented R19's mental trauma and anguish was a major issue and R19 had refused to leave her room for breakfast as R19 thought the facility was in lockdown. Staff reassured her that all the doors were locked, and no one was inside that should not be. The Nurse's Note, dated 05/17/23 at 03:57 PM, documented R19 barricaded her door with her walker and told staff that there was a black man who had tried to get into her room and staff had to go through another resident room to check on her. The Nurse's Note, dated 05/17/23 at 06:44 PM, documented R19 refused to eat and stated a large black man was loose in the community; he had ate his children's fingers and R19 thought he had been to her room twice that evening. Reassurance was given to the resident. The Nurse's Note, dated 05/18/23 at 04:59 AM, documented R19 was tearful and stated, My mom and dad don't want me. Reassurance was given to the resident. The Nurse's Note, dated 05/22/23 at 10:53 PM, documented R19 barricaded herself in her room as she thought there was a criminal loose and thought he tried to get into her room. The Nurse's Note, dated 05/26/23 at 10:49 PM, documented R19 barricaded herself in her room and refused all care and assistance. The Nurse's Note, dated 05/27/23 at 09:10 PM, documented R19 refused dinner and believed that something dangerous was going to happen so she blocked her room door. The Nurse's Note, dated 05/28/23 at 05:35 PM, documented R19 believed she was married to the physician, refused all medications, threw her dinner tray at staff, and called staff a derogatory name. The Care Plan Note, dated 05/31/23 at 01:27 PM, documented R19's family had concern related to her behaviors and delusions and stated R19 had times of sundowning at home but had never had the behaviors and aggression she was exhibiting now. The note further documented that family felt her behaviors had improved since treatment for recent heath issues were finished and agreed that arranging a mental health appointment was a good idea. The Nurse's Note, dated 06/07/23 at 11:08 PM, documented R19 believed her son called her to tell her that he no longer wanted anything to do with her, refused her shower, and would not let staff change her bedding as there was a small spot of bowel movement on it. The Nurse's Note, dated 06/11/23 at 11:00 AM, documented R19 continued to voice paranoia about people hiding secretly in rooms and behind doors. The Nurse's Note, dated 06/15/23 at 11:41 AM, documented R19 became increasingly irritable and had increased paranoia that something bad was going to happen. R19's EMR lacked evidence mental health support services were provided to R19. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/15/23 at 01:45 PM, Certified Nurse Aide -- stated R19 cussed at staff and they would go through the bathroom to check on the resident. CNA M further stated they received dementia computer training and through inservices. On 06/15/23 at 02:45 PM, Certified Medication Aide (CMA) R stated R19 had a lot of behaviors and when she got agitated, she barricaded herself in her room. CMA R further stated she snuck into the bathroom through an adjoining room to check on R19. On 06/15/23 at 03:00 PM, Licensed Nurse (LN) H stated R19 had days that she was happy and other days she was paranoid, often barricading herself in her room when she thought there was a criminal loose. LN H further stated R19's family was very supportive and come to the facility to assist staff when needed. On 06/19/23 at 10:34 AM, Administrative Nurse D verified the care plan lacked interventions to address specific behaviors and lacked resident specific interventions to address those. The facility's Care Plan Revisions policy, dated 11/16, documented the care plan would be revised whenever the behavior or cognition of a resident changed with either a deterioration or an improvement. The care plan would include specific individualized instructions to staff with interventions to meet the unmet needs of the resident . The facility failed to revise the care plan for R19, who had behaviors. This placed the resident at risk for injury and unmet needs.

The facility had a census of 19 residents. The sample included eight residents, with three reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for Resident (R) 19, who had dementia related behaviors. This placed the resident at risk for decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Admission Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had severely impaired cognition and required supervision and set up assistance for dressing, toileting, and independent with bed mobility, transfers, ambulation, eating, and personal hygiene. The assessment further documented R19 wandered four to six days, had no behaviors, and did not take any medications. The Quarterly MDS, dated [DATE], documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, directed staff to encourage R19 to participate in group activities, spend one on one time in the [NAME] to provide reorientation and comfort; administer medication as ordered. The plan directed to offer R19 puzzle or books appropriate to her cognition level, and take outside for a walk or to the patio when she felt anxious. The care plan lacked interventions to address specific behaviors, fears and/or triggers and lacked resident specific interventions to address those items. The Physician's Order, dated 04/21/23, directed staff to administer fluoxetine hci ,(an antidepressant medication) 20 milligrams (mg), by mouth, daily for depression. The medication was discontinued on 05/17/23. The Physician's Order, dated 05/07/23, directed staff to administer Xanax, (an antianxiety medication), by mouth every eight hours, three times per day, for the diagnosis of anxiety. The medication was discontinued on 05/09/23. The Physician's Order, dated 05/09/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice a day, as needed, for the diagnosis of anxiety. The medication was discontinued on 05/30/23. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Nurse's Note, dated 04/19/23 at 10:30 PM, documented R19 packed up some belongings and tried to leave out of the south door. The note further documented a Wanderguard (a monitoring device used to help ensure safety) was placed on her right wrist. The Nurse's Note, dated 04/25/23 at 12:30 AM, documented R19 stated that there were men threatening to kill people and staff reassured the resident that the doors to the facility were locked. The Nurse's Note, dated 05/02/23 at 09:30 AM, documented R19 would not answer to her name and told staff she had a different name, and she was little. The Nurse's Note, dated 05/03/23 at 08:07 PM, documented R19 was tearful, and did not to shower. The note further documented R19 cried throughout the shower and became aggressive with the Certified Nurse Aide (CNA) who tried to get her dressed. R19 stated she would not put clothes on because the CNA took her clothes off and swung at the resident. Staff offered R19 reassurance. The Nurse's Note, dated 05/13/23 at 09:39 AM, documented R19 reported she was in lockdown because there dangerous people in the facility. The resident used derogatory racial slurs as well. in the facility who was eating his own children. Reassurance given by staff. The Nurse's Note, dated 05/13/23 at 08:01 PM, documented staff heard the resident crying in her room and found her squatted down on her hands and feet, underneath her bedside table. The note further documented R19 tried to pick up a bucket of candy that fell to the floor and asked the nurse for assistance. While the nurse attempted to assist her, R19 grabbed the nurse's arm, dug her fingernails in the arm, scraping and breaking the skin. The note documented the nurse was able to remove her arm from the resident's grasp, finish cleaning up the candy, and sat in a chair across the room from R19. R19, who was still on the floor with her back against the bed began to scream for help. R19 screamed at the nurseand as the nurse tried to explain what happened, R19 called the nurse a liar and proceeded to try to slam her walker into the nurse. R19 threw two shoes, a bottle of lotion, a book and her hose at the nurse. R19 stated, As soon as I find my gun, I will shoot you! The nurse attempted to reorient R19 and tried to redirect her without success and refused to allow the nurse to assist her off the floor. The note documented the nurse left the room and returned with another staff member to assist R19 off the floor. As staff attempted to transfer R19 to her bed, she was extremely combative , hit, scratched, and pinched staff. The note documented staff checked on R19 multiple times over the next half hour and as staff checked on her, she would move her walker to the door and not allow anyone in. Staff had to go through another resident's room, through the bathroom to R19's room, to check on the resident. The Nurse's Note, dated 05/13/23 at 09:11 PM, documented R19 continued to barricade herself in her room and not allow anyone to enter. The note further documented R19 would curse and shout at someone she saw in her room that was not there. Staff would check on the resident through the bathroom door and she stated a black man tried to kill her. The Nurse's Note, dated 05/16/23 at 01:55 AM, documented R19 self-barricaded herself in her room and would not let the staff enter her room. The note documented staff went through another resident's room, through the bathroom, so they could check on the resident. The nurse went back to R19's room after 30 minutes, knocked on her room door and asked R19 if she could come in. R19 let the nurse in and started to talk about the big black man and that the sheriff was looking for him. The nurse told R19 that she thought the sheriff had caught the man and was able to assist R19 to bed. The Nurse's Note, dated 05/17/23 at 08:41 AM, documented R19's mental trauma and anguish was a major issue and R19 had refused to leave her room for breakfast as R19 thought the facility was in lockdown. Staff reassured her that all the doors were locked, and no one was inside that should not be. The Nurse's Note, dated 05/17/23 at 03:57 PM, documented R19 barricaded her door with her walker and told staff that there was a black man who had tried to get into her room and staff had to go through another resident room to check on her. The Nurse's Note, dated 05/17/23 at 06:44 PM, documented R19 refused to eat and stated a large black man was loose in the community; he had ate his children's fingers and R19 thought he had been to her room twice that evening. Reassurance was given to the resident. The Nurse's Note, dated 05/18/23 at 04:59 AM, documented R19 was tearful and stated, My mom and dad don't want me. Reassurance was given to the resident. The Nurse's Note, dated 05/22/23 at 10:53 PM, documented R19 barricaded herself in her room as she thought there was a criminal loose and thought he tried to get into her room. The Nurse's Note, dated 05/26/23 at 10:49 PM, documented R19 barricaded herself in her room and refused all care and assistance. The Nurse's Note, dated 05/27/23 at 09:10 PM, documented R19 refused dinner and believed that something dangerous was going to happen so she blocked her room door. The Nurse's Note, dated 05/28/23 at 05:35 PM, documented R19 believed she was married to the physician, refused all medications, threw her dinner tray at staff, and called staff a derogatory name. The Care Plan Note, dated 05/31/23 at 01:27 PM, documented R19's family had concern related to her behaviors and delusions and stated R19 had times of sundowning at home but had never had the behaviors and aggression she was exhibiting now. The note further documented that family felt her behaviors had improved since treatment for recent heath issues were finished and agreed that arranging a mental health appointment was a good idea. The Nurse's Note, dated 06/07/23 at 11:08 PM, documented R19 believed her son called her to tell her that he no longer wanted anything to do with her, refused her shower, and would not let staff change her bedding as there was a small spot of bowel movement on it. The Nurse's Note, dated 06/11/23 at 11:00 AM, documented R19 continued to voice paranoia about people hiding secretly in rooms and behind doors. The Nurse's Note, dated 06/15/23 at 11:41 AM, documented R19 became increasingly irritable and had increased paranoia that something bad was going to happen. R19's EMR lacked evidence mental health support services were provided to R19. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/15/23 at 01:45 PM, Certified Nurse Aide -- stated R19 cussed at staff and they would go through the bathroom to check on the resident. CNA M further stated they received dementia computer training and through inservices. On 06/15/23 at 02:45 PM, Certified Medication Aide (CMA) R stated R19 had a lot of behaviors and when she got agitated, she barricaded herself in her room. CMA R further stated she snuck into the bathroom through an adjoining room to check on R19. On 06/15/23 at 03:00 PM, Licensed Nurse (LN) H stated R19 had days that she was happy and other days she was paranoid, often barricading herself in her room when she thought there was a criminal loose. LN H further stated R19's family was very supportive and come to the facility to assist staff when needed. On 06/19/23 at 10:34 AM, Administrative Nurse D stated R19 had been having other health issues at the times that she was having the behaviors and R19's physician tried to manage those behaviors with medication. Administrative Nurse D further stated they had wanted to wait to seek mental health support after her health issues were taken care of and had the support of the family to wait. The facility's Dementia and Behavior Management policy, dated 03/20/23, documented all staff would be educated on appropriate dementia care and dealing with difficult behaviors prior to working with elders with dementia, at least annually and as determined to be necessary by the nursing supervisor. Training would be documented in the staff member's personnel record. All behaviors related to all types of dementia would be monitored and documented for the purpose of tracking and trending those behaviors. The development of person-centered individualized dementia care plan programming for each resident and Identification of triggers of specific behaviors to assist staff members to avoid these triggers of unmet needs which the resident was unable to verbalize or communicated, evaluate current behavior management programming intervention. The nurse will report pertinent findings from the behavior assessment to the physician and representative as appropriate. The facility failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R19, who had dementia related behaviors. This placed the resident at risk for decreased quality of life.

The facility had a census of 19 resident. The sample included eight residents. Based on observation, record review, and interview, the facility failed to ensure the facility had a system in place to acknowledge and address the Consultant Pharmacist's (CP) recommendations for Resident (R)10, which placed the resident at risk of impaired health. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), peripheral vascular (abnormal condition affecting the blood vessels) disease, dementia (progressive mental disorder characterized by failing memory, confusion), mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), kidney failure, atrial fibrillation (rapid, irregular heart beat), and history of urinary tract infection, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), hypertension (elevated blood pressure), and malignant neoplasm (cancer) of breast. The Quarterly Minimum Data Set, dated dated [DATE], documented R10 had moderately impaired cognition, dependent of one or two staff with activities of daily living, had scheduled pain medication, no ulcers, and received insulin. The Nutrition Care Plan, dated 06/13/23, documented R10 had an alteration in nutrition related to diabetes and dementia (initiated 08/17/18). The care plan directed staff to obtain lab per or of physician ordered. On 10/10/17, the Physician Order directed a Basic Metabolic Panel (BMP- a test that measures eight different substances in blood) and Hemoglobin A1C (HgbA1c)-blood test that measures average blood sugar levels over the past three months) every six months related to hypertension, diabetes mellitus due to underlying condition with diabetic neuropathy (dysfunction of nerves typically causing numbness ad weakness). The Pharmacy Consultant Review, dated 01/03/23, recorded R10 had orders for HgbA1c every six months, but no results on file in over a year. The recommendation requested to ensure all labs were drawn and reported in the chart as ordered. The Pharmacy Consultant Review, dated 05/02/23, documented R10 had no lab results on file in the past year despite orders for a quarterly BMP and HgbA1c every six months. The recommendation requested a complete blood count (CBC-lab test to that provide information about cells in a person's blood), a complete metabolic panel (CMP-test for chemical balance and metabolism), and HgbA1c at that time. The Pharmacist Consultant Review, dated 06/02/23, documented R10 had no lab results on file in the past year despite orders on file in recent weeks to get these updated. The recommendation requested the facility to ensure all labs were drawn and reported in chart. The EMR recorded a BMP on 04/11/22, a general chemistry (group of tests ordered to determine general health status) on 05/23/22. The EMR lacked a six-month BMP and HGbA1c as ordered. R10's EMR lacked evidence the CP recommendations were addressed by staff or physician. On 06/14/23 at 08:00 AM, observation revealed R10 sat in the dining room, in a high-backed wheelchair eating her breakfast. On 06/19/23 at 10:12 AM, Administrative Nurse D, reported R10's lab work orders were clarified in 05/2023. Administrative Nurse D verified the lack of response to the CP regarding the missing BMP and HGbA1c at six-month interval. The facility's Consultant Pharmacist Service Provider Requirements policy, dated 06/02/16 documented a review of the medication regimen of each resident monthly, utilizing federally mandated standards of care in addition to other applicable standards and document the review findings in the resident's medical record. Pharmacist will email the report to the DON/ADON for review. The recommendations will be sent to the provider for consideration. The facility failed to ensure the facility had a system in place to acknowledge and address the CP recommendations to obtain ordered laboratory blood test as ordered by the physician for R10, which placed the resident at risk of impaired health.

The facility had a census of 19 residents. The sample included eight residents, with six reviewed for unnecessary medications, Based on observation, record review, and interview, the facility failed to administer as needed clonidine (high blood pressure medication) for Resident (R) 9, who had systolic blood pressure (SBP-the maximum pressure the heart exerts while beating) above physician ordered parameters. This placed the resident at risk for physical decline and complications related to high blood pressure. Findings included: - The Electronic Medical Record (EMR) documented R9 had diagnoses of hypertension (high blood pressure), systolic heart failure (the heart muscle is weak and cannot contract normally), and diastolic heart failure (the heart muscle is stiff and cannot relax normally). The Annual Minimum Data Set Assessment (MDS), dated [DATE], documented R9 had intact cognition and was independent with all activities of daily living (ADLs). The assessment further documented R9 received seven days of a diuretic (medication to promote the formation and excretion of urine) during the lookback period. The Quarterly MDS, date 03/24/23, documented R9 had intact cognition and was dependent upon two staff for bed mobility, transfers, required extensive assistance of one staff for dressing, toileting, personal hygiene. R9 did not ambulate. The assessment further documented R9 received seven days of a diuretic during the lookback period. The Care Plan, dated 04/27/23, directed staff to administer medications as ordered, monitor R9's blood pressure according to standing parameters. The plan directed staff to encourage R9 to not ambulate or transfer independently and call for assistance if she felt dizzy; and observe for signs and symptoms of hypotension (low blood pressure) after administration of blood pressure medications and dizziness. The Physician's Order, dated 12/25/21, directed staff to administer losartan potassium (blood pressure medication) 100 milligrams (mg), by mouth, and hold if her systolic blood pressure was less than 110. The Physician's Order, dated 01/18/23, directed staff to administer clonidine, 0.1 mg, by mouth, as needed, if R9's systolic blood pressure was greater than 170 for the diagnosis of hypertension. The Physician's Order, dated 01/25/23, directed staff to administer Norvasc (blood pressure medication), 10 mg, by mouth at bedtime for the diagnosis of chronic combined systolic and diastolic heart failure. The Medication Administration Record (MAR) for March 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 03/02/23 at bedtime for the blood pressure of 175/57 millimeters (mm) of Mercury (Hg) 03/04/23 in the am for the blood pressure of 178/88 mmHg 03/08/23 at bedtime for the blood pressure of 174/89 mmHg 03/09/23 in the afternoon blood pressure of 186/86 mmHg 03/12/23 in the afternoon for the blood pressure of 171/88 mmHg 03/19/23 in the afternoon for the blood pressure of 173/93 mmHg The MAR for April 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 04/14/23 in the afternoon for the blood pressure of 192/93 mmHg 04/23/23 in the morning for the blood pressure of 172/87 mmHg The MAR for June 2023 documented R9's systolic blood pressure was out of parameters and lacked documentation she received the as needed clonidine medication the following days: 06/17/23 in the afternoon for the blood pressure of 172/70 mmHg On 06/14/23 at 03:48 PM, observation revealed R9 ambulated independently in her room. On 06/14/23 at 04:00 PM, Administrative Nurse D stated she felt the medication was given correctly and that the documentation was incorrect and confusing. On 06/14/23 at 04:12 PM, Licensed Nurse (LN) G stated R9's blood pressure was taken three times per day and if her systolic blood pressure was over 170, staff administered the clonidine. The facility's Physician Orders for Medications and Treatments policy, dated 05/2019, documented all medications would be administered as ordered by a health care professional authorized by the state to order medications. The facility failed to administer as needed clonidine to R9, as directed by the physician, when R9's SBP exceeded the ordered parameters., This placed R9 at risk for physical decline and complications related to high blood pressures.

The facility had a census of 19 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to attempt or address Resident (R)17's antipsychotic (mood altering medication) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications for a gradual dose reduction (GDR). The facility further failed to ensure R19's as needed antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication had a stop date as required This deficient practice placed R17 and R19 at risk for adverse side effects related to psychotropic (alters mood or thought) medication use. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear)disorder, chronic kidney disease, seizures (violent involuntary series of contractions of a group of muscles), hypertension (elevated blood pressure) and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderate cognitive impairment. R17 had no delirium, psychosis, or behaviors. The MDS further documented R17 had non-traumatic brain dysfunction, Alzheimer's disease, anxiety disorder and depression. R17 took an antidepressant and an antipsychotic which had been received on a routine basis only, with no GDR or physician documentation of the GDR as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment, dated 10/19/22, documented staff administered medication as ordered, monitor medication side effects and consult with the physician for GDR recommendations. The Care Plan, revision dated 04/18/23, documented R17 had a diagnosis of anxiety and depression and used the psychotropic medications paroxetine (antidepressant) and Abilify (antipsychotic). The care plain directed staff to administer medications as ordered, monitor for side effects, and consult with pharmacy, and the physician to consider dosage reduction when clinically at least quarterly. The Physician Order Sheet (POS), dated 05/04/23, directed staff to administer Abilify 2 milligrams (mg) one time a day (start date of 10/12/22) and paroxetine 30 mg one time a day (start date of 03/07/23). The Pharmacy Consultation Review, dated 04/03/23, documented R17 received Abilify 2 mg and paroxetine 30 mg daily since October; all agents with psychoactive properties fell under gradual dose reduction guidelines. The review further documented to consider a trial reduction to at least one of these agents if clinically appropriate. R17's EMR lacked evidence of a GRD or a response which documented GDR was contraindicated and the rationale. On 06/14/23 at 09:13 AM, observation reveal R17 in her room, sitting in her recliner, with eyes closed, walker next to recliner, bed in low position, call light within reach. On 06/19/23 at 10:20 AM, Administrative Nurse D reported the pharmacy review had been sent to the physician on 04/05/23 and verified the physician had not responded to the recommendation. The facility's Psychotropic Medication policy, dated 06/02/16, documented physician and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. The facility will make every effort to comply with state and federal regulation related to the use of psychopharmacological medication in the long-term care facility to include regular review of continued need, appropriate dosage, side effects, risk and/or benefits. The pharmacist and/or consulting pharmacist with monitor psychotropic drug use in the facility to ensure medications are not used in excessive doses or for excessive duration. Conduct a monthly medication review of residents and report findings to interdisciplinary team. Notifies the physician and nursing whenever medication is past due review and make recommendations for gradual dose reductions as indicated. The facility failed to attempt a GDR or document a physician response for contraindication which placed R17 at risk for adverse side effects related to psychotropic medication use. 32360 - The Electronic Medical Record (EMR) documented R19 had diagnoses of late onset Alzheimer dementia without behavioral disturbance (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had long and short-term memory problems and was independent with all activities of daily living (ADLs). R19 had disorganized thinking, hallucinations (perception of something not present), delusions (unshakable belief in something that's untrue), wandered one to three days, and had rejection of care four to six days. The MDS further documented R19 received antidepressant and antianxiety medication. The Care Plan, dated 05/31/23, documented Xanax had the following Black Box Warning (BBW-indicates that the drug carries a significant risk of serious or even life-threatening adverse effects) the resident at risk of abuse, addiction, respiratory depression and sedation. The Physician's Order, dated 05/30/23, directed staff to administer Xanax, 0.25 mg, by mouth, twice per day, as needed, for the diagnosis of anxiety. The order lacked a stop date for the as needed medication. The Medication Administration Record (MAR) for June 2023 documented R19 received the as needed Xanax on 06/04, 06/05, 06/07, and 06/12/23 x 2. The Medication Regimen Review, dated 06/02/23 documented the physician must reorder as needed Xanax for a specific number of days via stop date or discontinue. The EMR lacked documentation the physician provided a stop date for the medication. On 06/14/23 at 08:00 AM, observation revealed R19 eating breakfast in the dining room conversing with her tablemate's. On 06/19/23 at 10:34 AM, Administrative Nurse D verified there was not a stop date for the as needed Xanax. The facility's Psychotropic Medication policy, dated 01/20, documented orders for as needed psychotropic medications would be time limited (ie: two weeks) and only for specific clearly documented circumstances. The facility failed to ensure R19's as needed Xanax had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic medication.

The facility had a census of 21 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to ensure staff performed appropriate hand hygiene and/or glove usage during peri-care (involves washing the genital and rectal areas of the body or perineal area) for Resident (R) 8. This deficient practice had the risk for cross-contamination and increased risk for infection for the resident. Findings included: - On 12/16/21 at 10:40 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N entered R8's room, explained the procedure to the resident, applied gloves, and pulled down the residents' pants. CNA M unfastened the incontinent brief from the front of the resident, tucked it between the resident's legs. Wearing the same gloves, she removed an incontinent wipe package from the bedside table drawer and took out some wipes. CNA M placed the wipes and container on the resident's bed, provided peri-care to the resident's genitals and groin area. CNA N repositioned R8 to his left side while CNA M pulled the incontinent brief through the resident's legs to his backside, which revealed a small amount of soft formed brown bowel movement. CNA M provided perineal care to the resident's buttocks and rectal area and discarded the soiled incontinent brief in the trash. CNA M, with the same soiled gloves, placed the incontinent wipe package into the bedside table drawer, retrieved a container of powder, placed a new incontinent brief underneath the resident, sprinkled the powder on the resident's genitals, touched R8's shirt and pant leg, placed the powder and the incontinent wipes back in the drawer. CNA M then removed and discarded her soiled gloves. On 12/16/21 at 10:45 AM, CNA M verified she had not changed gloves after providing perineal care in the observation above. CNa M stated she should have changed her gloves and performed hand hygiene between glove changes. On 12/21/21 at 10:43 AM Administrative Nurse D stated she expected staff to change gloves between dirty and clean when providing incontinent cares. The facility's Standard Precautions policy, revised July 2018 , documented gloves should be changed between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms (a living thing that is too small to be seen with the naked eye, examples of microorganisms include bacteria). The facility staff failed to change gloves after providing perineal care, placing R8 at risk for development of infection and contamination.

The facility had a census of 30 residents. The sample included 13 residents of which 1 was reviewed for nutrition. Based on observation, interview and record review, the facility failed to identify, evaluate, and address nutritional needs for 1 of 1 sampled resident who had significant weight loss of 14% in in 90 days. (#28) Findings included: - The medical record documented the facility admitted the Resident #28 on 10/8/18. The (POS) Physician order [REDACTED]. symptoms, such as hallucinations (sensing things while awake that appear to be real, but the mind created) or delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and symptoms of a mood disorder, such [MEDICAL CONDITION](mood characterized by an unstable expansive emotional state, extreme excitement, [MEDICAL CONDITION]) and depression (low mood) disorder. The admission (MDS) Minimum Data Set assessment, dated 10/14/18, documented the resident had intact cognition with a (BIMS) Brief Interview for Mental Status score of 15, required staff supervision with eating, and limited to extensive staff assistance with other (ADLs) activities of daily living. The MDS documented the resident had broken teeth, mouth pain, was 59 inches tall, weighed 159 pounds, received a therapeutic diet, and had no swallowing problems. The 1/9/19 significant change MDS documented the same except BIMS 12, which indicated moderately impaired cognition and decision-making skills, weighed 136 pounds, documented weight loss, and now required limited staff assistance with eating. The 10/14/18 (CAA) Care Area Assessment summary for nutrition documented the resident received a regular diet with 1/2 scoop of protein powder in 8 ounces of milk, with breakfast. The summary documented the resident's teeth were not in good condition, and he/she chewed on the right side of his/her mouth due to pain at times to the left side. The summary documented the resident's weight was 158.6 on admission and 163 today. Hospital labs showed the resident's [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) was low at 3.4 (normal range 3.4-5.4). The 10/8/18 care plan for nutrition directed staff to provide ½ scoop of protein powder in milk at breakfast, serve diet as ordered, and monitor intake and record every meal. The care plan directed staff to ensure the (RD) Registered Dietician evaluated and made diet change recommendations as needed. The care plan directed staff to obtain weekly weights until stable, then monthly, and record, or report, to the physician significant weight loss of 3 pounds in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, or greater than 10% in 6 months. Updates to the care plan included: 1/7/19- encourage the resident to come to the dining room for breakfast or provide a room tray if he/she declined going to the dining room, place the resident at the assisted dining table and assist him/her with eating as needed. The care plan lacked direction for the staff to assist the resident when providing a room tray. Staff attempted a trial of ensure due to weight loss and diminished oral intake, but the resident did not take it well. Staff started super cereal and intake was not always the best, but staff are to keep offering. 1/26/19-provide staff assistance of 1, encourage the resident to hold a glass to drink and encourage him/her to eat independently. 1/27/19- provide 8 ounces of milk with 1/2 scoop of protein powder. 1/29/19- offer room tray for some of his/her meals to see if he/she felt more comfortable. The 10/10/18 Oral Assessment by nursing documented the resident complained of pain to his/her gums and gingivitis (inflammation of the gums) was noted. The assessment documented the resident ate on the right side of his/her mouth due to pain on the left side at times. The 10/22/18 at 4:18 PM, RD note documented the facility admitted the resident after a stay at the hospital. The resident wanted to try a mechanical soft diet, with ground meat as his/her teeth were in poor shape. The note documented the resident consumed 25-100% of his/her meals, and 50-100% of the 1/2 scoop of protein powder in milk daily at breakfast. The resident's weight was 163(#) pounds, and he/she reported a usual body weight of 150#. The note documented a nutrition care plan was initiated, continue protein powder, and provide a mechanical soft diet with ground meat. The weight record documented the following: 10/8/18= 158.6 admission weight 11/14= 156.4 11/21= 154.0 11/28= 148.6 12/4= 148.6 12/19/18= 141.8 (12.2 # or 7.9% loss in 30 days) 1/2/19 = 136.2 (22.4# or 14.0% loss in 90 days). The 1/2/19 physician office visit notes lacked documentation of weight loss. 1/15/19 = 138 1/30= 131.6 2/2 = 130.2 2/3= 126.2 (7.34% further weight loss in the last 30 days) The facility's weight record lacked documentation of weekly weights when the resident continued to lose weight. The medical record lacked documentation the staff notified the physician or the RD after the significant weight loss of 7.9% in 30 days on 12/19/18. 1/6/19 Dental Assessment documented the resident did not respond to teeth or gum pain and still had gingivitis. The 1/10/19 physician's orders [REDACTED]. (same as the 10/8/18 care plan) The 1/7/19 RD note documented the resident's current weight on 1/2/19 was 136.2#, (an 8.3% loss in one month, and a 14.1% loss in 90 days). The note documented the resident was on a regular diet and ate 25-75% of his/her meals, with staff assistance at times. The resident received 8 ounces of milk with ½ scoop of protein powder daily at breakfast, drank an average of 50%, and rarely ever snacked between meals. The note documented staff would try super cereal at breakfast (even though he/she often had cold cereal), and 4 ounces of Ensure (nutritional supplement) at meals, for 3 days. The note documented the RD noted staff had not provided a mechanical soft diet in October, but the resident's nutrition goal was met at times. The 1/10/19 nutrition assessment documented the resident received a regular diet, ½ scoop protein powder in milk at breakfast, his/her intake varied 25-100%, independent with eating, and did not use adaptive equipment. The note documented the resident had a weight loss of 14.1% in the past 3 months and was unable to manage his/her self-care related to weakness, aging process and needed assistance. The note documented staff provided Ensure for a few days, 1/7-1/10/19, the resident would only drink 25%, nutrition goal met, and updated care plan due to trial of ensure, starting super cereal and weight loss. The 1/15/19 at 2:50 PM, RD note documented the resident declined over the past month, with continued weight loss, however, since staff started to assist the resident with meals his/her weight went back up about 2#. The resident consumed 75%, with assistance, and staff will continue the milk (whole) with 1/2 scoop of protein powder daily and super cereal along with assistance at meals. The RD documented due to the resident's pain and complications, he/she could not rule out further weight loss. The 1/21/19 Social Services note documented staff had not scheduled a dental appointment for the resident due to his/her anxiety and pain. The note recorded family would inform staff when to schedule the dental appointment. The 1/30/19 RD note documented the resident continued to decline and to lose weight, a 7.2% weight loss in the past 30 days. The note documented the RD discussed the resident's condition with the dietary manager and assistant (DON) Director of Nursing, who reported the physician ordered several medication changes. The note documented staff would continue to assist with meals, provide whole milk with protein powder at breakfast, super cereal, and 4 ounces of milk at lunch and supper. The 2/4/19 meal intake record for 12:00 PM, documented the resident was not available. The meal intake record for 2/5/19 documented the resident ate 25-50% at breakfast, and 51-75% at lunch. The 2/5/19 at 12:59 PM, nurse's note documented the resident was in an exceptionally good spirits, was up for breakfast, ate with encouragement, and ate 100% of his/her lunch. On 1/31/19 at 11:30 AM, observation revealed the resident sat quietly in a wheelchair at the dining table. Nurse H wheeled the resident to his/her room and directed staff to assist the resident to bed, when the other residents were gathering for the noon meal. The resident was quiet and followed staff direction. On 2/4/19 at 12:05 PM, observation revealed the resident in bed, eyes closed, and Nurse H peeked into the room and stated the resident was asleep. Other residents went to the dining room and staff were serving beverages. Further observation, at 12:27 PM, revealed, Nurse H informed dietary staff the resident was sleeping and to save his/her tray. On 2/4/19 at 1:57 PM, Dietary Staff CC stated Nurse H informed dietary staff the resident needed his/her sleep more than his/her nutrition, so dietary staff placed the resident's meal in the refrigerator and would prepare a room tray for the resident when he/she awoke. On 2/4/19 at 3:30 PM, observation revealed the resident, in his/her wheelchair, at a dining table, with two 8-ounce bottles of water in front of him/her (one empty). The resident stated, help me, over and over. The nurse came by and asked what he/she needed help with. The resident got louder, then quieter, still repeating help me. Staff offered a snack. On 2/4/19 at 4:45 PM, Administrative Staff A verified staff had not provided lunch (still in the kitchen refrigerator) to the resident and were providing an early supper meal for him/her. On 2/5/19 at 11:55 AM, observation revealed staff took the resident to the dining table, where he/she spoke with his/her family member and independently drank water. At 12:05 PM, staff served the resident orange juice, and at 12:09 PM, staff served broccoli, chicken patty, roll, and fried potatoes. The resident's family member cut up the chicken, and the resident independently ate and drank 75-100% of the meal. On 2/5/19 at 3:37 PM, Nurse G stated the resident had erratic sleeping patterns, and staff do not wake him/her for meals, if sleeping. Nurse G stated staff save him/her a plate for when he/she does get up. Nurse G stated staff should ask the resident if he/she wants to get up for the meal. Nurse G stated staff fed the resident at one point and should re-assess the resident's need for assistance every meal, as it varied, due to pain or other things. Nurse G stated staff were to weigh residents weekly, if they lose over 5 pounds in a week. On 2/5/19 at 4:13 PM, Dietary Staff BB stated staff provided ensure with meals, but the resident did not care for it, and started super cereal a month ago. Dietary Staff BB stated staff provided whole milk with protein powder at breakfast 8 oz, and most of the time the resident will drink ½ of it. Dietary Staff BB stated staff were to notify the registered dietician with significant weight loss and inform him/her when staff try some other weight loss intervention. Dietary Staff BB stated nursing informs dietary staff if a resident was not coming to the meal, and dietary staff save a plate or fix the resident soup and a sandwich. Dietary Staff BB stated the resident ate a little better today and would tell dietary staff what he/she wanted to eat. Dietary Staff BB stated dietary staff document meal intake. On 2/6/19 at 1:36 PM, Administrative Nurse E verified staff should weigh the resident weekly after noted weight loss, and staff had not notified the physician and registered dietician to ensure he/she was aware of the resident's significant weight loss. On 2/7/19 at 2:15 PM, Physician HH's nurse stated he/she could not find any documentation the facility staff notified Physician HH of the significant weight loss on 12/19/18. On 2/7/19 at 2:32 PM, Registered Dietician JJ verified the facility had not notified him/her of the resident's significant weight loss on 12/19/18, until 1/2/19. Registered Dietician JJ verified he/she expected staff to monitor weights weekly after weight loss is noted and notify him/her of significant weight loss. The facility's 10/1/14 Weight loss policy recorded residents with a 5% weight change in one month, or who show a trend for gradual weight loss, will be identified for intervention. Nursing to obtain resident's weight weekly, biweekly, or monthly according to their care plan. The staff provide the weight record to the dietary manager, (ADON) Assistant Director of Nursing and the administrative assistant. The administrative assistant documents the weights in the weight tracking system and if there are concerns about a weight, the dietary manager or ADON notifies the RD. Residents identified with a 5% weight loss in the past month or more will be charted on by the DM, RD or both in the progress notes and the provider notified. The progress note will include the meal intake percentage for the resident, concerns with feeding skills, chewing, swallowing, or supplements tried along with interventions to try. The care plan reflects the support and interventions offered to the resident. The facility failed to ensure the resident's nutritional needs were met when staff neglected to ensure the resident was offered a noon meal on 2/4/19, did not weigh the resident weekly when the resident continued to lose weight, and when staff failed to notify the physician and registered dietician of the resident's significant weight loss, which placed the resident at risk for further weight loss and a decline in general health.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to provide care and treatment to adequately control pain for 1 of 1 sampled resident reviewed for hospice services. (#29) Findings included: - Resident #29's physician order [REDACTED]. low back pain. The significant change (MDS) Minimum Data Set assessment, dated 1/16/19, documented the resident had a (BIMS) Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance with bed mobility, dressing, eating, personal hygiene, and total staff assistance with transfers, locomotion on and off the unit, and toilet use. The MDS documented the resident had lower extremity impairment on one side, constant pain, and received scheduled and (PRN) as needed pain medications. The MDS documented the resident received hospice services. The pain (CAA) Care Area Assessment, dated 1/16/19, documented the resident had pain almost constantly over the past 5 days, which limited the resident's day to day activities, and the resident described the pain as very severe and horrible. The CAA documented the resident fell on [DATE], was admitted to hospital, had an (MRI) Magnetic Resonance Imaging (test that uses powerful magnets, radio waves, and a computer to make detailed pictures inside your body) on 12/18/18, which indicated the resident had a compression fracture at L1 (first vertebrae of the lower back) severe chronic T11 (bottom vertebrae of the lower spine) compression deformity (when a bone is fractured in a way that there is a force along its long axis, thereby producing some degree of compression of the bone into a smaller space), and post-surgical vertebral plasty (procedure for stabilizing compression fractures in the spine in which bone cement injected into back bones (vertebrae) that have cracked or broken), and the resident had 5 bulging lumbar discs (rubbery pads between the vertebrae). The CAA documented the physician prescribed routine and PRN pain medications. The CAA documented the resident was at risk for uncontrolled pain management and the hospice team assisted with that issue. The 1/26/19 revised care plan documented the resident had arthritis and instructed staff to administer pain medications as physician ordered, 1/2 hour before treatments or care. The care plan instructed staff to anticipate the resident's need for pain relief, respond immediately to any complaint of pain, and notify the physician and hospice nurse if interventions were unsuccessful or if current complaint is a significant change from the resident's past experience of pain. The care plan directed staff to observe and document side effects of pain medication, observe for signs of pain, and record/report to nurse any signs or symptoms of non-verbal pain such as noisy, deep/shallow, labored, fast or slow breathing, vocalizations such as grunting, moans, yelling out, silence, changes in behavior or mood, crying, worried, scared, clenched teeth, grimacing, and tense body, rocking, curled up, or thrashing. The care plan instructed staff to notify the physician immediately if the resident had breakthrough pain. The 12/17/18 at 8:04 PM, nurse's note documented staff found the resident on the floor by his/her chair in his/her room and notified the ambulance to transfer the resident to the hospital. The 12/17/18 at 8:32 PM, nurse's note documented the resident slipped and fell out of his/her recliner beside his/her chair landing on his/her buttocks. The note documented the resident had difficulty with back pain, a history of vertebral plasty, and received [MEDICATION NAME] every 6 hours with little effect for the pain. The 12/18/18 at 12:40 PM, nurse's note documented the resident admitted to the hospital for lower back pain. The 12/20/18 at 2:30 PM, nurse's note documented the resident returned from the hospital in a private vehicle with family, complained of low back pain, had facial grimacing, called out, spelled words, had slightly labored respirations, and appeared in pain. The nurse's note lacked documentation staff administered pain medication to the resident or if staff notified the physician and hospice. The 12/20/18 at 3:03 PM, nurse's note documented the nurse received a physician order [REDACTED]. The 12/21/18 at 4:51 PM, nurse's note documented the nurse received a physician order [REDACTED]. The note documented the nurse spoke with the physician regarding the family requesting a [MEDICATION NAME] (narcotic medication for severe pain) for the resident's pain and the physician did not give an order for [REDACTED].>The 12/21/18 at 8:33 PM, nurse's note documented the resident rested in bed with eyes closed, easily aroused to verbal stimuli, had facial grimacing, moaned, and tension with movement and repositioning. The note lacked documentation staff administered the resident pain medication or staff notified the physician or hospice regarding the resident's pain. The 12/22/18 at 12:35 PM, nurse's note documented the nurse called the physician to discuss the resident's status, current PRN [MEDICATION NAME] order, and received an order to continue the PRN [MEDICATION NAME] as currently ordered. The 12/27/18 at 10:53 AM, nurse's note documented the resident returned from a physician visit with a new order for a [MEDICATION NAME] (a topical pain medication) applied to back area daily, [MEDICATION NAME], 50 mg, four times a day, and call the physician this weekend with an update. The 12/28/18 at 8:39 PM, nurse's note documented a family member visited the resident and voiced concerns of the resident's uncontrolled pain. He/She stated the resident had pain just to sit at times, when the resident tried to stand, and the resident's pain was worse than when he/she last visited. The family member voiced he/she went with the resident to the physician visit on 12/27/18 and the physician explained to him/her if the [MEDICATION NAME] did not work, the physician could order a [MEDICATION NAME] for the resident's pain. The family member asked the nurse to call the physician and the nurse did, the physician ordered [MEDICATION NAME] (narcotic pain medication for moderate to severe pain) 5/325 mg every 6 hours PRN, continue the scheduled [MEDICATION NAME] and [MEDICATION NAME], and let him/her know tomorrow how the resident was doing. The note documented the nurse spoke to the family member, told him/her the facility did not have the initial dose of [MEDICATION NAME] (a pain medication) this evening and if the family member wanted the resident to receive it staff would have to obtain it from the hospital and it may cost more, or it could be ordered from the pharmacy and delivered in the morning to the facility. The note documented the family member stated the resident appeared to be comfortable and sleeping at the time and staff could order from the pharmacy and give it in the morning. The 12/30/18 at 10:40 AM, nurse's note documented the nurse notified the physician, staff administered the [MEDICATION NAME] in the early hours of the morning and the resident slept after he/she received it. The note documented around 9:30 AM staff assisted the resident to transfer to the recliner and the resident stated he/she just hurt, wished it would go away, hurt when he/she moved, and no one understood. The note documented the resident had not eaten his/her breakfast and lacked documentation staff administered pain medication to the resident. The 12/31/18 at 9:43 AM, nurse's note documented the resident's family member requested the nurse call the physician for a different order for pain medication due to the resident stated to the family member he/she had no idea where he/she was at and why he/she was at the facility. The note documented the family member requested the nurse ask the physician for an order for [REDACTED]. The 12/31/18 at 11:05 AM, nurse's note documented the resident had an appointment with the physician at 2:45 PM and the family member planned to accompany the resident. The 12/31/18 at 5:17 PM, nurse's note documented the resident returned from an appointment with the nurse practitioner with an order for [REDACTED]. The 1/2/19 at 12:21 PM, nurse's note documented the resident had an X-ray of his/her hip and pelvis and the results revealed no fracture or acute process in the hip. The note documented the resident's family member requested the resident receive an MRI and the nurse left a message with the physician's nurse. The 1/2/19 at 3:58 PM, nurse's note documented the nurse practitioner directed staff to increase the [MEDICATION NAME] to 25 mcg/hr. The 1/3/19 at 2:15 PM, nurse's note documented the resident's family member came to the nurse's station, spoke with the medication aide regarding the resident stating, if committing suicide means going to hell, he/she was ready, because this pain was unbearable. The note documented the resident's family member requested the medication aide give the resident something for pain now. The 1/3/19 at 12:23 PM, nurse's note documented the resident sat in a wheelchair, repeated over and over take me to the hospital, I can't take it, and staff administered PRN [MEDICATION NAME], ½ tablet for back pain. The note documented the resident had an appointment with the physician at 2:15 PM. The 1/7/19 at 2:33 PM, nurse's note documented the family member called the facility, requested a hospice consult, and the nurse contacted the physician for an order for [REDACTED].>The 1/10/19 at 1:31 PM, nurse's note documented staff assisted the resident with transfer using a full lift sling, and the resident called out in pain with the movement. The note documented the resident only received his/her scheduled pain medication today. The 1/10/19 at 2:12 PM, restorative aide note documented the resident had a lot of pain every time he/she tried to move or reposition. The note documented the resident received medications for pain and the resident's restorative therapy exercise program remained on hold due to the resident's high pain level. The 1/18/19 physician order [REDACTED]. Tylenol [MEDICATION NAME] (liquid pain medication), 650 mg (20 ml), every 4 hours PRN for pain or fever not to exceed 3 gm in 24 hours. (initiated on 7/8/15) Tylenol two 500 mg tablets every 6 hours PRN for pain. (initiated on 12/21/18) [MEDICATION NAME] 50 mg tablet every 6 hours PRN for pain. (initiated on 10/20/18) The 2/2/19 at 9:20 PM, nurse's note documented the hospice nurse at the facility due to family concerns of the resident's change in cognition and pain management. The note documented the nurse received an order from hospice to discontinue the current [MEDICATION NAME] order, and change it to 50 mg, twice a day. The 2/4/19 untimed, hospice care plan note documented during the care plan conference held today, the family voiced approval to consult the physician regarding administration of PRN pain medication prior to transfers and cares. The 2/4/19 at 5:57 PM, nurse's note documented the nurse received a physician order [REDACTED]. The note documented staff notified the resident's (DPOA) durable power of attorney with the new order and he/she agreed. The 2/4/19 at 6:10 PM, care plan meeting note documented 3 family members, the hospice nurse, and social worker were present. The note documented a discussion regarding pain medication and utilizing [MEDICATION NAME] prior to transfers. The 2/4/19 physician order [REDACTED]. The (MONTH) (MAR) Medication Administration Record [REDACTED]. The (MONTH) MAR from 2/1/19-2/6/19 documented staff administered PRN Tylenol, 500 mg tablets twice, PRN [MEDICATION NAME], 50 mg one time, [MEDICATION NAME], 0.25 ml on 2/4/19 at 7:36 PM, 2/5/19 at 7:01 PM, and lacked documentation staff administered [MEDICATION NAME] on 2/6/19 until 11:34 AM or PRN Tylenol [MEDICATION NAME]. Review of the medical record revealed no documentation staff used non-pharmacological (treatment that does not involved drugs) interventions to relieve the resident's pain. On 2/4/19 at 11:34 AM, observation revealed the resident sat in a broda (reclining wheelchair) in his/her room. Nurse H entered the resident's room, and told the resident he/she wanted to look at his/her feet. Observation revealed Nurse H gently lifted the resident's left foot from the foot rest, gently pulled up the resident's slacks, and the resident yelled out ow, ow my back. Nurse H stopped for a moment, then told the resident he/she was going to remove the resident's gripper sock to look at his/her foot, and when he/she gently pulled down the resident's sock, the resident yelled out my back hurts. Nurse H stopped for a minute, removed the sock, and assessed the resident's foot. Nurse H told the resident he/she wanted to apply some lotion on the resident's left leg and foot. Continued observation revealed Nurse H applied gloves, squeezed lotion into his/hands, and spread the lotion gently on the resident's leg, lifted the resident's leg to apply to his/her foot, the resident grimaced, and yelled out, my back hurts, please stop. Nurse H placed the resident's foot back on the footrest after placing the sock back on and pulled down the resident's pant leg. Further observation revealed Nurse H did not administer pain medication to the resident. On 2/4/19 at 4:06 PM, observation revealed Nurse I left the resident's room and stated he/she just administered scheduled and PRN pain medication to the resident. Observation revealed the resident lying on the bed, Nurse Aide O and Nurse Aide P applied gloves, and assisted the resident to turn from side to side as they pulled down the resident's slacks. Observation revealed with each turn the resident moaned, grimaced, and held his/her breath. Nurse Aide P removed the resident's incontinent brief, while Nurse Aide O assisted the resident in turning from his/her back to the right side, the resident moaned and grimaced with each movement during incontinent cares. Observation revealed Nurse Aide O attached the sling lift jacket to the full body lift machine, Nurse Aide P raised the resident off the bed, the resident grimaced and moaned the entire time staff transferred the resident to the broda chair. On 2/5/19 at 9:16 AM, observation revealed the resident sat in a broda chair in his/her room. Nurse Aide O, Nurse Aide Q, Administrative Staff A, and Administrative Nurse D entered the resident's room. The two nurse aides applied gloves, took the sling lift jacket to the full lift machine, and explained the procedure. Nurse Aide Q started to lift the resident up from the broda chair, the resident stated no, grimaced, and stated his/her back hurt. The aides transferred the resident to the bed, provided incontinent cares gently, turning the resident from side to side, with each movement the resident moaned and grimaced. Observation revealed Administrative Nurse told the aides to reassure the resident he/she was ok. Observation revealed after incontinent cares were completed, both aides fastened the lift jacket to the full lift machine, and the resident stated you are going to hurt my back and you don't care, the aides continued to lift the resident from the bed with the full lift, while the resident continued to grimace, moan, and stated his/her back hurt when transferred to a recliner. The resident moaned, grimaced, and Administrative Nurse D asked the resident what was wrong, and the resident replied, my back hurts. Administrative Nurse D placed a pillow behind the resident's back, and the resident continued to grimace. On 2/4/19 at 4:15 PM, Nurse I stated staff requested pain medication for the resident because they were going to provide cares, and by the time he/she took the medications down to the resident's room to administer them to the resident, staff already had the resident transferred to the bed. Nurse I verified he/she administered scheduled [MEDICATION NAME] 50 mg and two PRN Tylenol 500 mg to the resident at 3:58 PM. Nurse I stated the pain medications would not have had enough time to be effective for the resident's pain. Nurse I stated even if the resident received his/her pain medication sooner, he/she would be stiff and not understand when staff provided cares. On 2/6/19 at 9:26 AM, Administrative Nurse D stated he/she was unaware the resident was having so much pain until he/she worked the floor as an aide on Sunday 2/3/19 and transferred the resident with a full lift. Administrative Nurse D stated at that time he/she discussed with a family member about getting an order for [REDACTED]. Administrative Nurse D stated he/she had no documentation regarding the families wishes. Administrative Nurse D stated he/she expected staff to administer the [MEDICATION NAME] to the resident per family wishes. Administrative Nurse D stated the night shift probably used non-pharmacological interventions for the resident's pain but did not document the use of them. On 2/6/19 at 10:10 AM, Nurse H stated the reason he/she had not administered [MEDICATION NAME] to the resident prior to transfer this morning was because the resident was not in pain, was happy and smiling. On 2/6/19 at 10:14 AM, Nurse Aide N stated he/she transferred the resident with the full lift and the resident had excruciating pain during the transfer. On 2/6/19 at 10:27 AM, Nurse Aide M stated he/she assisted another aide to transfer the resident this morning, and the resident had pain but not as much. Nurse Aide M verified he/she and the other aide were the only staff in the room. On 2/6/19 at 10:53 AM, Hospice Nurse GG verified being in the resident's room when staff provided cares to the resident, noted at times the degree of pain severity changed, sometimes the resident did fairly well, but other times had a significant amount of pain and would state staff were breaking his/her back. Hospice Nurse GG stated it had been a challenge with controlling the resident's pain during transfers, so he/she met with the family on 2/4/19, discussed pre-medicating the resident with [MEDICATION NAME] prior to cares, and the family agreed with trying it. The facility's 1/11/17 Pain Management policy documented every elder had a right to the assessment and management of pain. It is the responsibility of all clinical staff to assess and periodically reassess the elder for pain and relief from pain. If the elder had been identified with pain, the elder will undergo reassessment of pain at least once per shift and before and after every pain control medication that is provided on a PRN basis. The facility failed to provide treatment and care for Resident #29's continued pain, placing the resident at risk for unrelieved pain.

The facility had a census of 30 residents. Based on observation and interview, the facility failed to provide a drainage system with a 2 inch air gap to prevent back flow into 1 of 1 ice machine used by the 30 residents, who reside in the facility. Findings included: - On 2/4/19 at 10:41 AM, observation revealed the facility's ice machine located in the dining room had 2 drainage tubes (zip-tied together) from the back of the machine with 90 degree elbow connectors in the ends which faced sideways. The ends were resting on top of the floor drain cover. On 2/4/19 at 2:48 PM, Maintenance Staff U verified the ice machine drainage system had no 2 inch air gap to prevent back flow to the ice machine. Upon request, the facility did not provide a policy for the ice machine air gap. The facility failed to provide a required drainage system, with 2 inch air gap, to prevent the back flow of bacteria into the ice machine for 30 residents in the facility who use ice from the machine, placing the residents at risk to receive contaminated ice.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review and interview, the facility failed to review and update the care plan for 1 of 13 sampled residents who sustained a fall with fractures. (#7) Findings included: - Resident #7's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 11/7/18, documented the resident had severely impaired cognition with a (BIMS) Brief Interview for Mental Status score of 5. The MDS documented the resident required limited assistance of 1 staff for bed mobility, transfers, walking and locomotion, extensive assist of 1 staff for dressing, toilet use, personal hygiene, bathing, and staff supervision and set-up help for eating. The MDS documented the resident had unsteady balance and required assistance of 1 staff to stabilize, was frequently incontinent of bowel and bladder, and a bed alarm in place. The 8/15/18 (CAA) Care Area Assessment documented the resident at high risk for falls related to unsteadiness, medications he/she received, and history of a fall with fracture. The 8/14/18 and 11/6/18 Morse fall risk assessments documented the resident scored 80, which is high risk for falls. The 8/17/18 and 11/13/18 care plans documented the resident a high risk for falls, and directed staff the resident used a front wheeled walker, a bed exit alarm when in his/her room, and staff ensure he/she wore appropriate footwear (tennis shoes) or non-skid socks when ambulating. The care plan further directed staff ensure the call light in reach, and respond promptly to all requests for assistance. The care plan also documented the resident had decreased safety awareness and judgement, got up spontaneously, did not use his/her call light to summon assistance, and directed staff to offer assistance if they saw the resident trying to get up. The care plan lacked documentation for direction to staff for non weight bearing and use of a full lift after the resident's fall and fractures on 9/13/18. The facility's fall log notebook documented no falls for this resident from 1/1/18 to 9/12/18, a fall with major injury on 9/13/18, and no falls from 9/14/18 to 2/6/19. The 9/6/18 restorative progress note documented the resident ambulated with a walker and staff assistance, and staff reminded him/her to call for help with transfers however he/she forgot, and would stand up and start walking without assistance. The resident had a fast gait, and denied having pain with mobility. The 9/13/18 at 4:15 PM progress note documented the resident fell in his/her room, the fall unwitnessed, and the bed exit alarm in place but malfunctioned. As staff assessed the resident, the resident stated his/her left hip hurt a little. Staff assisted the resident to stand but he/she was reluctant to put his/her full weight on his/her left leg. Staff immediately placed the resident in a wheelchair, notified the physician, and transported the resident to the emergency room . The 9/13/18 at 7:14 PM progress note documented the resident returned from the emergency room at 6:50 PM with a [DIAGNOSES REDACTED]. An (MRI) medical examination performed using magnetic resonance imaging to view detailed images of the organs and tissues within the body, was scheduled the following day at the hospital. Staff assisted the resident to his/her bed, and he/she complained of discomfort with movement. The 9/14/18 at 8:05 AM progress note documented the resident denied pain without movement, but upon assist with transfer the resident complained of pain in his/her left hip. The 9/14/18 at 4:48 PM progress note documented the MRI was completed and results showed non displaced superior and inferior pubic rami fractures (2 breaks in the pelvic bone) on the left and muscle strain. The resident continued to complain of pain to the left hip area. The note documented the physician ordered the resident to be non weight bearing to the left lower extremity for 3 weeks. The nurse, in consultation with the Director of Nursing, decided the resident needed to be assisted with transfers using a full lift and use a wheelchair for mobility when out of bed. The 9/14/18 at 8:09 PM progress note documented after supper the resident was sitting at the dining table and was observed to stand unassisted from the wheelchair and hold on to the table. Staff immediately assisted the resident to a seated position and the resident stated, I am trying to get that leg to work. Staff explained to the resident that his/her leg had been injured and he/she cannot stand on the leg right now. On 2/5/19 at 8:15 AM, observation revealed the resident sat at dining room table after breakfast, stated I don't know where I'm supposed to be, tried to stand several times, then finally stood and grabbed his/her walker. A (CNA) certified nurse aide came to the resident quickly, placed a gait belt (belt used to help transfer a person from one place to another) around the resident, and walked with him/her back to his/her room. The resident walked slowly and fairly steady. On 2/5/19 at 4:06 PM, Licensed Nursing Staff G stated when a resident fell , the charge nurse notified the Director of Nursing, Administrative Nursing Staff D, who advised them on what measures to implement or change for the resident's care. On 2/6/19 at 9:58 AM, Administrative Nursing Staff D stated it was the responsibility of the Director of Nursing or the MDS nurse to update the care plan, and verified staff had not reviewed or revised the care plan after the resident's 9/13/18 fall or the 9/14/18 physician's orders [REDACTED]. The facility's Care Plan policy, last reviewed 11/2016, documented the planning for care, treatment and services will include the following: regularly reviewing and revising the plan for care, treatment and services and the plan of care will be continually evaluated based on the patient's clinical condition, results of diagnostic tests, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the patient's changing condition. The facility failed to review or revise Resident #7's care plan after a fall with major injury and a subsequent temporary but significant change in the resident's mobility, which placed the resident at risk for further falls, injuries and impaired healing of his/her fractures.

The facility had a census of 35 residents. The sample included 11 residents. Based on observation, interview and record review, the facility failed to ensure the environment remained free of accident hazards, such as accessible chemicals, for the 4 cognitively impaired, independently mobile residents who reside in the facility. Findings included: - On 10/16/17 at 4:55 PM, observation during initial tour revealed the whirlpool room unlocked, and an unlocked cabinet had a partially used gallon container of Turb O Kleen detergent. The container's label stated Keep Out of Reach of Children.The cabinet was approximately 5 feet above the floor. On 10/16/17 at 4:55 PM, Nurse B verified staff should ensure the detergent was in a locked storage cabinet. On 10/18/17 at 2:20 PM, Administrative Nurse A verified staff should have secured the detergent in a locked cabinet. He/she reported 4 cognitively impaired, independently mobile residents, who could potentially reach the cabinet. The Turb O Kleen label documented the following: Mild irritation of sensitive skin and mucus membranes. Eyes: Irritation, Do not get into eyes. Eye Contact: Flush eyes thoroughly with plenty of water for 15 minutes. Do not ingest. The facility's 11/18/16 Control of Hazardous Chemicals policy stated all substances with warning labels such as keep out of reach of children will be locked and inaccessible to residents at all times. The facility failed to ensure the container of Turb O Kleen whirlpool detergent was secure, placing the 4 cognitively impaired, independently mobile residents who reside in the facility at risk for injury.

The facility had a census of 35 residents. The sample included 11 residents. Based on observation, record review, and interview, the facility failed to implement and maintain a safe, sanitary and comfortable environment, by leaving oxygen cannula (nose piece) and tubing stored incorrectly for the 3 of 5 residents who use oxygen (#20, #34, #17) and improper sanitation of a glucometer (blood sugar testing machine) for 4 residents who received blood sugar checks. Findings included: - On 10/17/17 at 7:51 AM, observation revealed in Resident #34's room, the oxygen tubing and cannula unbagged, rolled up, and placed on top of the oxygen concentrator. On 10/17/17 at 11:11 AM, observation revealed Nurse D cleaned the glucometer with an alcohol wipe after obtaining blood from a resident. On 10/17/17 at 2:17 PM, observation revealed in Resident #17's room, the oxygen tubing, and cannula, unbagged and coiled on top of the oxygen concentrator. On 10/17/17 at 2:18 PM, observation revealed in Resident #20's room, the oxygen tubing, unbagged, and hanging over the oxygen concentrator. On 10/18/17 at 4:28 PM, observation revealed in Resident #17's room, the oxygen tubing, and cannula, unbagged and coiled on top of the oxygen concentrator. On 10/18/17 at 4:49 PM, observation revealed in Resident #34's room, the oxygen tubing, and cannula unbagged, and draped across the bed. On 10/17/17 at 11:11 AM, Nurse D verified 4 residents required blood sugar testing using the same glucometer. On 10/19/17 at 8:35 AM, Administrative Nurse C verified the nasal cannulas and tubing were not placed into the bags on the side of the oxygen concentrator, and the staff were to clean glucometer with a germicidal cleaner. The 1/11/17 facility's Oxygen/Nebulizer Delivery Policy documented to store all cannulas in respiratory storage pouches when not in use. The 11/4/11 facility's Cleaning and Disinfection Procedure for glucometers, states to thoroughly wipe the surface of the scanner with a fresh germicidal wipe and leave wet for 1 minute and is allowed to air dry for an additional 1 minute, before drying with tissue. The facility failed to provide a safe, sanitary and comfortable environment by storage of oxygen tubing and cannula outside of bag attached to oxygen concentrator and not following cleaning and disinfection of the glucometer, placing the residents at risk for development and transmission of diseases.

The facility had a census of 35 residents. The sample included 11 residents, of which 5 residents were reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to obtain a risk versus benefit statement for the continued use of [MEDICAL CONDITION] (drugs that affect a person's mental state) medications for Residents #29 and #13, and failed to have an effective system for bowel monitoring for Residents #29 and #13, who were self-sufficient with toileting. Findings included: - Resident #29's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/19/17, documented the resident had moderately impaired cognition, with a (BIMS) Brief Interview for mental Status score of 11. The MDS documented the resident had no behaviors, required limited staff assistance with toileting, and received antipsychotic (class of psychiatric medication primarily used to manage [MEDICAL CONDITION]), antidepressant (drug used to treat [MEDICAL CONDITION]), and diuretic (medication to promote the formation and excretion of urine) medications during the 7 day look back period. The quarterly MDS, dated [DATE], documented the same. The 7/14/17 care plan for medications included the black box warnings (the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug) for the resident's medications, side effects of medications, and directed staff to obtain weekly vital signs. The care plan documented the resident used antidepressant and antipsychotic medications for depression and delusional thinking, and directed staff to observe and document side effects and effectiveness every shift. The care plan further directed staff to discuss with the physician and family the ongoing need for use of the medication. The care plan did not address constipation, hemorrhoids, or bowel management. The 8/12/17 social service note documented the resident's family reported the resident often says he/she does not know who he/she is, where he/she is at, and what he/she is supposed to do. The note documented the physician ordered staff to continue with the same medications and she/he would evaluate the resident at the 60 day visit (sometime in August). The 10/11/17 physician's orders [REDACTED]. [MEDICATION NAME] (antidepressant), 5 (mg) milligrams, daily, for depression, initiated 6/2/16. [MEDICATION NAME] (antipsychotic), 0.25 mg, twice daily, for [MEDICAL CONDITION], initiated 6/2/16. Senna (bowel laxative), 1 tablet, daily, for constipation, initiated 6/29/16. [MEDICATION NAME] (bowel softener), 100 mg, twice daily, for constipation, initiated 8/23/17. The 10/31/16 psychoactive medication assessment documented the resident received [MEDICATION NAME] and [MEDICATION NAME] daily, for depression and [MEDICAL CONDITION]. The assessment documented the resident had behaviors including paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), delusions (untrue persistent belief or perception held by a person although evidence shows it is untrue), and depression with tearfulness, but had no recent behaviors. The 10/9/17 psychoactive medication assessment documented the same. The pharmacist consultant reviews documented the following: 3/15/17 - recommended (GDR) Gradual Dose Reduction or discontinue [MEDICATION NAME]. The physician ordered no change and did not provide a risk versus benefit statement for the continued used of the drug. 5/10/17 recommended GDR of [MEDICATION NAME]. The physician ordered no change, and did not provide a risk versus benefit statement for the continued use of the drug. 9/19/17 recommended GDR of [MEDICATION NAME]. The physician ordered no change, and did not provide a risk versus benefit statement for the continued use of the drug. The facility's bowel movement monitoring report for the last 60 days documented self sufficient numerous times which did not reveal if the resident had a (BM) bowel movement or not. The (MONTH) (YEAR) Medication and Treatment Administration Records documented no intervention provided for constipation on 10/14/17, the 4th day without a BM documented. The 10/11/17 through 10/15/17 nurse's progress notes lacked documentation of assessment of bowel sounds or abdominal assessment. Further review of the facility's bowel monitoring system revealed an alert in the progress notes if staff documented no BM for 3 days. The system did not alert the nurse if staff documented the resident was self sufficient with toileting. On 10/17/17 at 7:46 AM, observation revealed the resident sat at the dining table and Nurse F administered medications to him/her. On 10/18/17 at 7:40 AM, Administrative Nurse C verified the facility staff documented the resident was self-sufficient, numerous times, when they were to document if the resident had a bowel movement. Administrative Nurse C verified the facility's documentation had not reliably shown if the resident's bowel management medication was effective or ineffective, and the resident was not a reliable historian. On 10/18/17 at 7:45 AM, Nurse Aide H stated the resident toilets him/herself at times. Nurse Aide H stated staff ask the resident if he/she had a BM, but he/she is not always able to remember, so staff chart the resident as self sufficient. On 10/19/17 at 8:40 AM, Administrative Nurse C stated the facility sends the pharmacist recommendations to the physician, the form is returned to the facility and was forwarded to the pharmacy if medications changes were ordered. The facility had informed the medical director of the need for risk versus benefit statements from the physicians. Administrative Nurse C stated the resident had significant [MEDICAL CONDITION] when the psychiatrist started [MEDICATION NAME], nursing educated the family about GDRs, but the family did not want [MEDICATION NAME] decreased. Administrative Nurse C stated the resident's physician had not written a risk versus benefit statement for the continued use of [MEDICATION NAME] or [MEDICATION NAME]. On 10/19/17 at 8:42 AM, Nurse G stated the resident had some confusion and his/her latest BIMS score was 9, which indicated moderate cognitive impairment. On 10/19/17 at 10:40 AM, Nurse Aide J stated if a resident was independent with toileting, staff chart self-sufficient. Nurse Aide J stated the resident self toilets and staff ask him/her if he/she had a BM, but sometimes the resident did not remember, so staff document self-sufficient and assume he/she may have had a BM. On 10/19/17 at 10:55 AM, Nurse D stated the resident informed staff when he/she had constipation issues. Nurse D stated he/she was not aware aides had documented self-sufficient and he/she verified that did not indicate if the resident had a BM or not. Nurse D verified the resident had issues with constipation and confusion at times, and stated the resident currently had complaints of constipation. On 10/19/17 at 1:35 PM , Administrative Nurse C verified the pharmacist consultant had not followed up the lack of risk versus benefit statements for [MEDICATION NAME] and [MEDICATION NAME]. The facility's 1/10/17 Bowel Monitoring policy documented bowels will be monitored to prevent fecal impaction or no bowel movements within 3 consecutive days. The policy documented staff would educate alert and oriented, independent residents to let staff know of any problems with their bowels or if they require an intervention for constipation. The policy stated, for residents who are confused or require assistance with toileting, all bowel movements will be documented and the electronic program will alert nursing staff daily of any resident who had not bowel movement in the last 3 days. The night shift nurse is responsible for assessing which residents are on the alert, and will assess for and note bowel sounds, abdominal distention, pain, or any complaints voiced by the resident. If the assessment is within normal limits, the nurse will administer (MOM) Milk of Magnesia (laxative) during the evening. The facility's Medication Monitoring Guidelines policy, dated 4/29/17, recorded a Gradual Dose Reduction (GDR) would be attempted with all residents who receive antipsychotic medications, unless clinically contraindicated and documented. The facility failed to have an effective system in place to monitor bowel movements for self sufficient residents and failed to complete a risk versus benefit statement for the continued use of [MEDICATION NAME] and [MEDICATION NAME] for Resident #29, which placed the resident at risk for adverse side effects and constipation. - Resident #13's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 8/9/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition, he/she had verbal behavioral symptoms toward others 1 to 3 days of the 7 day look back period and was independent with most (ADLs) activities of daily living, including toileting. The MDS further recorded the resident received antipsychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and diuretic (medication to promote the formation and excretion of urine) medications. The 8/12/17 care plan directed staff to administer physician ordered [MEDICATION NAME], a [MEDICAL CONDITION] medication, and observe for side effects and effectiveness every shift. The care plan lacked direction to staff regarding the resident's bowel management. The 10/12/17 physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic), 50 (mg) milligrams, by mouth, at bedtime, for [MEDICAL CONDITION] not due to a substance or known physiological condition, initiated on 4/24/17. [MEDICATION NAME] (a laxative), 100 mg, by mouth, (PRN) as needed, for constipation, initiated on 8/16/16. Saline Enema, 4.4 (gm) gram/118 (ml) milliliters, 118 ml, rectally, every 24 hours, PRN, for constipation, initiated on 11/30/15. Milk of Magnesia (a laxative), 1200 mg/15 ml, give 30 ml, by mouth, every 24 hours, PRN, for constipation, initiated on 11/30/15. Review of the pharmacy consultant reviews revealed a (GDR) Gradual Dose Reduction for [MEDICATION NAME] was suggested for the resident on 7/14/17, the physician denied the GDR, but the document lacked documentation of the risk for the continued use of the [MEDICATION NAME]. Further review of the medical record revealed the facility had documented self sufficient on the bowel tracking system and did not record if the resident had a bowel movement or not for August, (MONTH) and (MONTH) (YEAR). On 10/17/17 at 9:19 AM, observation revealed the resident ambulated, using a cane, with a slow steady gait, into the chapel with other residents. On 10/18/17 at 7:52 AM, Administrative Nurse C verified the facility lacked a bowel monitoring system for the self sufficient residents, verified the facility needed to monitor bowel movements on all residents, and the medical record lacked a risk versus benefit statement for the resident's continued use of [MEDICATION NAME]. On 10/19/17 at 10:43 AM, Nurse Aide E verified the resident took him/herself to the bathroom and staff had not asked the resident if he/she had a bowel movement or not. Nurse Aide E verified documenting self sufficient on the bowel tracking system would not indicate if the resident had a bowel movement or not. On 10/19/17 at 11:11 AM, Nurse D verified the resident took him/herself to the bathroom, documenting self sufficient on the bowel movement record did not indicate if the resident had a bowel movement or not and the facility needed to monitor bowel movements on all residents. The facility's bowel monitoring policy, dated 1/10/17, recorded bowels would be monitored by nursing staff to prevent more than 3 consecutive days without a bowel movement. The facility's Medication Monitoring Guidelines policy, dated 4/29/17, stated Gradual Dose Reduction (GDR) was attempted with all residents who receive antipsychotic medications, unless clinically contraindicated and documented. The facility failed to have an effective system in place to monitor bowel movements for self sufficient residents and complete a risk statement for the continued use of [MEDICATION NAME] for Resident #13, which placed the resident at risk for adverse side effects of an antipsychotic medication and constipation.

The facility had a census of 35 residents. The sample included 11 residents, of which 5 were reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to follow up on the pharmacist consultant recommendations for risk versus benefit reviews from the physician for the continued use of psychoactive (a drug affecting the mind) medications, and the consultant pharmacist failed to notify the director of nursing and physician of the facility's failure to have an effective system in place to monitor bowel movements for self-sufficient residents for 2 of 5 residents. (#13, #29) Findings included: - Resident #29's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/19/17, documented the resident had moderately impaired cognition, with a (BIMS) Brief Interview for mental Status score of 11. The MDS documented the resident had no behaviors, required limited staff assistance with toileting, and received antipsychotic (class of psychiatric medication primarily used to manage psychosis), antidepressant (drug used to treat clinical depression), and diuretic (medication to promote the formation and excretion of urine) medications during the 7 day look back period. The quarterly MDS, dated [DATE], documented the same. The 7/14/17 care plan for medications included the black box warnings (the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug) for the resident's medications, side effects of medications, and directed staff to obtain weekly vital signs. The care plan documented the resident used antidepressant and antipsychotic medications for depression and delusional thinking, and directed staff to observe and document side effects and effectiveness every shift. The care plan further directed staff to discuss with the physician and family the ongoing need for use of the medication. The 8/12/17 social service note documented the resident's family reported the resident often says he/she does not know who he/she is, where he/she is at, and what he/she is supposed to do. The note documented the physician ordered staff to continue with the same medications and she/he would evaluate the resident at the 60 day visit (sometime in August). The 10/11/17 physician's orders [REDACTED]. Lexapro (antidepressant), 5 (mg) milligrams, daily, for depression, initiated 6/2/16. Risperdal (antipsychotic), 0.25 mg, twice daily, for psychosis, initiated 6/2/16. Senna (bowel laxative), 1 tablet, daily, for constipation, initiated 6/29/16. Colace (bowel softener), 100 mg, twice daily, for constipation, initiated 8/23/17. The 10/31/16 psychoactive medication assessment documented the resident received Risperdal and Lexapro daily, for depression and psychosis. The assessment documented the resident had behaviors including paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking), delusions (untrue persistent belief or perception held by a person although evidence shows it is untrue), and depression with tearfulness, but had no recent behaviors. The 10/9/17 psychoactive medication assessment documented the same. The pharmacist consultant reviews documented the following: 3/15/17 - recommended (GDR) Gradual Dose Reduction or discontinue Risperdal. The physician ordered no change and did not provide a risk versus benefit statement for the continued used of the drug. 5/10/17 recommended GDR of Lexapro. The physician ordered no change, and did not provide a risk versus benefit statement for the continued use of the drug. 9/19/17 recommended GDR of Risperdal. The physician ordered no change, and did not provide a risk versus benefit statement for the continued use of the drug. The facility's bowel movement monitoring report for the last 60 days documented self sufficient numerous times which did not reveal if the resident had a (BM) bowel movement or not. The (MONTH) (YEAR) Medications and Treatment Administration Records documented no intervention provided for constipation on 10/14/17, the 4th day without a BM documented. The 10/11/17 through 10/15/17 nurse's progress notes lacked documentation of assessment of bowel sounds or abdominal assessment. Further review of the facility's bowel monitoring system revealed an alert in the progress notes if staff documented no BM for 3 days. The system did not alert the nurse if staff documented the resident was self sufficient with toileting. On 10/17/17 at 7:46 AM, observation revealed the resident sat at the dining table and Nurse F administered medications to him/her. On 10/18/17 at 7:40 AM, Administrative Nurse C verified the facility staff documented the resident was self-sufficient, numerous times, when they were to document if the resident had a bowel movement. Administrative Nurse C verified the facility's documentation had not reliably shown if the resident's bowel management medication was effective or ineffective, and the resident was not a reliable historian. On 10/18/17 at 7:45 AM, Nurse Aide H stated the resident toilets him/herself at times. Nurse Aide H stated staff ask the resident if he/she had a BM, but he/she is not always able to remember, so staff chart the resident as self sufficient. On 10/19/17 at 8:40 AM, Administrative Nurse C stated the facility sends the pharmacist recommendations to the physician, the form is returned to the facility and was forwarded to the pharmacy if medications changes were ordered. The facility had informed the medical director of the need for risk versus benefit statements from the physicians. Administrative Nurse C stated the resident had significant psychosis when the psychiatrist started Risperdal, nursing educated the family about GDRs, but the family did not want Risperdal decreased. Administrative Nurse C stated the resident's physician had not written a risk versus benefit statement for the continued use of Risperdal or Lexapro. On 10/19/17 at 8:42 AM, Nurse G stated the resident had some confusion and his/her latest BIMS score was 9, which indicated moderate cognitive impairment. On 10/19/17 at 10:40 AM, Nurse Aide J stated if a resident was independent with toileting, staff chart self-sufficient. Nurse Aide J stated the resident self toilets and staff ask him/her if he/she had a BM, but sometimes the resident did not remember, so staff document self-sufficient and assume he/she may have had a BM. On 10/19/17 at 10:55 AM, Nurse D stated the resident informed staff when he/she had constipation issues. Nurse D stated he/she was not aware aides had documented self-sufficient and he/she verified that did not indicate if the resident had a BM or not. Nurse D verified the resident had issues with constipation and confusion at times, and stated the resident currently had complaints of constipation. On 10/19/17 at 1:35 PM , Administrative Nurse C verified the pharmacist consultant had not followed up the lack of risk versus benefit statements for Risperdal and Lexapro, and had not notified him/her of the lack of an adequate system for bowel monitoring. The facility's 1/10/17 Bowel Monitoring policy documented bowels will be monitored to prevent fecal impaction or no bowel movements within 3 consecutive days. The policy documented staff would educate alert and oriented, independent residents to let staff know of any problems with their bowels or if they require an intervention for constipation. The policy stated, for residents who are confused or require assistance with toileting, all bowel movements will be documented and the electronic program will alert nursing staff daily of any resident who had not bowel movement in the last 3 days. The night shift nurse is responsible for assessing which residents are on the alert, and will assess for and note bowel sounds, abdominal distention, pain, or any complaints voiced by the resident. If the assessment is within normal limits, the nurse will administer (MOM) Milk of Magnesia (laxative) during the evening. The facility's Medication Monitoring Guidelines policy, dated 4/29/17, recorded a Gradual Dose Reduction (GDR) would be attempted with all residents who receive antipsychotic medications, unless clinically contraindicated and documented. The facility's 6/2/16 Consultant Pharmacist Services policy documented the consultant pharmacist reviewed the medication regimen of each resident monthly. He/she would e-mail the report to the DON/ADON for review and recommendations would be sent to the provider for consideration. If the provider declined the recommendation, documentation would be provided as to why. The pharmacist would be responsible to communicate to the physician potential or actual problems detected related to medication therapy and would submit a report concerning compliance with previous monthly recommendations. The facility's 4/29/17 Medication Monitoring policy recorded GDR is attempted with all residents who receive antipsychotic medications, unless clinically contraindicated and documented. The consulting pharmacist notifies the provider if any antipsychotic or antidepressant does not comply with the monitoring guidelines. The facility's Psychotropic medication policy documented efforts to reduce dosage or discontinue psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. The policy stated the pharmacist will make recommendations for GDR as indicated. The facility failed to complete a risk versus benefit statement for the continued use of Risperdal and Lexapro for Resident #29, which placed the resident at risk for adverse medication side effects and failed to have an effective system in place to monitor bowel movements for self-sufficient residents, which placed the resident at risk for bowel constipation. - Resident #13's physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 8/9/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 15, which indicated intact cognition, he/she had verbal behavioral symptoms toward others 1 to 3 days of the 7 day look back period and was independent with most (ADLs) activities of daily living, including toileting. The MDS further recorded the resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) and diuretic (medication to promote the formation and excretion of urine) medications. The 8/12/17 care plan directed staff to administer physician ordered Seroquel, a psychotropic medication, and observe for side effects and effectiveness every shift. The care plan lacked direction to staff regarding the resident's bowel management. The 10/12/17 physician's orders [REDACTED]. Seroquel (an antipsychotic), 50 (mg) milligrams, by mouth, at bedtime, for psychosis not due to a substance or known physiological condition, initiated on 4/24/17. Colace (a laxative), 100 mg, by mouth, (PRN) as needed, for constipation, initiated on 8/16/16. Saline Enema, 4.4 (gm) gram/118 (ml) milliliters, 118 ml, rectally, every 24 hours, PRN, for constipation, initiated on 11/30/15. Milk of Magnesia (a laxative), 1200 mg/15 ml, give 30 ml, by mouth, every 24 hours, PRN, for constipation, initiated on 11/30/15. Review of the pharmacy consultant reviews revealed a (GDR) Gradual Dose Reduction for Seroquel was suggested for the resident on 7/14/17, the physician denied the GDR, but the document lacked documentation of the risk for the continued use of the Seroquel. Further review of the medical record revealed the facility had documented self-sufficient on the bowel tracking system and did not record if the resident had a bowel movement or not for August, (MONTH) and (MONTH) (YEAR). Review of the 8/10/17, and 9/12/17 pharmacy consultant reviews revealed no documentation of a risk vs benefit statement for the resident's continued use of Seroquel. On 10/17/17 at 9:19 AM, observation revealed the resident ambulated, using a cane, with a slow steady gait, into the chapel with other residents. On 10/18/17 at 7:52 AM, Administrative Nurse C verified the facility lacked a bowel monitoring system for the self- sufficient residents, verified the facility needed to monitor bowel movements on all residents, and the medical record lacked a risk versus benefit statement for the resident's continued use of Seroquel. Administrative Nurse C verified the pharmacy consultant had not addressed the lack of a risk statement for the continued use of Seroquel. On 10/19/17 at 10:43 AM, Nurse Aide E verified the resident took him/herself to the bathroom and staff had not asked the resident if he/she had a bowel movement or not. Nurse Aide E verified documenting self-sufficient on the bowel tracking system would not indicate if the resident had a bowel movement or not. On 10/19/17 at 11:11 AM, Nurse D verified the resident took him/herself to the bathroom, documenting self-sufficient on the bowel movement record did not indicate if the resident had a bowel movement or not and the facility needed to monitor bowel movements on all residents. The facility's bowel monitoring policy, dated 1/10/17, recorded bowels would be monitored by nursing staff to prevent more than 3 consecutive days without a bowel movement. The facility's Medication Monitoring Guidelines policy, dated 4/29/17, stated Gradual Dose Reduction (GDR) was attempted with all residents who receive antipsychotic medications, unless clinically contraindicated and documented. The facility's consultant pharmacist services provider requirements policy, dated 6/2/2016, documented a review of the medication regimen of each resident would be completed monthly, utilizing federally mandated standards of care in addition to other applicable standards, and documenting the review and findings in the resident's medical record. The recommendations would be send to the provider for consideration and if the provider declined a recommendation, documentation would be provided as to why. The facility's consultant pharmacist failed to notify the director of nursing and physician, of the facility's failure to have an effective system in place to monitor bowel movements for self-sufficient residents and the physician's failure to complete a risk statement for the continued use of Seroquel for Resident #13, which placed the resident at risk for adverse side effects of an antipsychotic medication and constipation.

The facility reported a census of 37 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement (to leave without staff knowledge). Findings included: - Resident #1's physician's orders [REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 11, which indicated moderately impaired cognition. He/she had no wandering, required limited assistance with some activities of daily living (ADLs), such as toileting, dressing, and personal hygiene, and used a cane to walk about the unit. The elopement risk assessment dated [DATE] documented a score of 5, which placed the resident as a low risk for elopement. The care plan dated 1/18/17 documented the resident admitted to the facility on [DATE], had dementia, was not able to care safely for his/herself without 24 hour supervision, and did not expressed a desire to return to home. Review of the facility self-report investigation documented on 3/4/17 during staff shift change at 9:30 P.M., staff checked all alarmed exit doors and the doors functioned properly. Staff observed the resident at 10:45 P.M. in the hall near his/her room. On 3/4/17 at 10:50 P.M. staff located the resident outside the facility. The care plan update on 3/6/17 documented the resident was an elopement risk related to cognitive loss. Staff placed a wander guard bracelet (a signaling device to alert staff when a resident neared a facility exit) on the resident. Staff was to check its function every shift and report to the charge nurse if staff was unable to locate the bracelet. According to a step-off measurement (a calculation of a measurement by steps), the resident walked approximately 40 feet off of a secure unit, and walked another 30 feet to the sidewalk on the west (front) side of the building. According to wunderground.com, the outside temperature on 3/4/17 at 10:53 P.M. was 61.4 degrees. The winds were 19.5 miles per hour and the sky was clear. On 3/20/17 at 2:15 P.M., the resident slept in a recliner. He/she wore a wander guard bracelet on his/her right wrist. On 3/20/16 at 4:40 P.M., the resident did not remember exiting the facility on 3/4/17, and stated he was able to get back in. On 3/20/17 at 4:49 P.M., licensed nurse H stated the resident acted cognitively intact, but was quite confused. He/she said the resident was not aware of safety needs and precautions. Nurse H further stated when the resident first came to the facility, staff identified him/her as an elopement risk, and he/she wore a wander guard bracelet at that time. On 3/20/17 at 4:55 P.M., administrative licensed nurse D stated he/she believed the resident followed a visitor off the unit through an alarmed exit door, which led to a corridor to the adjacent hospital. The resident was dressed appropriately for the outside weather. The resident presented him/herself as cognitively intact. Administrative nurse D stated for the past 11 months, the resident did not wear a wander guard bracelet. Staff D further stated staff did not assess the resident as a wander risk for the last 20 months. The facility's Elopement Risk policy, revised 11/13/15, documented residents identified at risk to wander/elope must have an individualized plan of care. Potential care plan interventions may include to educate staff on the importance of visual checks of residents identified at risk of wandering/elopement, monitor response/reaction to events/activity in surroundings at the time of wandering, and provide activity at change of shift to keep resident busy at time of high noise and exiting of staff. The facility failed to ensure this cognitively impaired resident, identified at risk for elopement, received adequate supervision to prevent an elopement on 3/4/17.

The facility had a census of 37 residents. Based on observation, interview and record review the facility failed to ensure an environment free of accident hazards, regarding a hot steam table, for the 6 cognitively impaired, independently mobile residents, as identified by the facility, on 3 of 4 onsite days. Findings included: - On 3/22/16 at 10:30 AM, observation revealed the kitchen's steam table (equipment used to keep food hot until served) in the hall leading to the adjoining hospital. The steam table was plugged in and the surface temperature of the accessible lids registered 168 degrees (F) Fahrenheit. Continued observation revealed no staff in the area, and no residents unaccompanied by staff went past the steam table. Observation continued for 40 minutes without any residents approaching the hot steam table. At 11:10 AM, dietary staff started placing food in the steam table. On 3/22/16 at 3:30 PM, the steam table was in the hall, unplugged, and the surface was slightly warm to touch, not hot. On 3/28/16 at 11:35 AM, observation revealed the steam table plugged in and hot to touch on the 2nd lid, with steam escaping around the edges. On 3/28/16 at 11:40 AM, Dietary Staff A stated staff turn the steam table heat on about 5:30 AM, turn temperature down after breakfast and staff turn the heat up again about 10:00 AM. He/she stated staff unplug the steam table after lunch until close to suppertime. On 3/28/16 at 4:15 PM, observation revealed the steam table surface, third lid, was hot to touch. Environmental Staff B verified the lids were hot to touch and checked surface with a thermometer. The facility's thermometer revealed the surface temperature of 154 F. He/she verified that it was a concern that staff do not keep it in sight at all times when it was hot. On 3/29/16 at 10:00 AM, observation of the steam table revealed the 3rd lid from the right had a surface temperature of 156 F, with visible steam flowing out from under the lid. Further observation revealed no staff or residents in the area. On 3/28/16 at 5:05 PM, Administrative Nurse C reported the facility had 6 residents who were cognitively impaired, and independently mobile. He/she verified the potential hazard due to the steam table being accessible to residents and without direct supervision. The facility's 5/7/2012 policy for food temperatures directed staff to turn on the steam table at least 45 minutes before meal serving time and keep steam table lids on pans in the steam table wells to avoid heat loss. The facility failed to ensure the hot surface of the steam table was not accessible to the 6 cognitively impaired, independently mobile residents of the facility.

The facility had a census of 37 residents. The sample included 4 residents. Based upon record review, observation and interview the facility failed to provide adequate supervision to prevent falls for 1 (#1) a closed record review of 4 sampled resident who fell and sustained a fracture. Findings included: - Resident's #4's electronic medical record revealed the resident had a [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS) and displayed verbal behaviors 1 to 3 days during the 7 day assessment period. The resident required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, toilet use and personal hygiene and required limited staff assistance with dressing. The resident was not steady and was only able to stabilize himself/herself with staff assistance when moving from a seated to a standing position, walking, surface to surface transfers, and moving on/off the toilet. The resident had an impairment on one side of his/her upper extremity and on both sides of his/her lower extremity, and had 1 or more non- injury falls and 1 injury except major fall since the prior assessment. The resident's Cognitive Loss Care Area Assessment (CAA) dated 1/11/15 documented the resident was admitted last year with [DIAGNOSES REDACTED]. His BIMS score on admission was 10 (moderately impaired cognition) and three months later it was a four (severely impaired cognition) and the resident's family states he/she was more confused and did not always recognize them. At night the resident thought he/she was still working on the ranch. The resident's Fall CAA dated dated 1/11/15 documented the resident fell in his/her room on 11/27/14, 12/04/14, 12/17/14 at night each time and with each fall the resident was trying to go to the bathroom. The resident was not on a 2 hour toileting schedule at night. The resident required a walker and staff support to ambulate due to balance problems and poor safety awareness and was on a nursing restorative program to maintain function. The resident's Fall Assessments dated 3/17/15 and 6/16/15 identified the resident was at high risk for falling. The resident's care plan revised on 8/11/15 included the resident was at high risk for fall related to an unaware of safety needs, use of psychotropic medication, gait/balance problems, incontinence and actual falls. Since 1/11/15 the resident utilized a chair/bed alarm at all times, staff ensure the device was in place and was working. Staff anticipated and met the resident's needs and the resident did not use the call light. The resident fell at night and was on a two hour toileting schedule, staff kept the resident's room and hallways clutter free and frequently observed the resident. A nursing note (NN) dated 6/13/15 and timed 2:24 A.M. documented the resident bed alarm sounded. The resident stood up and urinated on the floor. The resident had on grippy socks, slipped on urine and fell into his/her bed. A NN dated 6/16/15 and timed 12:29 P.M. documented the resident's alarm sounded and as staff came around the corner the resident stood by the wall. The resident stood and walked unassisted without staff and his/her walker. The staff was unable to reach the resident before he/she fell on his/her buttock and then over to his/her right side on his/her elbow keeping his/her head forward. The resident complained of right arm, elbow, wrist and lower back and hip pain and the facility received a physician's orders [REDACTED]. A NN dated 8/9/15 and timed 2:05 P.M. documented the resident got out of a recliner in the living room without assistance and fell when he/she reached the dining room and tile floor. The resident had on shoes that were appropriately tied and the floor was dry. The event happened at shift change with the nursing staff at the nurses station finishing report. The resident laid on his/her right side, his/her right arm was behind his/her back and the resident leaned forward a bi. The resident moaned and groaned as in pain, complained of pain in his/her right shoulder and right hip. At 2:!5 P.M. the facility received a physician's orders [REDACTED]. At 2:55 P.M. the facility transferred the resident to the emergency for x-rays. A Radiology report dated 8/9/15 documented the reason for the exam was the resident fell . The impression was the resident had an acute fracture of the right acetabulum ((the socket of the hipbone, into which the head of the femur (thigh bone) fits) which also involved the right superior and inferior pubic ramus (group of bones that make up a portion of the pelvic bone). There was a medial displacement of the femur (thigh bone) and protrusion acetabuli. A NN dated 8/9/15 timed 7:00 P.M. documented the resident was transferred to a hospital for outpatient observation due to having 2 falls in the last 6 weeks that required x-rays. A NN dated 8/10/15 and timed 4:40 P.M. documented the resident arrived back to the facility. A NN dated 8/11/15 timed 11:01 A.M. documented the facility received the emergency room progress note. The note include the ER progress note read the resident was brought to the emergency room because the resident had a an unwitnessed fall. The resident was cognitive impaired and complained of right hip and shoulder pain. The note included the resident had a pelvic fracture into the acetabulum(the socket of the hipbone, into which the head of the femur (thigh bone) fits) and was bedrest and non-weight bearing for now. The physician doubted the resident was a surgical candidate due to the resident's age. A NN dated 8/17/15 and timed 9:10 P.M. documented the resident passed away at 5:03 P.M. Review of facility's investigation regarding the incident included that on 8/9/15 at approximately 2:04 P.M. the resident sat in a recliner in the living area, and rose form his/her chair. A pressure alarm was present in the seat of the recliner but the alarm did not sound. The resident walked, unassisted approximately 8 feet. Staff was present in the dining area however the resident was not visualized when he/she rose. The resident wore shoes with non-skid soles and were appropriately fastened. As a staff entered the area, he/she heard a noise that was later identified as the resident demonstrated loss of balance and fell to the floor. The facility counseled the staff involved in the incident, and assigned mandatory education classes preventing falls and trauma and preventing high risk occurrences on or before the staff's next assigned shift. On 9/9/15 at 1:32 P.M. direct care staff H stated the resident was at risk for falls. He/she stated the resident utilized a bed and chair alarm at all times. Direct care staff H stated he/she was on duty when the resident fell but he/she did not witness the fall. He/she stated it was his/her understanding an alarm was in the chair but was not turned on. He/she stated prior to the fall the resident sat in an electric lift chair. Direct care staff H identified the recliner where the resident sat at the time of the fall. Direct care staff H stated the resident often times sat in the electric lift chair and staff did not ensure the electric lift chair remote was not within the resident's reach. He/she stated the chair was always plugged in. Observation revealed the recliner was an electric lift chair. Further observation revealed no resident sat in the recliner, the remote to the recliner was on the arm of the chair and the chair was plugged in. On 9/9/15 at 2:13 P.M. licensed nurse F stated he/she worked the evening shift on the date of the incident. He/she stated the resident sat in a recliner with the foot rest up prior to the fall. Licensed nurse F stated after the fall the footrest of the recliner was down and he/she assumed the resident had lowered the footrest. He/she stated the remote was always accessible to residents and residents could figure out how to use the remote. Licensed nurse F stated he/she heard another yell, he/she went to see what was going on and he/she heard a noise like someone had hit the floor and he/she observed the resident on the floor. He/she there was an alarm pad in the recliner where the resident sat but it did not alarm. Licensed nurse F stated the resident was to utilize an alarm at all times. He/she identified the recliner where the resident sat. Observation revealed it was the electric lift chair identified by direct care staff H. On 9/9/15 at 3:30 P.M. administrative nursing staff D stated on the date of the incident the resident sat in a recliner in the living room. He/she stated there was an alarm pad in the recliner but it did not alarm. He/she stated the staff that placed the resident in the recliner did not turn the alarm on; therefore it did not alarm. Administrative nursing staff D stated the facility did not ensure residents with cognitive impairment were safe to use an electric lift chair with an accessible remote prior to placing residents in electric lift chairs. He/she stated if the footrest of the recliner was in an up position and the remote was not accessible the chair would be restraint which is why the facility did not ensure residents could safely use the electric lift chair. The facility's Fall Policy and Procedure dated 7/30/2014 included appropriate fall risk prevention interventions would be initiated on admission based on the residents fall risk assessment. The facility failed to provide adequate supervision, failed to ensure the alarm was on as planned and failed to ensure the resident's safety was not compromised prior to placing this severely cognitively impaired resident in an electric lift chair with access to the remote for this resident with a history of falls that fell and sustained a fracture.

The facility had a census of 35 residents. The sample included 3 residents. Based on observation, record review and interview, the facility failed to develop and implement interventions to prevent presure ulcer development for 1 of 3 residents who were reviewed for pressure sores. Resident #1 developed pressure areas on both buttocks from being placed on a fracture bed pan for an extended period of time. (# 1) Findings included: - Resident # 1's physician's orders [REDACTED].# 1 had [DIAGNOSES REDACTED]. bone tissue with an increased fracture risk),and anxiety ( a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The annual (MDS) Minimum Data Set 3.0 assessment, dated 1/8/14, indicated the resident had a (BIMS) Brief Interview for Mental Status score of 8 which indicated moderately impaired cognition and he/she required total assistance with bed mobility, transfers and toilet use. The MDS further indicated the resident was at risk for developing pressure ulcers, had pressure reducing devices for the bed and chair, on a turning and repositioning program and had no current pressure ulcers. The quarterly MDS, dated [DATE], indicated the resident had no pressure ulcers, on a turning and repositioning program and pressure reducing devices were used for the bed and chair. The 1/9/14 Activities of Daily Living care assessment summary (CAA), revealed the resident needed a mechanical lift for transfers and wheelchair mobility. The CAA also indicated the resident needed assistance with bed mobility and repositioning. The 1/9/14 care plan review revealed the resident at risk for alteration in skin integrity related to [MEDICAL CONDITION] and mobility problems. The care plan directed the staff to assist the resident with repositioning when he/she was in bed. The 1/7/14 Braden (a predicting pressure ulcer risk tool that helps establish if a resident is at risk for developing a pressure ulcer) assessment revealed a score of 16 which indicated the resident at a high risk for the development of pressure ulcers. The 1/11/14 at 5:00 AM, nurse's notes revealed the staff found the resident on a fracture bed pan and he/she had been on the bed pan for an extended period of time which caused indentions on his/her buttocks from the bed pan. The staff cleansed the resident's perirectal area and applied [MEDICATION NAME] ointment (a skin protectant with high [MEDICATION NAME] formula for preventing skin breakdown and to help treat red skin areas) was applied to the red areas on the resident's bottom. The 1/12/14 facility skin assessment documentation revealed the resident had red areas which were firm to touch in an outline of the fracture pan on his/her bottom. The skin assessment also indicated a 0.5cm (centimeters) by 0.1cm blood blister on his/her right buttock. The 1/12/14 at 6:30 PM, nurse's notes indicated the area on the resident's left and right buttocks continued to be red. The 1/13/14 nurse's notes, with no time indicated on the note, revealed the facility notified the physician regarding the area on the resident's left and right buttock which continued to be red. Further review of the nurse's notes indicated the physician ordered the wound care specialist to consult on the redness of the resident's buttocks.The physician changed the skin treatment order to [MEDICATION NAME] ointment (an ointment which acts as a protective covering on the skin, to prevent further skin breakdown and help heal skin). On 2/27/14 at 7:40 AM, observation revealed the resident, seated on a shower chair in the shower room. Further observation revealed Nurse Aide A used the sit to stand mechanical lift to stand the resident up from the shower chair. Nurse B then measured the area on the resident's left and right buttock.Further observation revealed the resident's left buttock had a dried brown circular area which measured 26.5 cm (centimeters), the resident's right buttock had a dried brown circular area which measured 26.5 cm. Nurse B verified the areas on the resident's buttocks were from when the resident had been left on the bed pan. Measurement of the fracture bed pan revealed each side of the bed pan measured 26.5 cm. On 2/26/14 at 4:00 PM, Nurse Aide C verified he/she placed the resident on a fracture bed pan on 1/10/14 at 8:45 PM. Nurse Aide C revealed he/she had not taken the resident off the bed pan and he/she did not think about the resident being left on the bed pan until he/she worked again on 1/12/14. Nurse Aide C revealed he/she thought the other Nurse Aide who worked on 1/10/14 had taken the resident off the bed pan. On 2/26/14 at 4:20 PM, Nurse E verified the staff notified the resident's Durable Power of Attorney (DPOA) 1/16/14 of the resident's skin concern and the resident being placed on a bed pan on 1/11/14 for an extended period of time. (6 days after the incident) On 2/27/14 at 6:45 AM, Nurse Aide D verified on 1/12/14 at 5:00 AM, he/she assisted the nurse with rolling the resident over on his/her side in the bed and staff removed the bed pan under the resident. On 2/27/14 at 7:00 AM, Nurse F stated on the morning of 1/12/14 at 5:00 AM, he/she entered the resident's room to place a [MEDICATION NAME] ( a topical medication patch for pain managment) on the resident's lower back as ordered by the physician. Nurse Aide D assisted Nurse F to roll the resident over on his/ her side in the bed,and at that time he/she found a fracture bed pan under the resident. Nurse F the resident was probably not even aware the bed pan was under him/her.(On bed pan for approximately 8 hours) On 2/27/14 at 9:40 AM, Nurse G revealed on 1/12/14 the staff had not notified, the resident's DPOA of the resident being left on the bed pan. On 2/27/14 at 10:10 AM, Administrative Nurse H revealed the staff are expected to check on all residents every 2 hours or more often if needed. Administrative Nurse H indicated the resident was at risk for pressure ulcer development. On 2/28/14 at 12:45 PM, Physician I stated he/she was aware the resident had been left on a bed pan for an extended period of time. Physician I revealed the resident was at risk for skin impairment and had received skin breakdown from being left on the bed pan. Physician I also indicated he/she was not aware the state agency was not notified of the incident. The 11/2003 facility's wound and skin protocol policy indicated all residents will have appropriate wound and skin care.The prevention of pressure skin problems can be carried out by repositioning. The facility failed to ensure appropriate care for Resident # 1 who developed pressure areas on his/her buttocks from being on a bed pan for an extended period of time. (approximately 8 hours)