Every finding on record at Cooney Healthcare and Rehabilitation

Based on observations, interviews, and record review, the facility failed to ensure baseline care plans were completed within 48 hours, to meet the residents' ADL needs, for 2 (#s 20 and 21) of 25 sampled residents. This deficient practice resulted in a delay in ADL cares for residents #20 and 21. Findings include:1. During an interview and observation on 12/30/25 at 4:32 p.m., resident #20 was lying in bed with family at the bedside. Resident #20 stated staff member R told her she needed to walk without her walker or the use of a gait belt over the weekend (12/27/25-12/28/25). Resident #20 stated she was not cleared by therapy to walk without a gait belt and walker. Review of resident #20's baseline care plan, revised 12/30/25, reflected that resident #20 was admitted on [DATE] and did not reflect the ADL care needs for walking, toileting, transfers, bathing, or eating. During an interview on 12/30/25 at 4:55 p.m., staff member S stated a gait belt and four-wheeled walker should have been used during any transfers or walking over the weekend of 12/27/25 - 12/28/25, per the therapy evaluation.During an interview on 12/31/25 at 10:05 a.m., staff member R stated he had received a report from the previous shift that resident #20 was not using any assistive devices. Staff member R stated he did encourage resident #20 to walk without the walker and gait belt because he was told she did not need them during the shift report.2. During an interview on 12/30/25 at 2:58 p.m., NF1 stated she came in on 12/25/25 to pick up resident #21 for the holiday. NF1 stated resident #21 was still in bed, wearing day clothes, not pajamas, was soaked in urine, and was told there was no shower room available at the moment.Review of resident #21's baseline care plan, last revised on 12/29/25, reflected resident #21 was admitted on [DATE] and did not reflect the ADL care needs for walking, toileting, transfers, or bathing.During an interview on 12/31/25 at 8:02 a.m., staff member B stated resident #20 and 21's baseline care plans were not completed and did not include the resident's ADL care needs. Staff member B stated the admitting nurse should have completed the baseline care plans at the time of admission.

Based on interviews and record review, the facility failed to provide ADL cares to meet the needs of dependent residents for 2 (#s 20 and 21) of 25 sampled residents. This deficient practice resulted in resident #20 fearing her safety during transfers and walking and resident #21 to be found by family wet and still in bed at 12:30 p.m. Findings include:1. During an interview on 12/30/25 at 4:32 p.m., resident #20 stated staff member R told her she needed to walk without her walker or gait belt over the weekend (12/27/25-12/28/25). Resident #20 stated she was not cleared by therapy to walk without a gait belt and walker. During an interview on 12/30/25 at 4:55 p.m., staff member S stated a gait belt and four-wheeled walker should have been used during any transfers or walking over the weekend of 12/27/25-12/28/25 per the therapy evaluation.During an interview on 12/31/25 at 10:05 a.m., staff member R stated stated he did encourage resident #20 to walk without the walker and gait belt because he was told she did not need them during shift report.Refer to F655 - Baseline Care Plans, for concerns related to the lack of information available on the resident care plan for #20. 2. During an interview on 12/30/25 at 2:58 p.m., NF1 stated she came in on 12/25/25 to pick up resident #21 for the holiday and resident #21 had not received the necessary ADL care that morning. Review of a statement by Staff member T, dated 12/29/25, reflected resident #21 was very sleepy and not waking up, so she let her sleep. Staff member T stated she had been told during shift report that resident #21 had a rough night (not sleeping well) and thought that was the reason for her sleepiness. Staff member T stated she was upset with herself when the family came in and was upset. Staff member T stated she should have been more aggressive in waking up resident #21 and toileting her. Refer to F655 Baseline Care Plans for resident #21.

Based on interviews and record reviews, the facility failed to ensure residents were free from abuse and neglect, psychosocial harm, and deprivation of services, for 10 (#s 3, 4, 5, 6, 7, 12, 13, 14, 15, and 16) residents, out of 19 sampled residents. These failures contributed to three new wound areas for resident #3, several residents were left all night in urine-soaked briefs/bedding, were subjected to verbal abuse or neglect, #5 was left on the commode for an extended period of time, #12 was left unclothed and soiled, and was not assisted out of bed, #16 had items taken away from him and staff were verbally abusive after he fell, and residents filed grievances and were afraid to use their call lights. Findings include:1. During an interview on 12/2/25 at 8:47 a.m., resident #10 stated she overheard the CNAs come into the room and tell her roommate (resident #3) that they would not change her brief because she was just damp, and it was a lot of work to change her because she required a Hoyer (full body) lift for brief changes, over the weekend (11/29/25 - 11/30/25). During an observation and interview on 12/2/25 at 8:49 a.m., resident #3 was in her wheelchair, wearing a brief and gown. CNA staff were exiting her side of the room with the Hoyer lift. Resident #3 stated she was not consistently getting her check and changes done when needed over the weekend of 11/29/25 - 11/30/25. Resident #3 stated she had her call light turned on, and a CNA complained about the time a Hoyer lift took and that two staff were needed to use the Hoyer lift. Resident #3 stated the CNA left her in a wet brief all night on 11/30/25.Review of resident #3's weekly head-to-toe skin check, dated 11/26/25, completed by the wound nurse, reflected that resident #3 did not have skin breakdown on her medial thighs or intergluteal cleft. Review of resident #3's Skin Issues report, dated 12/3/25, reflected three new areas of moisture-associated skin damage were found. The following skin concerns were noted: - Resident #3 was identified to have a new skin issue on the right medial thigh, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 4.8 Width (cm): 0.3 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery. - Resident #3 was identified to have a new skin issue on the left medial thigh, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 1.8 Width (cm): 0.7 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery. -Resident #3 was identified to have a new skin issue in the intergluteal cleft, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 1.5 Width (cm): 0.2 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery.2. Review of a facility-reported incident, dated 11/10/25, reflected that staff members failed to provide care in accordance with professional standards. The report showed there were allegations that residents may not have received the necessary toileting, and they were not attended to in a timely manner. Three agency staff members may have provided substandard care during the shift. The report showed residents #3, 4, 5, and 13 were affected. Review of a grievance, dated 11/10/25, reflected that resident #3 filed a grievance about a CNA who yelled at her, and then the CNA threw a blanket on her. Resident #3 stated the CNA refused to get her a drink, and when she requested a nurse, the CNA was mean to her.During an interview on 12/2/25 at 8:42 a.m., resident #3 stated she needed help on 11/10/25, and the CNA refused to assist her with toileting and was not doing the resident check and changes. Resident #3 stated the CNA yelled at her, and resident #3 kicked the CNA out of her room.3. Review of a grievance, dated 11/10/25, reflected that resident #13 filed a grievance regarding care on 11/9/25. The grievance reflected the staff-to-patient ratio was unacceptable. The grievance went on to reflect that resident #13 was still in her pajamas at noon, and she waited for her call light to be answered for over an hour. The report showed her wound dressing was not dated, and resident #13 had a UTI. On the back of the grievance was a note that showed the DON had met with staff about wound care protocols. Staff members A and F had met with the family about what was being done during times of short staffing. It was found that the weekend staff were reported to the State Survey Agency due to the concerns identified. Review of a facility provided email, dated 11/10/25, reflected the facility received, .10+ complaints on her (staff member K) for being too rough and mean to residents. Residents reported being scared to use their call light, so they didn't have to see her.During an interview on 12/2/25 at 9:45 a.m., staff member Q stated that most every resident on C and D halls filed grievances on 11/10/25 for the care received from staff member K. Staff member Q stated there were at least 10 residents complaining, including resident #s 3, 4, 5, 13, 14, and 15. Staff member Q stated she could not remember who the other residents were who complained. During an interview on 12/2/25 at 8:29 a.m., resident #4 stated on 11/10/25 no one (staff) came in to assist her, and she was not checked and changed. Resident #4 stated she regularly had diarrhea and needed to be changed, but no one ever came in when she turned her light on. Resident #4 stated she had diarrhea on 11/10/25. Resident #4 felt she did not get the care she needed the night of 11/10/25.4. Review of a facility-reported incident, dated 11/3/25, reflected that resident #6 was not being properly turned and repositioned as required, resulting in the resident being found wet with urine and in need of a full bed linen change. Staff member M was terminated for failure to provide the resident's care. During an interview on 12/1/25 at 3:11 p.m., resident #6 stated she did not get a check and changed when staff member M worked last, and she was wet with urine all night.During an interview on 12/2/25 at 8:29 a.m., resident #5 stated staff member M helped her to the toilet and then never came back. Resident #5 waited a long time on the toilet and had to finally get herself back to her bed on her own. Resident #5 stated staff member M was disgruntled and short with her when she assisted her to the toilet. 5. Review of a grievance, dated 11/10/25, reflected that resident #12 complained a CNA left her in bed naked, after complaining about changing her brief and hurting her, by leaving her covered in urine and feces overnight.During an interview on 12/3/25 at 1:30 p.m., resident #12 stated the CNA left her sitting in urine and feces all night. Resident #12 stated the CNA changed her in the morning, and then left her in bed naked, after complaining about having to change her brief. Resident #12 stated the CNA was supposed to get her up, but did not.6. During an interview on 12/2/25 at 3:07 p.m., NF2 stated she and her daughter both filed a grievance regarding a fall for resident #16 on 11/10/25, and due to abuse by staff. NF2 stated resident #16 tried to brush his teeth and fell. The nurse and CNA then yelled at him for self-transferring, and then they took his call light, water, and bedside table away, stating he wouldn't be bothering them anymore with getting up to urinate. NF2 stated that the CNA and nurse treated resident #16 like a criminal and then shut his door so he could not get help if he needed it. NF2 stated the CNA and nurse were travel staff and no longer working at the facility, as far as she was aware.During an interview on 12/3/25 at 12:35 p.m., staff member C stated she received the grievances for resident #16 on 11/10/25, and she and staff member F took them directly to staff member A, because they were abuse allegations.Review of a staff member statement, dated 12/3/25, reflected that staff member R reported that the ADON told her the night nurse and night CNA had verbally abused resident #16 after he fell, and then they took his water and call light away, so he would not get back up and fall. Review of a staff member statement, dated 12/3/25, reflected staff member S had arrived for his shift and noticed the doors were closed for the residents who were a fall risk. When he went in to check on resident #16, resident #16 told him the nurse was mean to him and took his water and call light away, so he did not self-transfer or fall.Review of a staff statement, dated 12/3/25, reflected staff member C stated on 11/11/25 she had a meeting with the family of resident #16, who reported two staff members entered resident #16's room and yelled at him saying, What the F*** are you doing on the floor? and after putting him back in bed, the two staff members removed his bedside table, call light, and water, and stated, We will not be having any more issues/problems with you tonight and shut the door. Staff member C stated she reported the abuse incident to staff member A. During an interview on 12/2/25 at 3:40 p.m., staff member A stated he had no knowledge of a fall or any grievances regarding resident #16. Staff member A stated he was not sure why he did not receive a notice of abuse for resident #16. The abuse was not investigated or reported to the State Survey Agency.7. Review of a facility-reported incident, dated 11/29/25, reflected that the Director of Nursing was notified by the RN assigned to the rehab unit of a concerning interaction involving staff member O and resident #7. The RN reported overhearing staff member O speaking to resident #7 in a harsh and inappropriate tone, stating: I am right here! Stop! Be respectful. Following the interaction, staff member O exited the resident's room and told the RN, The patient was yelling at me, so I told him to be respectful. The RN immediately instructed staff member O not to re-enter resident #7's room. The incident was reported to the DON, who directed that staff member O be removed from the schedule for the remainder of the day, and that she does not return to work at the facility pending completion of the investigation of alleged abuse.During an interview on 12/2/25 at 3:40 p.m., staff member A stated the incident reported on 11/29/25 for resident #7 was substantiated for verbal abuse, and the CNA was terminated.

Based on interviews and record reviews, the facility failed to have sufficient nursing staff available and working with the appropriate competencies and skills sets to provide nursing related services, taking the resident care needs and diagnoses of the facility's resident population into consideration, for 6 (#s 3, 5, 6, 10, 12, and 16) of 19 sampled residents. This deficient practice resulted in residents not receiving necessary ADL care and nursing services. Findings include:1. During an interview on 12/2/25 at 8:47 a.m., resident #10 stated she overheard the CNAs come into the room and tell her roommate (resident #3) that they would not change her brief because she was just damp (with urine) and it was a lot of work to change her because she required a Hoyer lift for brief changes. The Hoyer lift required two people to assist.During an interview on 12/2/25 at 8:49 a.m., resident #3 stated she was not consistently receiving the checks and changes for her brief use, when needed, over the weekend of 11/29/25 - 11/30/25. Resident #3 stated that staff complained about the time a Hoyer lift took, and that two staff members were needed to use the Hoyer lift. Resident #3 stated the CNAs left her in a wet brief all night on 11/30/25.2. Review of a facility reported incident, dated 11/10/25, reflected that staff failed to provide care in accordance with professional standards. The incident report showed residents may not have received toileting services, and they were not attended to in a timely manner. Three agency staff may have provided substandard care during the shift.3. During an interview on 12/2/25 at 8:42 a.m., resident #3 stated she needed help on 11/10/25, and the CNA refused to assist her with toileting and was not doing check and changes (brief checks/changes). 4. Review of a facility reported incident, dated 11/3/25, reflected resident #6 was not being properly turned and repositioned as required, resulting in the resident being found wet with urine and in need of a full bed linen change. During an interview on 12/1/25 at 3:11 p.m., resident #6 stated she did not get checked or changed when staff member M worked last, and she was wet all night.During an interview on 12/2/25 at 8:29 a.m., resident #5 stated that staff member M helped her to the toilet, but then she never came back. Resident #5 waited a long time on the toilet and had to finally get herself back to her bed on her own. 5. Review of a grievance, dated 11/10/25, reflected that resident #12 complained a CNA left her in bed naked and covered in urine and feces overnight.During an interview on 12/3/25 at 1:30 p.m., resident #12 stated the CNA left her sitting in urine and feces all night. Resident #12 stated the CNA changed her in the morning and then left her in bed naked. Resident #12 stated the CNA was supposed to get her up but did not.During an interview on 12/2/25 at 9:45 a.m., staff member Q stated she had several complaints regarding the travel/agency staff and call-offs. Staff member Q stated on 10/20/25, a travel CNA walked out on her shift, resulting in residents complaining. On 11/9/25, a core (non-agency) CNA walked out on his shift, and that night two agency staff abused a resident. Staff member Q stated on 11/30/25 that a nurse call-off resulted in complaints. Staff member Q stated that the staff's orientation to the building only happened if she was working, but no skills checklist was completed at the facility for travel agency staff. Staff member Q stated that the agency they contracted with completed the skills checklists with their staff.During an interview on 12/2/25 at 9:40 p.m., staff member T stated the weekend of 11/29/25 - 11/30/25 was difficult. Staff member T stated that due to a nurse call off on 11/30/25, which was for a 12-hour day shift, one nurse was covering all of the 46 long-term care residents. Staff member T stated staff member B was the admin on call and was notified. Staff member T stated staff member B stated she could not come in to assist because she had her grandchildren. Staff member T stated staff member B repeatedly stated she was on her way, when she dropped the grandchildren off, but she never came in. Staff member T stated she told her staff to prioritize residents who needed frequent brief changes, and the other residents would need to wait for care. Staff member T stated staffing on the nights and weekends was regularly short (less available) due to call offs, and rarely did management assist by coming in and working. Staff member T stated the facility relied heavily on travel staff and provided them with little to no orientation or training. Staff member T stated she frequently found herself as the only core staff with all others in the building being travelers. She stated she spent so much time orienting and answering questions for them that she was unable to complete her own nursing duties. During an interview on 12/2/25 at 9:59 p.m., staff member V stated she had worked at the facility for the last five or six nights and had no orientation or training for the facility. Staff member V stated she had fumbled through the tasks for the first few nights until she could find her way around and learn the residents. Staff member V's lack of orientation to the facility's policies and procedures hindered her ability to complete her duties. During an interview on 12/3/25 at 8:09 a.m., staff member U stated he was the only nurse for the long-term halls on 11/30/25 from 6:00 a.m.- 3:30 p.m. Staff member U stated staff member B never came into the building to assist. Staff member U stated he made sure medications were given and vitals taken, but the monitoring and treatments had already been checked off by staff member B, so it hindered his ability to do his job. It was found that staff member B was not on-site to complete the tasks she had been assigned, which was required. This concern was identified as falsification of documentation. Refer to F658 Professional Standards. During an interview on 12/3/25 at 12:35 p.m., staff member C stated there was not enough staff to meet the needs of the residents. Staff member C stated that call lights were on a long time and showers have not been consistently done since the shower aide position was deleted. During an interview on 12/2/25 at 3:40 p.m., staff member A stated the staffing for the facility was based on a formula provided by corporate, and staffing was met unless there are call-offs. Staff member A stated the admin on call and scheduler worked to try and fill the open shifts, but they have not always been able to fill them. Staff member A stated the facility did receive complaints on 10/20/25, 11/9/25, and 11/30/25 related to the lack of care, but felt the complaints were related to travel/agency staff, not necessarily staffing as a whole. Staff member A stated he did not know why the facility had difficulty with travel/agency staff providing appropriate care when needed.Review of the facility's shift sheets for each of the five units, which was not dated, reflected a total of 10 residents who required a two-person Hoyer lift for toileting and transfers. The Hoyer required two staff to assist. Eight residents required a two-person sit-to-stand lift for toileting and transfers, and 19 residents needed to be checked and or changed every two hours. Review of the facility's MDS Resident Matrix, dated 12/1/25, reflected 13 residents with one or more recent falls, 10 residents with dementia, and three hospice patients.In review of the interviews and record reviews, it was found multiple State Survey Agency incident reports showed that resident care was not being done. Residents and facility staff reported that call light waiting times were very long due to the lack of staff available to respond to them. Facility staff stated staffing was a problem due to the number of call-offs and difficulty finding replacements. Facility staff reported that the 18 residents who required the two-person lift transfers were difficult to complete, particularly at night, when there were only three CNAs in the building for all five units. It was also found that a contributing factor to the falsification of records by staff member B was the lack of staff available to complete the duties, so staff member B completed the duties from home. Refer to F600 Abuse and Neglect; F609 Abuse/Neglect Reporting; F658 Professional Standards, and F585 Grievances, for more information related to these staffing concerns.

Based on interviews and record reviews, staff member B, a licensed nurse, failed to uphold professional standards of practice for nursing care, and falsified medical record documentation and health information related to resident treatments and monitoring, when she was not working in the facility to complete the tasks personally, for 10 (#s 3, 5, 7, 8, 9, 10, 11, 17, 18, and 19) of 19 sampled residents. Findings include:During an interview on 12/2/25 at 9:40 p.m., staff member T stated on the weekend of 11/29/25 - 11/30/25 it was difficult. Staff member T stated that due to a nurse calling off on 11/30/25, for a 12-hour day shift, one nurse was covering all of the 46 long-term care residents. Staff member T stated that staff member B was the admin on call and was notified. Staff member T stated that staff member B said she could not come into the facility to assist because she had her grandchildren, so she was charting in the resident's medical records from her home. Staff member T stated she reviewed the charting on the treatments in the TAR and found staff member B had charted treatments, assessments, and the monitoring of all of the long-term care residents, and some rehab residents, when she had not been in the building to complete those specific tasks. During an interview on 12/3/25 at 8:09 a.m., staff member U stated he was the only nurse for the long-term halls on 11/30/25 from 6:00 a.m. - 3:30 p.m. Staff member U stated staff member B never came into the building to assist him with the provision of nursing services. Staff member U stated he made sure the medications were given to the residents, and that the vitals were taken, but the monitoring and treatments were already checked off by staff member B. During an interview on 12/3/25 at 8:50 a.m., staff member D stated she suspected staff member B was falsifying charting for a while but had not had a chance to confirm this.During an interview on 12/3/25 at 12:35 p.m., staff member C stated she had received a concern from a nurse who stated staff member B had charted on her treatments and skilled charting when she was not in the building to complete the tasks. The nurse reported she was concerned because she could not complete her own charting as a result. Staff member C stated she did not think much of it and assumed staff member B had a reason for the charting.1. Review of resident #8's TAR, dated 11/1/25 - 11/30/25, reflected the following charting completed by staff member B on 11/30/25: Skilled note, elevate float heels, left foot: heel Medix lift on at all times, and TBP precautions.Review of resident #8's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.2. Review of resident #5's TAR, dated 11/1/25 - 11/30/25, reflected the following charting completed by staff member B on 11/30/25: Assess shortness of breath lying flat, monitor side effects of antidepressant, and monitor hours of sleep.Review of resident #5's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.3. Review of resident #3's TAR, dated 11/1/25 - 11/30/25, reflected the following charting by staff member B on 11/30/25: oxygen tubing storage, bipolar and depression monitoring, and monitor for personality dependent disorder symptoms.Review of resident #3's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.4. Review of resident #7's TAR, dated 11/1/25 - 11/30/25, reflected the following charting was completed by staff member B on 11/30/25: Skilled note required, daily blood pressures, and oxygen tubing storage.5. Review of resident #17's TAR, dated 11/1/25 - 11/30/25, reflected the following charting was completed by staff member B on 11/30/25: EBP, medications with milk, and nephrostomy wound care and monitoring. 6. Review of resident #9's TAR, dated 11/1/25 - 11/30/25, reflected the following charting was completed by staff member B on 11/30/25: daily vitals, EBP, insulin and hypoglycemic monitoring, pain assessment, skin care: bilateral feet, monitoring for paranoia, suspicion, accusatory behaviors, antidepressant side effects, anticoagulation monitoring, depression monitoring, and sleep monitoring. Review of resident #9's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.7. Review of resident #10's TAR, dated 11/1/25 - 11/30/25, reflected the following charting by staff member B on 11/30/25: Bilateral elevation of legs with positioning pillows, monitoring for episodes of anxiety, depressive symptoms, and side effects of antidepressants, Roho cushion placement in wheelchair and recliner.Review of resident #10's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.8. Review of resident #18's TAR, dated 11/1/25 - 11/30/25, reflected the following charting was completed by staff member B on 11/30/25: monitor for antidepressant side effects, left elbow: monitor Steri-strips and for signs of infection.9. Review of resident #19's TAR, dated 11/1/25 - 11/30/25, reflected the following charting by staff member B on 11/30/25: Monitor for insulin and hypoglycemic concerns, wound care: right second toe monitor for infection, monitor for behaviors, and monitor for diuretic side effects.Review of resident #19's progress notes, dated 11/1/25 - 12/1/25, reflected that no skilled note or progress note was completed on 11/30/25.10. Review of resident #11's TAR, dated 11/1/25 - 11/30/25, reflected the following charting was completed by staff member B on 11/30/25: Wound care: left medial foot pressure ulcer dressing change, alert charting, TBP, and monitoring for antidepressant and opioid side effects.Review of resident #11's progress notes, dated 11/1/25 - 12/1/25, reflected that no dayshift skilled note or progress note was completed on 11/30/25.Review of staff member B's employee file and the Employee Handbook, signed 6/3/25, reflected:- .Some of the major conduct offenses are listed here.- . Falsifying Company records either by what you say or what you write.Review of the facility policy, Documentation in Medical Record, dated 6/6/25, reflected:- Principles of documentation include .- Documentation shall be factual, objective, and resident centered.i. False information shall not be documented.ii. Record descriptive and objective information based on first-hand knowledge of the assessment. observation, or service provided.

Based on interviews and record reviews, the facility failed to ensure a comprehensive grievance process was operationalized and followed effectively by staff for the resolution of grievances received, for 9 (#s 2, 3, 4, 5, 12, 13, 14, 15, and 16) of 19 sampled residents. This deficiency resulted in multiple grievances being mishandled, including ones not reported to the State Survey Agency, about abuse or neglect of care. Findings include:1. During an interview on 12/3/25 at 1:10 p.m., NF1 stated she was very angry about the room changes done for resident #2 on 11/3/25 and 11/11/25, because she was not notified when resident #2 would be moved. NF1 stated she also reported concerns about the safety of doors on the rehabilitation unit being left unlocked at night, along with the front door being locked at night, but no one was answering the door when she brought resident #2 back from an outing. NF1 stated she filed a complaint with staff members A and F regarding her concerns with the room changes and lack of notification, as well as the concerns with the doors. During an interview on 12/3/25 at 2:18 p.m., staff member F stated she did not obtain a consent signed by resident #2's representative for the room changes. Staff member F stated she did not complete the grievance form for NF1's concerns because she and staff member A talked to NF1 and apologized. Staff member F stated that no further investigation was completed or documented for the grievance. 2. Review of a grievance, dated 11/10/25, reflected that resident #12 complained that a CNA left her in bed naked, after the CNA complained about changing the resident's brief, and hurting her by leaving her covered in urine and feces overnight. The sections on the grievance form labeled Immediate corrective action taken, Documentation of investigation, and Resolution were not filled out.During an interview on 12/3/25 at 1:30 p.m., resident #12 stated the CNA left her sitting in urine and feces all night. Resident #12 stated the CNA changed her in the morning, then left her in bed naked after complaining about having the change her brief. Resident #12 stated the CNA was supposed to get the resident up, but did not. Resident #12 stated she did not receive a response to her grievance she filed about the lack of care, but had heard that CNA was not working at the facility anymore. 3. Review of a grievance, dated 11/10/25, reflected that resident #3 filed a grievance about a CNA who yelled at her, and then threw a blanket on her. Resident #3 stated the CNA refused to get her a drink, and when she requested a nurse, the CNA was mean. The grievance section labeled for the immediate actions taken, reflected, [Resident #3] clarified w/SSD that the blanket. [sic] On the back of the grievance form was a documented note which showed, SSD spoke with [Resident #3] about this. she reported she is ok. feels safe. I did let [Resident #3] know that this staff (the CNA) would likely not be returning (to work at the facility). she said OK . During an interview on 12/2/25 at 8:42 a.m., resident #3 stated she needed help on 11/10/25, and the CNA refused to assist her with toileting and was not doing the brief check and changes. Resident #3 stated the CNA yelled at her, and then resident #3 kicked the CNA out of her room. Resident #3 stated staff member F had just stopped by and told her the CNA would not be working at the facility anymore. During an interview on 12/4/25 at 1:35 p.m., staff member F stated she just completed the documentation note on the back of the grievance form from resident #3, and staff member A backdated the signature on the grievance after the surveyor requested the documents, as it was not done. 4. Review of a grievance, dated 11/10/25, reflected resident #13 filed a grievance regarding care on 11/9/25. The grievance reflected that the staff-to-patient ratio was unacceptable. The grievance went on to reflect that resident #13 was still in her pajamas at noon and waited for her call light to be answered for over an hour, a wound dressing was not dated, and resident #13 had a UTI. On the back of the form was a note that showed the DON had met with staff about wound care protocols, and staff members A and F had met with the resident's family about what was being done (provision of care) during times of short staffing. It was later identified that the weekend staff involved were reported to the State Survey Agency.During an interview on 12/4/25 at 1:35 p.m., staff member F stated she just completed the documentation note on the back of the grievance form from resident #13, and staff member A backdated the signature on the grievance after the surveyor requested the documents.5. During an interview on 12/2/25 at 3:07 p.m., NF2 stated she and her daughter both filed grievance forms regarding #16's fall on 11/10/25, to include abuse by staff. NF2 stated resident #16 tried to brush his teeth and fell. The nurse and CNA then yelled at resident #16 for self-transferring, and the staff took his call light, water, and bedside table away, stating he wouldn't be bothering them anymore with getting up to urinate. NF2 stated that the CNA and nurse treated resident #16 like a criminal, and they shut his room door, so he could not get help if he needed it. NF2 stated the CNA and nurse were travel staff, and they were no longer working at the facility as far as she was aware. During an interview on 12/2/25 at 3:25 p.m., staff member F stated that staff member C received the grievance reports for resident #16. Staff member F stated that grievances related to abuse or neglect would normally go directly to staff member A for reporting to the State Survey Agency. Staff member F stated she was not able to find all of the grievance forms from 11/10/25. Staff member F stated it was a crazy day, and she was not sure what happened to the grievance forms. During an interview on 12/2/25 at 3:40 p.m., staff member A stated he had no knowledge of a fall or any grievances regarding resident #16. Staff member A stated he was not sure why he did not receive the grievances.During an interview on 12/3/25 at 12:35 p.m., staff member C stated she received the grievances for resident #16 on 11/10/25, and she and staff member F took them directly to staff member A.Review of a facility provided email, dated 11/10/25, reflected the facility received, .10+ complaints on her (the CNA) for being too rough and mean to residents. Residents reported being scared to use their call light, so they didn't have to see her.During an interview on 12/2/25 at 9:45 a.m., staff member Q stated that almost every resident on C and D halls filed grievances on 11/10/25 for the care received from staff member K. Staff member Q stated there were at least 10 residents who had complaints, including residents #s 3, 4, 5, 13, 14, and 15. Staff member Q stated she could not remember who the other residents were who complained. Review of a facility policy, Resident and Family Grievances, dated 6/10/25, reflected:- . 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations.- . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member .a- . 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision.

Based on interviews and record review, the facility failed to provide care for a resident, who was identified to be at risk for pressure ulcers, in accordance with her comprehensive person-centered care plan, and the resident's choice, and the resident had skin breakdown due to the lack of staff assistance for incontinence, for 1 (#3) of 19 sampled residents. These failures contributed to three new painful wound areas for resident #3. Findings include:. 1. During an interview on 12/2/25 at 8:47 a.m., resident #10 stated she overheard the CNAs come into the room and tell her roommate (resident #3) that they would not change her brief because she was just damp, and it was a lot of work to change her because she required a Hoyer (full body) lift for brief changes, over the weekend (11/29/25 - 11/30/25). During an observation and interview on 12/2/25 at 8:49 a.m., resident #3 was in her wheelchair, wearing a brief and gown. CNA staff were exiting her side of the room with the Hoyer lift. Resident #3 stated she was not consistently getting her check and changes done when needed over the weekend of 11/29/25 - 11/30/25. Resident #3 stated she had her call light turned on, and a CNA complained about the time a Hoyer lift took and that two staff were needed to use the Hoyer lift. Resident #3 stated the CNA left her in a wet brief all night on 11/30/25.Review of resident #3's weekly head-to-toe skin check, dated 11/26/25, completed by the wound nurse, reflected that resident #3 did not have skin breakdown on her medial thighs or intergluteal cleft. Review of resident #3's Skin Issues report, dated 12/3/25, reflected three new areas of moisture-associated skin damage were found. The following skin concerns were noted: - Resident #3 was identified to have a new skin issue on the right medial thigh, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 4.8 Width (cm): 0.3 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery. - Resident #3 was identified to have a new skin issue on the left medial thigh, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 1.8 Width (cm): 0.7 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery. -Resident #3 was identified to have a new skin issue in the intergluteal cleft, which was moisture-associated skin damage. It was due to Incontinence Associated Dermatitis. The wound was acquired in-house and was continuously painful and burning, per the resident. The nurse identified interventions included Relaxation techniques and barrier cream. The wound size was: Length (cm): 1.5 Width (cm): 0.2 Depth 0 (cm), and the description showed it had 100% granulation, and there was light exudate with a mixture of serous and sanguineous fluid that was typically pale, red, and watery.A review of resident #3's MDS, with an ARD of 11/30/25, showed she had a BIMS of 15; cognitively intact. She needed assistance with self care and was coded as being dependent for toileting. She required substantial to maximum assistance with her dressing, and needed assistance with rolling in bed. The resident was coded as being at risk for pressure ulcers, and she was marked as having unhealed pressure ulcers, the section for Moisture Associated Skin Damage was not marked. Review of resident #3's Care Plan, dated 9/5/25, reflected:- [Resident #3] is at risk for skin breakdown r/t impaired mobility and occasional incontinence. Interventions: . Provide thorough skin care after incontinent episodes and apply barrier cream.- . Incontinent of bladder . Interventions: . Assist to toilet at her requests, reminded as needed.- . [Resident #3] has physical functioning deficit related to: Mobility impairment, Self-care impairment, Weakness. Interventions: . TOILET TRANSFER: DEPENDENT She uses sit to stand lift, however, if she is fatigued a Hoyer can be used.

Based on interviews and record review, the facility failed to investigate and report to the State Survey Agency verbal abuse for 1 (#16) of 19 sampled residents. Findings include:During an interview on 12/2/25 at 3:07 p.m., NF2 stated she and her daughter both filed grievance forms regarding a fall for resident #16 on 11/10/25 and abuse by staff. NF2 stated resident #16 tried to brush his teeth and fell. The nurse and CNA then yelled at him for self-transferring, and took his call light, water, and bedside table away, stating he wouldn't be bothering them anymore with getting up to urinate. NF2 stated the CNA and nurse treated resident #16 like a criminal and shut his door so he could not get help if needed. NF2 stated the CNA and nurse were travel staff and no longer at the facility, as far as she was aware. During an interview on 12/2/25 at 3:25 p.m., staff member F stated staff member C received the grievance reports for resident #16. Staff member F stated that grievances related to abuse or neglect would normally go directly to staff member A for reporting.During an interview on 12/2/25 at 3:40 p.m., staff member A stated he had no knowledge of a fall for #16 or any grievances regarding resident #16. Staff member A stated he was not sure why he did not receive the grievances. The abuse was not reported to the State Survey Agency.During an interview on 12/3/25 at 12:35 p.m., staff member C stated she received the grievances for resident #16 on 11/10/25, and she and staff member F took them directly to staff member A.Review of a staff member statement, dated 12/3/25, reflected staff member R reported that the ADON said to her that the night nurse and CNA had verbally abused resident #16 after he fell and then took his water and call light away so he would not get back up and fall. Review of a staff member statement, dated 12/3/25, reflected staff member S had arrived for his shift and noticed the doors were closed for all of the residents who were a fall risk. When he went in to check on resident #16, resident #16 told him the nurse was mean to him and took his water and call light away, so he did not self-transfer or fall.Review of a staff statement, dated 12/3/25, reflected staff member C stated on 11/11/25 she had a meeting with the family of resident #16 who reported two staff members entered resident #16's room and yelled at him, What the F*** are you doing on the floor? and after putting him back in bed, the two staff members removed his bedside table, call light, and water, and stated, We will not be having any more issues/problems with you tonight and shut the door. Staff member C stated she reported the incident to staff member A. Review of the State Survey Agency reporting portal reflected that no Facility Reported Incident was sent in as required for this incident, until the surveyor brought it to the Administrator's attention.Review of the facility policy, Abuse, Neglect and Exploitation, dated 7/25/25, reflected:- . VII Reporting/Response-1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified timeframes.

Based on interviews and record review, the facility failed to ensure a resident or representative was provided written notifications of room changes, for 1 (#2) of 19 sampled residents, and room changes reportedly caused the resident frustration and anxiety, which the representative wanted to avoid, but she was not provided the opportunity to be present to assist the resident with the room changes. Findings include:During an interview on 12/3/25 at 1:10 p.m., NF1 stated she was very angry about the room move completed for resident #2, which occurred on 11/3/25 and 11/11/25. NF1 stated she was not notified when resident #2 would be moved, even after she requested the notice, so she could assist resident #2 through the move. NF1 stated resident #2's dementia made the room changes more difficult for him, causing him frustration and anxiety. NF1 stated the facility, Just moved him, with no warning, no paperwork signed, and it was the second time they have done this (moved him without notice). Review of resident #2's EHR Census page, dated 12/3/25, reflected that resident #2 had been moved on 11/3/25 for rehabilitation and 11/11/25 for long-term care.Review of resident #2's EHR progress notes, dated 5/21/25 - 12/3/25, reflected no progress notes related to the room changes or adjustment of the resident for the room change. Review of resident #2's EHR documents (misc.), dated 5/21/25 - 12/3/25, reflected no room change consent forms were signed by the resident's representative for the notification. During an interview on 12/3/25 at 2:18 p.m., staff member F stated she did not get a consent signed by resident #2's representative because she thought an email she received from NF1 would be sufficient. Staff member F stated she should have read the email closely, as the email was a request to discuss a room move, and it was not a consent to move him. Staff member F stated NF1 was very angry, and she understood why when NF1 explained her reasons for wanting to be present.

Based on observations, interviews, and record review, the facility failed to ensure that timely pain management was provided for a resident who was exhibiting significant pain that was reportedly unbearable. consistent with professional standards of practice, for 1 (#11) of 26 sampled residents. Findings include:During an observation and interview on 9/8/25 at 2:49 p.m., resident #11 was lying in bed, holding his left wrist, wincing in pain. Resident #11 stated he was in 8/10 pain in his left wrist. Resident #11 stated he had carpel tunnel in the left wrist, and the pain was unbearable. Resident #11 stated he was only given Tylenol for his pain, and it was not helping. Resident #11 stated the nurse was aware of his pain. Resident #11 stated he received oxycodone for peripheral neuropathy twice a day.During an observation and interview on 9/8/25 at 8:06 p.m., resident #11 was lying in bed, holding his wrist and stated his left wrist pain was a 9/10 and moving up his arm. Resident #11 had a large area of swelling on the top of his hand and swelling around the wrist.During an interview on 9/9/25 at 10:25 a.m., staff member F stated resident #11 had been in pain for the last couple of days. Staff member F stated she reached out to the physician yesterday and had not received a response. Staff member F stated she reached out to the physician's office again this morning and was told the resident would be seen on 9/11/25. No orders were given for pain management. Staff member F stated she was frustrated by the difficulty she was having with responses from the physician's office and had no other options for pain management until the physician could see resident #11.During an interview on 9/9/25 at 10:45 a.m., with staff member C and F, staff member C stated the nurse should reach out to the Director of Nursing if she felt she was not getting the response she needed for the residents. Staff member C stated she would have resident #11 seen by the physician today.Review of resident #11's Visit Summary Order, dated 9/9/25 was later received for resident #11 to be seen in the urgent care for x-rays of his wrist. Resident #11 returned with a wrist splint. Resident #11's x-ray showed no fractures.During an observation and interview on 9/10/25 at 8:19 p.m., resident #11 was lying in his bed holding his arms above his head and floating both arms up in the air. Resident #11 had an ice pack under his neck/shoulders. Resident #11 stated, I'm sick as hell, I have so much neck pain. The wrist has now worked all the way up to my neck. It's a 9/10, I can't even move. The nurse entered the room and stated she would be giving him an oxycodone to help with his pain.Review of resident #11's care plan, dated 8/13/25, did not reflect resident #11 had pain in his wrist or carpel tunnel. Review of the facility's policy, Pain Management, dated 5/1/25, reflected:- The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences.

Based on observation, interview, and record review, the facility failed to ensure a resident who left the facility unattended was monitored and supervised sufficiently for elopement prevention, and the resident left the facility again, unattended and without staff knowledge, for 1 (#6) of 26 sampled residents, and resident #6 sustained minor injuries when he had a fall. Staff failed to follow the identified safety interventions for elopement prevention, and the facility classification of an elopement allowed the resident to exit the facility and be in an unsafe environment unattended. Findings include: Review of resident #6's EHR showed a nursing note, dated 8/20/25, which included, This nurse called on call provider. due to patient continuing with extreme agitation and anxiety regarding the earthquakes he has been talking about all night.Review of resident #6's EHR showed an IDT Event Review note, dated 8/20/25, which included, . alerted nurse that resident was located walking parking lot. Resident seemed frustrated that an earthquake was happening, and he needed to get to safety. Resident has a small laceration on index finger . 30 minute rounding started at 3:$5 am (sometime around 3:00 a.m.). [sic] There was no other documentation showing any details as to what occurred that night or how the resident had gotten out of the building.Review of resident #6's EHR showed a nursing note, dated 8/31/25, . 0048 (12:48 a.m.) is when resident was noticed to be missing . CNA alerted this RN that resident was no longer in the dining room. After searching the facility, resident was unable to be located. Resident was returned to the facility at 0124 (1:24 a.m.). During this incident, resident #6 fell and had a scrape to his right forearm and reported right hip pain. The facility later sent resident #6 for an x-ray to rule out a broken hip. Both incidents on 8/20/25 and 8/31/25 resulted in resident #6 getting out of the facility and resulted in an injury to resident #6, The event on 8/31/25 was reported to the State Survey Agency. During an observation and interview on 9/8/25 at 11:33 a.m., staff member GG was sitting in resident #6's room and stated that resident #6 was on a 1:1 staff-to-resident watch as the resident had eloped in the past.During an observation and interview on 9/8/25 at 8:04 p.m., the facility's front doors were unlocked. Staff member H stated the facility's front doors were never locked or expected to be locked until that night. Staff member H stated that night, they were unlocked because staff called administration and asked for the doors to stay open until 9:30 p.m., as there was a family member staying until that time.During an observation on 9/8/25 at 8:50 p.m., resident #6 did not have a 1:1 sitter with him.During an observation on 9/9/25 at 8:31 a.m., resident #6 did not have a 1:1 sitter with him. During an interview on 9/9/25 at 1:04 p.m., staff member GG stated last night they did not have another staff member available to give report for a 1:1 sitter with resident #6, so there was no sitter last night. Staff member GG stated staff was responsible for watching resident #6 24/7 to ensure he did not elope and would document this on the paper in the resident's room.During an interview on 9/9/25 at 1:14 p.m., staff member DD stated resident #6 was an elopement risk and was on 1:1 and 15-minute checks by staff member DD. They stated resident #6 was on 15-minute checks, and if the resident was showing any behaviors or was exit seeking, then the resident would be 1:1 at that time. Staff member DD stated all of the nurses and CNAs communicated this to one another, and this was how all staff were notified. Staff member DD stated prior to the elopement on 8/31/25, resident #6 did show signs of wandering, even though he had left the facility previously. Staff member DD stated they were able to keep track of the 15 minutes by their timer on their watch(s). During an observation on 9/9/25 at 2:06 p.m., staff member DD was observed in the rehab department and giving showers to other residents.During an observation on 9/9/25 at 2:33 p.m., staff member DD was not in resident #6's room, and resident #6's 15-minute check sheet had not been documented on since 2:15 p.m.During an observation on 9/9/25 at 2:40 p.m., staff member DD had not been in resident #6's room since 2:33 p.m. and there was no documentation for the 15-minute checks since 2:15 p.m. During an observation on 9/9/25 at 2:49 p.m., staff member DD returned to resident #6's room. During an observation and record review on 9/9/25 at 2:59 p.m., resident #6's 15-minute check documentation showed staff member DD was in resident #6's room at 2:30 p.m. and 2:45 p.m. However, staff member DD had not been in resident #6's room for 34 minutes, as observed by this surveyor. During an interview on 9/9/25 at 3:04 p.m., staff member G stated resident #6 had eloped and had fallen outside. Staff member G stated this was probably the reason the front door was locked now. Staff member G stated the 15-minute checks were news to them, but assumed one staff member would check on resident #6 every 15 minutes, and an additional staff member would be 1:1 with resident #6. Staff member G was very unclear to how the facility would have both 1:1- and 15-minute checks at the same time. They assumed a nurse would tell them in report. Staff member G stated resident #6 did not sleep well, and this could explain why he wandered at night. Staff member G stated they felt resident #6 would benefit from a Wanderguard as he did wander around the building.During an interview on 9/10/25 at 11:11 a.m., staff member E, stated there had been a change in resident #6's baseline cognitive status, and said he used to ask staff to take him outside as he liked to go outside very frequently. Staff member E stated the night of 8/31/25, a night shift staff member had last seen resident #6 in the dining room around 11:30 p.m. or 12:00 a.m. Staff member E stated resident #6 was not found until hours later. Staff member E stated the facility used to have Wanderguards, but that was more than a year ago, and stated there were other residents who also wandered and who got out of the facility as well. Staff member E stated resident #6 had gotten out of the facility twice. Staff member E stated they had no idea why the front doors were not locked after the first time resident #6 had gotten out of the building. Staff member E stated the doors were locked, preventing entry but not exit.During an interview on 9/10/25 at 11:24 a.m., with staff members A and C, staff member A stated resident #6 eloped on 8/31/25, and this incident was reported to the State Survey Agency. Staff member A stated resident #6 was being checked by a staff member every 15 minutes. Both staff members A and C stated when resident #6 had left the faciity on 8/20/25, and found in the parking lot, this was not considered an elopement. Staff member A stated the facility had changed their policy where the company would not consider a resident eloping if the resident was on the facility's grounds. Staff member A stated that with the incident on 8/20/25, resident #6 was still in the facility's parking lot, and staff member A stated the parking lot was still considered the facility's space. Staff member A stated resident #6 had made it 1.1 miles away from the facility on 8/31/25, where he then fell. Staff member A stated resident #6 was a 1:1 from 8/31/25, which then ended Monday morning. Staff member A stated the facility was in the process of getting a Wanderguard system put in. Staff member A stated the Wanderguard system was not put in sooner because a conversation was made with the physicians regarding all of the residents in the facility, and no residents were deemed as an elopement risk. During an interview on 9/10/25 at 11:45 a.m., staff member EE stated the facility was in the process of getting a Wanderguard put in. Staff member EE stated a Wanderguard would be smart because there were a couple of residents who liked to wander outside, specifically stating resident #6 was one. Staff member EE stated it was a good thing that the doors were locked now, but stated a resident could still exit the doors from the inside.During an interview on 9/10/25 at 12:01 p.m., staff member P stated the front door was watched from the normal business hours but was not watched after that time. Staff member P stated, To me it does feel unsafe (to have the front door unlocked). Staff member P, stated, I want them (the residents) to be safe. They are like our family. Staff member P stated the staff members created a bond with the residents. Staff member P stated the facility would consider a resident to have had eloped if they got to the end of the walkway or passageway. Staff member P stated, Personally, (I would not be comfortable with them going that far) not even that far. Staff member P stated they felt a resident would be unsafe if they got out of the facility for safety reasons because many of the residents were confused, a resident could get into an unknown vehicle, the resident could fall, or the resident could get hit by a car.During an interview on 9/10/25 at 3:52 p.m., staff member II stated the facility could not do both 1:1 and 15-minute checks. Staff member II stated it did not make any sense for the same person to do those two tasks at the same time. During an observation and interview on 9/10/25 at 8:01 p.m., staff member II opened the front door of the facility from the inside. No keys or code was needed to open the door. Staff member II stated this was normal for this door to open from the inside, but to be locked from the outside.During an interview on 9/10/25 at 8:00 p.m., staff member K stated, Staffing is terrible here at night. We need more help to answer all the call lights. We have several dementia patients wandering all night, multiple two-person Hoyer patients, and only three CNAs.During an interview on 9/10/25 at 8:03 p.m., staff member J stated, We only have three CNAs in the building; we can't keep track of all these residents, much less the elopers.During an interview on 9/10/25 at 8:06 p.m., staff member JJ stated being assigned to the 1:1 with resident #6, and staff member JJ also had to verify #6's location every 15 minutes.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer wounds were identified, closely monitored, treated, and prevented so they did not develop in the facility or worsen; and, it was found pressure wounds were not treated per the physician orders; the wound care nurse was not informed of new wounds, failed to follow safe infection control processes during wound care, or have the necessary skillset for wound care services and oversight of the wound program; licensed nursing staff were documenting wound care was completed when not done; nursing staff failed to reposition residents with wounds as needed; and the cumulative effect of this failure was the wound development or wound worsening for 4 (#s 2, 6, 8 and 9), of 7 residents sampled for wounds. Resident #2 had a Stage II wound that developed in-house. Resident #6 had two Stage II pressure ulcer develop in the facility. Resident #8 was on hospice and had a Stage I pressure ulcer that worsened into a Stage II pressure ulcer with six new deep tissue injuries located on both buttocks. Resident #9 had a Stage II wound, and the wound care nurse was not aware of the wound. This failure significantly increased the risk of worsening wounds or for more wounds to develop on any resident who had wounds or was at risk for wounds. Findings include: 1. Wound care oversight, lack of training, and resident #9: During an interview on 9/10/25 at 8:14 a.m., staff member F stated they were new to the wound care position and had no prior experience. Staff member F also stated they were not certified as a wound care nurse yet. Staff member F stated they acted as a wound care nurse on Wednesdays; all other days of the week, the floor nurses were expected to complete the wound care dressing changes by following the physician's orders. Staff member F stated being unaware of any wounds with resident #9, who had documentation of a Stage II pressure ulcer. Staff member F stated, That's also a work in progress, as to how staff member F got notified of new wounds from the floor staff. Staff member F stated that sometimes the staff will tell her directly, text her, or there is a box outside of the administration's office where floor staff can notify someone. Staff member F also stated being new to the position, many staff members did not know who staff member F was yet. Staff member F stated this process (the wound care system) was not perfect yet, and many areas within the system still needed improvement to ensure there closed-loop communication between staff member F, the floor staff, and the administrative staff.During an interview on 9/10/2025 at 4:10 p.m., staff member F stated they would have never known about resident #9's Stage II pressure ulcer if the surveyor had never notified them of it. Staff member F stated the floor staff nurse who discovered it should have notified the administrative staff or staff member F, and should have notified a physician to obtain wound care orders. Staff member F stated it was hard for them to do wound care on a resident they did not even know had a wound. 2. Resident #2:During an observation on 9/10/25 at 9:24 a.m., staff member F was completing a wound care dressing change on resident #2. Staff member F removed an old silicone foam sacral dressing, and staff member F stated the previous dressing was not signed or dated, which made it difficult to determine when the dressing was last changed. Staff member F also stated there was no residual zinc ointment (Triad) on the skin, which indicated the previous nurse did not follow the physician's orders. Staff member F stated all of the floor staff had access to the necessary wound supplies in their own carts, but if they needed anything specific, the floor staff also had easy access to the wound care cart. Review of resident #2's EHR showed the physician order, revised 8/21/25, which included: Wound Care: Stage I pressure wound sacrum 1. Clean with saline. 2. Triad 3. Sacral foam 3x weekly or PRN if soiled.3. Resident #6:During an observation and interview on 9/10/25 9:51 a.m., staff member F dressed resident #6's wound to the left and right buttocks. Staff member F stated this was a Stage II pressure ulcer as the first layer of skin was missing, but there was no subcutaneous tissue observed. An observation of the wound showed similar findings to what staff member F described, as the first layer of the skin was gone, leaving a light pink wound bed below on the bilateral buttocks. Staff member F stated (on 9/10/25 at 8:14 a.m.) that resident #6 was new for her and on the wound list as of 8/27/25, and the wound had not been open the last time staff member F observed the wound. Therefore, the wound was worsening.Review of resident #6's EHR showed the physician order, dated 8/28/25: Wound Care: Redness right buttock 1. Triad cream. There were no physician orders concerning the left buttock wound.4. Resident #8:During an observation and interview on 9/9/25 at 1:07 p.m., resident #8 stated her buttock area hurt all the time. She stated her buttock hurt at a 10/10 pain when using the zero to ten pain scale. She stated the staff members would not reposition her regularly.During an observation and interview on 9/10/25 at 10:13 a.m., staff member F removed resident #8's left ear bandage, which showed the bandage was last changed by staff member F on 9/3/25 (a week prior). Staff member F stated the floor nurses were not following the physician's orders because the initials on the bandage were staff member F's, and this dressing should have been changed every other day. Staff member F then turned on the light above resident #8's bed and removed resident #8's right ear dressing. Staff member F also touched the wound care Ipad and Healx stickers with the soiled gloves. No hand hygiene was performed between these tasks. Staff member F stated the resident's right ear dressing had been last changed by them as well on 9/3/25. They stated these dressings should have been changed multiple times before the staff member F coming in the next week. Then, staff member F stated resident #8 had six new deep tissue injury wounds to her buttock area that were not present last week. Staff member F stated these areas could be from moisture, shearing, and pressure, but due to resident #8's catheter, moisture was slightly less of a concern. Staff member F stated the facility should be turning the resident at least every two hours as she was on hospice and had a pressure ulcer. Staff member F stated they tried to make sure there were orders in for dependent residents for repositioning every two hours. Staff member F stated that repositioning should be a standard practice for CNAs and nurses, but an order was a good idea for the dependent residents. Staff member F stated the facility should probably be turning her every hour. During the dressing change, staff member F took off the old dressing and touched the Ipad, Healx stickers, and clean supplies located in the wound cart without doffing gloves or performing hand hygiene first. Staff member F later applied the triad cream to resident #8's coccyx after the surveyor had pointed out the ointment had been missed, and staff member F had doffed gloves, performed hand hygiene, and was getting ready to leave the room.Review of resident #8's EHR showed a physician's order: . Sacrum stage 1 pressure. Cleanse with NS. 2. Apply triad cream . [sic]Review of resident #8's EHR showed a physician's order showed the bilateral ear dressings needed to be changed every other day.Review of resident #8's EHR showed on the TAR for on 9/5/25 and 9/7/25, resident #8's bilateral ear dressings were documented as completed, although the surveyor observed the dressing on the resident's ear dated 9/3/25. During an interview on 9/10/25 at 1:30 p.m., staff member FF stated the skin breakdown noted on resident #8's buttock area was due to pressure and a lack of repositioning. Staff member FF stated there should be physician orders that the facility could put in concerning repositioning. Staff member FF stated the staff could do something as simple as micro shifts that would relieve pressure and not wake up a resident or cause them any pain.5. No positioning for resident #8 leading to further skin breakdown:Review of resident #8's EHR showed hospice was initiated for resident #8 on 4/29/25, and completely dependent on staff for repositioning and skin care.Review of resident #8's EHR showed a facility task for the past 30 days which included: . Roll left and right: The ability to roll from laying on back to left and right side, and return to laying on back on the bed. [sic] Resident #8 was Dependent . or required Substantial/maximal assistance . 26 out of 30 opportunities documented.The following observations below, from 9/8/25 to 9/9/25, where resident #8 was laying directly on her back, showed no positioning devices or pillows were in use to offload resident #8 from her coccyx:-9/8/25 at 11:03 a.m.,-9/8/25 at 3:44 p.m.,-9/8/25 at 8:17 p.m.,-9/8/25 at 8:50 p.m.,-9/9/25 at 8:30 a.m.,-9/9/25 at 1:02 p.m.,-9/9/25 at 1:21 p.m.; and,-9/9/25 at 2:13 p.m.During an observation on 9/9/25 at 2:21 p.m., staff members assisted resident #8 up with a lift to change her bedding. Resident #8 was back to bed by 2:49 p.m., lying directly on her back, without any pillows or positioning devices, supporting the resident's positioning on either side of the body. During an observation on 9/9/25 at 3:27 p.m., staff member F stated the staff members rotated the dependent residents every couple of hours, side to side. Staff member F stated documentation for repositioning was located in the TAR for the nurses and was a basic skill learned in nursing and CNA school.The following additional observations were made from 9/9/25 to 9/10/25, where resident #8 was lying directly on her back with no positioning devices or pillows in use to offload resident #8 from her coccyx:-9/9/25 at 3:30 p.m.,-9/9/25 at 3:51 p.m., -9/9/25 at 4:20 p.m.,-9/10/25 at 8:10 a.m.,-9/10/25 at 8:45 a.m., and-9/10/25 at 10:13 a.m., resident #8 was turned for wound care at this time.During an interview on 9/10/25 at 8:14 a.m., staff member F stated every resident who was on hospice or had any pressure ulcers should have a physician order to reposition the resident every two hours. Staff member F stated, pressure, any shearing forces, Hoyer lifts, moisture, and any trauma (such as from a fall, or adaptive equipment) could contribute to or worsen a pressure ulcer. Staff member F stated the facility should assess pain and could use positioning wedges to help with positioning.During an interview on 9/10/25 at 3:55 p.m., staff member CC stated repositioning was a basic skill that both CNAs and Nurses should know. Staff member CC stated the facility staff could benefit from more of a check off system on the MAR as there was only a twice-a-day reminder on the TAR. Staff member CC stated many of the nurses would only look at the TAR towards the end of the shift. Staff member CC stated the CNAs could benefit from a paper check off system for repositioning.During an interview on 9/10/25 at 8:05 p.m., staff member BB stated they felt low staffing numbers contributed to residents not being repositioned. Staff member BB stated, Oh, there is definitely not enough staff for repositioning, most of the time it never gets done, so yeah staffing is my main concern working at this facility. Refer to F725 for further information on staffing.Review of a facility policy, titled Turning and Repositioning, dated 6/10/25, showed, . 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned . 3. A routine turn schedule includes both side-lying and back positions, alternating from the right, back, and left side.Review of residents #2, #6, and #8's EHRs and Weekly Wound Assessments showed these wounds were In-House Acquired.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented during the transportation of dirty laundry to prevent transmission of communicable diseases, and failed to ensure enhanced barrier precautions and aseptic technique were followed while performing a wound dressing change for 3 (#s 2, 8, and 53). Findings include: 1. During an observation and interview on 9/10/25 at 1:01 p.m., staff member AA was observed rolling a dirty laundry cart from the laundry room on the first floor to the basement, while touching three different doorknobs and one push-button door code, all while wearing the same soiled gloves, and without hand hygiene. Staff member AA stated it was hard to transport dirty laundry to the basement since the elevator broke in October of 2024 and stated she does not know when it is going to be fixed. Staff member AA stated, We need to improve our infection control; I don't like that my dirty gloves are touching everything. We should be better. During an interview on 9/11/25 at 8:03 a.m., staff members B, C, and D stated staff member AA came and spoke with them on 9/10/25 about her concerns regarding transporting dirty linens with hand hygiene related to being in compliance, and stated, We need to add hand hygiene to our list (of topics to work on). 2. During an observation on 9/10/25 at 9:24 a.m., staff member F did not perform hand hygiene or follow enhanced barrier precautions (no gloves or gown were donned) when entering resident #2's room for a wound care dressing change. Staff member F brought the wound care cart into resident #2's room and did not clean the cart or surface of the cart after exiting the room. During the wound dressing change, staff member F took off resident #2's old silicone foam sacral dressing and then touched the wound care Ipad with the same gloves. Staff member F also touched the wound care cart drawers, the contents within the drawers to get clean wound supplies, and the Healx sticker packaging (a tool used to assist with a wound measurement when using the wound care Ipad). Staff member F took a photo of resident #2's coccyx wound and then placed the Ipad back on the wound care cart. Staff member F then removed the gloves, performed hand hygiene, then donned new gloves. Staff member F grabbed the clean supplies (gauze, cleanser, sacral foam, and zinc) that had been previously touched by the soiled gloves and placed a new dressing on resident #2's coccyx. 3. During an observation on 9/10/25 10:13 a.m., staff member F entered resident #8's room without performing hand hygiene and did not follow enhanced barrier precautions as no gown or gloves were donned. The wound care cart was brought into resident #8's room. Staff member F first removed resident #8's left ear dressing, then touched the overhead light above resident #8's bed with the same gloves. Staff member F then touched the following items with the same dirty gloves: the wound care Ipad, the Healx stickers, an adhesive remover which was located inside of the cart, and all of the supplies resident #8 required for her new dressings which were located inside of the wound care cart. 4. During an observation on 9/9/25 at 10:49 a.m., staff member F prepared to provide wound care for resident #53's wounds. Resident #53 was lying on his side. Staff member F put on gloves, cleansed the wound on resident #53's sacrum, placed the dressing, and degloved. Staff member F put on new gloves from her pocket, cleansed resident #53's right knee wound, went into her supply cart for a bandage, dated the bandage, and placed the bandage on the knee. Staff member F degloved and put on new gloves. Staff member F assessed a new wound on resident #53's right great toe, used betadine to cleanse the wound, and degloved. Staff member F put on new gloves and collected supplies from her cart. Staff member F cleansed the wound on resident #53's right ankle, took a picture with the Ipad, and then placed the new dressing on the wound. Staff member F failed to used hand sanitizer between glove changes and did not change gloves between dirty and clean tasks. During an interview on 9/9/25 at 11:45 a.m., staff member F stated she just did not think about changing gloves when all the wound care was for the same resident. Staff member F stated she had not had any formal training on wound care. During an interview on 9/11/25 at 8:03 a.m., staff member D stated staff member F was very new to the role for wound care, and there was a large amount of education to learn. Staff member D stated was also new to infection control, as the previous DON had quit, and it was staff member D's first week working with infection prevention.

Based on observations, interviews, and record review, the facility failed to ensure a registered nurse was on duty for at least eight consecutive hours a day, seven days a week. Findings include:Review of the facility's CASPER PBJ Staffing Data Report dated 1/1/25-3/31/25, reflected: -The facility reported no registered nursing hours for 1/4/25, 1/5/25, 1/19/25, 1/25/25, 1/26/25, 2/15/25, 2/16/25, 3/2/25, 3/9/25, 3/15/25, 3/16/25, 3/22/25, and 3/23/25. Review of the facility provided time punches for the dates listed above reflected the [NAME] PBJ data report was accurate. During an interview on 9/10/25 at 1:10 p.m., staff member A stated he thought maybe the director of nursing covered the shifts in question, but he no longer worked at the facility. Staff member A stated he reviewed medication administration and notes but was unable to confirm the director of nursing worked the shifts in question. Review of facility provided, Census vs Budget, dated April 2025 - June 2025, reflected the average daily census was 66.76. Review of the facility's policy, Nursing Services and Sufficient Staff, dated 5/13/25, reflected: - . 3. The facility is required to provide licensed nursing staff 24 hours a day .8. the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.9. The Director of Nursing may serve as a charge nurse only when the facility has an average daily census occupancy of 60 or fewer residents. [sic]

Based on interview and record review, the facility failed to have sufficient staff to meet the needs of the residents for 3 (#s 2, 11, and 54) of 26 sampled residents. Findings include:1. During an interview on 9/8/25 at 4:09 p.m., resident #2 stated the facility could get so short staffed that she would have to wait as long as 45 minutes to receive help. She stated if she waited too long she would go to the restroom without a staff member because she could not wait any longer. During an interview on 9/9/25 at 7:54 a.m., resident #2 stated staffing was awful and weekends were the worst. Resident #2 stated pain medications were late, and no one answered the call lights when help was needed at night or on the weekends. Resident #2 stated this facility was the worst she had been to, and she even had to insist on having her sheets changed because they had not been changed in weeks. Resident #2 stated the facility needed more help. 2. During an interview on 9/8/25 at 2:53 p.m., resident #11 stated he had several incontinence incidents since his admission because staff do not assist timely to the toilet. Resident #11 stated CNAs would come in during the night and turn off the call light and state they would return to help him but never returned. Resident #11 stated he had bowel movements in his bed as a result. Resident #11 stated it often took move than 30 minutes to get assistance when he needed to use the toilet. Resident #11 stated he was normally continent of both bowel and bladder and found the incontinence episodes to be . humiliating and frustrating. Review of resident #11's Care Plan, dated 8/13/25, reflected resident #11 required moderate to substantial assistance with toileting. During an interview on 9/9/25 at 10:25 a.m., staff member F stated she had heard from resident #11 and his wife that resident #11 had a few bowel movements in his bed on night shifts. Staff member F stated the day shift did not have any trouble meeting his call light needs, and he had not had bowel movements in his bed during her day shifts. Staff member F stated resident #11 was continent of bowel and bladder so long as he had assistance to the toilet. During an interview on 9/10/25 at 3:15 p.m., staff member E stated she regularly received complaints on Mondays and at care conferences from residents and families about weekend staffing, showers, and call light times. Staff member E stated she immediately reported these concerns to the Administrator. During an interview on 9/10/25 at 8:00 p.m., staff member K stated, Staffing is terrible here at night. We need more help to answer all the call lights. We have several dementia patients wandering all night, multiple two-person Hoyer patients, and only three CNAs. During an interview on 9/10/25 at 8:03 p.m., staff member J stated, We only have three CNAs in the building; we can't keep track of all these residents, much less the elopers. During an interview on 9/10/25 at 8:05 p.m., staff member BB, stated she did not feel the staffing was safe, especially when the 6-10 p.m. float nurse left early, then stated, Like tonight, she left at 7:15 p.m., and it happens a lot. Staff member BB stated she did not like to be put in those kinds of situations because it was not safe for residents. Staff member BB stated management rarely comes in to help, then stated, They know we are short tonight and no help. Staff member BB stated she answered call lights within 60 seconds, even if she must go to a hall she was not covering, while some staff will ignore lights, then stated, Some staff ignore lights even if they are standing right next to a room, that's alarming. Staff member BB stated, Oh there is definitely not enough staff for repositioning, most of the time it never gets done, so yeah staffing is my main concern working at this facility. 3. During an interview on 9/8/25 at 11:05 a.m., resident #54 stated the facility was so short handed and she had to wait a while for help sometimes. Resident #54 stated that sometimes she had to wait a long time for a staff member to bring her pain medication. She stated, I've had it where they're really short and it felt like an hour. During an interview on 9/10/25 at 3:55 p.m., staff member CC stated residents were not getting repositioned due to low staffing numbers and weekends and night shifts were known to be the worst shifts for low staffing. During an interview on 9/10/25 at 8:06 p.m., staff member JJ stated the facility did not have the staff to provide enough care, especially at night. Staff member JJ stated, There's not enough of us to go around. Staff member JJ also stated there was not enough staff to consistently turn and reposition the residents every two hours.

Based on interview and record review, the facility failed to implement and educate staff on an antibiotic stewardship program in order to promote the appropriate use of antibiotics. This deficient practice increased the risk for residents to develop drug-resistant organisms and/or complications. Findings include: During an interview on 9/11/25 at 8:03 a.m., staff members B, C, and D stated they did not currently have an antibiotic stewardship program implemented or provide training on the program to staff. Staff members B, C, and D stated the antibiotic stewardship program would be put in place after the next QAPI meeting, which was scheduled for 9/23/25. Review of a facility policy, titled, Antibiotic Stewardship Program, Date Reviewed/Revised 4/9/25, showed: . It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

Based on interview and record review, the facility failed to ensure MDS assessments were submitted timely. This deficient practice was corrected in August 2025. Findings include: Review of the MDS error dashboard, submission dates 1/1/25 - 9/8/25, showed of the 604 assessments counted, there were 190 with errors. Errors included: late MDS transmissions, late care plans for CAA signatures, late admission assessments, and resident information mismatches. Errors by the month included: -[DATE]: 16 errors.-[DATE]: 11 errors.-March 2025: 28 errors.-April 2025: 33 errors.-May 2025 no assessments submitted.-June 2025: 28 errors.-July 2025: 21 errors.-August 2025: three errors.During an observation and interview on 9/10/25 at 1:45 p.m., the facility's MDS dashboard was viewed with no late indicators shown. Staff member HH stated that once an MDS was late, it would trigger many other alerts as well. Resident mismatches were common for various reasons, including a missing middle initial or discrepancies in data from previous facilities. Staff member HH stated the late submission issues were from the previous MDS coordinator who had left in July, and maybe did not know about the 14-day submission deadline. Staff member HH stated the current MDS role was remote, and the facility was following MDS timelines.

Based on observation, interview, and record review, the facility failed to ensure staff member F received the appropriate and sufficient education prior to starting a position as a wound care nurse. This deficient practice resulted in staff member F not following enhanced barrier precautions or aseptic technique while performing wound dressing changes for 2 (#s 2, and 8) of 7 sampled residents with wounds; and medication errors for 3 (#s 12, 27, and 32) of 36 medications observed. Findings include:During an interview on 9/10/25 at 8:14 a.m., staff member F explained that their position was new, and staff member F had no prior experience in wound care. Staff member F stated they did not have any wound care certifications as this was a new process (type of position). Staff member F stated they worked as a floor nurse on Mondays and Tuesdays but would work as the wound nurse on Wednesdays. Staff member F stated they often had to work overtime and take work home to finish the work for the wound care position. Staff member F stated for the new position the Weekly Wound Evaluations were completed, wound measurements, with and without using the Ipad measuring tool, identified the types of wounds, staged (determined severity) wounds, identified the characteristics of a wound, and determined the treatments for wounds. During an observation and interview on 9/10/25 at 10:13 a.m., staff member F stated that it was sometimes difficult to classify the severity of a wound due to being so new to the position. Staff member F pulled out three cards with photos on them and asked the surveyor's advice when staging and classifying (determining severity and type) of the wounds during all of the observations (on 9/10/25 at 9:24 a.m., 9/10/25 at 9:51 a.m., and 9/10/25 at 10:13 a.m.). 1. During the wound care observations (on 9/10/25 at 9:24 a.m., and 9/10/25 at 10:13 a.m.), staff member F failed to properly follow aseptic technique while performing the wound care dressings for residents #2, and #8. During the wound dressing observation for resident #2, no gown or gloves were donned prior to entering the room to follow enhanced barrier precautions; the wound care cart had been taken into the resident's room and was not cleaned after exiting the room; and multiple surfaces were touched with soiled gloves after a dirty wound dressing had been taken off of resident #2. During the wound dressing observation with resident #8, staff member F took of a dirty dressing from resident #8's right ear then touched the overhead light, the wound care Ipad, the Healx stickers, and items located within the wound care cart. Please see F880 - Infection Control, for further details related to these failures. During an interview on 9/11/25 at 3:23 p.m., staff member C stated staff member F's knowledge of wounds was a competency issue. Review of staff member F's competencies, which was requested on 9/11/25 at 4:30 p.m., showed the facility provided staff member F's generalized nursing competencies that covered Weekly Head To Toe wound competencies, but failed to show the education provided to staff member F regarding the facility wound care nurse position, specifically and the various duties requires which were relayed by staff member F during the interview on 9/10/25 at 8:14 a.m. 2. During an observation and interview on 9/9/25 at 4:04 p.m., staff member G prepared and administered medications for resident #32. The following occurred: Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass. Staff member G prepared Voltaren Gel by squeezing approximately two drams (1 dram = 1.77 grams) into a medicine cup. Staff member G stated she did not have a way to measure grams of the gel, so she used the drams measurement on the medicine cups. 3. During an observation on 9/9/25 at 4:20 p.m., staff member G prepared and administered medications for resident #12. Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass. During an interview on 9/10/25 at 10:07 a.m., staff member G stated she found the measuring tool for the Voltaren gel in the box and asked her nurse about how to measure out the High Cal Med Pass and learned she should measure out two 30 mL medicine cups to equal the 60 mL order. Staff member G stated she was now aware she was giving double the amount listed in the orders for Voltaren gel and High Cal Med Pass for several residents. Staff member G stated she was now aware drams did not equal grams. 4. During an observation and interview on 9/10/25 at 8:05 a.m., staff member L prepared and administered medications for resident #27. Staff member L stated resident #27 prefers her Phospha 250 Neutral cut in half. Staff member L cut the pill in half and administered the medication to resident #27. Review of resident #27's physician Order Summary List, dated 9/10/25, reflected an order showing, May crush meds or open capsules as needed unless contraindicated. Review of Drugs.com Phospha 250 Neutral patient information (Phospha 250 Neutral Uses, Side Effects & Warnings), How should I take Phospha 250 Neutral? dated 2025, reflected: - The tablet form may need to be dissolved in water or swallowed whole. During an interview on 9/10/25 at 3:00 p.m., staff member D stated the nurse should have requested the liquid form of the Phospha or dissolved the pill, if the resident could not take the pill whole.

Based on observations, interviews, and record review, the facility failed to ensure medication error rates remained below five percent, administering medications with the correct dose for 2 (#s 12 and 32); and the correct route for 1 (#27) of 36 sampled medications. The medication error rate was 11 percent. Findings include:1. During an observation and interview on 9/9/25 at 4:04 p.m., staff member G prepared and administered medications for resident #32. The following occurred: Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass.Staff member G prepared Voltaren Gel by squeezing approximately two drams (1 dram = 1.77 grams) into a medicine cup. Staff member G stated she did not have a way to measure grams of the gel, so she used the drams measurement on the medicine cups. 2. During an observation on 9/9/25 at 4:20 p.m., staff member G prepared and administered medications for resident #12. Staff member G poured 120 mL of High Cal Med Pass into a cup. The order was for 60 mL of High Cal Med Pass.During an interview on 9/10/25 at 10:07 a.m., staff member G stated she found the measuring tool for the Voltaren gel in the box and asked her nurse about how to measure out the High Cal Med Pass and learned she should measure out two 30 mL medicine cups to equal the 60 mL order. Staff member G stated she was now aware she was giving double the amount listed in the orders for Voltaren gel and High Cal Med Pass for several residents. Staff member G stated she was now aware drams did not equal grams.3. During an observation and interview on 9/10/25 at 8:05 a.m., staff member L prepared and administered medications for resident #27. Staff member L stated resident #27 prefers her Phospha 250 Neutral cut in half. Staff member L cut the pill in half and administered the medication to resident #27. Review of resident #27's physician Order Summary List, dated 9/10/25, reflected an order showing, May crush meds or open capsules as needed unless contraindicated.Review of Drugs.com Phospha 250 Neutral patient information (Phospha 250 Neutral Uses, Side Effects & Warnings), How should I take Phospha 250 Neutral? dated 2025, reflected:- The tablet form may need to be dissolved in water or swallowed whole.During an interview on 9/10/25 at 3:00 p.m., staff member D stated the nurse should have requested the liquid form of the Phospha or dissolved the pill, if the resident could not take the pill whole. Review of the facility's policy, Medication Administration, dated 5/7/25, reflected:- 10. Ensure that the six rights of medication administration are followed .17. Administer medication as ordered in accordance with manufacturer specifications.

Based on observations, interviews and record review, the facility failed to ensure medications stored for use were not expired. The failures could affect any resident using medications or supplies from the storage area. Findings include:During an observation and interview on 9/9/25 at 2:52 p.m., with staff member B, the following items were found in the medication storage room:Hydro gel expired 3/2025 x 2Vancomycin Injection fluid bags with the following expiration dates: 12/2024, 11/2024, 1/2025, 12/2024, 6/2025, 2/2025, 11/2024, 2/2025, 11/2024, and 11/2024A box of Ipratropium Bromide expired 5/2025Covid 19 test kits expired 1/18/24 x 3Lovenox expired 8/2025 x 9Timolol Opthalmic solution expired 1/2025 x 3Bisacodyl suppository expired 1/2025 x 2 boxesLatanoprost Opthalmic solution expired 12/2024 and had no patient name Wound vac supplies stored on the floor x 4 boxesDuring the medication room observations, staff member B stated she was not sure why the medications were missed during the weekly checks or why alcohol was not secured in a locked cupboard. During an interview on 9/9/25 at 3:00 p.m., staff member M stated she reviewed the medication rooms for expired medications weekly. Review of the facility's policy, Medication Storage, dated 6/25/25, reflected:- . 9. Expiration dates: Medication rooms and carts will be inspected periodically for expired medications and nurses will observe expiration dates prior to administration. Any medication found to be expired will not be administered and will be destroyed in accordance with our Destruction of unused drugs policy.

Based on interview and record review, the facility failed to ensure that 1 (#1) of 3 sampled residents was kept safe while using her motorized wheelchair in the [Entity Name] parking lot while coming from an appointment. This deficient practice resulted in a resident falling outside of the facility and suffering from multiple fractures, which resulted in hospitalization; and the residents using motorized wheelchairs did not feel safe when being transported due to the type of transport offered or used, for 2 (#s 1 and 2) out of three sampled residents. Findings include:Review of resident #1's EHR showed a BIMS of 15, cognitively intact. A weight of 357.8 pounds (as of 6/8/25), and a consistent oxygen requirement of three liters per minute. Resident #1's relevant diagnoses were: Type 2 diabetes, obesity, chronic obstructive pulmonary disease, acute on chronic diastolic (congestive) heart failure, unspecified atrial fibrillation, osteoarthritis, contusion of left lower leg, long-term use of anticoagulants, and pulmonary hypertension.During an interview on 8/5/25 at 7:40 a.m., staff member M stated resident #1 was 100% cognizant and was cleared to operate her motorized wheelchair independently around the facility. Staff member M stated resident #1 required a staff member when leaving the facility on her motorized wheelchair. Staff member M stated the day of 7/8/25, resident #1 had been short of breath and could not keep her oxygen saturations up during her rehabilitation. Staff member M stated her oxygen requirements increased to four liters per minute, which was not her normal. Staff member M stated resident #1 was later suspected of a pulmonary embolism (PE). Staff member M stated resident #1 went to the hospital to get a CT, but refused to go in the van and did not want to go with EMS. Staff member M stated resident #1 was an obese woman and felt that when she traveled with EMS, they would have to manhandle her, which she did not like. Staff member M stated on the way back from the scan, resident #1 hit a speed bump in her motorized wheelchair, fell out, broke her femur, and was transferred to the hospital. Staff member M stated they were unsure why this happened, as resident #1 was able to complete high-level assessments while driving her motorized wheelchair. Staff member M stated the long-term goal for resident #1 was to go to an assisted living facility. Staff member M stated this was partly why a motorized wheelchair was ordered in the first place.During an interview with staff member B and H, on 8/5/25 at 10:52 a.m., staff member B stated the incident occurred (resident falling from wheelchair) with resident #1 because occupational therapy had not cleared the resident to be transported with any other staff members other than a physical therapist or occupational therapist specifically. Staff member B stated a nurse had taken resident #1 over to the hospital, and a transport staff member took her back to the facility. Staff member B stated that right after the incident, staff member D called the facility, and staff member C responded to the incident, who then called 911. Staff member B stated that staff member D should have called 911 right away. Staff member H stated staff member D sat resident #1 up, after she fell because the resident had told staff member D that the pavement was too hot. Staff member B stated staff member D acted negligently because staff member D did not call 911 immediately and moved the resident without a proper evaluation first. Staff member B also stated staff member D had a history of not completing job duties correctly and delegating orders.Review of resident #1's occupational therapy assessment showed Power-Mobility Indoor Driving Assessment: Score Sheet. The written score was a 96% out of 100% with the comments: Resident cleared for in facility with outside requiring close supervision and verbal cues for safety.During an interview on 8/5/25 at 11:08 a.m., staff member K stated resident #1 had met all goals regarding her motorized wheelchair. She was at a supervisory level when outside. Staff member K stated a physical therapist or occupational therapist did not have to be with resident #1 when the resident was outside, as the Rehabilitation Department had cleared the resident to have met this goal. Staff member K stated, She (the resident) was at a supervision level so anyone could have watched her.During an interview on 8/5/25 at 11:24 a.m., staff member C stated that morning, staff member C and resident #1 went over the same speed bump with no issues. Staff member C stated that they later got a call from staff member D, went to the scene, and then called 911. Staff member C stated that resident #1 must have just hit the curb wrong, and it was an unfortunate accident. Staff member C stated that resident #1 would have gone to the hospital by herself if staff member C had not offered to go with her. Staff member C stated that resident #1 did not have a phone, so if something had happened, she would have been out there alone. Staff member C stated it did not look like resident #1 was moved when staff member C came on to the scene, but they stated it was hard to say, as resident #1 was sitting up, and staff member C did not know how she landed. Staff member C stated staff member D described what happened as resident #1 fell out of the chair on her hands and knees and then fell back on her buttocks to the left side.During an interview on 8/5/25 at 2:54 p.m., staff member L stated they would not allow anyone with a suspected PE to take themselves across the parking lot, even if they went along. Staff member L stated if a resident's oxygen saturations were low, there would always be a potential for respiratory issues. Staff member L stated they could throw that blood clot any minute, with a suspected PE as well, which could be fatal. Staff member L stated they would feel uncomfortable being stuck in the parking lot if something occurred. Staff member L stated, Anything bad can happen from that point. We don't want all of the things to happen that did happen. Staff member L stated this incident should never have happened.During an interview on 8/5/25 at 3:04 p.m., staff member I stated a seatbelt with a motorized chair could have been helpful to prevent a fall out of the chair. Staff member I stated it depended on the dynamics of the fall.During an interview on 8/5/25 at 3:13 p.m., staff member B stated right before the incident, they had been made aware that the van could not hold resident #1's weight and her motorized wheelchair as it was too heavy. Staff member B stated by the time a new plan could be made, staff member D had already left to get resident #1. Staff member B stated staff member D was outside of their scope of practice as they moved resident #1 by sitting her up, and staff member D should have known to get the nurse first and call for assistance.During an interview on 8/5/25 at 7:35 p.m., staff member D stated they did not walk the resident over to the appointment, but staff member C did. Staff member D stated they walked with resident #1 back from her appointment. Staff member D stated resident #1 was not wearing her seatbelt when she fell out of her motorized wheelchair, and staff member D stated they did not have enough time to react to try to catch her. Staff member D stated the motorized wheelchair did not tip over when resident #1 fell out of the chair. Staff member D stated they called staff member C right away. Staff member D stated they put resident #1's oxygen back on and sat her up, but were unsure of the exact time the resident was sat up to when the nurse responded to the scene. Staff member D stated the nurse called 911, then left to call staff member B. Staff member D stated they were left alone with resident #1 until EMS arrived. Staff member D stated they were not BLS certified and said it was not required at the facility. Staff member D stated they've been doing their job for about five years. Staff member D also stated the facility's van was not working at that time. Staff member D stated resident #1 did not like to use the borrowed van with the manual lift because of the steep incline to get into the van.Review of staff member D's staff file showed no documentation of BLS certification.Review of resident #1's hospital admission note showed: atrial fibrillation with RVR (rapid ventricular response). Atrial fibrillation with RVR is a heart condition with rapid contractions of the atria and the ventricles beat too quickly, resulting in the body not receiving enough oxygenated blood.During an interview on 8/6/25 at 7:30 a.m., staff member E stated they were unable to find a weight limit on the facility's van lift. Staff member E looked at the pamphlets in the glove compartment and stated the weight limit should be obvious and easily seen by all staff members using the van. Staff member E stated, (The van lift) should be rated to 1,000 pounds, and should have held resident #1 and her motorized wheelchair if it had been working that day. Staff member E stated the facility's van was not working for many months, because the back door was broke, and this did not allow the mechanical lift to work. Staff member E stated they fixed the door last Saturday.During an interview on 8/6/25 at 9:14 a.m., resident #2, who also used a motorized wheelchair, stated she would take her motorized chair to appointments with the accompaniment of a staff member. She stated she felt unsafe and uncomfortable with the borrowed manual van because the ramp was so steep with her motorized wheelchair.Review of resident #1's hospital ER documents showed:- Discharge diagnoses/cause of death: Principal Problem: Open fracture of shaft of left femur . Leg hematoma, left, subsequent encounter . Closed bimalleolar fracture of left ankle .-History of Present Illness on admission: .-Trauma - Ejected from wheelchair in parking lot, scraped leg on chair and now has uncontrolled bleeding to L lower (left lower leg) .-went over speed bump too fast as she did not see it coming. She said the chair went up in the air, and she bucked out of it forward onto her left leg. She presented with an open distal femur fracture, bimalleolar fracture and an open left leg wound as the impact dislodged her wound vac. She was in Afib with RVR on arrival to the ED .-Interventions in the ED: 2 units of PRBC started .

Based on observation, interview, and record review, the facility licensed nursing staff failed to follow physician wound care orders; failed to complete wound treatments; and failed to document the wound status/severity sufficiently, for 1 (#23), and failed to follow physician orders; complete wound dressing changes properly; licensed nursing staff used improper aseptic technique with a dressing change; and licensed nursing staff failed to follow the facility policy and procedures for wound care services, for initialing wound dressings, adding times, or dates, for 1 (#32) of 3 sampled residents requiring wound care. These failures made it more difficult to accurately determine the status of wounds, locations of wounds, and severity, for ongoing treatment/needs to be met, for both residents who had wounds being treated. Findings include: 1. Review of resident #23's EHR showed an increasing size wound throughout time, missed weeks of documentation in the Weekly Wound Reviews, missed wound treatments, and reports from the [Clinic Name] showing wound care dressings were not completed by the physician's orders. Review of resident #23's MAR showed in the month of July 2024, two opportunities were missed for a dressing change for the right gluteal fold wound, which was on 7/6/24 and 7/27/24. Review of resident #23's EHR showed a Visit Report from [Clinic Name], with the date of service of 7/3/24 and 7/31/24, that showed, Patient has shown up to the [Clinic Name] multiple times without prescribed dressings on. Please make sure that you are following provider orders. Review of resident #23's EHR showed a Physician's Telephone Order from [Clinic Name], which showed: Pt again was noted to not have prescribed dressing in place when he arrived. All wound dressings are the same. [sic] Below shows the review of resident #23's Weekly Wound Review documentation of the right gluteal fold: 2/14/24 - The wound was documented as Pressure (not staged) with measurements of 0.4 cm x 1.1 cm x 1.0 cm 5/19/24 - Pressure ulcer Stage III no measurements documented. Wound measurements difficult to obtain due to lack of help with positioning resident . 7/18/24 - Pressure Stage IV with measurements of 0.9 cm x 0.25 cm x 0.2 cm 8/1/24 - Pressure Stage IV 0.8 cm x 0.4 cm x 0.7 cm - no and yes were both documented for odor 8/8/24 - This document was blank and was in progress 2. Review of resident #32's EHR showed documentation was completed for the assessments shown below, but the wound location was not specified, measurements or specific wound characteristics were not always provided, and there were instances (ex: 6/25/24) where no skin issues were noted, but the week prior there were skin issues documented with no resolution (ex: 6/20/24). Review of resident #32's EHR wound assessment documentation, from 6/20/24 - 8/1/2024, showed: 6/20/24 Weekly Skin Check - Right 2nd toe - wound - Left 1st and 4th - toes have wounds - In the Weekly Heel Check section of this assessment, no identifiable heel skin issues were charted 6/25/24 Weekly Skin Check -No was selected which showed the resident did not have any skin issues 7/2/24 Weekly Head to Toe - Showed a skin issue to the Toes on bilateral feet - In the Weekly Heel Check section of this assessment, no identifiable heel skin issues were charted 7/12/24 Weekly Wound Review - Left heel 5.2 cm x 3.9 cm x 0.1 cm - Unstageable 7/12/24 Weekly Skin Check - Left heel - pressure ulcer (not staged) 5.3 cm x 3.9 cm x 0. 1cm - Left 2nd toe - 0.5 cm x 0.5 cm x 0.1 cm - Left 4th toe - 0.9 cm x 0.6 cm x 0.1 cm - Right 3rd toe - 0.6 cm x 0.5 cm x 0.1 cm 7/19/24 Weekly Wound Review - Left heel blister - 3.8 cm x 4.6 cm x 0.3 cm -2nd left toe trauma - 0.6 cm x 0.5 cm x 0.1 cm 7/28/24 Weekly Head to Toe - Left heel - mentioned in documentation but no wound measurements or characteristics of wound. - Right 3rd toe - healing - Left great toe - healing - Left 2nd toe - small - Left 5th toe - small 7/30/24 Weekly Head to Toe - showed: no skin issues 8/1/24 Weekly Wound Review - Left heel - pressure ulcer Stage III - 3.5 cm x 6.3 cm x 0.5 cm - Left toe (location not specified) - trauma Stage II - 0.4 cm x 0.5 cm x 0.1 cm - Right toe (location not specified) - skin tear and N/A stage - 0.7 cm x 0.5 cm x 0.1 cm - Right toe (location not specified) - pressure ulcer Stage II - 0.8 cm x 0.4 cm x 0.1 cm During an observation on 8/14/24 at 12:43 p.m., resident #32's wound dressing did not have any initials, date, or time. Staff member E and N removed the majority of the dirty wound dressing from the left heel but left the old hydrofera blue dressing on. Staff members E and N doffed gloves, cleaned hands, and donned new gloves. Staff member E removed the hydrofera blue dressing, cleaned the left heel wound with a cleaning solution, painted the wound with betadine, then placed a new hydrofera blue pad on the heel. Next, staff member E wrapped the area with kerlix then coban. Gloves were not changed after removing the dirty dressing before placing the new dressing on the wound. Review of resident #32's physician order showed, Left Heel: betadine paint, hydrofera blue, ABD, kerlix, coban. During the observation (on 8/14/24 at 12:43 p.m.), no ABD pad was applied to the wound dressing. The left heel wound bed was slightly larger in size and circumference than a half dollar coin, with both sides of the wound bed also extending outward medially and laterally, about an inch and a half. The wound bed was pink in color with intermittent red areas. The entire heel was calloused and yellow along with the surrounding tissue around the wound bed. During an observation on 8/14/24 at 1:01 p.m., staff member E placed the following dressings on #32's left 2nd toe: betadine, hydrofera blue, 4 inch kerlix (doubled), then coban. Review of #32's physician order for the left 2nd toe showed: Left 2nd toe: betadine paint, kling, coban. When asked why staff member E was applying kerlix instead of kling, staff member E stated, I've went to the appointments with him and [the physician] is okay with it. During an observation on 8/14/24 at 1:08 p.m., staff member E applied the following dressing to #32's 3rd and 4th right toes: betadine, four inch kerlix (doubled), and coban. The 3rd and 4th toes were noticeably pushed apart from one another due to the doubled kerlix material. No dates, times or staff initials were written on any of the observed dressings. Review of #32's physician orders showed, Right 4th toe: clean with wound cleanser, betadine, conforming gauze, coban one time a day. R third toe: betadine paint, hydrofera blue, kling, coban. [sic] Review of a facility provided document titled, Wound Care, revised October 2010, showed: .10. Follow Physicians orders for cleansing and dressing the wound . 13. [NAME] tape with initials, time, and date and apply to dressing.

Based on interview and record review, the facility failed to provide quality care services to a skilled care resident admitted for rehabilitation services and nursing care; failed to identify a severe weight loss totaling 21.8% and implement nutritional interventions for prevention of further loss; failed to obtain, document, and assess vital signs as ordered by the physician; failed to follow physician orders; and failed to assess and identify behavioral care needs, to include pain, and ensure documentation was included in the EHR; Prior to his ER transfer, nursing staff failed to sufficiently assess and address a significant change in condition and provide oxygen for a decline in respiratory status, for 1 (#1) of 4 sampled residents. Resident #1 expired the same day he was transferred to the local hospital after his change in condition. On [DATE] at 9:30 a.m., the facility administrator was notified of an Immediate Jeopardy situation related to resident #1, and deficient practices related to F684-Quality of Care. The Severity and Scope of the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy, lowered to a G. Findings include: During an interview on [DATE] at 2:18 p.m., NF1 stated resident #1 weighed 106 pounds when he discharged from the hospital on [DATE], and was admitted to the facility. NF1 stated the resident weighed 88 pounds when he was weighed at the hospital on [DATE], after he trasnferred from the facility, after a change in condition. NF1 stated there was a CNA in a different room who heard resident #1 yelling for help on [DATE]. The resident had a fall, and the staff got the resident up and in his bed. The resident was reported to lose consciousness. When staff assessed the resident after the fall, the resident's airway was adjusted, and the resident was sent to the hospital for further assessment and care. When the resident arrived at the emergency department, he was immediately diagnosed with sepsis, and his vital signs were not good. NF1 stated the resident had been on oxygen at the facility but had kept taking it off. NF1 stated the resident showed signs of pain such as teeth clattering, his behavior, and moaning. NF1 stated resident #1 had lost 20 pounds in 30 days, his abdomen was concaved (sunken in), and it was very noticeable that the resident had lost a significant amount of weight. NF1 stated when the resident arrived at the hospital, he was incontinent of stool, and the stool was black and tarry. During an interview on [DATE] at 3:31 p.m., staff member E stated the dietician was in one time per week and weights were reviewed. Staff member E stated the dietician either met with her or emailed concerns to her to ensure the residents were getting the right nutrition. During an inteview on [DATE] at 10:37 a.m., staff member D stated protein shakes were added to resident #1's MAR for nutritional supplement. Staff member D stated she meets with the IDT to review weights. Staff member D stated Nutritional Assessments were completed 7 to 14 days following admission. Staff member D stated resident #1 was gone by the time she came to the facility to complete an assessment. Resident #1's first Nutritional Assessment was completed on [DATE]. The resident's first admission was on [DATE] and re-admission was on [DATE] Review of resident #1's After Visit Summary, from [Hospital Name] for his stay from [DATE] to [DATE], showed he weighed 110 pounds, oxygen saturations were 91%, and his respirations were 18. He had no diet restrictions, and it showed he, may return to regular diet. The resident was prescribed an antibiotic during his stay, Ciproflaxacin HCI, 500 mg tablet, by mouth, one in the morning and one in the evening. The resident also had lisinipril 20 mg tablet, by mouth, once a day, for his blood pressure management. Clobetasol was ordered for the treatment to his legs due to skin concerns. Review of resident #1's [Hospital Name] After Visit Summary, dated [DATE], showed the resident weighed 110 pounds on discharge from the hospital. Review of resident #1's weight record, dated [DATE], showed he weighed 110# on his admission to the facility, which correlated with the hospital weight. Review of resident #1's facility admission nursing assessment, dated [DATE], showed: - Alert and oriented times four - Weight was 110 lbs - Regular diet with ability to eat independently - One person assist with use of sit to stand lift for transfers, and walker/wheel chair for mobility - Respiratory effort 20 per minute - 96% on room air - Pain level three Review of resident #1's nutritional assessments showed he did not have an assessment completed during his facility stay from [DATE] to his first discharge on [DATE]. He also did not have a nutritional assessment or interventions put in place for his severe weight loss over the short period of time he was at the facility, in an attempt to prevent further loss, or in an attempt to identify potential causes of the loss. Review of resident #1's facility meal intake record, dated [DATE] through [DATE] showed the following: - Nine out of 24 times the resident consumed ,d+[DATE]% of meals. - Five out of 24 times the resident consumed ,d+[DATE]% of meals. - Four out of 24 times the resident consumed ,d+[DATE]% of meals. - Four out of 24 times the resident consumed ,d+[DATE]% of meals. - Two out of 24 times the resident refused his meals. - 12 times of missed documentation for meal consumption. - The resident had significant decreased meal intake between [DATE] through [DATE] after treatment for a fractured hip. The resident was not in the facility from [DATE] until readmission on [DATE]. 33275 Review of resident #1's weight records, from the [Hospital Name] showed he weighed 88 lbs, which was a severe weight loss prior to his first hospital admission, which occurred on [DATE]. Review of resident #1's facility nursing notes showed he had a fall on [DATE], and he was sent out to the hospital after the fall. Details included the resident fell backwards and landed on the floor. The resident refused to bear weight on his right lower extremity. The resident was assisted to the wheelchair by two staff. The resident was sent to the emergency room via EMS at 3:15 p.m. The nursing notes did not show if an assessment of injuries was completed prior to the decision of assisting the resident to his wheel chair. Review of resident #1's fall assessment, dated [DATE], showed the cause of the fall was related to his mobility, pain, weight, and contributing factors, oxygen use or problems with his breathing or respiratory status Review of resident #1's facility admission records showed he was admitted to the skilled nursing home on [DATE], after he discharged from the local hospital. Review of resident #1's Power of Attorney showed he had a living will and he, .desired to receive treatment for comfort or to alleviate pain ., and there were no exceptions noted. Review of resident #1's Physician orders, for his admission to the facility, showed he was to receive Occupational, and Physical therapy five times per week for 12 weeks, and Speech Therapy three times per week, for four weeks. Review of resident #1's physician standing orders showed oxygen ,d+[DATE] liters per minute per nasal cannula or a mask if oxygen saturations were less than or equal to 89%, and staff were to follow facility protocol related to oxygen use and maintaining his oxygen saturation above 89%, and his diet was documented to be a regular diet. Review of resident #1's physician progress notes showed he was not seen by the physician during his nursing home stay from [DATE] to [DATE]. Review of resident #1's admission nursing assessment, dated [DATE], showed: - Alert and oriented to person only - Weight was 112.6 lbs - Regular diet with ability to eat independently - One person assist with use of sit to stand lift for transfers, and wheel chair for mobility. The resident was using a walker prior to his fall on [DATE]. - Respiratory effort 17 per minute - 93% on oxygen via nasal cannula - pain level seven Review of resident #1's Medication Administration Record (MAR), dated [DATE]-[DATE], showed the resident was monitored for behaviors including name calling, inappropriate language, excessive wandering or elopement attempts, every shift. Staff were to document adverse behaviors in the progress notes. This monitoring was noted to be discontinued on [DATE]. There was no additional monitoring for behaviors, and how his behavior may be related to pain due to his hip fracture, after the resident returned to the facility on [DATE]. The resident was not at the facility between [DATE] and [DATE] Review of resident #1's facility Pain Assessment, Post Incident, completed on [DATE] at 3:07 p.m., and 3:59 p.m., showed the resident was resistive to cares, restless, had fluctuations in mental functioning, aggressive and he had a loss of interest. Weight loss was not noted. He had a pain level marked as 9 and 9.5, with a level of 10 being the highest. He was not able to verbalize his pain, and pain was marked as being mild. The pain was new, and it was due to a fall, per the note. The Plan of Care showed he had satisfactory pain managment. Review of resident #1's [Hospital Name] record, for his admission on [DATE], after his fall with hip pain, showed he was moderately demented. He had been discharged a week prior for lower bilateral lower extremity cellulitis and bilateral lower extremity venous stasis dermatitis. At the time of his discharge, he was ambulating freely and interacting with staff, and he was then discharged to the nursing home. The notes showed he stated a man shoved him to the ground, and he landed on his butt and immediately had pain in his right bottock and hip. He was provided Dilaudid for his pain management and admitted for surgical fixation of the right intertrochanteric hip fracture. Information provided from the resident was limited due to dementia and he was pleasantly demented. The record showed he had a weight of 83 pounds and 5.3 ounces, which was a severe loss over the prior seven days. His oxygen saturations were 83% and respirations 16. The resident was placed on 2 liters of oxygen by nasal cannula, had a regular diet, and he had a do not resuscitate in place for his advance directives. Within the same notes, dated [DATE], the record showed resident #1 did not understand that he fractured his femur. His weight remained just over 83#. With his oxygen on, his saturations remained above 90%, except for one occasion on [DATE] and he was at 87%, and he had just been changed to room air. Under the Musculoskeletal section, documentation showed he had, Pain with any motion of the right hip. Tenderness to palpation of the right hip. Review of resident #1's [Hospital Name] Case Classification note for his surgery, dated [DATE], showed he continued his regular diet, and he had two pressure injuries to his left and right heel, both hospital aquired. He had acute hypoxemic respiratory failure for a diagnosis and edema. The resident was in the hospital for his hip fracture from [DATE], and he discharged on [DATE], back to the nursing home. Review of resident #1's [Hospital Name] records and medications showed on ,d+[DATE], ,d+[DATE], and [DATE], he received: - oxyCODONE, 5 mg table, as needed every four hours, for moderate to severe pain. He received the medication twice on [DATE] and [DATE], and once on [DATE], and then he was discharged . - He received RisperiDONE in the evening and at night, for agitation, on ,d+[DATE] and [DATE]. - Tylenol was prescribed at 650 mg tablets, while awake, which he received three times on [DATE] and four times on [DATE], and on the day of discharge, he received two doses. - On [DATE], both his right and left heel developed a pressure injury, which were hospital aquired, and first noted at 11:35 a.m. that day. - The resident was discharged with the availablity to receive oxyCODONE 5 mg tablet for pain management and amoxicillin for the treatment of an infection. - The resident was discharged back to the nursing home on [DATE]. Review of resident #1's SNF Progress Note, dated [DATE], which is the day after he was readmitted to the nursing home following his fractured hip surgery, showed he had acute hypoxemic respiratory failure and fracture of his right hip. He was on Augmentin due to pneumonia in left lower lobe, which was started [DATE]. The note showed the family decline oxygen use due to the tubing being a trip hazard. This was not documented in the resident's medical record. The resident's lasix was held, and due to his poor appetite and need to monitor edema, daily weights were ordered. The resident was to have vitals taken two times daily with his blood pressure monitored. There were no open areas on the resident's buttocks, but neither the heels, nor the weight loss, were noted. He did have schedule narcotics for pain, per the documenation. The resident was found wandering and defecating in a garbage can, and staff did not notice a baseline change. The Medications section of the note showed he was to have oxyCODONE 5 mg tablet by mouth every four hours, as needed, for moderate pain. Under the Vitals section, the notes showed, There is no height or weight on file to calculate BMI. Review of resident #1's facility Weights and Vitals Summary, from [DATE] to [DATE] showed the resident had no documented weights between [DATE] to [DATE] and [DATE] to [DATE]. The resident was admitted to the facility on [DATE], went to the hospital on [DATE] and returned to the facility on [DATE] following repair of a fractured hip. Review of resident #1's [Hospital Name] History and Physical, dated [DATE], showed the resident's hospital admission weight was 83 pounds. When resident #1 arrived at the emergency roiagnom on [DATE] he weighed 88 pounds. Review of resident #1's MAR, dated [DATE]-[DATE], showed nursing were to assess the resident for pain using the numeric scale every shift. The resident had oxyCODONE 5 mg every four hours as needed for pain with a start date of [DATE], following re-admission after surgical repair of the right hip fracture. Review of resident #1's facility Admission and Baseline Care Plan/Summary, dated [DATE], showed the resident had a pain level of seven, he was oriented to person only, and had oxygen via nasal cannula at 2 L/min. Review of resident #1's Pain Assessment-Post Incident, dated [DATE], showed the resident was unable to answer questions due to cognitive or communication deficit Review of resident #1's facility Progress Notes, dated [DATE] -4 /,d+[DATE], showed the resident was readmitted back to the facility on [DATE]. The progress notes had no information related to admission, orders, cognitive status, or pain level. Review of resident #1's facility Fall report, dated [DATE], showed the resident was found on the floor in his room by staff. The resident fell backwards out of his wheel chair, was drowsy, oriented to person only, and had skin tears to right elbow, forearm skin tear, and left finger. There were no bumps or lacerations to the resident's head. The resident was unable to describe what happened related to his fall. Review of resident #1's facility Neurological Evaluation, dated [DATE], showed: - The resident was lethargic. - Oriented to person only. - Blood pressure ,d+[DATE]; oxygen saturations 75% on room air. There was no evidence nursing staff applied oxygen to the resident to improve the saturation level. - His pupils were equal. Review of resident #1's Pain Assessment-Post Incident, dated [DATE], showed the resident was unable to answer the questions due to his cognitive or communication deficit During an interview on [DATE] at 3:38 p.m., staff member C stated resident #1 fell out of his wheel chair on [DATE], he was drowsy, and he had a decreased level of consciouness. Staff member C stated the resident had not had any visible injuries to his head. Staff member C stated the resident's speech was slow. Review of resident #1's emergency room hospital record showed he was admitted at 8:56 a.m., on [DATE]. The Chief Complaint was documented as Shortness of Breath, PT arrived by ems from [Facility] for unwitnessed fall, no thinners, unknown loc, c/o sob. 70's RA for ems. Hx DNR and comfort measures, recent femur fx repair. The resident was found on the ground at the nursing home and was found to have a pulse oximetry of 70% on room air. His advanced directives were reviewed, and he had no CPR and comfort focused treatment only. The resident's blood pressure was documented to be ,d+[DATE], his pulse 89, respirations were 7, and his weight was 88 lbs and 2.9 oz. He was in significant respiratory distress. The resident was found to have, Equisite tenderness to palpation with decreased bowel sounds, and Mottled skin of bilateral lower expremities. The resident was confused and disoriented. While in the emergency room , the staff provided the resident HYDROmorphone (Dilaudid) for pain at 9:19 a.m., 9:38 a.m., and 10:09 a.m., and when the residents comfort was discussed at 9:53 a.m., he was still Uncomfortable which is why the 10:09 a.m. dose was provided. Due to the resident's status and decline, he was provided end of life care. The Procedures section showed he was clearly uncomfortable and in pain upon arrival. Review of resident #1's emergency room Provider Note, dated [DATE], showed the resident was in the ER for nine hours before passing away. During an interview on [DATE] at 1:30 p.m., staff member N stated residents receiving skilled services have their vitals taken two times each shift, unless the person is sick, then it may be more. If the resident's blood pressure is out of range, the employee taking the vitals should immediately report the concern to the charge nurse, and then a recheck is done in 30 minutes. She stated sometimes, a check is done right away, just to verify accuracy. Staff member N considered a low blood pressure to be ,d+[DATE], and a high blood pressure to have a systolic over 140. When discussing pain symptoms, staff member N stated she would observe pain in a resident who displayed a fever, moaning, making noises (made by resident), crying, or wandering. Staff member N stated resident #1 did wander, but she did not feel he expressed non-verbal pain indicators or symptoms. She said when he returned from the hospital, after his hip fracture, he was walking fine and would get up and forget about the hip fracture as he was more disoriented. Staff member N was not sure of resident #1's baseline pain level, as to help identify if he had pain symptoms not being addressed, but stated he sundowned, so his behaviors increased at night, and he would get upset at times, but this was not related to pain. Staff member stated resident #1 was kept out in the social area of the facility (sitting area between the units) due to his behaviors, as to help keep him occupied. Then if the resident was attempting to wander or standing up and down in his chair, staff would notice, and try to stop him. Staff member N did not identify the wandering, getting up/down in his wheelchair, sundowning behaviors, or getting upset with others were possible indicators of pain.

Based on interview and record review, facility nursing staff failed to provide supplemental oxygen for a resident's saturation level of 75%, with standing orders to apply oxygen two liters via nasal cannula for saturations less than 89%, for 1 (#1) of 8 sampled residents, and the resident had a decline in status and was sent to the ER. Findings include: During an interview on [DATE] at 3:38 p.m., staff member C stated when she assessed resident #1 after his fall on [DATE], he was drowsy, had a decreased level of consciousness, and slow speech. During an interview on [DATE] at 1:03 p.m., staff member C stated oxygen would need to be applied if oxygen saturations were less than 90%. Review of resident #1's Fall documentation, dated [DATE] at 7:37 a.m., showed the resident had an unwitnessed fall in his room. The resident fell backwards out of his wheel chair, was drowsy, was oriented times one, had skin tears to his elbow, forearm skin tear, and left ring finger. No bumps or lacerations were noted to the resident's head. The resident was unable to describe what happened. Under immediate action taken the resident's vital signs were taken, skin tears were cleaned. The resident was not taken to the hospital at that point, but was later transferred to the hospital. Review of resident #1's facility Fall Assessment-Post Incident and Neurological Evaluation failed to show oxygen was applied to the resident when his saturations were 75%. 33275 A review of resident #1's [Hospital Name] emergency room hospital record showed he was admitted at 8:56 a.m., on [DATE]. The Chief Complaint was documented as Shortness of Breath, PT arrived by ems from [Facility] for unwitnessed fall, no thinners, unknown loc, c/o sob. 70's RA for ems. Hx DNR and comfort measures, recent femur fx repair. The resident was found on the ground at the nursing home and was found to have a pulse oximetry of 70% on room air. His advanced directives were reviewed, and he had no CPR and comfort focused treatment only. The resident's blood pressure was documented to be ,d+[DATE], his pulse 89, respirations were 7, and his weight was 88 lbs and 2.9 oz. He was in significant respiratory distress. The resident was found to have, Equisite tenderness to palpation with decreased bowel sounds, and Mottled skin of bilateral lower extremities. The resident was confused and disoriented. While in the emergency room , the staff provided the resident HYDROmorphone (Dilaudid) for pain at 9:19 a.m., 9:38 a.m., and 10:09 a.m., and when the residents comfort was discussed at 9:53 a.m., he was still Uncomfortable which is why the 10:09 a.m. dose was provided. Due to the resident's status and decline, he was provided end of life care. The Procedures section showed he was clearly uncomfortable and in pain upon arrival. During an interview on [DATE] at 2:18 p.m., NF1 stated the resident had been on oxygen at the facility but had kept taking it off.

Based on interview and record review, the facility failed to protect the residents right to be free from physical and emotional abuse by staff members for 2 (#5 and #24) of 2 sampled residents, resulting in emotional and physical harm. Findings include: 1. Review of a facility reported incident submitted to the State Survey Agency on 4/19/23, showed resident #5 had reported to a staff member, staff member NF7, had pulled her legs hard and squeezed her hand, and hurt her. During an interview on 8/15/23 at 9:59 a.m., resident #5 stated she remembered a little bit about the incident that occurred on 4/19/23. Resident #5 stated, I remember the black girl hurt me. Resident #5 stated she felt safe now that she had not seen NF7. Review of the investigation for the facility reported incident on 4/19/23, showed NF7 was immediately suspended pending an investigation into the allegations, and asked to leave. After NF7 was asked to leave she was found in the room of resident #5, questioning her about what had been told to staff. NF7 was walked out of the building at that time. Nursing staff assessed resident #5, and she was found to have no injuries. Later on in the morning, it was noted that resident #5 had swelling and complained of pain in her hand. Resident #5 was sent to a medical facility for an evaluation. During an interview on 8/17/23 at 9:56 a.m., staff members A and B stated abuse was not tolerated in the facility. Staff member B stated the number one priority was to keep the resident safe. Staff member B stated the expectation for abuse reporting was to start an investigation right away and notify administration. The accused was to be suspended and escorted off the property. If the accused did not leave, law enforcement should be called. Staff member A stated staff member B and herself should be notified of any issues and a follow up call to them should be made once the staff member had left the property. Staff member A stated NF7 was no longer employed at the facility, and the investigation was turned in to the staffing agency. 47785 2. Review of the facility reported incident, submitted on 7/20/23, showed resident #24 reported NF8 came to her room when she requested to use the bathroom. After requiring her to utilize a bedpan, NF8 .slammed . her against the wall causing resident #24 to have pain and feelings of anxiety and fear. Review of the investigation related to the facility reported incident, submitted on 7/20/23, showed resident #24 requested NF8 no longer be allowed to care for her as she was nervous with her. Resident #24 told the facility interviewer she was very relieved when told NF8 would not be providing cares for her anymore. During an interview on 8/16/23 at 4:52 p.m., staff member A reported the police were in the facility continuing the investigation regarding resident #24 and NF8, recently. Staff member A reported NF8 was no longer employed at the facility. Review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed it was the facility responsibility to .protect the residents from abuse, neglect, exploitation or misappropriation by anyone including but not necessarily limited to: a. facility staff .

Based on observation, interview, and record review, the facility failed to provide ordered supplements, and assistance with meals, for 1 (#52) of 4 sampled residents, and the resident had a severe weight loss of 11.64% over six months. Findings include: Review of the weight documentation for resident #52 showed: - Resident #52's weight on 2/17/23 was 96.2 pounds, and on 8/13/23 her weight was 85.0 pounds, representing a severe weight loss of 11.64% over six months, During an observation on 8/15/23 at 9:00 a.m., resident #52 was sitting at a table in the dining room, with her breakfast tray in front of her. Resident #52 appeared to be asleep. There was no attempt from staff to wake resident #52 to assist her with her meal. During an observation on 8/15/23 at 2:32 p.m., resident #52 was lying in her bed. There were two unopened peanut butter and jelly sandwiches on her nightstand and a small glass of red fluid. During an observation on 8/15/23 at 4:45 p.m., resident #52 was lying in her bed and two unopened peanut butter sandwiches continued to be on her nightstand, the glass of red fluid was still full, and the outside of the glass was warm to the touch. During an interview on 8/15/23 at 4:50 p.m., staff member F stated resident #52 needed assistance with eating. Staff member F stated she needed verbal cueing at the very least. During an observation on 8/16/23 at 12:58 p.m., resident #52 was sitting at the dining room table, with her meal tray in front of her. On her tray was long fettucine noodles, uncut with light sauce, large sized broccoli florets, a full, uncut bread stick, and a glass of water. Resident #58 had picked up the bread stick and tried to take a bite. She put the bread stick down, unable to eat it. Resident #58 tried to eat some of the fettucine noodles and started to cough. The lunch ticket on resident #52's tray showed she was to have a regular mechanical soft level three diet, with a house shake over ice, and a peanut butter and jelly sandwich at all meals. There was no peanut butter and jelly sandwich or house shake on her lunch tray. During an interview on 8/16/23 at 1:00 p.m., staff member R stated resident #52 did not eat well and sat at a table where she could be monitored. During an observation on 8/16/23 at 1:10 p.m., resident #52 was still sitting at the table in the dining room, a staff member was sitting at the table with the residents. There was no cueing done for resident #52 to eat. Resident #52 had no measureable intake from her meal. During an interview on 8/16/23 at 3:22 p.m., staff member Q stated the resident was to have peanut butter and jelly sandwhiches at all meals, and for snacks, to help supplement when she does not eat well. Staff member Q stated resident #52 is also supposed to have a house shake as a supplement. Staff member Q stated the resident had to be cued or assisted with meals, and the speech therapist was currently re-evaluating resident diets and textures. Staff member Q stated the error on resident #52's lunch tray must have been an oversight. A review of resident # 52's comprehensive care plan, with a revision date of 1/12/23, showed, . eating assistance to eat . A review of a physician's progress note, dated 3/20/23, showed: Patient has had about a 20-pound weight loss in the past few months. She reports she does not like the boost or other shakes. I did discuss with nursing who reports she is eating better . Patient is on Risperdal which should be an appetite stimulant. I am concerned. A request for the most recent physician progress notes were requested and not recieved by the end of the survey.

Based on observation, interview, and record review, the facility failed to have oxygen supplies available to a resident with low oxygen saturations for 1 (#52), resulting in the resident's inability to maintain oxygen levels above 89-94%; failed to maintain oxygen tubing for 2 (#s 18 and 45), and failed to properly maintain and clean a CPAP machine for 1 (#18) of 6 sampled residents, increasing the potential for respiratory infections and medical decline. Findings include: 1. During an observation and interview on 8/16/23 at 12:45 p.m., resident #52 was lying on her bed and appeared dusky in color. An oxygen saturation level was checked by staff member F, and resident #52's oxygen saturations were at 86% room air. There was no oxygen concentrator, oxygen tubing, or oxygen tank available in residents #52's room. Staff member F did not attempt to medically assess resident #52. Staff member F did not listen to resident #52's lungs or heart. Staff member F stated, I am ok with her oxygen saturations that low. I have had other doctors tell me that number is ok. Staff member F stated she had not had resident #52's doctor tell her those numbers were ok. Staff member F could not verbalize what the oxygen/respiratory policy showed for situations where residents had low oxygen saturations. Staff member F could not describe what steps should be taken when low oxygen saturations occurred. Staff member F stated resident #52 would not keep the oxygen tubing on. A review of resident #52's physician's orders showed an order for 1 liter of oxygen, continuously. During an interview on 8/16/23 at 1:35 p.m., staff member B stated when a resident has a low oxygen saturation, The expectation is the nurse will assess the resident, check orders for oxygen, check diagnosis, check for any signs or symptoms of respiratory distress, call the physician, place oxygen and ongoing monitoring of the resident. During an observation on 8/16/23 at 2:00 p.m., resident #52 was lying on her back in bed. Resident #52 continued to look dusky in color. There was an oxygen concentrator in the room, not plugged in, oxygen tubing was on the side table, not attached to the concentrator, and no humidifier on the concentrator. Staff member F checked resident #52's oxygen saturation level again, and the resident's saturations had dropped to 84% room air. Staff member F did not medically assess resident #52 or place oxygen on resident #52 to improve the residents oxygen saturation level. During an interview on 8/17/23 at 9:03 a.m., NF5's office nurse called related to resident #52's low oxygen level. The office nurse for NF5 stated, Patients that have respiratory conditions should be on oxygen and have an oxygen saturation of 89-94%, this is concerning. I will have [NF5] call you back. During an interview on 8/17/23 at 3:00 p.m., NF5 stated she was concerned about the oxygen level with resident #52. NF5 stated, [Resident #52] does have a history of taking off her oxygen, but the supplies needed to be available for her to use if she needed them. This could be harmful to [Resident #52]. I never received a call from the facility notifying me of the change in condition (decreased oxygen saturations). This really is concerning. A review of a facility document, titled, Acute Condition Changes, with a revision date of March 2022, showed: .2. The nurse shall assess and document/report the following baseline information. a. Vital signs ., .d. level of consciousness ., .j. active diagnosis ., .k. all current medications ., .8. The nursing staff will contact the physician . 2. During an observation and interview on 8/14/23 at 4:40 p.m., resident #45 was sitting in an electric wheelchair, in his room. Resident #45 was wearing oxygen via nasal cannula. The oxygen tubing was brown in color, and there was crusty like debris around the nasal cannula. Resident #45 stated he had to use his oxygen all of the time. Resident #45 stated he did not know when the last time the oxygen tubing was changed, but it had been quite some time. During an observation and interview on 8/15/23 at 10:00 a.m., resident #18 was sitting on the bedside commode with a blanket covering her lap. Her oxygen tubing was lying on the floor in front of the commode. The oxygen tubing was brown in color and had crusty like debris on the nasal cannula. There was no date on the concentrator or tubing showing when it was changed. Resident #18 stated she was not sure when the last time her oxygen tubing was changed. During an interview on 8/16/23 at 1:35 p.m., staff member B stated oxygen tubing should be changed weekly. Staff member B stated the oxygen companies maintained the concentrators but could not state when the last time the oxygen company was out to look at the concentrators. A review of resident #18's MAR and TAR, dated July 2023 and August 2023, did not show any documentation of when the oxygen tubing was changed. A review of resident #45's MAR and TAR, dated July 2023 and August 2023, showed the tubing was to be changed weekly, but had only been done once in July 2023 and once in August 2023. 3. During an observation and interview on 8/15/23 at 10:00 a.m., resident #18's CPAP machine was on the night stand next to the bed. The face piece and tubing for the mask were coated in a white, crusty substance. Resident #18 stated she used her CPAP every night. Resident #18 stated she did not recall any of the staff cleaning her CPAP machine at all. During an interview on 8/16/23 at 7:45 a.m., staff member F stated, I don't change oxygen tubing, night shift does. A review of a facility document, titled, Oxygen administration, with a revision date of Q3, 2022, showed: General guidelines, . 2. oxygen tubing is changed every 7 days and as needed if contaminated or visibly soiled. The requested CPAP policy was not provided to the surveyors by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure the Facility Assessment identified appropriate staffing levels to provide basic care needs for residents, which caused mental anguish for 1 (#49), and caused 3 (#s 60, 64, and 70) of 7 sampled residents to voice concerns about staffing due to care needs not being met; and failed to update the Facility Assessment to include COVID-19 care and services. These failures increased the risk of a negative outcome for residents residing at the facility. Findings include: 1. Basic Care Needs: a. During an interview on 8/30/22 at 10:29 a.m., resident #49 stated he had not had a shower in two weeks and had made requests. Resident #49 said, I am a grown man and I have an issue with wetting the bed. It really bothers me and is embarrassing, and I haven't had a shower in two weeks. It is humiliating. b. During an interview on 8/29/22 at 2:00 p.m., resident #70 stated she had only received one shower since her admission on 8/19/22. Resident #70 said she had been informed by staff that there were not enough staff, so her shower would be provided when staff had a time. c. During an interview on 8/29/22 at 10:11 a.m., resident #60 said she had only had two showers since she was admitted on [DATE]. d. During an interview on 8/29/22 at 10:24 a.m., resident #16 said she got a shower a couple of times a week. Resident #16 said she had gone 2 weeks without a shower in the past. Resident #16 said she would tell staff, I need a shower, and she would get one within a couple of days. Resident #16 said, Staff are busy and there's not enough of them to get everything done. e. During an interview on 8/29/22 at 2:27 p.m., resident #64 stated he had only showered twice since his admission on 8/9/22. f. During an observation on 8/29/22 at 2:00 p.m., resident #5 was in his room in his bed his hair appeared disheveled, oily, and he had a stale body odor. Review of resident #5's bathing documentation showed, in August 2022, the resident did not receive any showers. In July of 2022 the resident only received one shower on 7/16/2022. g. During an observation on 8/30/22 at 9:36 a.m., resident #13 was calling out, Help me, I am wet and need to be changed. Resident #13 was lying in bed wearing a disposable brief and a hospital gown. Staff member I entered the room to assist resident #13's roommate into a wheelchair. Resident #13 asked staff member I if she was going to get her up for the day, and staff member I replied, Not now, I will be back later when I can. During an interview on 9/1/22 at 8:23 a.m., staff member G said she had stayed over her shift to help with showers. Staff member G said there were residents in need of showers and staff were not available to give residents showers. Staff member G said there was one aide per hall during the day. At night, there was 1 aide assigned to two halls. Staff member G said she worked hard her entire shift and there is no way she could get everything done and get resident showers done too. Review of the Facility Assessment showed the facilty had a year to date census of 67 residents. The Facilty Assessment identified the resident population as having wounds, fractures, multiple sclerosis, cerebral palsy, amyotrophic lateral sclerosis, physical abnormalities, and dysphagia problems. The Facility Assessment did not identify the percentage of the resident population with these physical disabilities. Review of the Facility Assessment showed an identified resident population with dementia, mental health disorders, traumatic brain injuries, strokes, and seizures. The Facility Assessment did not identify the percentage of the resident population with these cognitive disabilities. The facility could not accurately identify needed staffing levels due to the failure to identify the percentages of residents with physical and cognitive disabilities During an interview on 9/1/22 at 8:15 a.m., during the quality assurance interview staff member A stated the facility had a performance improvement project implemented for showers in the facility. Review of the facility's admission packet, dated 2/2021 showed, .We are concerned about all aspects of your loved one's daily care needs, including the importance of bathing. The residents of the Facility are bathed every other day unless a resident has other prefrences. While showers are avalible, we encourage full body baths to maintain good skin integrity and revitalize circulation . 40068 2. COVID-19 Mitigation plan: Review of the Facility Assessment, dated 1/3/2022, failed to show any information related to COVID-19 care and services. The assessment did not include: - COVID-19 as an infectious or communicable disease. - Isolation needs as a result of COVID-19. - Changes in staffing as a result of COVID-19. - An updated Infection Prevention and Control risk assessment which addressed COVID-19. During an interview on 8/30/22 at 3:55 p.m., staff member A stated the facility does have a plan on how they would handle a COVID-19 outbreak in the facility. However, it is not a part of the facility assessment. The facility's assessment was requested at entrance, a COVID-19 mitigation plan was not part of the facility's assessment. 45448

Based on observation, interview, and record review, the facility nursing staff failed to ensure professional standards of practice were followed by not appropriately identifying a resident prior to medication administration for 2 (#s 1 and 5), which resulted in resident #1 being given the wrong medications, and nursing staff failed to accurately read the MAR for 1 (#2) of 5 sampled and supplemental residents, which resulted in resident #2 receiving an overdose of medication. Findings include: Identification of residents: 1. During an interview on 5/22/19 at 12:45 p.m., staff member B stated resident #1 received another resident's medication on 5/6/19. Staff member B stated staff member [NAME] was preparing medications for another resident, when resident #1 called and requested to have her medications. Staff member [NAME] had drawn up resident #1's medications earlier and had put them aside as resident #1 had not wanted them at that time. Staff member B stated staff member [NAME] grabbed the wrong medication cup and gave resident #1 the medications belonging to another resident. Resident #1 received [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mg instead of her prescribed medications. Staff member B stated the resident was transferred to the hospital via ambulance for evaluation. Staff member [NAME] failed to ensure the right medications were administered to resident #1, which precipitated the transfer. During an interview on 5/22/19 at 3:30 p.m., staff member B stated the expectation for medication administration was for it to be done appropriately and safely. During an interview on 5/22/19 at 5:00 p.m., staff member B stated the protocol for medication pass was to observe the rights of medication administration. Review of resident #1's nurse's note dated 5/6/19 showed resident #1 was given another residents medication and was transported to the hospital via ambulance. The note showed the hospital informed the facility the resident had a previously documented reaction to oxy ([MEDICATION NAME]). Review of resident #1's Admission Record showed an allergy to [MEDICATION NAME]. 2. During an observation of medication pass, staff member D administered medications to resident #5. Staff member D had pre-poured the resident's medications. She grabbed the cup the medications were in and walked over and handed the medications to resident #5. Staff member D did not ask the resident her name or attempt to identify her in any other manner. During an interview on 5/22/19 at 8:45 a.m., staff member D stated the MARs have pictures to assist in identifying the residents. Staff member D stated if there was no picture she would ask the CNAs who the residents were. Staff member D stated she had only been working at the facility for one week. During an interview on 5/22/19 at 8:50 a.m., staff member C stated if a resident was coherent then she would ask them their name. Staff member C stated the MARs have pictures to help identify the residents. Reading the MAR: 3. During an interview on 5/22/19 at 12:40 p.m., staff member B stated resident #2 had received an extra 15 mg dose of [MEDICATION NAME], a sedative, on 12/28/18. Staff member B stated the resident was supposed to have 45 mg of [MEDICATION NAME] at bedtime, however the facility was out of 15 mg tablets. Staff member B stated resident #2 received two, 30 mg doses of [MEDICATION NAME]. Staff member B stated the night nurse did not accurately read the MAR indicated [REDACTED]. Review of resident #2's nurse's note, dated 12/29/18 at 4:30 a.m., showed resident #2 had a fall at 3:40 a.m., after the administration of the extra [MEDICATION NAME]. The note also showed the resident was very somnolent. Review of resident #2's nurse's note, dated 12/29/18 showed the nurse that worked the 6-10 shift the night prior had administered 30 mg of [MEDICATION NAME] to resident #2 at 9:00 p.m., and the night shift nurse had administered another 30 mg of [MEDICATION NAME] at 11:00 p.m. Review of the facility policy titled General Dose Preparation and Medication Administration showed the following: - .#3 Dose preparation 3.2 Facility staff should only prepare medications for one resident at a time . - .#4 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dosage, at the correct route, at the correct date, at the correct time, for the correct resident. 4.1.2 Confirm that the MAR indicated [REDACTED]. - .#5 During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Identify the resident per facility policy .

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 2 (#s 1 and 2) of 4 sampled residents. Resident #1 was given the wrong medication and required transport to the hospital. Resident #2 was given an overdose of medication and sustained a fall following the incident. Findings include: 1. During an interview on 5/22/19 at 12:45 p.m., staff member B stated resident #1 received the wrong medications. Staff member B stated staff member [NAME] had drawn up medications for resident #1, however the resident had refused the medications at that time. Staff member [NAME] then began to draw up medications, [MEDICATION NAME] 40 mg and [MEDICATION NAME] 75 mg, for another resident when resident #1 called and stated she was ready for her medications. Staff member B stated staff member [NAME] grabbed the wrong medication cup and gave resident #1 medications belonging to another resident. Staff member B stated resident #1 was transferred from the facility to the hospital for evaluation following the incident. Staff member B stated she observed staff member [NAME] administering medications to other residents and there were no further incidents that night. Staff member B stated there was a staff meeting on 4/25/19 in which she discussed with nursing staff how to file a medication error report. Staff member B stated there was a staff meeting last Wednesday (5/15/19) in which she went over the rights of medication administration. There was no evidence of follow up on staff member E's competency with medication administration. Review of resident #1's nurse's note, dated 5/6/19 at 8:00 p.m., showed resident #1 received another resident's HS meds around 7:15 p.m. The resident had just left the facility via ambulance for monitoring at the ER. At 9:20 p.m., the facility received word from the hospital that resident #1 would be admitted for observation. The resident did not return to the facility. The nurse's note showed the ER nurse informed the facility the resident had a previously documented reaction to oxy ([MEDICATION NAME]), that being hallucinations. Review of resident #1's Admission Record showed an allergy to [MEDICATION NAME]. During an interview on 5/22/19 at 3:23 p.m., NF1 stated resident #1 had been transferred to the hospital because she received the wrong medications. NF1 stated the physician stated the resident received a very high dose of medication. During an interview on 5/22/19 at 3:30 p.m., staff member B stated it was the expectation that medication administration be done appropriately and safely. During an interview on 5/22/19 at 4:40 p.m., staff member C stated she received two days of orientation on the day shift and one day of orientation on the night shift. During an interview on 5/22/19 at 4:45 p.m., staff member D stated she received three days of orientation. During an interview on 5/22/19 at 5:00 p.m., staff member B stated the facility had just added medication errors to QAPI recently and had not started the monitoring yet. Staff member B stated the facility was implementing a checklist for safe medication administration but hadn't officially started them yet. Staff member B stated the protocol for medication pass was to observe the rights of medication administration. Staff member B stated nurses get three days of orientation on the floor. Staff member B stated the protocol for refused medications was to reapproach the resident, contact the physician, and waste the medications. The facility failed to have a system in place for monitoring nursing staff's competency with medication administration. 2. During an interview on 5/22/19 at 12:40 p.m., staff member B stated resident #2 had received an extra 15 mg of [MEDICATION NAME], a sedative, on 12/28/18. Staff member B stated the resident was to receive 45 mg, however had received 60 mg. Staff member B stated the nurse that worked the 6-10 shift had administered 30 mg of [MEDICATION NAME]. The resident was to receive 45 mg, however the facility did not have the 15 mg tablets available. Staff member B stated the nurse that worked the night shift came on at ten and administered another 30 mg of [MEDICATION NAME]. Staff member B stated the night nurse did not check to see whether the medication had already been given. Review of resident #2's nurse's note, dated 12/29/18 at 4:30 a.m., showed resident #2 fell while being assisted from wheel chair to recliner at 3:40 a.m. The note showed the resident had not received injuries and was very somnolent. The resident refused transport to the ED. Review of resident #2's nurse's note, dated 12/29/18 at 6:30 a.m., showed the night nurse stated resident #2 was given her [MEDICATION NAME], 30 mg, at 11:00 p.m. on 12/28/18. The 6-10 nurse happened to be at the nurse's station and stated resident #2 had received [MEDICATION NAME] 30 mg at 9:00 p.m. on 12/28/18. Nursing then instructed a CNA to get a full set of vital signs on resident #2. The residents blood glucose was 64 and required intervention. The resident's vital signs were as follows: -At 6:40 a.m., 88/62, 72, 18, 90%, 98.1 -At 8:00 a.m., 95/70, 78, 19, 94%, 97.8 -At 11:35 a.m., 116/82, 78, 19, 94%, 97.9 -At 3:00 p.m., 128/85, 86, 19, 95%, 98.0 During an interview on 5/22/19 at 8:45 a.m., staff member D stated the MARs had pictures of the residents and if there was no picture, she would ask the CNAs who the residents were. Staff member D stated she had only worked at the facility for one week. During an interview on 5/22/19 at 8:50 a.m., staff member C stated if the resident was coherent she would ask the resident to state their name and if not, there were pictures on the MARs to help identify the resident. Review of the facility policy titled, General Dose Preparation and Medication Administration, showed the following: - .#3 Dose preparation 3.2 Facility staff should only prepare medications for one resident at a time . - .#4 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dosage, at the correct route, at the correct date, at the correct time, for the correct resident. 4.1.2 Confirm that the MAR indicated [REDACTED]. - .#5 During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.1 Identify the resident per facility policy .

Based on record review and interview, the facility failed to prevent serious injury from falls, update care plans with appropriate interventions and monitor the interventions for efficacy for 3 (#s 1, 5, and 7) of 15 sampled residents. Specifically resident #1 had a fall that resulted in a left hip fracture. Resident #5 had a fall that resulted in a jaw fracture; and resident #7 had a fall that resulted in a left arm fracture of the humerus. The facility also failed to prevent falls, update care plans with appropriate interventions and monitor the interventions for efficacy for 6 (#s 3, 6, 8, 9, 10, and 19) of 28 sampled and supplemental residents. Findings include: IMMEDIATE JEOPARDY The facility failed to respond to repeated falls for 9 identified residents who had falls with and without injury. The facility failed to implement interventions for fall prevention and resident safety, failed to update the residents' plan of care for identified measurable interventions; failed to monitor the implemented interventions for efficacy and modify the interventions when needed. On 2/11/16 at 12:20 p.m., the facility administrator, the administrator in training and the director of nursing were notified by the surveyors that an immediate jeopardy situation existed for 9 of the 28 sampled and supplemental residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an abatement for the immediate jeopardy on 2/11/16 at 12:20 p.m. The deficient practice remained at the scope and severity of an H once the immediate jeopardy was abated. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: For resident #1, the staff will ensure that soft shoe/slipper was on the resident's left foot at all times while the resident is up in the wheelchair. Resident #1 to be monitored by adding to the treatment administration record and being checked by nursing staff every shift. This intervention was added to the resident's care plan on 2/10/16. For resident #5, the staff will respond to the resident's personal alarm when it sounds and provide the resident with non-pharmacological interventions such as food, fluids and items for tactile and sensory stimulation. The interventions were updated to the resident's care plan on 2/10/16. The effectiveness will be monitored by recording the number of personal alarm activations which was added to the treatment administration record for recording, and reviewing the fall intervention book weekly by the IDT. For Resident #7, the staff will provide non-pharmacological intervention such as food, fluids, tactile and sensory stimulation to prevent the resident from leaning forward in the wheelchair. The intervention was updated in care plan on 2/10/16. The fall intervention book will be monitored weekly for effectiveness of fall interventions by the IDT. For resident #10, a physical therapy evaluation will be done on 2/10/16. Resident #10's shoe laces were changed to follow the physical therapy evaluation to make it safer for resident to tie shoes and to assist in compliance with her wearing shoes. The staff will ensure the resident is wearing her shoes or non-slip socks at all times while up and ambulating. The interventions were initiated and updated to resident #10's care plan on 2/10/16. The effectiveness of the implemented interventions will be monitored by adding this intervention to the treatment administration record to be checked by the nurse every shift. For resident #8, the staff will increase the frequency of rounds to anticipate needs, this intervention was updated in care plan in 2/10/16. The effectiveness of the implemented intervention will be monitored weekly by the IDT as well as the fall intervention book to identify any new issues. For resident #9, physical therapy completed an environmental assessment of the resident's room at 3:00 p.m., on 2/11/16, to identify safety and risk factors for the resident when he self transfers, including proper placement of his wheelchair. The staff will monitor for the proper placement of the resident's wheelchair while resident is in bed. This Intervention was updated to the care plan on 2/11/16. The monitoring will be added to the resident's treatment administration record and to be checked by the nurse on every shift. The effectiveness will be monitored by weekly reviews of the fall intervention book and by the IDT and the IDT will follow up on identified issues as needed. For resident # 19, the staff will increase the frequency of their rounds to anticipate the resident needs. The effectiveness of the interventions will be monitored by the IDT during the weekly reviews of the fall intervention book and the IDT will follow up on any identified issues. For resident #3, the staff will ensure resident #3 has slipper socks on at all times while in bed. This intervention will be monitored by adding it to the treatment administration record and it will be checked by nursing staff at every shift. This intervention was updated to the care plan on 2/11/16. The effectiveness of this intervention will be monitored by adding the shift checks to the treatment administration record. The IDT will review the fall intervention book weekly and monitor for efficacy. For resident #6, the director of nursing or designee will provide education the resident of the risks of injury for continuing to self transfer. The education was provided on 2/11/16 at 2:00 p.m. The resident generally self transferred out of his bed. The facility staff will increase their frequency of rounds while the resident is in bed in order to anticipate his needs. This intervention was added to the resident's plan on care on 2/11/16. The effectiveness of the implemented intervention will be monitored by weekly review of the fall intervention book by the IDT. The IDT will follow up on any identified issues. These above individuals will be reviewed and evaluated to ensure the care plan will be updated with individualized approaches to limit further chances of injury from falls. As a preventative approach to prevent falls, the facility will identify all other residents to be reviewed and evaluated to ensure the care plan will be updated with individualized approaches to limit further chances of injury from falls. The facility will ensure that a licensed nurse will revise the care plan with appropriate interventions within 48 hours of any fall that occurs. After a fall, the IDT will complete a post fall evaluation, update the fall assessment, and revise the care plan with new interventions. The IDT will look at the whole clinical aspect of the resident, the resident's environment and will update the resident's care plan and the resident's clinical record. The IDT will monitor and observe for the effectiveness of the implemented interventions, and will document weekly in the clinical record using the the care plan review and evaluation form. The facility's post fall evaluation form was updated to ensure the care plan interventions were instituted following every fall. The facility will identify any new targeted fall care plan interventions and add those to the treatment administration record which will facilitate data gathering and assist the IDT in monitoring for intervention effectiveness. A fall intervention book was initiated that will include fall interventions on any resident with a recent fall. The implemented book will give all staff a chance to document on the effectiveness of newly implemented interventions and have input and ownership of the fall prevention process. The fall intervention book will be monitored by the IDT members at least weekly to analyze the data gathered. The fall intervention book was initiated on 2/12/16 at 5:00 p.m. New fall interventions will be instituted and changed if previous interventions have been found to be ineffective. The facility provided in-service education to all staff coming on shift on 2/10/16 and 2/11/16. The education was to continue until all direct care staff have been educated prior to their next working shift with an end date of 2/20/16. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Record review showed the resident had three falls with minor injuries: - On 8/12/15 resident #1 was attempting to self transfer from his bed to a wheelchair. The resident fell receiving an abrasion to his left biceps. The care plan was not updated with new interventions after this fall. - On 10/15/15 resident #1 was attempting to get out of bed. He fell receiving a 2 cm abrasion to his left forehead. The care plan was not updated with new interventions after this fall. - On 11/2/15 resident #1 was attempting to stand up and walk in a hallway and he fell . After the fall, he was observed to have an abrasion to the left side of his head. The care plan was not updated with new interventions after this fall. Record review showed the resident had three falls with no injuries: - On 6/28/15 resident #1 was attempting to self transfer and fell with no injury. His care plan was not updated with new interventions after the fall. - On 8/2/15 resident #1 was attempting to self transfer and fell with no injury. His care plan was not updated with new interventions after the fall. -On 10/22/15 resident #1 was attempting to get out of bed and fell with no injury. His care plan was not updated with new interventions after the fall. Resident #1's care plan was updated 11/2015, a specific date not indicated, with the following intervention: Rounds to anticipate needs for bathroom, fluids, hunger, activities. Focus Area stated: (Name) is at risk for falls r/t history of falls, left [DIAGNOSES REDACTED] with contractures. Date initiated: 04/17/14. Goal Area stated, (Name) will be free of major injury through the review date. Date initiated: 04/17/14, Target Date: 01/22/2015. The facility did not have any monitoring documented showing the efficacy of this intervention. Record review showed the resident had one fall with a major injury: -On 11/27/15 the resident was attempting to self transfer in the bathroom and fell ; a left hip fracture was diagnosed on [DATE]. Resident #1's care plan was updated on 12/4/15 with the following treatment interventions: -Care plan focus on 12/4/15: (resident name) has a fx (sic) of (L) hip. -Care plan goal 12/4/15: (resident name) will remain free from complications r/t hip fx (sic), such as contracture worsening, embolism, and immobility through the review date. -Care plan interventions 12/4/15: *Anticipate and meet needs. Ensure call light is within reach. *NWB (sic) on LLE (sic) x 2-3 months. *Observe for swelling/skin changes to LLE. Notify MD of abnormalities. *PT/OT to eval and treat PRN. *Reposition frequently to prevent skin breakdown. *Observe for and report to MD PRN s/sx of hip fx complications: Contracture forming/worsening embolism s/sx cyanosis, pain, petechia, increased pulse, tachypnea, dyspnea, impaired mobility, unrelieved pain, pneumonia, poor air exchange, increased incontinence. *Administer pain medication for pain PRN per MD orders. The resident's care plan was not updated with new fall interventions. Nursing Notes: - On 11/27/15 at 9:30 p.m., resident #1 fell and the physician was notified of fall via fax. -On 11/28/15 at 2:30 a.m., resident #1 had complaints of left lower extremity pain related to fall. Tylenol 650 mg was given with effective results. -On 11/29/15, resident #1 had complaints of left lower extremity pain in the early morning which was resolved with scheduled Tylenol. -On 12/2/15 at 6:30 p.m., resident #1 was seen by the nurse practitioner. She examined resident #1's left hip and ordered an x-ray. -On 12/4/15 at 3:30 p.m., resident #1 was sent to x-ray in the morning. He was transferred back to the facility. The nurse practitioner called the facility at 2:30 p.m. to report a left hip fracture and an order to be seen in the ER for a CT scan was given. -On 12/4/15 resident #1 returned from ER at 1830. New orders were given for resident #1 to be non-weight bearing on his left lower extremity for 2 to 3 months. During an interview on 2/9/16 at 2:15 p.m. staff member B said dietary, therapies, activities, and nursing put their interventions in place on the care plan and nursing was responsible for ensuring all interventions are in place. Staff member B stated resident #1's fall interventions were not updated because of his cognitive limitations and left sided impairment. She did not know what fall interventions should be put in place for resident #1 since he insists on self transferring. Staff member B said fall interventions had been tried in the past for resident #1 but he refused to follow through. Staff member B did provide a copy of an old care plan for resident #1 showing personal alarms for a fall intervention. The personal alarms had been discontinued on 11/1/14 since resident #1 would take the alarms off himself. Staff member B said resident #1 would become very agitated when the alarms went off. No other documented fall interventions were provided by the facility for resident #1. 2. Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of Interdisciplinary and Post Fall Evaluation notes for Resident #5 showed the resident had three falls with no injury: -On 6/18/15 (Resident #5) was found in room lying next to the bed on the fall mat. Resident stated she sat down. Post Fall Evaluation dated 6/9/15. No changes to care plan specified. Continue with current care plan. Her care plan was not revised or updated with new interventions. -On 7/21/15 in an Interdisciplinary Note, staff documented an unwitnessed fall. The note read, (Resident #5) was found on floor in dining room. When resident #5 was questioned by the staff, the resident says she was getting up and just (fell ). Post Fall Evaluation dated 7/22/15. No changes to care plan specified. Care plan not revised or updated with new interventions. -On 8/10/15 in an Interdisciplinary Note, staff documented an unwitnessed fall. The Note reflected, Notified by another resident's family member that someone (Resident #5) was sitting/kneeling on floor in parlor. Staff found resident (with) left knee and hand on floor (and right) foot on floor resident then fell back onto her buttocks. Resident stated she was waiting for her friends in the bushes. ROM intact no complaints of pain or discomfort when helping resident to standing position. Her care plan was not revised or updated with new interventions. Resident #5 care plan was updated and revised on 9/9/15. Focus: (Resident #5) is at risk for falls r/t history of falls and Alzheimer's Disease. Date initiated: 9/28/15. Revision on: 9/9/15. Goal (Resident #5) will be free of major injury related to falls through the review date. Date initiated: 9/28/15. Revision on: 9/9/15. Target date: 12/28/15. Interventions (Resident #5) needs a safe environment with: even floors free from spills and clutter; a reachable call light, the bed at comfortable height for ease in transfers, and personal items within reach. 9/11/15 May use w/c for mobility for safety. Date initiated: 9/28/15. Revision on: 9/9/15. Review of Interdisciplinary Notes, Post Fall Evaluation notes and Cat Scan results showed Resident #5 had one fall with major injury. -On 12/11/15 in an Interdisciplinary Note, staff documented an unwitnessed fall. The note reflected, (Resident #5) found on floor. Large hematoma L cheek, laceration under chin. Bleeding from mouth. Teeth loose in mouth. Resident was responsive. Order received from doctor to transfer to ER. CT scan of sinus and face on 12/11/15 showed, comminuted mildly displaced fracture of condylar process of the right mandible. Moderate left facial and left periorbital soft tissue swelling. Returned to the facility 10:15 P.M. with verbal order for soft diet and liquid through straw. Care plan updated 12/11/15 with new goal (name) will have no further fall related injury through review date. Interventions added 12/11/15, Personal alarm and/or chair alarm. D/C alarms if cause (increased) agitation/behavior (and) exit attempts from chair occur. In addition, fall mat and bed in lowest position. 3. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #7's Fall Risk Assessment showed a resident who scores a 10 or higher is at risk. Resident #7's Fall Risk Assessment showed: - On 4/26/15 a total fall risk score of 15. - On 6/15/15 a total fall risk score of 15. - On 8/6/15 a total fall risk score of 20. - On 11/2/15 a total fall risk score of 20. A review of resident #7's Post Fall Evaluation-Fall Committee records showed the resident had six falls with no injuries between 3/13/15 to 5/28/15: - On 3/16/15 the investigative findings showed a fall on 3/13/15. Resident #7 was found sitting on the floor as staff entered her room. No Injuries noted on exam. Investigation findings stated, At this time no further or new interventions and will continue to support family/resident wishes. The plan to prevent recurrence showed the fall mat was circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. - On 4/2/15 the investigative findings showed a fall on 4/1/15. Resident #7 had a witnessed fall. Resident #7 was sitting on the edge of bed and as staff entered room, she slipped off the edge of the bed, landing on fall mat. The resident had no injuries on the exam. The family requested no changes as it is vital for the resident quality of life. The plan to prevent recurrence showed the fall mat was circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. - On 4/6/15 the investigative findings showed a fall on 4/5/16. Resident #7 had a witnessed fall. While walking with her daughter in the hallway resident #7 tripped and fell . No injuries were noted on the exam. Staff discussed with the daughter (not the POA) about resident using a wheelchair. Resident #7's daughter denied, stating she wanted resident #7 to ambulate as long as she can before needing a wheelchair. The plan to prevent recurrence showed no intervention circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. - On 4/15/15 the investigative findings showed a fall on 4/14/15. Resident #7 was found lying on the floor next to bed. No injuries were noted on the exam. Investigative findings showed, unavoidable falls due to continued self transfers, independent ambulation in a resident with dementia with behaviors and cognition. The plan to prevent recurrence showed the fall mat was circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. - On 4/27/15 the investigative findings showed a fall on 4/26/15. Resident #7 was found on the floor beside the extra bed in room. No injuries were noted on the exam. The investigative findings showed, The family aware and continue to want her to be allowed to walk as long as she can for quality of life, refuse alarms. The plan to prevent recurrence showed the fall mat was circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. - On 6/1/15 the investigative findings showed a fall on 5/28/15 at 4:00 p.m. Resident #7 was found on the floor by bedside. No injuries noted on exam. Resident #7 was assisted back into wheelchair. At 4:30 resident #7 was witnessed slipping out of wheelchair to the floor in the area in front of the nurse's station. No injuries noted on the second exam. Anti-rollback brakes attached to wheelchair. In the any other action taken section of the Post Fall Evaluation form showed, UA obtained 5/29/15, antibiotic started for UTI on 5/29/15. A lengthy discussion with resident #7's daughter on 6/1/15 re: fall mat decision made to leave fall mat at bedside. An addendum showed, Discussed in person with (PCP) at facility current plan 6/2/15. 6/2/15 discussed restorative with POA (daughter). For the fall on 5/28/15 the Post Fall Evaluation reflected the changes made to the care plan were anti-roll backs to the wheelchair on 5/29/15. The plan to prevent recurrence showed the fall mat was circled. A review of resident #7's care plan showed the update for a wheelchair was not initiated until 6/22/15. The anti-rollbacks were not updated or initiated on the care plan until 6/19/15. The care plan was not updated for 25 days after the fall occurred. A review of resident #7's Post Fall Evaluation-Fall Committee records showed the resident had one fall with minor injury: - On 6/8/15 the investigative findings showed a fall on 6/5/15. Resident #7 was found on the floor behind her room door with a blanket between her knees and ankle. Resident most likely self transferred from bed to floor and may have crawled across floor which is consistent with previous behaviors. Floor dry, street clothes and shoes. The plan to prevent recurrence showed no intervention circled. The care plan was not updated with new interventions after this fall and the previous interventions were not monitored to evaluate for efficacy. A review of resident #7's nursing notes dated 6/5/15 at 7:00 p.m., showed, resident was found on floor behind door to her room. She was lying on her back with her pants and a blanket around her ankles .Bruising noted on the inner 3rd and 4th finger and pinkie of the right hand. A review of resident #7's Post Fall Evaluation-Fall Committee records showed the resident had one fall with major injury: - On 6/22/15 the investigative findings showed resident fell on [DATE]. Resident #7 attempted self transfer from wheelchair and was witnessed by other nurse on shift falling. No injuries, no signs or symptoms of pain or discomfort. Changes to care plan showed no was circled and continue with care plan, allow independence per family request as long as possible. Nothing was circled under the the plan to prevent recurrence. A review of resident #7's nursing notes showed the following notations: - On 6/20/15 at 1:30 p.m., Resident attempted self transfer from wheelchair and fell out onto left shoulder. ROM intact. VSS. No injury to area found. - On 6/20/15 at 6:30 p.m., Resident guarding left arm and saying 'owe' or wincing with movement. No obvious injury seen. No edema/redness or bruising. - On 6/20/15 at 7:00 p.m., Spoke with (daughter with POA) via (other daughter's) cell. (Daughter with POA) does not want resident transferred to urgent care/ER. Wants residents arm iced, some PRN pain meds (sic). Call out to on-call physician. Awaiting call back. - On 6/20/15 at 7:30 p.m., (on-call physician) on call for (PCP) called with orders received for 1) IBU 600 mg P.O. PRN TID, pain. 2) Ice to left arm TID. 3) monitor resident for changes. Called (Daughter with POA) back to notified of same. (Daughter with POA) does not want resident sent to ER/Urgent care. - On 6/21/14 at 9:05 a.m., resident left upper arm swollen and warm to touch non-reddened. Still winces in pain. Spoke with (Daughter with POA) who wants resident sent to urgent care with (other daughter) who's present. (On-call physician) for (PCP) called and order received to send resident for evaluation and treatment. -On 6/21/15 at 1:25 p.m., Resident returned at 12:20 p.m., with daughter. Dx: Subcapital humerus fracture and UTI with new orders. A review of resident #7's records indicate an X-Ray on 6/21/15 showed an impression: 1. Findings suggestive of fracture involving the left inferior portion of the humeral head and lesser tuberosity. A review of resident #7's Care Plan date initiated on 8/29/12 with target date of 8/27/14 showed a hand written entry on 6/22/15 for the Focus: Resident #7 had a fall with major injury. The Goal: Resident #7 will resume normal activities, fracture will heal without complication by review date. The care plan was updated with treatment interventions as follows: -Apply sling to LUE for comfort. -Apply ice 4-5 times day -Observe for non-verbal signs of pain. Give medications for pain as needed. -No ROM to LUE -Use caution when providing care. Avoid moving LUE as much as possible use button up shirts when available, dress left side first, avoid raising LUE above head, maintain arm alignment. -Talk to resident #7's nurse before removing sling. -Use caution during transfers. Do not pull on hands or arms. -Elevate left arm when in bed. Place pillow under left elbow and position left hand so it is resting on chest. -7/21/15 PT/OT to evaluate weakness and general decline due to decreased ambulation. No implementation of interventions to prevent further falls, previous interventions where not monitored for effectiveness. A review of resident #7's Care Plan initiated 6/22/15 showed resident #7 had fall with major injury. Goal: Resident #7 will resume normal activities and fracture will heal without complications by review date. Target dated 9/22/15. Interventions initiated on 6/22/15 showed resident #7 may need to use a wheelchair. Transfer with assistance of 1-2 and apply gait belt appropriately. A review of resident #7's Post Fall Evaluation-Fall Committee records showed the resident had two falls with no injuries on 9/30/15 to 10/4/15: - On 10/1/15 the investigative findings showed a fall on 9/30/15. Resident #7 was found on the floor in gathering area. Other residents reported resident #7 had attempted to get up to walk and fell out of wheelchair. No injuries noted on exam. Family continue to not want alarms applied as they feel would cause too much stress, want her to be able to walk if able. Changes to care plan showed no was circled with a notation of not at this time. Nothing was circled under the the plan to prevent recurrence. - On 10/5/15 the investigative findings showed a fall on 10/4/15. Resident #7 had a witnessed fall when the resident attempted to stand up from wheelchair and slid to the ground. The changes to care plan showed no was circled and a notation of, Continue with current plan of care, will reassess if further fall occurs will coordinate with family. An addendum on form showed, Received call from (daughter with POA) to discuss possible interventions, continue to refuse alarms. Discussed possible lowering wheelchair to discourage her from standing to encourage to sit back. Discussed possible new cushion with slight wedge. PT did get cushion with very slight wedge to encourage sitting back. A review of resident #7's Care Plan initiated on 6/22/15 with a target date of 9/22/15 showed a hand written intervention on 10/16/15 for Wheelchair cushion in place to ensure safety and positioning to decrease falls. A review of resident records showed another fall occurred on 10/10/15 before the Care Plan was updated with the recommended intervention of a wheelchair cushion from the fall that occurred on 10/4/15. The care plan did not show monitoring of the effectiveness of the implemented intervention. A review of resident #7's Post Fall Evaluation Committee records showed the resident had two falls with minor injuries from 10/10/15 to 12/18/15: - On 10/12/15 investigative findings showed resident #7 fell on [DATE] and was found on the floor. Spoke with (daughter with POA) will have PT assess wheelchair for positioning and to see if it can be adjusted to encourage sitting back. Did recently place a different cushion. Both yes and no where circled for changes to care plan. A review of resident #7's nursing notes dated 10/10/15 at 5:45 p.m., showed, Resident found on floor in hallway of dining room. 2.5 cm laceration to left eyebrow. Cleansed and Steri-strips applied. 1 cm skin tear to top of left hand. A review of the Physical Therapy note dated 10/12/15 showed, Will not modify wheelchair at this time but will continue to address positioning to minimize risk of falls while preserving current level of function. A review of resident #7's Care Plan initiated on 6/22/15 with a target date of 9/22/15 showed a hand written intervention on 10/19/15, May use blue transfer sheet around shoulders and upper back to facilitate supine sitting. - On 12/21/15 the investigative findings showed a fall on 12/18/15. Resident #7 fell out of wheelchair to the floor. Resident does self propel herself with her feet in her wheelchair. Has not been attempting to stand from wheelchair. No falls in 60 plus days. Will continue to assess her mobility to self transfer attempts. No care plan changes at this time. No changes to care plan was noted. For the plan to prevent recurrence, No alarms at this time as POA/daughter continue to refuse use of alarms as feel will agitate resident. Discussion with POA/daughter at this time will not place alarms per request. A review of resident #7's nursing notes dated 12/18/15 at 11:20 a.m., showed, Resident fell forward out of wheelchair. Abrasion/hematoma on left forehead and swelling around left eye. Resident had emesis after fall. POA stated they did not want CT. Received order for zofran for nausea and vomiting. POA was not wanting CT or neuros done. Received order to continue with neuros per facility policy. A review of resident #7's most recent Care Plan initiated 6/22/15 with a target date of 9/22/15 did not reflect implementation of interventions to the care plan or monitoring for efficacy of implemented interventions to prevent future falls. 4. Resident # 6 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #6's most recent significant change MDS with an ARD of 11/9/15, showed the resident with a BIMS of 8, cognition moderately impaired. A review of resident #6's Fall Risk Assessment on 1/7/16 showed resident #6 at a fall risk of 13. A resident who scores a 10 or higher is at risk. A review of resident #6's Post Fall Evaluation Fall Committee records showed the resident had six falls with no injuries between 7/18/15 to 11/1/15: -On 7/20/15 the investigative findings showed a fall for resident #6 on 7/18/15. The resident was found on floor in the door way of his room. Resident stated that he had fallen out of bed. No injuries noted. The resident can self ambulate with walker or cane and does not have a fall mat since would create an increased risk for tripping. Is able to use call light. Resident worried about mattress, mattress is secure on assessment but will have maintenance apply Velcro to mattress to prevent slipping of mattress. No changes to care plan were noted on the form. The plan to prevent recurrence showed patient education circled. A review of resident #6's Care Plan dated 7/18/15, showed an implemented intervention on 7/24/15 for Velcro to underside of mattress to prevent mattress from slipping. - On 9/17/15 the investigative findings showed a fall for resident #6 on 9/16/15. The resident self reported fall. Stated he slipped off the edge of bed, hit his back and then got himself off floor and walked to door. No redness to back upon exam post fall. Nothing in the way that he could have hit his back on according to nurse. Call light was within reach but did not use. There is serious question as to if this actual fall occurred as felt resident unable to get self off floor without assist. Resident reminded to use call light. Has Bolster mattress which is secured prevent slippage. Environmental assessment completed to ensure room/furniture is safe. The changes to care plan reflected No was circled. Nothing was circled for plan to prevent recurrence. A review of resident #6's Care Plan dated 7/18/15, failed to show updated interventions for the fall on

Based on observation, record review and interview, the facility failed to provide the necessary staff training, monitoring, and care for a resident with contractures, that potentially resulted in a fracture/dislocation to a limb that had contractures; failed to implement a care plan identifying the contractures, and implement interventions for staff for the provision of daily care relating to the contractures; and failed to adequately identify, monitor and document the status of non-pressure related skin concerns for one (#7); and failed to adequately identify, monitor and document the status of non-pressure related skin concerns for one (#14) out of 15 sampled residents. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's Significant Change MDS, with an ARD of 12/22/14, showed the resident was able to understand some of the time. The resident's cognition was unable to be determined. The resident had severely impaired decision making, scored a 21 (severe depression) on the PHQ9 assessment, and required total assistance of one or two plus persons for ADL care. The resident was always incontinent of bowel and bladder, and her pain level was unable to be determined. The resident had continued to show a decline in health and was receiving end of life care. a. Contractures and Fracture A review of the resident's nursing progress notes, dated 2/25/15 at 7:00 p.m., showed CNA reports large purple bruise left forearm near elbow which is surrounded by yellowing. Arm is swollen and fluid filled. Skin is fragile. The progress note showed the director of nursing was notified of the injury. The nursing progress notes lacked evidence of any bruising or injury to the resident's arm prior to this date, or for monitoring of the injury after identification on 2/25/15 until 2/28/15. A review of a facility facsimile sent to the resident's physician on 2/25/15 showed the resident had a Large purple bruise with yellowing borders noted (sic) left arm of unknown origin. The facsimile did not include information that the resident had swelling with the injury, or that it was fluid filled. The medical record lacked evidence that the physician had acknowledged the notification of the injury, or that the nurse reattempted to notify the physician of the concern. A review of the resident's facility investigation documents showed the injury was reported to the state agency on 2/26/15. The bruise was noted to be on the resident's left upper forearm by the elbow. Documentation lacked evidence to show when the bruise originated, although the bruise was showing signs of yellowing/healing. The final summary of the event report sent to the state agency showed the director of nursing and the rehabilitation director assessed the resident in an attempt to determine a cause for the unknown injury. A lateral support on the resident's wheelchair was believed to have caused the concern. Pillows were identified as an intervention, which would be placed under the resident's left arm when in the wheelchair. The intervention was not added to the resident's care plan at that time. A review of the nursing progress notes showed on 2/28/15 (time not documented) that the resident's left arm was bruised and swollen. The arm was elevated and ice was applied. At 9:15 p.m., the resident had profuse swelling to the left arm. The arm was black and blue with yellow bruising and scabbing with open areas to the crease of the inner arm/elbow area. The resident was assessed for vitals, and an order was obtained to send the resident to the emergency room . A nurse documented that the resident's left arm was lying straight at the resident's side. The skin was taut and tender to the touch. A review of the resident's investigation file for a second injury of unknown origin showed the facility determined the bruise to the left elbow/arm area was not the same injury as the one reported to the SA on 2/25/15. The resident was transferred to the emergency room and the left elbow was found to be dislocated. The facility noted the plan to prevent future abuse was the addition of pain medication to treat the arm, and employee related measures were taken. The injury was not deemed as intentional or malicious, but was found to have potentially occurred while the resident was being dressed. The report explained how the emergency room physician documented the bruise to the left elbow was the same bruise identified on 2/25/15. The physician was concerned with a potential delay in treatment for [REDACTED]. Further review of the facility investigation file for the resident showed a handwritten employee statement completed by staff member I, CNA, on 3/1/15. The statement showed, Monday 2/23/15, I was A-Hall aide. Went into (resident room) to get her up and ready for the day. Pulled back her night gown and saw a bruise. Got my radio called (nurse name) in to look at it. She came (sic) look at it. Said alright, left went about (sic) procedures. The investigation file lacked evidence for any further investigation on the bruise identified on 2/23/15, the size, location, description, or what potentially could have caused the injury. During an interview on 6/4/15 at 7:30 a.m., staff member I, CNA, stated the resident's bruise was on the left forearm by the elbow. She explained the bruise was the size of a quarter when she first discovered it. She stated she requested the nurse come to assess the injury. She watched the nurse enter the room and bend over the resident. The nurse then looked at the resident's arm, and lifted it slightly. The nurse said alright, and exited the room. Neither the state reporting log, nor the facility reports, showed the bruise identified by the CNA 2/23/15, was investigated or reported to the SA. The medical record for the resident lacked evidence of the bruise reported on 2/23/15. During the interview on 6/4/15 at 7:30 a.m, staff member J, CNA, stated the facility had not approached her on the concern of the bruise after the statement was written. Reveiw of the facility investigation for the 2/28/15, unknown injury, showed the bruise reported on 2/23/15 was not considered to be a factor in the resident's left elbow/arm injury, although the bruising on 2/25/15 and 2/28/15 had yellowing/healing around the borders of the bruise. A statement obtained from staff member O, LPN, did not include evidence that the facility questioned the nurse on the bruise reported on 2/23/15. During the interview with staff member J, CNA, on 6/4/15 at 7:30 a.m., she stated she reported the bruise to staff member O, LPN, on 2/23/15. A review of a physician's progress note, dated 2/28/15, showed the resident was transferred to the emergency room , because of a 4-day history of bruising and swelling about the left elbow, which has become worse. The resident was having pain in the left elbow and was able to indicate she had the pain. The report showed the physician contacted advocacy agencies, about whether or not the resident received proper attention after the accident, and it was unlikely the resident injured herself due to her condition. A review of the orthopedic physician's progress note, dated 2/28/15, showed the resident was found to have a left elbow posterior fracture-dislocation, with an incarcerated fragment. As the patient was comfort measures, it was decided that surgical repair was not an option for the treatment of [REDACTED]. During an interview and observation on 6/4/15 at 9:40 a.m., the resident was lying in bed. The resident agreed to allow the blanket to be moved so the left arm could be viewed. The left arm was slightly bent at the elbow, was up on a pillow, and lying on the resident's abdominal area. The resident nodded yes when asked if her left arm/elbow hurt. The left arm had a large softball size discolored area that was purple and bluish brown, which covered the front of the arm and extended around the sides of the elbow area. The resident responded to questions with a nod of her head for yes or no. She nodded up and down that she was aware of how the injury occurred, and nodded up and down that it occurred during care. The resident did not nod when asked who was involved, but nodded up and down that she was given pain medications to treat the pain. During an interview and observation on 6/2/15 at 8:30 a.m., staff member K, CNA, was assisting the resident from the wheelchair to the bed. An ARJO mechanical lift was used for the transfer. Staff member K explained how two people were required to complete the transfer for the resident due to the resident's medical status and arm contractures. Staff member K stated if he had a question on transfers, or ADL care, he would refer to the resident's care plan. He stated the resident's past elbow injury still caused the resident pain when moved. A review of the resident's care plan initiated on 11/27/13, showed a lack of evidence that the resident had contractures. The care plan lacked evidence for any changes relating to the injuries until 3/12/15, which was for splints to the left upper extremity. The fracture was included in a care plan problem added on 4/1/15, which included positioning interventions. The plan did not show interventions were immediately implemented to prevent future reoccurrences of injury to the resident due to the contractures. During an interview on 6/3/15 at 2:15 p.m., staff member C, unit manager, stated the resident's dislocated elbow did not change her level of care. She stated the CNA staff should have known how to provide care for a resident with contractures as it was general CNA knowledge, therefore this was not added to the care plan. Staff member C stated she was responsible for the development of the resident care plan. During an interview on 6/3/15 at 9:45 a.m., staff member B, director of nursing, stated the caregiver, who potentially caused the injury during care, was dressing the resident. Staff member B stated the caregiver had the tools necessary to complete the resident's care, and it was not the first time the CNA had provided care to the resident. Staff member B stated she believed the CNA was trained on contracture care during the CNA training class. During an interview on 6/4/15 at 8:55 a.m., staff member N, CNA, reported she had not received individualized training for the care of resident #7, before or after the fracture. She remembered being told to be careful with the resident during care, but did not recall who told her. On 6/4/15 at 9:20 a.m., staff member L, CNA, stated she learned how to care for residents with contractures through experience, trial, and specifically error. She stated she was not trained on anything specific relating to the care of resident #7, or for contractures. On 6/4/15 at 9:30 a.m., staff member M, CNA, stated she did not recall learning to care for a resident with contractures during the CNA class, or while at work. She stated someone told her to make sure the resident's arms were elevated. She could not recall who told her this. She stated the resident was difficult to dress due to the contractures, and she did not want to injure the resident. She stated she holds the resident's hand when dressing her, and extends the resident's arms as she puts the clothing up the arm and over the shoulder. b. Skin/Wounds/Bruises A review of the resident's nursing progress notes from 9/12/14 to 5/7/15, the physician orders, facility investigation records, and wound tracking records (which are not part of the resident record) showed the resident had the following skin areas identified: - Buttocks - On 12/2/14, a dime size ulcer was found on the right buttock. Skin prep was applied. The medical record lacked evidence for the cause of the wound, the monitoring of the wound, and/or the healing of the wound. - Buttocks - On 1/9/15, the resident's right buttock began to show moisture breakdown. Barrier cream was applied four times a day and as needed. The medical record lacked evidence of wound healing after 2/1/15. During an interview on 6/1/15 at 10:30 a.m., staff member D, unit manager, stated she was responsible for the skin/wound management program, and maintained the skin documentation for wounds/skin concerns. She stated the right buttock wound identified on 12/2/14 and 1/9/15 was the same area, which was a reoccurrence of a wound. She stated the nursing notes did not reflect the area was the same. On 6/2/15 at 4:35 p.m., staff member D provided a Non-Pressure Skin Tracking Sheet that showed the area was healed. - Left arm/elbow - A review of the resident's investigation documents, for a bruise of unknown origin, reported on 2/28/15, showed an alternate bruise was reported to the nurse on duty on 2/23/15. The medical record lacked evidence of the nursing assessment for the injury, or that the injury was monitored for healing after it was reported. During an interview on 6/4/15 at 7:30 a.m., staff member J, CNA, stated the resident's bruise was on the left forearm by the elbow. She explained the bruise was the size of a quarter when she first discovered it. She stated when she requested the nurse to come and assess the injury, she watched the nurse enter the room, bend over, look at the resident's arm and then she lifted the arm slightly. The nurse said alright, and exited the room. Neither the state reporting log, nor the facility reports, showed the bruise identified by the CNA on 2/23/15 was investigated or reported to the SA. The medical record for the resident lacked evidence of the bruise. During an interview on 6/3/15 at 11:30 a.m., staff member O, LPN, stated she did not recall a bruise being reported to her on 2/23/15. She stated she was not approached by the DON or administrator about the bruise being found by the CNA. - Left arm/elbow - A review of a investigation file for the resident, for an injury of unknown origin, showed a bruise was reported on 2/25/15. The bruise was swollen and purple in color. The medical record lacked evidence that the bruise/swelling was monitored for healing. The intervention identified by the DON and physical therapist to prevent future reoccurrences, related to the resident's lateral wheelchair support, and placement of pillows to support the resident's left arm, was not added to the care plan at that time. - Left arm/elbow - A review of the investigation file, for a injury of unknown origin, which was identified on 2/28/15, showed the resident's left arm was bruised and swollen. The resident had a scabbed over area in the crease of the arm. The resident was transferred to the ER. The medical record lacked evidence of monitoring or healing of the skin areas identified. The care plan lacked evidence of the interventions identified to prevent future occurrences of this type of injury. The medical record lacked evidence of why the area was already scabbed showing signs of the healing process. During an interview on 6/3/15 at 2:15 p.m., staff member C, unit manager, stated she was the primary staff person assigned to complete resident care plans, and revise the plans as needed. Staff member C stated the resident's care, to include the care of contractures, was general knowledge for the CNAs. Therefore the contractures were not added to the plan. She stated the care plan did not change because the resident was a total assistance prior to and after the injury. - Right toe - On 3/10/15. The resident's right toe was draining pus, and on 3/11/15, the physician ordered soapy foot soaks and Bactracin to be applied for seven days. The medical record lacked evidence for the cause of the toe injury/infection, monitoring of the toe, and when/if the toe healed. During an interview on 6/1/15 at 3:15 p.m., staff member D, unit manager, stated the toe care was followed by the podiatrist, therefore the facility did not have documentation to show the progression or healing of the toe. - Left wrist - On 4/6/15, shearing was identified on the resident's left wrist, caused by a splint. Antibiotic ointment was applied. The medical record lacked evidence to show the facility monitored the shearing or when the shearing healed. - Left elbow - On 4/6/15, shearing was identified on the resident's left elbow from a splint. Antibiotic ointment was started. The medical record lacked evidence of the left elbow monitoring and healing progression of the shearing caused by the splint. During an interview on 6/2/15 at 4:25 p.m., staff member D, unit manager, stated the left wrist was documented as healed on 4/20/15, and again on 5/7/15, but staff member D stated the skin assessment, prior to the interview, showed the wrist was healed, but the left elbow continued to have a small scab present, which was the size of a BB. - Left ankle - On 4/22/15 a red skin area was identified on the resident's left ankle, which had slough. The medical record lacked evidence to show the monitoring or healing progression to the left ankle. During an interview on 6/2/15 at 4:35 p.m., staff member D, unit manager, stated she assessed the resident's left ankle after the concern was identified, and it was not skin slough. She stated the area was dry, perhaps [MEDICAL CONDITION], and needed lotion. The medical record lacked evidence for this assessment, or the healing of the documented skin slough. 2. Resident #14 was admitted to the facility on [DATE]. A review of the resident's Significant Change MDS, dated [DATE], showed the resident had severely impaired cognition. The resident received extensive assistance of one person, or more as needed, for ADL care. A care plan was initiated for end of life services on 10/20/14. A review of the resident's nursing notes, physician orders, physician progress notes [REDACTED]. - On 10/3/14, a scab on the resident's right elbow reopened. The medical record lacked evidence of the monitoring and healing of the reopened scab, or if the nurse notified the physician of the skin concern. - On 3/19/15, staff identified superficial moisture related skin breakdown to the resident's bilateral buttocks. The medical record lacked evidence for the monitoring of the skin breakdown after 3/21/15, or if the physician was aware of the concern. - On 3/29/15, the resident hit her right lower leg on the wheelchair and caused a 3 cm skin tear. The medical record lacked evidence for what measures were taken to prevent future reoccurrence of a skin tear of this nature, or if the wheelchair was assessed for hazards. The documentation failed to show the status of the skin tear after it was identified. -4/1/15-The resident was attempting to hit a staff member and caused a 1-1/2 inch skin tear to her right forearm. The medical record lacked the status of the skin tear after 4/3/15, and what measures were taken to prevent future injuries during care. During an interview and observation on 6/3/15 at 9:00 a.m., staff member D, UM, provided documentation on the skin tear which showed it healed after 4/13/15. Staff member D stated the documentation was not part of the medical record, but was on a non-pressure related tracking sheet. - On 4/12/15, the nurse documented a one inch in size skin concern on the resident's left toe. The nurse documented the wound nurse would be notified. The medical record lacked evidence of the measures taken for the toe, or documentation of the physician/responsible party notification for the new skin concern. A request for documentation for the resident's skin concerns was made on 6/2/15 and 6/3/15. No further information was received. A review of the resident's skin care plan, initiated on 8/22/13, lacked evidence for the risks, goals, or interventions identified to prevent future non-pressure related skin concerns from occurring. During an interview on 6/3/15 at 10:30 a.m., staff member D, unit manager, stated skin tears were tracked until they were healed, and on a weekly basis, she reviewed the skin concerns with staff member B, DON. Staff member D stated the skin concerns would be documented on an incident report and would be tracked on the treatment sheets to show the skin area was resolving.

Based on observation, record review, and staff, family, and resident interview, the facility failed to provide the necessary care and services to attain the highest level of well-being for 12 (#s 2, 3, 4, 8, 10, 11, 13, 15, 17, 18, 22, and 23) of 39 sampled and supplemental residents. Specific failures were: - Two (#s 2 and 22) residents were not physically assessed following placement of CMS ankle/foot boots after sustaining ankle/foot fractures. Resident #2 had swelling and complained of pain following application of the boot. - Six residents (#s 2, 3, 10, 13, 17, 18 ) failed to have neurological assessments completed to rule out head injuries following unwitnessed falls or falls in which they may or did hit their heads. - Resident #8, who was blind and hard of hearing, failed to have physician's orders followed regarding checking and changing hearing aid batteries. The resident exhibited behaviors when her hearing aid was not functioning. - Resident #13's dizziness after a fall was not assessed. - Resident #3's vital signs were not completed in accordance with physician's orders. IMMEDIATE JEOPARDY Four residents (#s 4, 11, 15, 23) did not receive adequate nursing care and services for [DIAGNOSES REDACTED].#15. Resident #15's physician was not notified of hypoglycemic and hyperglycemic incidents in accordance with the facility's standing orders; nurses failed to follow up after hypoglycemic incidents by administering a glucose product and rechecking blood sugar. There was a lack of assessment and documentation of resident #15's condition for critical hypoglycemic and hyperglycemic incidents. Nurses failed to follow physician's orders regarding the administration of insulin for all four residents; numerous errors were made. None of the four residents had care plans developed to address their [DIAGNOSES REDACTED]. The facility policy was insufficient to provide comprehensive guidance to nurses regarding diabetes management. Nurses were not aware of the diabetic management policy. The facility did not have glucose and [MEDICATION NAME] readily available when the surveyors asked during the survey. Nurses did not know where the glucose and [MEDICATION NAME] were stored or had to search to find it. These failures created an immediate jeopardy situation for residents #s 4, 11, 15, 23. On 10/29/13 at 9:50 a.m., the facility administration was notified by the surveyors that an immediate jeopardy situation existed for 4 (#s 4, 11, 15, and 23) sampled diabetic residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 10/30/13 at 4:35 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: The facility's policy for Blood Glucose Monitoring was updated with the following changes: "Perform Calibration: (Routine calibration performed weekly) -Before testing with glucometer for the first time. -When you open a new bottle of test strips. -Whenever you suspect the meter or test strips may not be functioning properly. -If the test results appear to be abnormally high or low or are not consistent with clinical symptoms. -To check your technique. -When the meter has been dropped. -Each time batteries are changed." The policy and procedure for Systemic Medical Emergencies of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] included the following changes: "-If a resident has lo (sic) blood sugar (below 60) with symptoms, administer Glucose Gel 1 tube, 15 gram if resident is able to take something by mouth, contact physician and recheck in 15 minutes, assign license staff member to monitor and assess resident condition. -[MEDICATION NAME] is also available in the Emergency drug box for administration per physician standing orders. *Refer to standing order. If after 15 minutes resident remain non responsive call 911, assign license staff member to monitor and assess resident condition. -Notify responsible party or (sic) change in conditions. -Document in clinical record all observations, finding and interventions; including but not limited to blood sugar, any emergency medications administered, clinical presentation, blood sugar results, vital signs, medications administered (doses) resident response to med administered, notification made." The facility instituted measures to ensure glucose gel and [MEDICATION NAME] were available. The nurse manager was responsible for auditing the medication cart daily to determine that the glucose gel was available and the Emergency Kit to determine the [MEDICATION NAME] was available. The director of nursing, nursing managers and nurses were inserviced on the new policies and procedures. A post test was administered to assess for competency. Copies of the policy were posted in the medication room, on the medication carts and nurses were required to have a copy of the policy with them as part of their uniform. New licensed nursing staff would be inserviced and oriented on diabetic management prior to their first shift. The MARs and clinical records were audited daily for all three shifts. Audits included review of the physician's orders and checking it against the MAR, verifying correct insulin dosages, and checking the clinical record to ensure physician and family notification occurred as needed. Inaccuracies would be reported to the attending physician by the nurse manager for additional instruction. Written disciplinary action would be implemented to the nurse committing the errors by the director of nursing and or administrator. The immediate jeopardy was abated on 10/31/13 at 2:30 p.m. The deficient practice remained at the scope and severity of a G once the immediate jeopardy was abated. The findings include: I. DIABETES BACKGROUND INFORMATION Uncontrolled type II diabetes with [MEDICAL CONDITION] (high blood sugar) over time can lead to damage of the nerves and small blood vessels of the eyes, kidneys, and heart leading to [MEDICAL CONDITION], or hardening of the arteries that can cause [MEDICAL CONDITION] and stroke. The symptoms of [MEDICAL CONDITION] can present as follow; increased urination, increased thirst, nausea, vomiting, fruity smell to breath, blurred vision, dry mouth, and abdominal pain. [DIAGNOSES REDACTED] (low blood sugar) with a blood sugar below 70 can present with symptoms of sweating, nervousness, shaking, nausea, hunger, dizziness, headache, blurred vision, fast heartbeat, and feeling anxious. Diabetics with a blood sugar below 40 may appear confused, irritable, slurred speech, unsteadiness, muscle twitching, and have personality changes. If a diabetic's blood sugar decreases to below 20 a [MEDICAL CONDITION], loss of consciousness, stroke, and even death can occur?. STAFF INTERVIEW & AVAILABILITY OF GLUCOSE/[MEDICATION NAME] On 10/28/13 between 4:00 and 5:00 p.m. nursing staff members (TT, X, B, Y, SS, and Z) were interviewed by surveyors while in the facility concerning the treatment of [REDACTED]. Staff did not know where glucose gel and [MEDICATION NAME] were located, or could not find them without searching. Question #1 - How often is the glucose meter calibrated? - Staff member TT - "In the a.m." - Staff member X - "nocs" - Staff member B - "will check policy" - Staff member Y - "not sure" - Staff member SS - "nightly" - Staff member Z - "when using new strips" Glucometers were not on a regular calibration schedule at the time of interviews. Question #2 - Can you tell me the signs of [MEDICAL CONDITION]? - Staff member TT - "confusion, lethargic, combative" - Staff member X - "anxious" - Staff member B - "would refresh my memory" - Staff member Y - "increased thirst, fruity smell, dizzy, increased urination" - Staff member SS - "sleepy, can't wake up, diaphoretic, increased blood sugar" - Staff member Z - "shaking, agitation, flushing, keto acetic breath, increased urination" Some signs and symptoms of [MEDICAL CONDITION] are increased thirst, increased urination, headache, drowsiness, flushed face, skin hot/dry, fruity smell to breath, nausea/vomiting, rapid pulse/respirations, and loss of consciousness?. Question #3 - Can you tell me the signs of [DIAGNOSES REDACTED]? - Staff member TT - "lethargic, cold sweat" - Staff member X - "lethargic, sleepy, anxious, each one is different" - Staff member B - "would refresh my memory" - Staff member Y - "dizzy, lethargy, confusion, sweaty" - Staff member SS - "can't wake, disoriented, diaphoretic" - Staff member Z - "fatigue, decreased level of consciousness" Some signs and symptoms of [DIAGNOSES REDACTED] are diaphoresis, weakness, nervousness, pale skin color, hunger, tremors, headache, blurry vision, slurred speech, agitation, stupor, loss of consciousness, [MEDICAL CONDITION], and death.? Question #4 - What do you do if a resident has a blood sugar under 50? - Staff member TT - "wouldn't give insulin, give glucose, use injection if unable to swallow" - Staff member X - "give glucose gel" - Staff member B - "follow MD orders" - Staff member Y - "check orders from doctor - give juice, recheck in a couple of minutes - if unresponsive give glucose gel" - Staff member SS - "check blood sugar every 15 minutes, give them something, lay them down, call doctor if they don't come up in a half hour, call family if not coming up" - Staff member Z - "give apple juice if asymptomatic because it bumps up BS fast, with symptoms if they can swallow give apple juice or [MEDICATION NAME] if they have a gag reflex followed by ensure, if no swallowing or gag reflex call 911" Per the standing order provided to surveyors on 10/28/13 at 4:55 p.m. before the IJ abatement process, "if blood sugar <60 or non responsive the nurses were directed to administer [MEDICATION NAME] 1 mg SQ and recheck in 15 minutes and notify the MD. These standing orders were signed by the Medical Director on 2/5/13. Question #5 - What do you do if a resident has a blood sugar over 400? - Staff member TT - "based on signs and symptoms, insulin depends on order, possible recheck" - Staff member X - "depends on MD order" - Staff member B - "follow MD order" - Staff member Y - "call doctor, some of have parameters to give med and call doctor" - Staff member SS - "check again, use sliding scale or call doctor if no PRN (as needed) scale" - Staff member Z - "check physician's orders as some have sliding scale that cover it, recheck BS in 20 minutes if taking by mouth, call doctor if >400" There were no standing orders for residents with high blood sugar at the time of the interviews. Some residents did have individual orders from their physicians with parameters. Question #6 - What do you do if the glucometer reads high? - Staff member TT - "recheck" - Staff member X - "report to MD, some residents it happens a lot, may have orders" - Staff member B - "in policy" - Staff member Y - "call doctor, don't give insulin, assess patient and see if responding and recheck" - Staff member SS - "check again, reclean finger, call doctor if insulin is needed" - Staff member Z - "recheck, can go clear up to 500-600, call doctor to cover their highest and get further instructions, judge if having problems and tell doctor, hold food" There were no standing orders for residents with high blood sugar at time of questioning directing staff what to do if the meter read "high." Some residents had orders from the physician with parameters for rechecking blood sugar. Question #7 - Where can I find standing orders for diabetics? (insulin, BS ranges, provider notification) - Staff member TT - "only have MD orders per resident" - Staff member X - "per MD" - Staff member B - "will check policy" - Staff member Y - "would need to find out" - Staff member SS - "on med cart, but no diabetic orders" - Staff member Z - "not for diabetics, all off special orders in chart" Standing orders were available but none of the six nurses interviewed were able to show surveyors where to find the standing orders at the time of the interviews. Question #8 - When do you notify the MD of blood sugar? - Staff member TT - "below 50, not right away, give glucose and wait to come up, then call" - Staff member X - "not sure, don't know of any standing orders, MD notified of too high based on orders" - Staff member B - "per policy" - Staff member Y - no answer - Staff member SS - "if order give parameters, call doctor if unable to lower or increase, call family" - Staff member Z - "depending on what orders say and clinical symptoms (agitation, fruity breath, polyuria)" Standing orders stated for blood sugar below 60, nursing staff were to notify the MD. Question #9 - Where is the emergency [MEDICATION NAME] or glucose for diabetics kept? - Staff member TT - "on med cart" - Staff member X - no answer - Staff member B - "kept in med cart" - Staff member Y - "I have not seen it here" - Staff member SS - "glucose tabs are in the cart, there is no gel in the cart but normally there is [MEDICATION NAME] in med room." - Staff member Z - "cart or med room" At time of questioning, [MEDICATION NAME] injections were not found by staff in the medication carts or in the medication room. One tube of Glucogel was found in the treatment cart by staff member Z who stated "it was for a specific resident". Glucose tabs were only found in one of three carts by the nurses interviewed. DIABETIC FAILURES FOR RESIDENTS #4, #11, #15, #23 1. Resident # 15 was admitted to the facility on [DATE]. The resident passed away on 9/27/13 following hospitalization . The resident's [DIAGNOSES REDACTED]. Care Plan for Diabetes: According to review of the resident's closed record, the facility did not care plan interventions for the [DIAGNOSES REDACTED]. The facility failed to respond appropriately to the potentially critical incidents. The physician's insulin orders for this resident were as follows: - [MEDICATION NAME] 100 unit/mL - 11 units SQ Q (every) AM - [MEDICATION NAME] 100 unit/mL - 6 units SQ Q HS -The resident also had a sliding scale of [MEDICATION NAME] 100 units/mL after meals everyday with the following blood sugar guidelines for dosing: 200-250 give 2 units, 251-300 give 3 units, 301-350 give 4 units, 351-400 give 5 units, > 400 give 6 units, if monitor reads "Hi" give 8 units. Hold if resident does not eat. The following instances were captured of either hypo or [MEDICAL CONDITION] in the resident's record from April 2013-September 2013. Inaccurate insulin doses were administered, physician orders were not followed, and no interventions were documented (forms of glucose were given, notification was made to the physician for high/low blood sugars, that the blood sugars were rechecked, and the resident was assessed for signs and symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]). April: - 4/6/13, BS of 45 in the a.m. No interventions were documented in response to the low blood sugar. - 4/10/13, BS of 454 in the a.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME], 0 units were given. The nurse's note did not include the meal intake for breakfast. - 4/14/13, BS of 41 in the p.m. The order stated "do not give diabetic boost or supplement for low BS". Glucerna shake was given. - 4/19/13, BS of 39 in the a.m. No interventions were documented in response to the low blood sugar. - 4/23/13, BS of 39 in the a.m. No interventions were documented in response to the low blood sugar. - 4/23/13, BS of 55 in the p.m. No interventions were documented in response to the low blood sugar. - 4/25/13, BS of 44 at lunch. No interventions were documented in response to the low blood sugar. - 4/28/13, BS of 43 at lunch. No interventions were documented in response to the low blood sugar. May: - 5/2/13, BS of 111 at HS. The scheduled 6 units of [MEDICATION NAME] was at not given. - 5/2/13, BS of 33 at HS. Oral glucose was given. The resident was documented, in the nurse's note, as being lethargic and not taking oral fluids well. No interventions were documented in response to the low blood sugar. - 5/8/13, BS of 41 in the a.m. No interventions were documented in response to the low blood sugar. - 5/8/13, BS of 51 in the p.m. No interventions were documented in response to the low blood sugar. - 5/8/13, BS of 56 time unknown (BS charted in nurse's note, not on MAR). The physician's order stated "do not give diabetic boost or supplement for low BS." Med plus supplement was given. No notification to the provider/family was documented. - 5/10/13, BS of 35 in the a.m. No interventions were documented in response to the low blood sugar. - 5/10/13, BS of 281 in the p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 5/12/13, BS "High" in the p.m. According to the physician's order, staff were to give 8 units of [MEDICATION NAME] when the glucometer read, "High"; 6 units were given. - 5/14/13, BS of 40 in the a.m. No interventions were documented in response to the low blood sugar. - 5/16/13, BS of 40 at lunch. No interventions were documented in response to the low blood sugar. - 5/27/13, BS of 279 in the p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 5/28/13, BS of 42 in the a.m. No interventions were documented in response to the low blood sugar. - 5/31/13, BS of 40 in the a.m. No interventions were documented in response to the low blood sugar. June: - 6/3/13, BS of 44 at HS. A "snack" was documented as given on MAR. The type of snack, effectiveness of the snack provided, and a re-check of the blood sugar was not documented in the medical record. - 6/6/13, BS of 54 at lunch. No interventions were documented in response to the low blood sugar. - 6/6/13, BS of 57 at HS. No interventions were documented in response to the low blood sugar. - 6/7/13, BS of 200 in the a.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 6/7/13, BS of 351 at lunch. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 4 units were given. - 6/8/13, BS of 311 in the a.m. According to the physician's order, staff were to give 4 units of [MEDICATION NAME]; 3 units were given. - 6/10/13, BS of 307 at lunch. According to the physician's order, staff were to give 4 units of [MEDICATION NAME]; 3 units were given. - 6/20/13, BS of 40 in the a.m. No interventions were documented in response to the low blood sugar. - 6/22/13, BS of 48 in the a.m. No interventions were documented in response to the low blood sugar. - 6/23/13, BS of 119 at HS. The scheduled 6 units of [MEDICATION NAME] was not given. - 6/25/13, BS of 39 in the a.m. and re-checked BS was 57 (time unknown). No interventions were documented in response to the low blood sugar. - 6/27/13, BS of 42 at lunch. No interventions were documented in response to the low blood sugar. - 6/29/13, BS of 56 at HS. No interventions were documented in response to the low blood sugar. - 6/29/13, BS of 163 at HS. The scheduled 6 units of [MEDICATION NAME] was not given. July: - 7/2/13, BS of 50 in the a.m. No interventions were documented in response to the low blood sugar. - 7/5/13, BS of 220 in the p.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 7/7/13, BS of 126 at HS. The scheduled 6 units of [MEDICATION NAME] was not given. - 7/8/13, BS of 209 in the a.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 7/11/13, BS of 37 in the p.m. No interventions were documented in response to the low blood sugar. - 7/15/13, BS of 122 at HS. The scheduled 6 units of [MEDICATION NAME] was not given. - 7/18/13, BS of 43 in the p.m. The nurse's note stated "resident largely unresponsive, wouldn't open mouth for glucose tabs, glucogel was tolerated fairly, sugar recheck was 60, another glucogel given and she became more responsive." No notification to the provider was documented. The wrong intervention per facility standing order was implemented. - 7/22/13, BS of 219 in the a.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 7/23/13, BS of 27 in the p.m. The nurse's note stated "1700 patient lethargic BS 27, given orange juice and Medplus, 1720 BS 43, 1805 BS 109". No notification to the provider or family was documented. The wrong intervention per facility standing order was implemented. - 7/25/13, BS of 395 at HS. According to physician's order, staff were to give the scheduled 6 units of [MEDICATION NAME] at HS daily; 3 units were given. No notification to provider was documented for the dosage change. - 7/26/13, BS of 367 in the p.m. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 2 units were given. - 7/27/13, BS of 375 in the p.m. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 2 units were given. - 7/28/13, BS of 394 in the p.m. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 3 units were given. - 7/28/13, BS of 307 at HS. According to the physician's order, staff were to give the scheduled 6 units of [MEDICATION NAME] at HS daily; 3 units were given. No notification to provider was documented for the dosage change. - 7/29/13, BS of 265 at HS. The scheduled 6 units of [MEDICATION NAME] were not given. - 7/31/13, BS of 493 in the p.m. According to the physician's order, staff were to give 6 units [MEDICATION NAME]; 2 units were given. August: - 8/1/13, BS of 28 in the a.m. No interventions were documented in response to the low blood sugar. - 8/1/13, BS of 259 at HS. The scheduled 6 units of [MEDICATION NAME] were not given. - 8/3/13, BS of 501 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units given. - 8/4/13, BS of 212 at HS. The scheduled 6 units of [MEDICATION NAME] were not given. - 8/5/13, BS of 266 at HS. The scheduled 6 units of [MEDICATION NAME] were not given. - 8/7/13, BS of 38 in the a.m. No interventions were documented in response to the low blood sugar. - 8/8/13, BS at HS not recorded. The scheduled 6 units of [MEDICATION NAME] were not given. - 8/10/13, BS at HS not recorded. The scheduled 6 units of [MEDICATION NAME] were not given. - 8/15/13, BS of 490 at HS. According to the physician's order, staff were to give the scheduled 6 units of [MEDICATION NAME] at HS daily; 3 units were given. No notification to the provider was documented for the dosage change. - 8/16/13, BS of 40 in the p.m. No interventions were documented in response to the low blood sugar. - 8/16/13, BS of 228 at HS. According to the physician's order, staff were to give the scheduled 6 units of [MEDICATION NAME] at HS daily; 2 units were given. No notification to provider was documented for the dosage change. - 8/17/13, BS of 422 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. - 8/18/13, BS of 475 at lunch. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 5 units were given. - 8/19/13, BS of 223 at HS. The scheduled 6 units of [MEDICATION NAME] was held due to "no HS snack." The physician's order did not state to hold this dose if a bedtime snack was not consumed. - 8/20/13, BS of 485 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. - 8/21/13, BS of "High" at lunch. According to the physician's order, staff were to give 8 units of [MEDICATION NAME] if the glucometer read "High"; 4 units were given. - 8/21/13, BS of 408 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. - 8/22/13, BS of 163 at HS. The scheduled 6 units of [MEDICATION NAME] was held due to "no HS snack." The physician's order did not state to hold this dose if a bedtime snack was not consumed. - 8/24/13, BS of 419 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. September: - 9/1/13, BS of 274 in the a.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 9/3/13, BS of 574 in the a.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. - 9/5/13, BS of 229 in the a.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. The nurse's note did not include the meal intake record. - 9/7/13, BS of 52 in the a.m. No interventions were documented in response to the low blood sugar. - 9/7/13, BS of 338 at lunch. According to the physician's order, staff were to give 4 units [MEDICATION NAME]; 3.5 units were given. - 9/8/13, BS of 54 in the a.m. No interventions were documented in response to the low blood sugar. - 9/9/13, BS of 495 at lunch. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 4.5 units were given. - 9/12/13, BS of 57 at HS. No interventions were documented in response to the low blood sugar. - 9/13/13, BS of 422 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 4 units were given. - 9/14/13, BS of 464 in the p.m. According to the physician's order, staff were to give 6 units of [MEDICATION NAME]; 3 units were given. - 9/16/13, BS of 42 in the a.m. No interventions were documented in response to the low blood sugar. In April 2013 the resident had seven instances of [DIAGNOSES REDACTED] and one instance of [MEDICAL CONDITION]. However, the resident's physician had not been notified and was not aware of this. A provider note from 5/8/13, under the heading of assessment and plan for DM (Diabetes), stated "Staff tell me that she has been free from hypo and [MEDICAL CONDITION] episodes. Will continue with current regimen and tailor as necessary." The next provider note dated 8/28/13, under the heading of assessment and plan stated "Staff tell me that she has been free from hypo or [MEDICAL CONDITION] episodes. Appears well managed pharmacologically as well as diet controlled. Will continue current regimen and tailor as necessary". The provider's orders for this resident remained the same with no adjustments to insulin dosing. A comment was also noted on the pharmacist consultation report dated 2/13/13 for Resident # 15 concerning the documentation in chart. The comment section stated "Charting for several meds on the MAR indicated [REDACTED]." The recommendation section from pharmacist stated "Please remind nursing staff to chart medication administration appropriately. Please remind staff that if medications are circled and not administered, the back of the MAR indicated [REDACTED]." The surveyor noted numerous blanks on the MARs, as well as, lack of documentation for no insulin or adjusted insulin doses administered. 2. Resident #11 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The physician insulin orders for this resident were as follows: - [MEDICATION NAME] 100 unit/mL - 10 units SQ Q (every) AM - [MEDICATION NAME] 100 unit/mL - 60 units SQ Q HS. (increased to 63 units on 10/11/13) - [MEDICATION NAME] 100 units/mL 10 units SQ TID (three times a day) with meals -The resident also had a sliding scale of [MEDICATION NAME] 100 units/mL with meals and before HS everyday with the following blood sugar guidelines for dosing: 150-200 give 2 units 201-250 give 3 units, 251-300 give 5 units, 301-350 give 7 units, 351-400 give 8 units and recheck BS in 2 hours and follow above instructions The following instances were captured in the resident's record from September-October 2013 concerning inaccurate insulin doses administered and physician orders not being followed. September: - 9/26/13, BS 219 at lunch. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 9/26/13, BS 256 in p.m. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 3 units were given. - 9/27/13, BS 207 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 9/28/13, BS 215 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 9/29/13, BS 217 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 9/29/13, BS 214 at HS. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. The scheduled 60 units of [MEDICATION NAME] were not given. October: - 10/1/13, BS 247 at lunch. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/1/13, BS 193 in p.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/1/13, BS 237 at HS. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/2/13, BS 205 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/2/13, BS 161 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/3/13, BS 213 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/3/13, BS 248 at lunch. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/3/13, BS 261 in p.m. According to the physician's order, staff were to give 5 units of [MEDICATION NAME]; 3 units were given. - 10/6/13, BS 218 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/6/13, BS 186 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/7/13, BS 184 in p.m. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/7/13, BS 165 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/8/13, BS 236 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/8/13, BS 195 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/9/13, BS 240 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/9/13, BS 216 at HS. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/10/13, BS 231 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/10/13, BS 214 at HS. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/12/13, BS 246 at HS. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/13/13, BS 178 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/14/13, BS 176 at HS. According to the physician's order, staff were to give 2 units of [MEDICATION NAME]; 0 units were given. - 10/15/13, BS 227 in p.m. According to the physician's order, staff were to give 3 units of [MEDICATION NAME]; 2 units were given. - 10/16/13, BS 238 at lunch. According to the physician's order, staff we

Based on observation, resident interview, staff interview, family interview and record review, the facility failed to ensure the environment remained as free of accident hazards as possible, adequate supervision was provided, and assistive devices were available to prevent accidents for 9 (#s 2, 3, 13, 15, 17, 18, 19, 22, and 26) of 39 sampled and supplemental residents. Specifically, the facility failed to identify hazards and evaluate risk factors for falls, implement interventions to reduce the risk of falling and monitor or modify the interventions to prevent additional falls. Four residents (#s 2, 3, 15 and 18) experienced actual harm or significant injuries: -Resident #2 had numerous falls; one sustaining two fractures to her ankle. -Resident #3 had numerous falls resulting in injuries including leg pain, an injury to her right knee, abrasion to her left shoulder and arm, pain to her hip, a bump to her head and bruising to her buttock. -Resident #15 had 2 falls and sustained two fractures, to her patella (knee) and femur (leg), and a hematoma. -Resident #18 had 10 falls, 2 with injuries including bumping/hitting her head twice and right knee swelling and pain. The findings include: FALL POLICY On 10/23/13 at 8:30 a.m. employee A, administrator, provided the fall policy, Falls: Minimizing Risk of Injury, the Neurological Check policy and the Post Fall Neuro Check form. The purpose of the Falls policy was to identify risk of falls, minimize injuries and develop an interdisciplinary care plan with fall/injury prevention strategies. The clinical policy for falls indicated the following should occur after a fall: -Residents shall be assessed for risk of falling upon admission, annually quarterly and prn. -Residents will be referred to therapy for a rehab screen and/or treatment. -Residents who fall will be evaluated following the occurrence by the IDT team to identify potential causes of the fall. -The resident's care plan will be reviewed and updated with any interventions to prevent falls as appropriate. -All falls will be reviewed by CQI to identify trends and common causes. On 10/23/13 at 8:30 a.m., the Neurological policy was provided by staff member A. The policy outlined how the facility would assess a resident's neurological status and assess the resident following a head injury, TIA, seizure or any other situation, which may alter neurological status. The Post Fall Neurological Check was to be completed on required timelines with date/time, hourly increments, vitals, pupils, level of consciousness, vertigo, swelling, blurred vision, change in behavior and the initials of the assessor. On 10/24/13 at 5:25 p.m. the nursing Documentation policy was provided to the surveyor by employee B, director of nursing, which listed required steps the nurse would take for specific events to include a fall. Under the heading, "Upon Falling" a line item was identified, which directed the nurse to complete the Interdisciplinary Fall Risk Assessment with A & I (Accident and Incident Report). On 10/29/13 at 10:15 a.m. the policy was verified to be accurate and complete by employee A, administrator. 1. Resident # 15 was admitted to the facility on [DATE]. The resident passed away on 9/27/13 following hospitalization . The resident's [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident was unable to be assessed for a BIMS score as she was unable to answer the questions. Her decision making ability was also moderately impaired. She scored a 3 on the wandering assessment segment which indicated she had a behavior of wandering on a daily basis. She required assistance with bed mobility, transfers, and toileting; she used a wheelchair. She was always incontinent of bowel and bladder function. She also experienced pain daily and staff used pain indicators (vocal, body, expression) to monitor her condition. The resident was administered an antidepressant and a diuretic 7 days a week. The resident also had a significant change MDS assessment completed on 6/20/13. Her depression score of 9 (mild) on the quarterly MDS dated [DATE] increased to a 12 (moderate) during the significant change period. She also had some decline in her ADLs for support from staff. Her medications also changed. An anti-anxiety medication was added 4 times a week. The care plan addressing falls, dated 5/23/13, for resident #15 had not been updated since it was initiated on 11/26/12. A revision date of 2/20/13 was listed under falls, however the surveyor completed a side-by-side comparison of the last three care plans dated 11/27/12, 2/20/13, and 5/23/13 and no changes to interventions had been made. The following interventions were listed on all three care plans: - Evaluate for environmental hazards - date initiated: 11/26/12 - Fall assessment as indicated per facility policy - date initiated: 11/26/12 - (Resident's name) needs a safe environment with: even floors free from spill and/or clutter; a working and reachable call light, the bed in a low position at night; Red Dot (Do not leave (Resident's name) alone in the bathroom), and personal items within reach - date initiated: 11/26/12 - Personal alarm on when in bed or chair - date initiated: 11/26/12 - Provide proper fitting clothing and footwear - date initiated: 11/26/12 - Rearrange furniture to maintain clear pathways as needed - date initiated: 11/26/12 - Use gait belt and provide extensive assistance of one person for transfers - date initiated: 11/26/12 The resident also had a care plan for "Risk For Leaving The Building" initiated on 11/27/12 with no changes to the interventions since it was initiated. The following interventions were listed on the care plan: - Distract resident from wandering by offering pleasant diversions, food, take her to the central area where she can observe others or listen to music - Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes - Redirect (Resident's name) away from exit doors and other resident rooms as needed - Secure guard. Review risks and benefits of secure guard ankle bracelet as needed. - Reassess quarterly and as needed to determine appropriateness of continued use of secure guard. The resident's Fall Risk Evaluation was completed on a quarterly basis. A resident who scored a 10 or higher was at risk for falls. Resident #15's results were as follows: 3/5/13 - 18 6/20/13 - 18 9/27/13 - 22 The nurse's notes revealed the resident fell on 2/28/13 and 9/25/13. Both falls involved injuries with fractures and bruising. There were no care plan updates after the 2/28/13 fall to prevent future falls. Fall #1 on 2/28/13 - Patella fracture of the right knee The nurse's note dated 2/28/13 read, "Pt (patient) seen by kitchen person just as she was able to leave dining room entry door to outside. Pt tipped over in wheelchair landing on knees and hands near curb. Helped up by 3 staff - complains of knees hurting, L (left) bruised R (right) has abrasion. Daughter aware, called by phone. Administrator notified. Dr. notified by fax, will monitor pain, neuros started, pain medications given per routine direction." A fall committee review was completed by staff members A, B, and G. The following was written on the review "Resident was able to wheel self out of facility. Staff responded promptly as she was seen going out door. Resident fell out of wheelchair. Abrasion to R (right) knee, bruising to L (left) knee. All interventions were in place. Appropriate contacts made. Resident is high risk for falls. Fall was unavoidable. No changes to care plan". The resident's care plan stated to "redirect (resident's name) away from exit doors..." The resident was to wear a secure guard per care plan. There was no mention in the notes if the resident had her secure guard on or if it was working properly to automatically lock the doors or sound alarms upon getting within so many feet of the exit door. No new interventions were put into place to prevent this from recurring. A request was made to staff member A on 10/30/13 at 8:00 a.m. for the investigation report. A second request was made at 11:05 a.m. Staff member A reported at that time "I cannot find the report, I know we did one, but it must have been misplaced after (past DON) left." At 11:10 a.m. two surveyors measured how many steps it was from the door to the parking lot where the curb was located. The distance from the outside door to the curb was 40 feet. The sidewalk to the curb had a downhill grade with no barrier in place. On 10/30/13 at 3:20 p.m. an interview was conducted with Staff member A concerning the conflicting information from the nurse's notes to the fall committee report. The nurse's note stated "Pt seen by kitchen person just as she was able to leave the dining room entry door to outside...", however the fall committee report stated "...Staff responded promptly as she was seen going out the door...". The question presented to staff member A was "If resident was seen promptly going out the door, how did she make it to the curb (40 feet) before tipping over in the wheelchair"? Staff member A was not able to answer the question. Staff member A was also asked which curb the resident tipped over and her statement was "it was the first curb from the outside door. A second surveyor conducted an interview on 11/7/13 at 4:30 p.m. with maintenance, social services, and physical therapy. They stated resident #15 actually went through the double doors, 100 feet down the sidewalk, over the first curb, and across the parking lot before tipping over after hitting a curb stop where the visitors park their cars. It should also be noted that this resident was in a wheelchair and needed to go through two sets of doors in order to get outside the building. The resident's care plan stated to "redirect (resident's name) away from exit doors..." The resident was to wear a secure guard per care plan. Fall #2 on 9/25/13 at 2:35 a.m. - femoral neck fracture of the left leg and hematoma to head. The nurse's note dated 9/25/13 at 3:45 a.m. read, "Patient was found on the floor on her fall mat. C/O (complaints of) left shoulder and hip pain, large hematoma on left side of forehead. Sent to ER (emergency room ) for eval at 3:15 a.m." A fall committee review was completed by staff members A and B. The following was written on the review "Resident found on floor on left side. All fall precautions were in place - low bed, fall mat, alarm, was checked a 1/2 hour before fall. Fall reasonable and unavoidable related to resident condition. Appropriate contacts made." It was unknown why the fall was determined to be reasonable and unavoidable. The fall investigation report from the facility included a section for staff to describe the incident. Staff member JJ documented, "I was grabbing coffee from Rehab, came back over and (Resident's name) was saying 'help me' 'god damn racist' and I looked in and she was lying on the floor on her left side." This is a discrepancy with the nursing notes that read she was found on her fall mat. There are two questions on the form that were originally answered with "no" that were circled and then crossed out and "yes" was circled. Those questions were: Were alarms attached appropriately? and Was fall mat in place? It is unknown why the responses were changed. The findings of the report were marked as "Reasonable related to condition/event." The resident was admitted to the hospital and diagnosed with [REDACTED].? and low digoxin level at 0.3?. It was decided between the POA and the physician, that surgery was not a good option for the resident. The patient spent two days in the hospital and was then sent back to the facility on [DATE]. 2. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the MDS assessments dated 9/11/13 (quarterly) and 6/11/13 (significant change), Resident #2 had a BIMS score of 2 showing she was severely impaired in cognition. Her wander assessment on the MDS for both dates was a 0 which means she did not exhibit wandering behaviors. On the resident's actual Wandering Assessment Screen dated 10/18/13 she scored an 18, showing moderate risk with an increase in supervision needed. These reports had conflicting information, even though they were completed just over a month apart. A significant change MDS was not completed during this month to reflect a change for this resident. Falls were reported on the MDS as 2 or more with no injury and 0 with injury. The resident's MDS showed the resident needed extensive/2+ person assist with most activities of daily living, including bed mobility and transfers. The care plan concerning risk for falls was initiated on 11/28/12 and revised on 9/19/13. Resident #15 had 7 falls and sustained a fracture incident in a four month period between 6/24/13-10/15/13. The care plan interventions were not updated after the first 5 falls to prevent future incidents. The care plan interventions were as follows: - Encourage (Resident's name) to wait for help. Encourage her to use her call light when needing help - (resident had a BIMS score of 2 and is severely cognitively impaired) - date initiated: 11/28/12 - Fall assessment as indicated by facility policy - date initiated: 11/28/12 - (Resident's name) needs a safe environment with: even floors free from spills and/or clutter; a pressure alarm, a working and reachable call light, the bed in a low position when staff are not in attendance; landing pad and personal items within reach - date initiated: 11/28/12 - Rearrange furniture to maintain clear pathways as needed - date initiated: 11/28/12 - Red Dot: Do not leave (Resident's name) unattended in the bathroom - date initiated: 11/28/12 - Remind (Resident's name) to use her wheelchair and not try and walk on her own without help - date initiated: 11/28/12, revision on: 9/19/13 - Toilet frequently throughout all shifts - date initiated: 11/28/12 - Use gait belt and assistance of one for transfers - date initiated: 11/28/12 - W/C locomotion - added on 10/9/13 - Move bedside table/furniture away from bed to decrease outcome when exiting bed without assistance - added on 10/9/13 (however, the intervention that stated to keep items in reach conflicted with this intervention) The resident's Fall Risk Evaluation had been completed on a quarterly basis. A resident who scores a 10 or higher was at risk. Resident #2's results were as follows: 3/5/13 - 22 6/13/13 - 22 9/8/13 - 22 10/18/13 - 22 Fall #1 - 6/24/13 - no injury: The nurse's note dated 6/24/13 stated "2:45 p.m. - CNA found resident sitting on floor next to bed on fall mat. Bed in low position, no injury - said "No" did not bump head when asked. V.S. (vital signs) 128/67 - 98.1 - 75 - 20 - Sats 87%. Administrator, DON, Dr., family notified". It should be noted also that vitals were not re-checked for this fall with an low oxygen saturation of 87%?. Neuro checks were not started. This resident did not have a [DIAGNOSES REDACTED]. There were only two oxygen saturation readings recorded in the resident's chart, the second reading was recorded at 95%. A fall committee review was completed by staff members A, B, and the previous DON. The following was written on the review, "Fall reasonable R/T (related to) condition esp. (especially) increased weakness decreased cognitive abilities. Unavoidable R/T choice and free will. Resident continues to attempt occasional self transfer despite inability to do so without assist. No changes to care plan @ this time. Notifications made to MD, Administrator, DON, and family." On the facility investigation report, falls was circled as being the nature of incident, but was crossed out and error written. A question on the form was - Were alarms attached appropriately? N/A (not applicable) was written. The findings of the report were identified as being: "Reasonable Related to Condition/Event." It was unknown why the fall was determined to be reasonable and unavoidable. Also this resident was severely cognitively impaired and the fall committee review stated the fall was unavoidable related to choice and free will. Fall #2 - 6/26/13 - no injury The nurse's note dated 6/26/13 read, "2:30 p.m. Resident sitting on the floor leaning against bed. Bed in low position/sitting on fall mat with legs out in front of her. V/S (vital signs) 112/78 - 97.3 - 72 - 16. Administrator, DON, Dr. and family notified". Neuro checks not started. A fall committee review was completed and read, "Review of meds, chart & care plan. Resident cont.(continues) to attempt self transfers. Found on fall mat after she was seen napping in bed no changes @ this time to allow least restrictive lifestyle. Unavoidable R/T (related to) choice and free will. Notifications made to MD, Admin, DON and family". On the facility investigation report fall was circled and then crossed out with "error" written. A question on the form was - Were alarms attached appropriately? "No" was circled, crossed out, then "yes" was circled. The findings of the report were checked as being: "Reasonable Related to Condition/Event. It was unknown why the fall was determined to be reasonable and unavoidable. Also this resident was severely cognitively impaired and the fall committee review stated the fall was unavoidable related to choice and free will. Fall #3 - 7/5/13 - no injury The nurse's note dated 7/5/13 at 3:30 a.m. "Found resident on floor. Resident was sitting in a upright position beside the bed on the fall mat. Bed was in the lowest position and call light was within reach. No c/o(complaints of) pain or discomfort ROM (range of motion) WNL (within normal limits). No apparent injury. DON texted about the incident. Neuros started due to unwitnessed fall. Resident returned to bed and is resting". Neuros were not completed correctly as the first 4 hour check was not completed at 8:15 a.m. The fall committee Review read, "Resident found on floor next to bed. Review of MARs (medication administration record), chart and care plan. Resident attempts to self-transfer despite physical limitations. Falls reasonable R/T (related to) resident condition - unavoidable. Notifications made: MD, DON, Admin and family. No changes to care plan @ this time". The facility investigation report's findings are checked as: Reasonable Related to Condition/Event. It was unknown why the fall was determined to be reasonable and unavoidable. Fall #4 - 7/13/13 - no injury The nurse's note dated 7/13/13 at 12:00 p.m. stated "Resident found on the floor laying on right side, along side the bed. No apparent injuries, neuros started, ROM (range of motion) WNL (within normal limits). Denies discomfort." Neuros were started but done incorrectly as two of the neuro checks were not completed in the first hour. A fall committee review was completed and read, "Review of meds, care plan and chart. Resident found on floor beside bed after being in bed napping. Resident cont. (continues) with decreased cognitive ability and weakness. Falls reasonable and R/T (related to) condition. Unavoidable R/T free will and resident freedom of choice. Notifications made: MD, Admin, DON and family". On the facility investigation report "fall" was circled and then crossed out. It is unclear why that change was made. The findings of the report were checked as: Reasonable Related to Condition/Event. It was unknown why the fall was determined to be reasonable and unavoidable. Also this resident was severely cognitively impaired and the fall committee review stated the fall was unavoidable related to choice and free will. Fall #5 - 7/21/13 - Laceration to Right Forearm The nurse's note dated 7/21/13 stated "At 1905 (7:05 p.m.), Pt (patient) scooted/rolled self from lowered bed onto fall mat on the floor. Her PA (personal alarm) was attached and she developed a 2 cm skin tear to her R (right) forearm. Skin tear was irrigated and had 2 steri- strips placed. A transparent covering was placed over the tear. She has no other injuries. Vss (vital signs stable), afebrile, Neuro at baseline and grossly intact -Neg (negative) LOC (level of consciousness), Neg strike to head or neck. Personal contact notified. Pt denies pain - has no c/o (complaints of) any kind. Monitoring her accordingly". The fall committee review read, "Review of chart, meds and care plan. Resident witnessed rolling self from bed to fall mat. Current interventions prevented injury. Resident cont. (continues) to lower self from bed @ times. Reasonable unavoidable R/T (related to) resident choice and decreased mental capacities. No changes to care plan @ this time. Notification made to Admin, MD, DON and family". On the facility investigation report fall was circled as the nature of the incident. Findings of the report were checked as: Reasonable Related to Condition/Event and also Not Preventable. The report does also state the fall was witnessed by two staff members. It was unknown why the fall was determined to be reasonable and unavoidable. Also this resident was severely cognitively impaired and the fall committee review stated the fall was unavoidable related to choice. Injury - 8/20/13 - with Fracture of Right Ankle of unknown origin: The nurse's note dated 8/20/13 read, "It was brought to my attention at 0700 (7:00 a.m.) this morning by CNA that resident R (right) ankle was swollen and bruised and that resident was crying out in pain each time she was moved and when attempting to put resident's socks on. Brought Nurse Mgr (manager) in to also look at it, ice was put on ankle and foot was elevated with foot pedals of W/C (wheelchair). Resident was given 2 Tylenol 650 mg at 0755 (7:55 a.m.) with good results. Resident was laid down after breakfast and slept through most of lunch. Family (daughter) in for visit and notified of R (right) ankle. Leaving note in NP's (Nurse Practitioner's) box for her to look at 8/21". Staff member LL, Nurse Practitioner, was in to see the resident on 8/21/13. The Nurse practitioner visit note for this day was read and was placed in quotes, "I am seeing this patient today at the request of staff at Cooney. They tell me that on 8/20/12 they noticed that her right ankle was quite swollen and bruised; the patient is complaining of increased pain and they deny knowledge of any injury. Staff do state to me 'she doesn't always lift her feet up when we wheel her wheelchair so maybe she got it caught or something'....When I asked her what happened, she states to me 'I don't know.' I try to perform PROM (passive range of motion) of toes, foot, and ankle and she cries out in pain and retracts her leg......" An X-ray of the right ankle was completed on 8/30/13 at approximately 9:00 a.m. revealing two fractures of the ankle. A fracture boot was fitted on the right foot to stabilize the fractures. It should be noted that several surveyors witnessed multiple residents during the annual survey being told by staff to "pick your feet up" as they were pushed in their wheelchairs by staff; foot rest pedals were not attached to the wheelchairs/in place. During an observation on 10/22/13 at (9:15 a.m.) Staff member J, PT, pushed resident #39 down the hall in her wheelchair without any foot pedals on the wheelchair. The resident had to hold her legs and feet extended in front of her from the rehab area to her room, approximately 40 - 50 feet. At 10:10 a.m., staff member J again pushed resident #39 from the rehab area to her room. The resident, who was in her wheelchair with no foot pedals attached, was holding both feet up off the ground while being pushed. When the resident and staff member arrived at the resident's room, the resident put her left foot down and wheeled her wheelchair with that foot while the staff member pushed the wheelchair. During an interview on 10/23/13 at 3:10 p.m., staff member B, DON, stated, "(It was a) therapy decision. They (residents) all start out with pedals, then they (therapy) assess and decide to remove or not (the pedals). (This) may or may not be documented." Fall #6 - 10/3/13 - Laceration to Forehead: The nurse's note dated 10/3/13 at 4:30 a.m. read, "Resident found on the floor beside bed on RT (right) side on fall mat. Head beside FX (fracture boot) that was on floor. Blood on FX boot. ROM (range of motion) WNL (within normal limits), no complaints of pain or discomfort. Small laceration on RT (right) of head, area cleaned with soap and H2O (water), ice applied. Neuros started, (staff member name) DON notified per text at 0645". A fall committee review was completed and read, "Resident found on R (right) side, bedside bed fall mat in place, bed in low position, personal alarm on. Fall unavoidable related to resident condition. Appropriate contacts made." On the facility investigation report, "fall" was not circled as being the nature of the incident. The second page of the report was not given to surveyors so the findings of the investigation were unknown. No investigation documented about what caused the head laceration. Updates to the care plan occurred on 10/9/13 that stated the following: - W/C locomotion - Move bedside table/furniture away from bed to decrease outcome when exiting bed without assistance Fall #7 - 10/15/13 - no injury: The nurse's note dated 10/15/13 read, "Today at 1350 (1:50 p.m.) resident was found sitting on floor on fall mat. Resident denies hitting head. No injuries and resident stated she wanted to get into her W/C (wheelchair) and personal alarm went off and aide was right in the room. Resident's family called, admin notified, vitals taken 122/88, 18, 55, and 98.4". A fall committee review was completed and read, "Resident continues behavior of getting out of bed. All precautions in place low bed, fall mat, fall alarm. Resident asked to lay down and once down she attempted to get up. Appropriate contacts made". On the facility investigation report "fall" was circled as being the nature of the incident. Findings of the report were checked as: Reasonable Related to Condition/Event. No change to care plan following this fall to prevent further incidents. According to the Falls Tracking Log provided by staff member A on 10/24/13 at 10:50 a.m. 4 of the 7 falls (6/24, 6/26, 7/13, and 10/15) occurred in the afternoon hours between 12:00-2:45 p.m. Two falls occurred between 3:20-4:30 a.m., and one fall occurred at 7:05 p.m. Resident at no time in the care plan was placed on routine checks for fall precautions. the resident's care plan did not give a measurable time frame for toileting but instead directed staff to "Toilet frequently throughout all shifts". The facility failed to determine what the causes of the resident's falls were, such as whether she wanted get in or out of bed or to get to the toilet, etc. The resident was documented as choosing to fall when her mental status showed she exhibited severe cognitive impairment. The facility failed to implement new interventions on her care plan when the existing approaches were ineffective to prevent falls. The facility failed to determine what the causes of the resident's falls were, such as whether she wanted get in or out of bed or to get to the toilet, etc. The resident was documented as choosing to fall when her mental status showed she exhibited severe cognitive impairment. The facility failed to implement new interventions on her care plan when the existing approaches were ineffective to prevent falls. 3. Resident #3 was first admitted to the facility on [DATE] and re-admitted on [DATE]. The resident [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], the resident required extensive one person assist for locomotion and bathing. The resident required total assistance with one person for dressing, toilet use and hygiene. The resident was also coded as frequently incontinent and utilized a wheelchair to move around in her room and facility. A position bar was in place for assistance with bed mobility. On the MDS, the resident was coded as being cognitively intact. In April 2013 the resident began therapy sessions. She was evaluated by the therapist and found to be minimally impaired for safety awareness with precautions for (L) sided hemiparesis and (L) sided neglect from past CVA. The occupational therapist documented the resident as moderately impaired cognitively and 51-70% of the time needed frequent direction. For personal safety awareness, resident #3 was said to have only 71-80% awareness of risk factors. Treatment notes included documentation of the resident's confusion and that she required verbal reminders of what she was working on with the therapist. One of the physical therapy goals was for the resident to pick up her (L) foot rather than dragging it as she would often sit without warning. The resident was very distracted during her treatments and remained unpredictable. The resident was discharged from therapy services with the recommendation and goal that she would ambulate with two staff members assisting at each side or utilize her wheelchair, which she was also unsafe with. Resident #3 had an ongoing care plan in place for falls. This was initiated on 9/6/12 with a revision date of 8/22/13. The care plan problem was documented as: (Resident name) is at High risk for falls r/t Fall Risk Score of 18 (which is the score from the resident fall assessment). The goal was to be free of falls. Interventions for falls included: -Encourage exercise to increase strength and ability. -Ensure proper footwear. -Fall assessment quarterly. -Keep call light in reach and encourage use and wait for assistance. -Provide (resident name) with a safe environment, even floor free from spills, clutter, call light, bed at comfortable height for transfers, position bars and personal items in reach. Care plan reviews were completed by the facility for resident #3 on: 4/5/13, 4/16/13 and 5/22/13 but did not reflect changes to the residents care plan for falls. Resident #3's Fall Risk Evaluation had been completed on four occasions. Any resident scoring a 10 or higher was considered high risk. Resident #3's results were: -2/18/13 score of 22 -4/28/13 score of 26 -7/15/13 score of 18 -10/14/13 score of 22 The nursing notes of the medical record were reviewed on 10/21/13 and indicated the resident fell 7 times within the dates of 1/29/13 to 9/19/13. Three of the falls resulted in injuries. For 5 of the falls, it was documented the resident was "found" on the floor. Injuries included an abrasion, pain in the left arm, hip, left leg, bumps to the head and bruising to buttock and left leg. The progression of the resident's falls and action taken by the facility were as follows: Fall #1 on 1/29/13-No injury The nurses note dated 1/29/13 at 1815 (6:15 p.m..) reflected the following, "Resident found on floor by maintenance staff. No new injuries noted. VS 97.3, 74, 24, 142/84. Denies pain." No further assessment was conducted by the nurse, such as skin assessment, range of motion or a description of the events of the fall. It is unknown if the staff interviewed the resi

Based on observations and record review, the facility failed to ensure 2 (#s 12 and 13) of 5 residents, who were observed during transfers, were transferred in a safe manner.? Findings include: 1. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #12's most current quarterly MDS of 11/13/13, under Section G (Activities of Daily Living), showed resident #12 used a wheelchair and needed extensive assistance of one person for transfers and toileting. Resident #12 was not steady with balance independently, but was able to stabilize with staff assistance. During observation of cares on 2/19/14 at 1:30 p.m., resident #12 was transferred by staff member E, a CNA, to the toilet. Staff member E wheeled resident #12 into the bathroom and locked the brakes on the wheelchair. Staff member E put a gait belt around resident #12's waist and secured the gait belt with her right hand and put her left forearm beneath resident #12's armpit. Staff member E assisted the resident to stand, turn and sit on the toilet with her forearm beneath the resident's armpit. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to resident #13's significant change MDS, dated [DATE] under Section G (Activities of Daily Living), resident #13 used a wheelchair for mobility, needed extensive assistance and weight bearing support of two people for transfers. Resident #13 had impairment on one side of her upper and lower body. During observation of cares on 2/19/14 at 1:42 p.m., resident #13 was transferred to her bed with the assistance of CNAs E and G. Staff member E wheeled resident #13 to her bedside, locked her wheelchair brakes and put a gait belt around the resident's waist while she was sitting her in wheelchair. Staff member G came into resident #13's room and assisted staff member E with transferring resident #13 to her bed. Staff members E and G placed their forearms under resident #13's armpits and grabbed the gait belt and lifted her onto her bed. 3. STAFF TRAINING The facility performed training and audits for the months of January and February 2014. Review of the Mandatory CNA Inservice dated 2/17/14 under Transfer Techniques read, Do not lift patients from under the armpits (you risk injuring patient's Brachial Plexus or dislocating the shoulder). REFERENCE ? According to Hegner and Gerlach, due to the risk of resident injury, staff should never place their hands under a resident's arms during a transfer. A transfer belt should be used unless it is contraindicated. Hegner, B.R., & Gerlach, M.J. (2007). Assisting in long term care (5th ed.). United States: Thomson Delmar Learning.

Based on observation, staff interview and record review, the facility failed to ensure staff locked the wheels on lifts and wheelchairs while transferring 2 (#13 and #28) out of 30 sampled residents. Findings include: According to the Plan of Correction to the annual recertification survey ending on 10/31/13, the facility would identify risk of falls, minimize injuries and develop an interdisciplinary care plans with fall injury prevention strategies in accordance with facility policy. The facility failed to follow the plan of correction; this tag was recited on the revisit dated 1/16/14. 1. Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 12/11/13 quarterly MDS, the resident was totally dependent on staff for transfers. During an observation on 1/14/14 at 9:30 a.m. staff members Q and R removed the foot pedals from the wheelchair. After sanitizing their hands, the CNAs lifted Resident #28 (who was in a wheelchair) forward to put the lift sling behind her. The resident shouted, "No, No, No!" The aides asked the resident if she wanted to go to bed? The resident stated, "yes." The resident's wheelchair brakes were unlocked and the chair moved forward. The lift was brought forward to meet the chair. The wheelchair brakes were not locked. The sling was hooked to with the lift; The lift brakes were not locked. The resident was raised with by the mechanical lift. The resident was transferred to her bed; the lift was lowered with CNA Q holding her foot against the leg of the lift. The resident was placed in her bed and the bed was raised. The CNAs tucked the sling under the resident and the sling was removed. The transfer was not conducted safetly; wheelchair and lift brakes were not locked during the transfer.? ? 2. The surveyor observed staff member H and an unidentified outside contract employee transfer resident #13 from the wheel chair to the toilet on 1/13/14 at 11:20 a.m. Staff member H did not have the wheel chair brakes in the locked position when transferring resident #13 to the toilet.? Resident #13 had a significant change MDS with an ARD 1/12/14. Section G staff members documented resident #13 required 2 person extensive assistance for transfers. During an interview with staff member K on 1/15/14 at 4:20 p.m., she stated the wheel chair brakes should always be locked during a transfer. She further stated the brakes on the lifts should be locked during transfers as well. During an interview with staff member M on 1/15/14 at 4:40 p.m., she stated the brakes should always be in the locked position on a wheel chair or lift when transferring a resident. REFERENCES ?According to Basic Skills for Nursing Assistants in Long-Term Care By Sorrentino and Gorek, the procedure for transferring a person using a mechanical lift the aide needs to, " ...18. Lock the lift wheels in position ... " Sorrentino, Sheila & Gorek, Bernie, (2005). Basic Skills for Nursing Assistants in Long-Term Care St. Louis: Elsevier Mosby. ?MT Candidate Handbook Page: 23 Updated: 2-24-09 Printed: 4/7/2011 ... 4. Insures resident's safety. Locks wheelchair brakes... MT Candidate Handbook Page: 23 Updated: 2-24-09 Printed: 4/7/2011

Based on observations, resident interview, staff interview and record review, the facility failed to ensure 1 (#26) of 30 sampled residents maintained nutritional parameters. The resident was not served when she refused to go to the main dining room for meals. Findings include: The facility failed to follow the plan of correction to the 10/31/13 recertification survey; this tag was recited on the revisit dated 1/16/14. Resident #26 was admitted to the facility on [DATE]; current [DIAGNOSES REDACTED]. The resident was prescribed an antipsychotic medication daily. According to the 12/25/13 quarterly MDS, the resident was able to understand others and make herself understood. The only behavior identified on the assessment was rejection of care. Interdisciplinary notes showed frequent refusals to take her medications. According to the 12/25/13 MDS, she was independent with eating and required no set up or supervision with meals. The resident was 5'1" tall and weighed 111 pounds; she had no signs or symptoms of a swallowing disorder. The Nutritional Evaluation forms and notes were reviewed and the facility had not determined what the resident's usual or desired or ideal body weight was. The 12/19/13 Nutritional Evaluation form indicated the resident had no concerns with chewing or swallowing and that she was independent with meals. The following was documented, "Prefers room trays." The resident had a history of [REDACTED]. Review of interdisciplinary notes included the following documentation regarding her preference to stay in her room, being served room trays and eating in the dining room: -11/19/13 - "Resident stayed in rm (room) for all meals..." -11/25/13 - "Room trays since she refuses to leave her room." -11/28/13 - "Continues to refuse scheduled meds or to come out of her room." -12/08/13 - "Continues to refuse sched (scheduled) meds or to leave her room." -12/11/13 - "Resident continues to stay in rm and will not come down for meals." -12/18/13 - "Refused to leave room this shift - as usual." -12/22/13 - "Refuses to leave room. Room tray for supper." -12/23/13 - "Refuses scheduled meds or to come out of her room pleasantly... room tray." -12/24/13 - "Resident cont (continues) to stay in rm this shift. Had rm trays.." -12/24/13 - "Continues to stay in room... Room tray" -12/28/13 - "Refuses scheduled meds or to come out of her room - room tray..." -12/29/13 - "Believes there are chemicals in the food and medications and she doesn't need them. Room tray..." -12/31/13 - "Pleasantly refused her sched meds. Did however come out of her room and eat supper in dining room." - 1/03/14 - "Resident out to dining for breakfast today and ate well. Resident came down for lunch but did not stay." - 1/03/14 - "Resident refused to come to meal and did not wish to get a snack." - 1/05/14 - "Resident refused to come down to meals and refused to eat." - 1/07/14 - "Patient was out for dinner, ate very little." - 1/12/14- "Resident refused meds and coming out for meals despite much encouragement." - 1/15/14 - "Resident remains in room and cont to ref (refuse) all meds. Snacks offered." An initial tour of the facility, C hall, was conducted on 1/13/14 starting at 8:40 a.m. with the director of nursing, staff member A. Resident #26 was in her room and stated she did not go to breakfast in the dining room that morning; the resident stated she wanted to eat meals in her room. Staff member A told the resident she had to go to the dining room for meals and that she could not eat in her room. The resident stated, "They make fun of me in the dining room. I need to be here (in her room) for my safety." The DON told the resident a second time she needed to go to the dining room for meals. The resident became teary eyed, turned her back and walked away from the doorway, where she had been standing, into the room. On 1/15/14 at 8:45 a.m. resident #26 was observed in her room, sitting on the edge of her bed. On 1/15/14 at 8:50 a.m. dining room observations were made. Approximately 20 residents were in the dining room at this time finishing breakfast. The dietary manager, staff T, was interviewed. He verified resident #26 was not in the dining room and stated, "She eats in her room. We try to get her to come down (to the dining room)." On 1/15/14 at 12:00 noon, dining room observations were made. Residents were in the dining room for lunch. Resident #26 was not in the dining room. On 1/15/14 at 12:35 p.m. resident #26 was interviewed in her room. She stated it had been "about six days" since the facility had stopped serving meals to her in her room. She stated, "They say they won't bring meals to my room. I ate in my room before." She said she had not been served lunch that day and stated, "Sometimes I eat graham crackers." She stated she would probably be served an afternoon snack consisting of graham crackers or fruit bars and that this was what she had recently been subsisting on since meal trays were no longer delivered to her. She stated her physician indicated she should be able to eat in her room On 1/15/14 at 12:45 p.m. dining room observations were made. Resident #26 was not in the dining room. The dietary manager was interviewed and stated that resident #26 would be served food within an hour after meal service concluded, when the CNAs had time to sit with her in her room while she ate. The dietary manager stated the resident would be served a sandwich or a snack or some type of packaged food. When asked about receipt of a regular meal, he stated there were concerns with holding food that long, but she could request a meal tray. He stated the facility was instituting a new policy to encourage residents to eat in the dining room. He stated there were 19 or 20 residents previously that ate in their rooms. On 1/15/14 at 1:00 p.m. the resident was observed in her room sitting on the edge of her bed. There was no evidence of food having been served. She stated she had not been served any food yet. She explained she had some allergies and stated, "I am [AGE] years old." She stated she did not have swallowing problems or choking concerns. On 1/15/14 at 2:00 p.m. the resident was observed in her room sitting on the edge of her bed. There was no evidence of food having been served. She stated she had not been served lunch or any food and at this point was waiting for the afternoon snack of graham crackers or a fruit bar. On 1/15/14 at 4:00 p.m. the resident was lying in bed. There was no evidence of a meal tray or lunch having been served. On 1/15/14 at 4:30 p.m. the dietary manager was interviewed and asked about resident #26's lunch meal service. He stated he did not know if the resident had been served lunch but he would check. Several minutes later he reported the resident had been served an afternoon snack of graham crackers and that she had not been served any other food. He stated he talked to the CNA who was responsible and told her if the resident did not eat in the dining room, she should be offered a meal. He stated the resident had just been served yogurt, a sandwich, and milk and was eating now. On 1/16/14 at 10:00 a.m. resident #26 was interviewed. She was sitting on her bed and stated that she was served dinner on 1/15/14 and breakfast this morning in her room. She smiled and stated, "I am happy about it." She stated, "I can eat without supervision." She stated, "Thank you", referring to the surveyor bringing the issue to the attention of staff and it now being resolved so she could eat again in her room. The meal intake records for the month of January 2014 showed the resident refused all three meals for the seven day period from 1/08/14 through 1/14/14. This corresponded with the resident's account of when the facility stopped serving her meals in her room and her subsiding on snacks of graham crackers and fruit bars. There was a lack of evidence the facility offered the resident meals when she refused to come to the dining room to eat during this timeframe. The resident's weight records showed an initial weight of 114.6 pounds upon admission to the facility on [DATE]. Her weekly weights for the month of December 2013 fluctuated between 111.2 pounds on 12/23/13 and 108.6 pounds on 12/02/13. Between 1/06/13 and 1/13/14 (period corresponding with a lack of room trays being served) the resident's weight decreased from 109.2 pounds to 107.8 pounds. The resident was weighed on 1/16/14 and her weight was 108.2 pounds. On 1/15/14 at 12:45 p.m., the administrator, staff B, was interviewed and stated there was a draft policy addressing residents eating in their rooms. She stated there were 19 residents who previously preferred to eat in their rooms and now there were only two residents who ate in their rooms. She stated staff remained with the two residents (#s 29 and 30) who ate in their rooms. Resident #26 was not one of the two residents allowed to eat in her room. On 1/15/14 at 12:45 p.m., a draft policy dated 12/20/13 was provided to the surveyors. The policy statement read, "It is the facility policy that room trays are not provided for residents on a regular basis to protect from potential aspiration risk and potential isolation." The procedure read, "1. Residents are not allowed to have room trays and eat in their room. 2. If there is a medical need that would require a resident to eat in their room, the IDT would meet and determine if the resident eating in their room was medically necessary. 3. Upon the IDT approval, the resident will be allowed to eat in their room only with a staff member present while the resident is eating. 4. This approval will be reviewed as needed for the appropriateness and duration of the resident's medical need for room trays."

Based on observation, record review, resident interview and staff interview, the facility failed to recognize, evaluate and implement interventions in response to significant unplanned weight changes for 4 (#s 4, 8, 16, and 22) of 39 sampled and supplemental residents. Resident #16, who was severely malnourished, did not receive adequate protein and calories via her feeding tube to meet her nutritional needs. The resident experienced weight loss. Specific failures included: -Not obtaining reweighs when residents' weights were potentially incorrect; -Assessments of residents' nutritional status were incomplete. -Not identifying weight loss in a timely manner; -Not implementing nutritional interventions in response to nutritional risk and weight loss; -Not notifying physicians of significant weight loss. The findings include: 1. Resident #16 was sent to the hospital on [DATE] and re-admitted to the facility on [DATE] with a newly placed [DEVICE] after having sustained a stroke. The resident's [DIAGNOSES REDACTED]. On 9/26/13, before going to the hospital, the resident weighed 89.7 lbs (pounds). On 10/17/13 the resident weighed 86.11 lbs. This was a 4% unplanned weight loss in 21 days. The physician's hospital admission note dated 10/4/13 stated the resident had "severe malnutrition", the resident was "significantly malnourished", and "adequate nutrition would be essential for any recovery." When the resident was readmitted to the facility on [DATE] she was prescribed [MEDICATION NAME] tube feeding formula 1.5, 237 mL TID (three times a day) by route of a peg feeding tube. The tube feeding provided a total of 1066.5 calories per day and 51 grams of protein per day. The resident's diet order revealed she was to consume no food or fluids orally; all her nutrition was to come via the tube feeding. There was no evidence the dietitian assessed the resident's nutritional needs to determine whether the tube feeding regimen was nutritionally adequate. Based on a subsequent assessment (10/16/13 noted below), the tube feeding regimen did not meet the resident's calorie needs of 1100 - 1200 per day. On 10/16/13, the resident's tube feeding order formula was changed resulting in a decrease in nutritional content. The tube feeding regimen was not sufficient to meet the resident's nutritional needs. The order was changed to Glucerna 1.0, 240 mL (cans come in 237mL) per feeding tube to be administered 3 times a day with a 100 cc water flush pre and post administration of the tube feeding. The tube feeding provided a total of 711 calories per day and 29.7g grams of protein per day. On 10/16/13 staff member U, the dietician, documented in a nutritional progress note "Tube feeding: (new tube feeder) estimated needs 1100-1200 kcals (calories), 40-45 g of protein, [PHONE NUMBER] mL of H2O. Currently formula Glucerna 1.0 24 0 mL....Also recommend adding an additional bolus - did not speak with GNP about this so will write communication order to GNP and monitor acceptance. Will continue to follow." The dietitian did not assess the current tube feeding order to determine whether it met the resident's nutritional needs. It is unknown whether the dietitian intended to add another can of Glucerna or additional water per her note to increase the bolus. Per the dietitian's calculations of the resident's nutritional requirements, the resident was not receiving adequate calories and protein to maintain her nutritional status. The surveyor calculated the calories and protein provided by the Glucerna tube feeding order of 3 cans daily. The tube feeding provided a total of 711 calories daily; the resident required 1200 calories to maintain her nutrition status. The tube feeding provided a total of 29.7 grams of protein daily; the resident required 40 - 45 grams of protein to maintain her nutritional status. On 10/23/13 at 3:45 p.m. staff member U, the dietitian, was interviewed and stated the resident's current tube feeding would not meet her needs. On 10/21/13 the resident was transferred to the hospital for abnormal labs. The physician's admission note from the hospital stated her current [DIAGNOSES REDACTED]. -acute [MEDICAL CONDITION] secondary to dehydration -[MEDICAL CONDITION] secondary to dehydration and SIADH -malnutrition with recent PEG tube placement -protein calorie malnutrition -[MEDICATION NAME] present on admission secondary to Esherichia coli Also included in these [DIAGNOSES REDACTED]. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 9/2/13 Significant Change MDS assessment, the resident was coded as being highly impaired in vision and hearing. The resident was coded as requiring supervision at meals. She was coded as being 5'4" tall and weighing 150 pounds. The resident was coded as having experienced a weight loss that was not prescribed by the physician. The facility failed to identify a significant weight loss for resident #8 during the time period from 3/10/13 through 6/9/13. According to review of the Vitals record, the resident's weights included the following: -180.4 pounds on 3/10/13 -179.2 pounds on 4/9/13 -169.4 pounds on 5/7/13 -164.7 pounds on 6/9/13 This represented a significant (greater than 7.5% weight loss in 90 days) weight loss of 15.7 pounds (8.7%). There was no evidence the resident was reweighed when there were significant variations between weights. On 10/8/13 the resident weighed 154.3 pounds. The Nutritional Evaluation completed on 3/13/13 reflected resident #8 weighed 181.2 pounds. According to the Nutritional Evaluation, the resident's ideal body weight ranged from 108-132 pounds; her usual body weight had not been assessed (blank on the assessment). The resident was prescribed a mechanical soft, no added salt diet with one can of Ensure supplement daily. The resident normally consumed 75% of her meals. The assessment did not identify any concerns and there were no recommendations made at this time. The resident's weights were noted to be followed on a weekly basis. On 6/13/13, the Nutritional Evaluation noted the resident's weight to be 164.7 pounds. On the evaluation, a significant weight loss over 6 months had been identified. On this assessment, the resident's intake ranged from 34-40%, which was significantly less than the prior assessment (75%). The document also reflected that the resident had only been eating chicken noodle soup. The dietitian documented, "Left a note to GNP (general nurse practitioner) about weight loss." The dietitian documented the resident as having "really bad anxiety about not being able to hear" as a potential cause of the weight loss. The resident was identified as refusing the Ensure supplement 10 times in the month of May 2013. A recommendation was made to change to Medplus supplement 2.0, 3 ounces. The resident was documented as requiring some assistance at meals due to [MEDICAL CONDITION]. The dietitian documented the continuation of weight monitoring for the resident. On 10/16/13 the dietitian completed a weight review of the resident. The resident's current weight was documented at 154.3 pounds (taken on 10/8/13). On 10/23/13 at 4:35 p.m., staff member U, consultant dietitian, stated, "Weights are taken on the unit and given to the dietary manager who inputs the information and identifies changes. I review for problems and need to follow up on them." The surveyor reviewed the weight trending form with staff member U for resident #8. The form included weekly weights for the past month and weights 180 days prior as well as 90 days prior. The spreadsheet calculation for weight change compared the current weekly weight to the previous weekly weight, when the intent according to the dietitian, was to compare the current weight to either 30 days or 180 days prior. The dietitian stated the form did not display the desired information and they had discontinued using it. This was explained by the staff member as why the facility chose to begin utilizing a different weight tracking system. When asked why the significant weight loss for the resident, beginning in February of 2013, was unaddressed in the medical record or with interventions, staff member U stated, "I can't explain why it was missed." Upon discovering the weight loss in June of 2013, the dietitian did implement nutritional interventions for prevention of further weight loss (Med Plus supplement). The resident's care plan, initiated on 9/13/12 and revised on 8/27/13, identified the problem of altered nutrition related to therapeutic diet and history of significant weight loss. The goal was for the resident's weight to be stable. Interventions were: -"Chart intakes. Report decreased intakes to dietary manager/consultant (initiated 9/13/12). -Fortification of meals with protein powder (initiated 8/27/13). -Provide and serve diet mechanical soft diet, no added salt as ordered. Offer alternative choices at mealtimes to encourage increased intake. Provide Ensure QD (revised 5/22/13). -Provide and serve Med Plus BID (revised on 8/27/13) -Provide assistance in the dining room as needed; such as explanations of food items/locations due to low vision (initiated 9/13/12). -Refer to dietary manager/consultant as needed per facility weight loss/gain policy (initiated 9/13/12). -Weights weekly (revision 9/13/12)." Two meal observations were made during the survey. Staff did not provide meal assistance or cueing to the resident per the directions in the care plan. She struggled to find the food on her plate and feed herself: On 10/22/13 at 8:20 a.m. resident #8 was sitting in the dining room waiting for her meal. At 8:24 the resident's meal arrived. The resident did not receive assistance with her plate, but rather the employee placed the tray in front of her and walked away. The resident had two fried eggs on her plate. Due to her severely impaired eyesight, the resident was unable to see the food on her plate or pick up the eggs with her fork. The resident pushed the eggs around on the plate and tried to feel them with her fingers. At 8:40 a.m., 16 minutes after the start of the meal, resident #8 displayed frustration by sighing and putting her fork down and looking around the room as if she was seeking assistance. No staff were in the area to assist the resident at the time. The resident then attempted to pick up the eggs with a knife, but this was also unsuccessful. Then the resident picked up one of the fried eggs with her fingers and held it like a sandwich and consumed the egg. The remainder of the meal was eaten with her fingers. On 10/22/13 at 12:50 p.m. resident #8 was again in the dining room eating her meal. She had been observed by the surveyor for the last 25 minutes from a distance. When approached, the resident commented the food was good and asked, "Did I eat it all"? This showed the resident was unable to see the food on her plate. During the observation, the resident again had difficulty finding the food items on her plate and also difficulty using the utensils to pick up the food. She frequently dropped the food prior to getting a bite to her mouth. 3. Resident #22 was admitted to the facility on 2/5/13 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/28/13 at 9:00 a.m. the medical record review was completed, which reflected a significant weight increase from 118 pounds to 147.4 pounds for resident #22. The resident's weights (documentation from Nutritional Evaluation Assessments and progress notes) read as: -3/13/13 118 lb -4/1/13 120.9 lb -4/28/13 134.6 lb -5/14/13 136.8 lb -6/16/13 139 lb -7/3/13 140.5 lb -9/26/13 150 lb -10/2/13 147.4 lb On 3/25/13 the initial Nutritional Evaluation, the resident was assessed as being 5'6" tall and she weighed 118 pounds. The resident's usual body weight and ideal body weight were not assessed (left blank on the form). [MEDICAL CONDITION] was noted. The section for assessment of medications was not completed (left blank on the form). The resident's physician prescribed a regular diet. At this time, resident #22 consumed approximately 86% of her meals. No recommendations were made. The resident's care plan initiated on 4/4/13 identified the problem of risk for weight loss related to dementia. The goal was for the resident to maintain adequate nutritional status by maintaining her weight within 5%. Care plan interventions were: -Encouraging the resident to take snacks from the snack cart; -Encouraging fluids and good intake at meals; -Providing and serving a regular diet as ordered and monitoring intake and recording each meal; a low sodium diet was added on 5/13/13; -Having the dietitian evaluate and make diet change recommendations as needed; -Weighing the resident as needed. On 4/24/13 the physician ordered weights to be obtained on resident #22 three times a week. On 4/25/13 the physician ordered a 2 gram sodium diet. On 7/13/13 the quarterly Nutritional evaluation was completed. Resident #22 now weighed 140.5 pounds. This was a 22.5 pound weight increase from the initial Nutritional Evaluation completed on 3/25/13. The dietitian did not document any assessment in regards to the weight gain and did not identify that it was a significant weight change. Causes of the weight gain were not assessed. The resident was prescribed an antipsychotic medication, [MEDICATION NAME] daily as 0.5 at bedtime daily. Recommendations for use of [MEDICATION NAME] include monitoring body mass index (measurement for adequacy of weight for height) and consideration of titrating to a different antipsychotic agent for weight gain more than 5 lbs above of the initial weight.? For the quarterly assessment review period, the resident consumed approximately 95% of her meals. The dietitian documented "0 recommendations at this time. Continue current plan of care." The resident's care plan was not updated; it indicated the resident continued to be at risk for weight loss with interventions aimed at increasing nutritional intake and preventing weight loss. On 9/26/13 a nutritional progress note indicated an MDS was being completed for a significant weight gain; the resident's current weight was 150 pounds. On 10/2/13 the next quarterly assessment was completed and a nutritional progress note reflected the resident's weight at 147.4 pounds. This was an increase of 29.4 pounds in 6 months. No recommendations were made at the time of the assessment for a continuing plan of care or to address the significant change. The resident's care plan continued to address the problem of risk for weight loss with interventions aimed at increasing nutritional intake. The resident's weight gain was not assessed to determine whether interventions were necessary to prevent further weight gain. The causes of the weight gain were not evaluated. There was no evidence the resident was reweighed at any time when weight changes were significant. On 10/23/13 at 4:35 p.m., staff member U, consultant dietitian, stated, "I review for problems and needs to follow up on. We had problems with PCC (Point Click Care/electronic medical record program) during March, April and May (of 2013), which we addressed... The facility is now using a different system to identify significant weight fluctuations." 4. On 7/15/13 resident #4 was admitted to the rehabilitation unit of the facility with [DIAGNOSES REDACTED]. The facility failed to identify, assess and respond to a significant unplanned weight loss for resident #4 during the time period from August through October 22, 2013. Review of the facility Roster Sample Matrix, Form CMS -802, given to the surveyors on 10/21/13 after the entrance conference, reflected an unmarked square under problem #18, Excessive Weight Loss/Gain for resident #4. According to this document, the resident had not experienced a significant weight change. Review of the facility Weight Trends Record on 10/21/13 at 10:00 a.m. reflected resident #4's weights as follows: -218.6 pounds June -219.1 pounds July -210.6 pounds August -207.75 pounds September -188.2 pounds October (updated after first review) Resident #4's record for Summary of Weight Changes read, 90 days weight loss = -14.1%; 30 days -9.41%. Review of Resident #4's Care Plan dated 8/26/13 did not identify or address the resident's weight loss. Resident #4 had a care plan for a potential nutritional problem related to diabetes and therapeutic diet. The resident was identified as being at risk for aspiration related to a recent stroke. This care plan had a goal for the resident to maintain adequate nutritional status as evidenced by maintaining weight within 5% by review date. The interventions were about what he could drink, what type of syrup he could use, that the staff were to encourage him to have a good intake, that the staff were to report signs/symptoms of dysphagia, refusing to eat or if he appeared concerned during meals. Also the interventions were about a clothing protector preference, for the staff to provide the appropriate diet and record his intake, that the registered dietitian was to evaluate and make diet change recommendations as needed and that he was to be weighed as needed. The plan did not identify the significant weight loss or that he had failed to meet the goal of his weight not to decrease more than 5%. There were no new interventions added in response to the weight loss. Review of the Daily Skilled nursing notes dated 10/20/13 reflected the resident's current weight on this date was 188.2 pounds. Review of the General Nurse Practitioner (GNP) notes dated 7/24/13 reflected, "Endo: Denies [MEDICAL CONDITION] problems, excessive thirst or sweating, heat/cold intolerance, unexplained weight change, polydipsia, polyuria, changes in facial or body hair or skin striae. Review of the GNP notes dated 09/05/13 reflected, "Details: Assessment: diabetes mellitus type 2, [MEDICAL CONDITION], muscle weakness, [MEDICAL CONDITION], low back pain, nursing home admission. Review of History of Present Illness, details: Patient seen today for nursing home readmission. He had been seen previously at (NH) for rehabilitation but became profoundly weak. There was concern a near (sic) had a repeat stroke versus a urinary tract infection and he was readmitted to the VA Hospital. He was treated for [REDACTED]. He was then transferred back to VA for continued rehabilitation. He has continued to slowly improve. Under Exam-general, the note read, "chronically ill; nutritional status, normal." This note followed the resident's hospital admission on 07/29/13. The plan was to initiate an antidepressant and to continue medications and treatments. There was no assessment or plan regarding the resident's weight loss. Review of the GNP notes dated 10/02/13 reflected: HPI (history of present illness) Documentation, "Pt is being seen at (nursing home) for his regulatory review. Staff states he has no recent infections, illnesses or adverse health reactions. Staff state, "he is doing well, ... healthwise he is doing good, we have no concerns." NN (nursing notes), physician notes, MARs (medication administration record), TARs (treatment administration record), labs, weights, vital signs, and medical record reviewed. He does look as though he has lost some weight to me today, however he is otherwise clinically stable, please refer to ROS (review of symptoms) and PE (physical exam) for pertinent negatives. ROS Documentation: Constitution: he weighed 209 on July 29 and 222 on July 15 per medical record review, no fever, no chills, malaise, fatigability, weight changes or night sweats. Endo: Denies [MEDICAL CONDITION] problems, excessive thirst or sweating, heat/cold intolerance, unexplained weight change, polydipsia (increased thirst), polyuria (increased urine), changes in facial or body hair or skin striae. (The weight loss recorded here represented a 13 pound weight loss in 14 days). Review of The Nutritional Evaluation completed after the resident was readmitted on [DATE] (form had no date) reflected: PO Intake 95-100%. Height 72" Wt 207.5 8/15 208.4 Resident is a [AGE] year old male readmitted for care. Current [DIAGNOSES REDACTED]. Current weight 207.5, relatively stable since re-admission. Currently meeting estimated nutritional needs. Current diet ADA low sodium, low cholesterol, clarify diet to reduced concentrated sweet, no added salt, low cholesterol. PT has currently been working with resident for swallowing. Resident is an independent eater who consumes meals in the dining room with supervision. No pressure sores noted. No recommendation at this time. Continue current POC (plan of care). Review on 10/21/13 at 10:21 a.m. of Resident #4's Nutritional Progress Notes dated 10/3/13 read, "Interview with the resident's wife related to concerns with increased blood sugars levels and requested (sic) be care planned that resident should not get any fruit juice with meals and eggs allowed only 4x per week (sic) Mon Wed Fri Sat and on the days residents don't get eggs provide and serve yogurt with granola crumbles. Will honor and accommodate request and monitor." Review of the Weight Management Committee Report dated 10/17/13 reflected 9 residents were reviewed/suggested for next review and resident #4 was not listed. Review of the Weight Management Committee Report dated 10/23/13 reflected resident #4's reason for review was, "spoke with GNP unsure if having diarrhea monitor x 1 week with po (by mouth) intakes and weights. GNP questions BM. Intake really good. The plan or change read, "supplements may aggrivate (sic) BM issue (sic) rewt (reweigh) (sic) recommend live culture yogurt just in case he is having diarrhea." The resident was documented as having frequent loose stools, during which time laxatives were being administered; cross refer to F329. There was a lack of identification and assessment of the loose stools in regards to the resident's weight loss and nutritional status. -Review of Resident #4's Flow Sheet dated September 2013 31 loose stools during the month. -Review of Resident #4's Flow Sheet dated August 2013 reflected the resident had 18 loose stools during the month. -Review of Resident #4's Flow Sheet for July 2013 reflected the resident had had 5 loose stools during the month. Review of the GNP's review of systems dated 9/05/13 concerning the resident's gastrointestinal area reflected: Denies abdominal pain. Under "Exam: Gastrointestinal: abdomen description: normal, bowel sounds: LUQ (left upper quadrant): normal; RUQ (right upper quadrant) normal. Under Exam - General "Nutritional status: normal." Review of the GNP's Review of Systems dated 10/02/13 reflected, "Gastrointestinal: Denies changes in appetite, intolerance of any foods, dysphagia, heartburn, nausea, vomiting, hematemesis, constipation, diarrhea, change in stool color or contents, flatulence, hemorrhoids and no change in bowel habits." Review of Resident #4's Medication Administration Record [REDACTED]. Documentation showed it was given from July 1st - 17th when it was discontinued. The MAR indicated [REDACTED]. On 10/18/13 at 10:00 a.m., there was a telephone order to change [MEDICATION NAME] (laxative) 17 gms QOD (every other day) to prn (as needed). Documentation showed the resident was not consistently offered snacks. Review of the "CNA-ADL Tracking Form dated 6/13 reflected that the resident was offered a snack on five of sixteen days from 6/14/13 thru 6/30/13. Review of the July 2013 form reflected the resident was offered a snack for 7 of 28 days of the month. Review of the August 2013 form reflected the resident was offered a snack for 11 of 25 days of the month. Review of the October 2013 form reflected the resident was not offered a snack from October 1st through October 21st. Review of the resident's Daily Skilled Nursing Notes (DSNN) dated 10/20/13 revealed the resident's weight on this date was 188.2 pounds. Continued review of the notes did not reflect any notification of the physician of the weight loss. Review of Resident #4's telephone orders dated 6/14/13, 6/24/13, 7/8/13, 7/17/13, 7/24/13, 7/26/13, 7/29/13, 8/6/13, 8/16/13, 8/20/13, 9/4/13, 9/17/13, 9/19/13, 9/23/13, 10/16/13, 10/18/13 and 10/23/13 reflected there were no orders concerning any changes in his diet, weight loss, meals or supplements. Following the surveyor's investigation into the resident's weight loss, the dietitian became aware of the weight loss and the facility began to implement interventions. During an interview on October 23, 2013 at 3:45 p.m., staff member U, the dietitian, stated, "For Resident #4 we have started yogurt with live cultures for him. Last week was the first time I was aware of his weight loss. I ordered a re-weigh. I didn't get the results until yesterday (October 22, 2013). I didn't look at the weights until today at our meeting. Today we met and discussed diarrhea issues. I will follow up with possible [MEDICAL CONDITION] (intestinal bacterium). I will bring in my notes from last week." During an interview on 10/23/13 at 10:30 a.m., staff LL, the GNP stated, "His wife is diligent about everything. She called me on my personal cell phone - she was frustrated with his 30 pound weight loss over 2 months. I saw him last week. No one reported to me he had weight loss. I got a note on the weight loss today. I wrote orders for the weight problems." Review of the GNP's telephone order dated 10/23/13 reflected: 1. Track all intake % of intake. 2. Daily weight q a.m. before breakfast. 3. Chart consistency of BMs (bowel movements). 4. Report information to me in two weeks, please. Review of a TARs (Treatment Sheet) dated 10/1-31/13 reflected Resident #4's recent weights were: The resident's weights were taken before breakfast on a daily basis and the wheelchair weight was 49.04 pounds. -188.4 pounds on 10/24/13 -188.7 pounds on 10/25/13 -209.6 pounds (a.m.); 210.1 pounds; and 205.6 pounds (p.m.)10/26/13 -209.4 pounds on 10/27/13 -209.4 pounds on 10/28/13 -214.78 pounds on 10/29/13 -213.6 pounds on 10/30/13 During an interview on 10/24/13 at 2:00 p.m., staff member F, RN stated they had switched out wheelchairs and that they didn't know the previous weights (of the wheelchairs). She stated Resident #4 did not have fluid retention, but he did have diarrhea. She stated the staff were using the wheelchair scale and they should weigh him in the same chair. During an interview on 10/24/13 at 8:55 a.m., staff member O, certified dietary manager, stated, "188.4 to 214 or 213 was a 25.2 pound weight loss." Staff member O stated it could be fluid. Staff member O stated they had identified a lot of weight differences with wheelchairs. Staff member O stated they were beginning to look at that. During an interview on 10/24/13 at 9:10 a.m., staff member FF, CNA, stated, "Some CNAs were using the chair scale and some were using the wheelchair scale." However, even after identifying potential problem with the scales and wheelchair weights, Resident #4's weights increased from 188.4 - 214.78 pounds over the period of one week - October 24-30. Two surveyors weighed themselves on both scales. There was a one pound difference between the two scales for both surveyors. 5. Facility weight policy Review of the facility Weight Policy and Procedure provided to the surveyors on 10/23/13 at 5:35 p.m. reflected: "Policy: Residents are weighed a minimum of one time each month. Procedure: 1. Residents will be weighed within 24 hours of admission to the facility, then weekly for 3 weeks, and at least once monthly there after. 2. Weekly weights are completed for residents with a physician order, or residents deemed to be on the weekly weight list by the weight team using their clinical judgment. 3. Specific weighing procedures are followed by the Nursing Department to ensure accuracy of weights. 4. Resident's weight information is recorded by the Nursing Department. The information will be given to the Dietary Manager weekly for those residents in need of weekly weights and monthly for all other residents to enter into the Weight Change Spreadsheet to document trends in resident weight. 5. Weight changes are calculated through the use of Weight Change Spreadsheet. 6. The weight team will meet to evaluate resident weights. 7. The Registered Dietitian will review residents who are being weighed weekly on a weekly basis. 8. The Registered Dietitian assesses each resident with a significant weight change, and makes appropriate recommendations. Recommendations will be passed on to the Nursing Staff as well as the Dietary Manager. Resident's (sic) with significant weight change will be communicated to the Nursing staff, MDS staff and Dietary Manager. 9. Nursing notifies the Registered Dietitian of changes in weighing frequency, such as physician's orders [REDACTED]. 10. The Registered Dietitian notifies the Nursing Department of changes in weighing frequency such as discontinuation of weekly weights for a resident with stable weights. 11. Re-Weights will be performed at the request of the registered dietitian or clinical staff." The facility policy did not have automatic parameters established for obtaining reweighs when significant changes in weights were noted for a specific individual. Residents in the survey sample were not reweighed when discrepancies were found. Furthermore, there was a lack of a procedure to ensure the same scale and methodology were used for weighing residents, i.e. whether or not residents were clothed, weighed in their wheelchairs, how wheelchair weights were recorded, etc. REFERENCES ?Todd P Semla, Pharm D, BCPS, FCCP, Judity Ll Beizer, PharmD, CGP, FASCP, Martin D. Higbee, PharmD, Geriatric Dosage Handbook, 12th Edition, Lexi-Comp Publishing, 2007 pgs 1389-1393.

Based on observations and record review, the facility failed to promote the prevention and healing of pressure ulcers for 2 (#s 10 and 16) of 8 residents identified by the facility as having pressure sores. The facility failed to evaluate the residents' clinical condition and pressure ulcer risk factors; define and implement interventions, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate. Findings include: 1. Resident #16 was admitted on [DATE] at 4:25 p.m.; [DIAGNOSES REDACTED]. The Hospital Discharge Summary Report indicated "NO" under the category Any Redness or Pressure Ulcer Noted on Discharge, dated [DATE]. The Admission Evaluation and Interim Care Plan did not assess skin condition under Section E and did not assess risk for predicting pressures sores under Section E. Under Section E a note dated [DATE] read, "Wouldn't get undressed." On [DATE] the CNA ADL PLAN of CARE did not address skin precautions or note any pressure areas or ulcers. According to the MDS admission assessment with an ARD of [DATE], the resident was at risk for pressure ulcer development and had a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device (M0100A) (M0150). Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was marked "No." (M0210). Skin and ulcer treatment included, a pressure reducing device for chair and a pressure reducing device for bed (M1200). No care plan was located following this MDS assessment. According to the pressure ulcer CAA, dated [DATE], the licensed nurse documented the following analysis: "Upon admission res #16 (sic) had 3 red areas on his spine as well as a stage I on his coccyx. On ,[DATE] skin review it was noticed that the Stage I was now a Stage II. Dressed with a TP ([MEDICATION NAME] Pad) cover. The Norton score was 10 as he had low H/H and [MEDICATION NAME] count. He has dx of Diabetes and hypertension that place him with risk factors. His Physical condition on admission was fair. His activity and mobility were limited. He was under weight at 98 pounds." In the MDS Section V, it was determined that this would be care planned and noted the following: "Assess location, size, stage, presence and type of drainage, presence of odors, condition of surrounding skin. Note if eschar or slough is present. Note whether granulation tissue (required for healing) is present and the wound is healing as expected." No care plan was developed for this resident other than the admit CNA/ADL care plan which did not address skin conditions. According to the [DATE] MDS Admission Assessment, Section M indicated that the pressure ulcer had now become a Stage II pressure ulcer and was triggered for Care Planning. The care planning did not occur and no documentation of this was located. The following nursing notes depicted the status of the resident's skin related to the presence of pressure ulcers: -[DATE], a box checked for pressure ulcer. On the back of the nursing note it read, "Still ref.(sic) to take clothes off no skin assessment done yet." -[DATE], a box checked for pressure ulcer. On the back of the nursing note it read, "Three Pressure areas noted on mid spine. Also Stage I on coccyx. Encouraged to stay off back in bed." -[DATE] to [DATE], boxes checked for pressure ulcer. Nothing was noted on the back of the nursing notes regarding care, assessment, monitoring, or preventive measures taken for the previously noted pressure areas or Stage I ulcer to the coccyx. -[DATE], a box checked for pressure ulcer. On the back of the nursing note it read, "new open area on coccyx, covered w/TP ([MEDICATION NAME] Pad.)". -[DATE] to [DATE], boxes checked for pressure ulcer. Nothing was noted on the back of the nursing notes regarding care, assessment, monitoring, or preventive measures taken for the previously noted pressure areas or new open area on coccyx. -[DATE], boxes checked for pressure ulcer. On the back of the nursing notes it read, "Coccyx area unchanged (illegible) previous tour. Plan to (illegible)." -[DATE], boxes checked for pressure ulcer. Nothing was noted on the back of the nursing note regarding care, assessment, monitoring, or preventive measures taken for the noted pressure ulcer. -[DATE], boxes checked for pressure ulcer and other open lesion. On the back of the nursing notes, there was nothing noted regarding the care, assessment, monitoring of, or preventive measures taken for the noted pressure ulcer or the other open lesion noted. There is no indication of the nature of the new open lesion. -[DATE], boxes checked for pressure ulcer and other open lesion. On the back of the nursing notes nothing was noted regarding the care, assessment, monitoring of, or preventive measures taken for the noted pressure ulcer and other open lesion. -[DATE], nothing was noted on the front or back of the nursing notes regarding skin condition or care. -[DATE], a box was checked for other open lesion. Nothing was noted regarding the previously noted pressure sore. On [DATE], nursing notes had boxes checked for Skin tear/cut and other open lesion. On [DATE], nursing notes had boxes checked for Skin Tear/cut and other open lesion. Despite indications for open [MEDICAL CONDITION], Skin Tear/cut, and the previously noted pressure sore, nothing was noted for these dates on the back of the nursing note regarding the care, assessment, monitoring of, or preventive measures taken. -[DATE], nursing notes had a check mark for "yes" under skin condition but does not indicate the nature of the skin condition. Also on the [DATE] nursing note was a note dated [DATE] that read, "Dr faxed for (illegible) St II decub to coccyx. see under wound/skin.) Nothing was noted under wound/skin other than "yes." -[DATE], nursing notes had nothing indicated under Skin Condition. Nothing was noted on the back of the nursing note regarding the care, assessment, monitoring of, or preventive measures taken for skin conditions. On [DATE], a fax to the physician was noted that read, "(Resident #16's name) has a ST II to his coccyx-need tx-Would like: Duoderm to St II coccyx changed (sic) q ,[DATE]d + prn until healed. Vit C 500 mg (one) p.o. BID, zinc 220 mg (one) p.o. daily & [MEDICATION NAME] (sic) (one) pkt BID daily- DC 7d (post) (sic) skin is healed/supplements." No return orders were noted from the physician. Also on [DATE] was noted a document entitled "Continued Skin Reviews." This document was noted to be an "initial" assessment. The document identified a "Stage II" decub to the "coccyx" that is "1 cm around" , drainage "0," appearance of wound bed "white," Necrotic Tissue "0," granulation "yes," appearance of surrounding skin, "degree of redness is mod (sic)," and noted that the "Dr. faxed for tx" This document also noted a change was needed on the MDS and "copy of review to MDS co-ordinator & dietician." -[DATE], nursing notes had boxes checked for Pressure ulcer and other open lesion. On the back of the nursing notes it read "Dressing intact to coccyx." -Subsequent notes dated [DATE] and [DATE], nursing notes had boxes checked for Pressure ulcer and other open lesion. Nothing was noted on the back of the nursing notes regarding care, assessment, monitoring of, or preventive measures taken for skin conditions. -[DATE], nursing notes had nothing checked for skin conditions. Nothing was noted on the back of the nursing notes regarding the care, assessment, monitoring of, or preventative measures taken for skin conditions. -[DATE], nursing notes had boxes checked for pressure ulcer and other open lesion. Nothing was noted on the back of the nursing notes regarding care of, assessment of, or preventative measures taken for skin conditions. The resident was discharged to home on this date. On [DATE], resident #16 was discharged to home. On the MDS Discharge Assessment of that date he was noted to still have a Stage II ulcer. On [DATE] at 7:20 a.m., a request was made in writing to staff member O, Interim DON, to provide any additional documentation available for resident #16 regarding skin care and assessment, including; MDS's, careplans, skin assessments, wound sheets, notes from wound nurse, and care committee notes. None were provided as of the exit date [DATE]. On [DATE] at 1:00 p.m., a request was made in writing to staff member Q, Vice President of Operations, to provide any additional documentation available for resident #16 regarding skin care and assessments, including: careplans, skin assessments, bath sheets, or any documentation to be considered in the careplanning and treatment for [REDACTED].#16. Staff member Q provided Nursing notes for [DATE] and [DATE]. 2. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A significant change MDS with an ARD of [DATE] was coded at M0150 to indicate the resident was at risk of pressure ulcers and at M0210 to indicate the resident had one stage II pressure sore The quarterly MDS with ARD of [DATE] was coded at M0150 to indicate the resident was at risk of pressure ulcers and at M0210 to indicate the resident had one stage II pressure sore. Nurses progress note dated [DATE] contained, "St II coccyx. . . ." A note dated [DATE] contained, "St II coccyx healed." Her care plan initiated [DATE] included a "Focus" of, "(Resident #10's name) is at risk for skin problems related to incontinence and Norton Plus Pressure Ulcer Score: 9. (A score of 10 or less indicates high risk.)" One of the interventions for risk for skin problems was, "Turn and reposition as needed."? Another was, Pressure relif (sic) mattress for bed and pressure relief pad for wheelchair." On [DATE], resident #10 was observed sitting in her wheelchair from 7:40 a.m., when she was already in the parlor with her eyes closed, until 10:17 a.m., when she was put to bed. She sat in her wheelchair for more than two hours and 35 minutes. ?"Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in a chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals." Pressure Ulcers in Adults: Predication and Prevention. Agency for Health Care Policy and Research, Rockville, Maryland. AHCPR Publication No. ,[DATE] [DATE]. p. 26.

Based on clinical record review, observation, and staff and resident interview, the facility staff failed to prevent pressure ulcer development for 1 (#8) of 2 sampled residents with pressure ulcers. Findings include: Resident #8 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. A Braden Scale For Predicting Pressure Sore Risk was used to evaluate the resident's risk factors for developing skin breakdown. The assessment was completed on three dates, 11/30/12, 12/5/12, and 12/12/12. On each occasion, the licensed nurse assigned a score of 18 points to the resident's risk assessment. The Braden score key was as follows, less than or equal to 9 points meant very high risk for pressure sore development, 10 - 12 points indicated high risk, 13-14 points indicated moderate risk, and 15-18 points translated to at risk for pressure sore development. An initial physical assessment of the resident was completed by an LPN on 11/30/12. The LPN noted the resident had a surgical incision on the right hip and "black areas" on the left foot on the first and second toes. In Daily Skilled Nurse's Notes from admission through 12/11/12, the licensed nurse intermittently (not daily) noted a surgical wound and bruising. The skin condition assessment was negative for pressure ulcers. The clinical record was reviewed for an interim plan of care that identified potential care issues and interventions. On 12/17/12 at 2:00 p.m., staff member E, an RN, stated while the MDS assessment process was in progress, the nursing Admission Evaluation and Interim Care Plan along with the CNA ADL Plan of Care, served as the care guides. Both documents were dated 11/30/12. Neither document included interventions to prevent skin breakdown. Based on an interview on 12/18/12 at 9:30 a.m., with staff member H, a COTA, she discovered the wounds while she assisted the resident with a shower. Staff member H stated she had assisted the resident with a shower on 12/6/12 and the wounds were not present. Staff member H informed staff member D of the wounds on the resident's heels. On 12/12/12, in an untimed entry, staff member D, an LPN, documented the presence of a stage II pressure ulcer on the resident's right heel and a stage III pressure ulcer on the left heel. Staff member D notified staff member I, a nurse practitioner, who examined the resident and dictated a note that was dated 12/12/12 at 10:26 a.m. The nurse practitioner's note included the assessment of new pressure ulcers on both of the resident's heels, the same staging as earlier noted and orders for treatment that included daily whirlpool, [MEDICATION NAME] dressings, and increased dietary protein and calories to promote healing. On 12/17/12 at 1:50 p.m. and on 12/18/12 at 11:45 a.m., the resident was interviewed. On both occasions the resident stated he did not know how the heel wounds developed. On 12/18/12 at 11:45 a.m., the wound location was identified by staff member D. Both heels were covered with dressings. On 12/18/12 at 11:00 a.m., staff member C, a NHA, stated the facility would not have developed a plan of care to prevent pressure ulcers as the resident was not at risk for skin breakdown. On 12/18/12 at 11:50 a.m., staff member C provided manufacturer's information on the pressure reducing mattress and stated all of the beds in the rehabilitation unit were equipped with the mattress. An admission MDS assessment with an ARD of 12/13/12 was completed. A Brief Interview of Mental Status was conducted and the resident demonstrated that he was cognitively intact (C0500 13). The resident's Functional Status was assessed and he required extensive assistance with bed mobility, transfers, and dressing (G0110 A, B, and G 3/2). In summary, on admission the resident presented without pressure ulcers. The resident received 18 of 23 possible points on the Braden assessment of skin at risk for pressure ulcer development. A higher Braden score indicated a higher level of functioning and, therefore, a lower risk of pressure ulcer development. However, the resident's risk factors for pressure ulcer development included his advanced age, as a result of recent repair of a [MEDICAL CONDITION], impaired/decreased mobility, decreased functional ability, and possibly impaired blood flow to the lower extremities evidenced by black areas on two toes. The "black areas" on the left foot toes were not addressed in subsequent nurse's documentation (progress notes or wound tracking records) or in the nurse practioner's assessment of the heel wounds. Within 12 days of admission, the resident developed two pressure ulcers, one stage II on the right heel and one stage III on the left heel. The interim plan of care did not include targeted interventions to address the resident's risk of skin breakdown.

Based on record review, staff and resident interviews, the facility failed to ensure the use of its resources effectively and efficiently, to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 11 (#s 1, 2, 4, 5, 7, 8, 13, and 14) of 18 sampled residents. Findings include: 1. As a result of the complaint investigation survey, the facility is cited for substandard quality of care at F323 for not providing adequate supervision to minimize the fall risk for four residents as evidenced by the following: * Resident #5 fell on [DATE] at 9:30 p.m. and sustained a 2.5 cm full thickness laceration on the back of head requiring four stated to close the laceration. On 7/13/12 at 2:45 p.m., the resident fell again. * Resident #1 fell on [DATE] at 5:00 a.m. and on 7/14/12 at 4:30 a.m. On 7/14/12, after the fall, the resident sustained [REDACTED]. left side of her forehead, and the resident's left pupil was sluggishly reactive to light. As a result, the resident required Steri Strips and a dressing to closed the cut on the forehead. * Resident #2 fell on [DATE] at 5:55 a.m. and on 7/22/12 at 7:15 a.m. On 7/22/12 resulted in a 6 cm abrasion on the resident's lower back. * Resident #4 fell on [DATE] at 4:50 p.m. The resident stated she "was in pain all over". The resident was sent to the emergency room for evaluation. The resident returned to the facility with documentation of "probable [MEDICAL CONDITION]-comfort care". 2. As a result of the complaint investigation survey, the facility is cited for substandard quality of care at F353 for insufficient staffing in order to properly care for the residents residing in the facility as evidenced by the following: * Supervision to prevent accidents for 4 residents (#s 1, 2, 4, and 5) who fell . * Staff not answering call lights. - On 8/2/12 at 9:30 a.m., a staff nurse did not answer two call lights for rooms [ROOM NUMBERS]. - On 8/1/12 from 7:50 a.m. until 8:22 a.m., two CNAs and another staff member walk by a room and not answer the call light. - On 8/2/12 at from 8:15 a.m. until 8:35 a.m., a call light was answered after 20 minutes. - On 8/1/12 at 10:30 a.m., a CNA stated she was assisted by another staff person in the rehab unit 8:00 a.m. After 8:00 a.m., the CNA stated she was the only CNA working on the rehab unit. - On 8/1/12 at 7:00 a.m., resident #7 was observed in the middle of the hallway trying to not fall as he slid out of his wheelchair, his elbows on the armrests, his buttocks beyond the seat edge and his feet extended out in front, and calling for help. A nurse was observed across the day room area, less than 30 feet away, not paying attention to the resident's request for help. No other staff were in the vicinity. * Staff not providing baths for resident #s 4, 7, 8, and 13 for 10 to 15 days during the month of July 2012. 3. One resident (#14) was assessed at risk for falls as a result of a significant change in condition assessment on 5/5/3/12. The plan of care dated April 2012 included falls as a potential problem. The resident sustained [REDACTED]. However, there were no revisions to the Plan of care for fall prevention (See F280).

8. The surveyor observed the call light for resident #15 was sounding on 8/1/12 from 7:50 a.m. until 8:22 a.m. During the observation time, on the 200 hall, the surveyor observed 2 unidentified CNAs and another unidentified staff member walk by the room and not answer the call light. During an interview with resident #15 on 8/1/12 at 10:15 a.m., she stated sometimes it takes more than 15 minutes for the staff to answer the call light. 9. The surveyor observed the call light for resident #16 was sounding on 8/2/12 from 8:15 a.m. until 8:35 a.m. The call light was answered by a staff member at 8:35 a.m., twenty minutes after the resident initially rang for assistance. During an interview with staff member K on 8/1/12 at 10:30 a.m., she stated there was another CNA to assist her on the rehab unit until 8:00 a.m. Staff member K stated that after 8:00 a.m. she was the only CNA working on the rehab unit with a census of 48.. 10. On 8/1/12 at 7:00 a.m., the surveyor was walking into the B hall. Resident #7 was in the middle of the hall. He had slid out of his wheelchair, his elbows on the armrests, his buttocks beyond the seat edge and his feet extended out in front as he tried to not fall onto the floor. He was calling out for help. A nurse was noted across the day room area, less than 30 feet away. The nurse did not pay attention to the resident's requests for help until the surveyors asked the nurse to assist the resident. At that time, she came over and assisted him back into his chair. No other staff was in the vicinity. Bathing: 11. Residents of the LTC, #s 4, 7, 8, and 13, did not receive baths for 10 to 15 days during the month of July 2012. The average daily resident census was 48 for July 2012. The average CNA staffing for day shift for July 2012 was 3. The average CNA staffing for evening shift for July 2012 was 3. The average CNA staffing for night shift for July 2012 was 2. During an interview on 7/31/12 at 11:00 a.m. with staff member B, she stated the facility's staffing ratio was 1 CNA per 15 residents since July 4, 2012. 12. On 7/31/12 at 8:40 a.m., staff member A, the administrator, was interviewed. She stated that in June, the facility laid off staff as census was low. Then the facility accepted 21 new residents. The facility hired 3 CNAs. Since the new admits, the facility was using staff from their sister facility outside town and contract labor. The administrator had ads in the local newspaper, offering a hire on bonus along with planning an upcoming CNA training class. She stated the facility was having a difficult time with staffing. On 8/2/12 at 12:50 p.m., staff member A, the administrator,verified that stated employees had told her more staff was needed. 6. Resident #4 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The nurses' progress note entry, dated 7/17/12 at 16:50 (4:50 p.m.), revealed the resident had an unwitnessed fall and was found laying on her right side. Range of motion was checked and the resident indicated she "was in pain all over." The right leg was most painful and unable to extend. The physician order [REDACTED]. A falls investigation worksheet was completed on 7/17/12. The time of the fall was noted to be 16:50 (4:00) p.m. The worksheet specified the resident was transferring self to bed-"assumed" and the fall was unwitnessed. Under recommendations/interventions, staff wrote the resident was sent to the emergency room for evaluation after the resident was assessed and noted the resident having right leg pain and a decrease in range of motion of the leg. Documentation on the discharged paperwork from the hospital with a date of 7/18/12, revealed the resident had returned to the facility with "probable hip fx (fracture)-comfort care." The facility had a census of 49 residents on 7/17/12. Staffing for the afternoon shift was 3 CNAs for 49 residents. Call lights: 7. On 8/1/12 at 9:30 a.m., the surveyor observed the call light turn on and sound from room [ROOM NUMBER] in the rehabilitation unit. Within a couple minutes, the call light was observed to turn on. The surveyor observed the nurse at the unit nurses' station. She did not respond to the call lights. On 8/2/12 at 8:15 a.m., resident #7 was interviewed. He stated that staff would take 15 minutes to an hour to answer call lights. He said night staff took longer to answer call lights. He stated at times the length of time he waited for staff was not acceptable. On 8/2/12 at 9:30 a.m., resident #11 was interviewed. She said she would have to wait 30 minutes at night on some occasions for a staff member to answer her call light. She said she understood the wait at those times was due to "2 girls on her floor." Based on observations, clinical record review, and staff and resident interviews, the facility failed to provide sufficient nursing staff to attend to 11 of (#s 1, 2, 4, 5, 7, 8, 11, 13, 14, 15, and 16 ) of 18 sampled residents' safety and care needs. Findings included: Supervision to prevent accidents: 1. Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident fell on [DATE] at 9:30 p.m. and 7/13/12 at 2:45 p.m. The daily staffing schedule was reviewed for 7/9/12 and 7/13/12. On 7/9/12, the resident fell at 9:30 p.m. The LTC census was absent from the staffing document, but the census on 7/8/12 was 49 residents and the resident census on 7/10/12 was 48. On 7/9/12, two CNAs were scheduled to work on the afternoon shift (2:00 p.m. - 10:00 p.m.), for a census of approximately 48 residents (outside the rehabilitation unit). A third CNA was assigned to provide baths and one nurse was on duty. On 7/13/12, the resident fell at 2:45 p.m. The daily staffing document revealed the LTC census was 48 residents. Two CNAs were scheduled to work on the afternoon shift (2:00 p.m. - 10:00 p.m.). A third CNA was assigned to provide baths and restorative services and two nurses were on duty. (see F353) 2. Resident #1 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Based on the fall log, the resident fell in her room on 7/13/12 at 5:00 a.m. and on 7/14/12 at 4:30 a.m. The daily staffing schedule was reviewed for 7/13/12 and 7/14/12. On 7/13/12, the resident fell at 5:00 a.m. The LTC census was 48. On 7/13/12, two CNAs were scheduled to work on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was assigned for resident care. On 7/14/12, the resident fell at 4:30 a.m. The daily staffing document revealed the LTC census was 48 residents. Two CNAs were scheduled to on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was assigned for resident care. (see F353) 3. Resident #2 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Based on clinical record review, the resident sustained [REDACTED]. The daily staffing schedule was reviewed for 7/17/12 and 7/22/12. On 7/17/12, the resident fell at 5:55 a.m. The LTC census was 49. On 7/17/12, two CNAs were scheduled to work on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was assigned for resident care. Based on Nurse Progress Notes dated 7/17/12 at 7:15 a.m., the resident stated he was attempting to empty the urine container in the bathroom, the resident stated his call light was on, but he didn't want to wait any longer for staff to assist him. On 7/22/12, the resident fell at 7:15 a.m. The LTC census was absent from the staffing document, but the census on 7/23/12 was 49 residents. Two CNAs were assigned to work the units and 3 CNAs were allocated for baths and restorative services. Two nurses were assigned for resident care. (see F353) 4. Resident #14 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. Five of the eight falls (7/8/12, 7/11/12, 7/16/12, 7/17/12 and 8/2/12), occurred on the night shift (10:00 p.m. to 6:00 a.m.). On two of the night shifts (7/8/12 and 7/17/12), there were two CNAs assigned to 47 residents in the LTC and one licensed nurse was on duty. (see F323) 5. On 8/1/12, the CNAs (H, I, and J) assigned to day shift for the LTC were interviewed. Two of the CNAs were assigned 16 residents and one CNA was assigned 14 resident. One of the CNAs stated the facility did not have enough help. Two of the CNAs stated the restorative CNA was "pretty good about helping" when she could by assisting the residents to the bathroom and answering call lights.

Based on clinical record review, staff and resident interviews, the facility failed to provide adequate supervision to minimize fall risk for 4 (#s 1, 2, 4, and 5) of 14 sampled residents. Findings included: 1. Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. An Admission Evaluation and Interim Care plan was completed on 7/5/12. The licensed nurse screened the resident for fall risk. The resident's fall risk score was 12. A score of 10 or greater was considered a fall risk. The nursing interim plan of care did not include potential environmental hazards, an analysis of hazards and risks, or interventions to reduce the risk of an accident. On 8/1/12 at 7:50 a.m., the resident was interviewed. The resident's speech was clear. The resident was unable to contribute understandable information regarding her needs. An admission MDS assessment was completed with an ARD of 7/10/12. The Fall CAA dated 7/21/12 was reviewed. The CAA Worksheet included trigger areas from the MDS assessment but lacked analysis of the resident's risk factors and interventions to mitigate the resident's risk for falls. The resident's fall risk factors included concerns with balance during positioning transitions (G0300D 2, G0300E 2), antipsychotic and antidepressant medication use, incontinence, cognitive impairment and osteoporosis. On 8/2/12, at approximately 9:30 a.m., staff member G, the MDS coordinator, stated a plan of care was not developed after the MDS assessment process. The facility's Fall Prevention Investigation and Preventative Measures policy was reviewed. The policy document included the following, "A copy of the (fall) report will be given to the Director of Nursing/Staff Development coordinator to investigate and make commendations (sic) as to how future falls could be prevented." The facility staff changed shifts at 6:00 a.m., 2:00 p.m. and 10:00 p.m. The resident fell on [DATE] at 9:30 p.m. and 7/13/12 at 2:45 p.m. On 7/9/12, the resident was transferred to an acute care facility for evaluation of her injury in the ER. The resident sustained [REDACTED]. The laceration was closed with four staples. The Fall Investigation Worksheets dated 7/9/12 and 7/13/12 were reviewed. The worksheet dated 7/9/12 did not include an analysis of the collected information or recommendations/interventions to decrease the risk of additional or future falls. The daily staffing schedule was reviewed for 7/9/12 and 7/13/12. * On 7/9/12, the resident fell at 9:30 p.m. The LTC census was absent from the staffing document but the census on 7/8/12 was 49 residents and the resident census on 7/10/12 was 48 (outside the rehabilitation unit). On 7/9/12, two CNAs were scheduled to work on the afternoon shift (2:00 p.m. - 10:00 p.m.) to provide resident care such as toileting, transferring, turning and re-positioning, assistance with the evening meal, answering call lights and preparing for bed. Additionally, a third CNA was assigned to provide baths and one nurse was on duty. * On 7/13/12, the resident fell at 2:45 p.m. The daily staffing document revealed the LTC census was 48 residents. Two CNAs were scheduled to work on the afternoon shift (2:00 p.m. - 10:00 p.m.) A third CNA was assigned to provide baths and restorative services and two nurses were on duty. (See F353.) 2. Resident #1 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. An Admission Evaluation and Interim Care plan was completed on 7/5/12. The licensed nurse screened the resident for fall risk. The resident's fall risk score was 16. A score of 10 or greater was considered a fall risk. The nursing interim plan of care did not include potential environmental hazards, an analysis of hazards and risks, or interventions to reduce the risk of an accident. A CNA ADL Plan of Care dated 7/5/12 was reviewed. The plan of care included required assistance for activities of daily living such as bed mobility, transfers, and toileting. Safety interventions included bed alarm, chair alarm, and landing pad. 'Fall Risk' was not highlighted on the document. The facility staff changed shifts at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Based on the fall log, the resident fell on [DATE], in her room at 5:00 a.m. and fell on [DATE] at 4:30 a.m., in her room. The fall on 7/14/12 at 4:30 a.m. necessitated an emergency room visit. The resident sustained [REDACTED]. left side of her forehead, and the LPN documented the resident's left pupil was sluggishly reactive to light. The Imaging Data from the emergency room Note indicated the shoulder was not fractured and there was not an intracranial bleed. The resident's forehead cut was closed with Steri Strips and a dressing was applied. The Fall Investigation Worksheets dated 7/13/12 and 7/14/12 were reviewed. The worksheets did not include an analysis of the collected information or recommendations/interventions to minimize fall risk. The daily staffing schedule was reviewed for 7/13/12 and 7/14/12. On 7/13/12, the resident fell at 5:00 a.m. The LTC census was 48. On 7/13/12, two CNAs were scheduled to work on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was on duty. On 7/14/12, the resident fell at 4:30 a.m. The daily staffing document revealed the LTC census was 48 residents. Two CNAs were scheduled to on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was on duty. (see F353) 3. Resident #2 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. An Admission Evaluation and Interim Care plan was completed on 7/12/12. The licensed nurse screened the resident for fall risk. The resident's fall risk score was 15. A score of 10 or greater was considered a fall risk. The nursing interim plan of care did not include potential environmental hazards, an analysis of hazards and risks, or interventions to reduce the risk of an accident. A CNA ADL Plan of Care dated 7/12/12 was reviewed. The plan of care included required assistance for activities of daily living such as bed mobility, transfers, and assistance with toilet use. The document did not include the resident's fall risk. The facility staff changed shifts at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Based on clinical record review, the resident sustained [REDACTED]. Based on Nurse Progress Notes, the fall on 7/22/12 resulted in a 6 cm (centimeter) abrasion on the resident's lower back. The daily staffing schedule was reviewed for 7/17/12 and 7/22/12. On 7/17/12, the resident fell at 5:55 a.m. The LTC census was 49. On 7/17/12, two CNAs were scheduled to work on the night shift (10:00 p.m. to 6:00 a.m.). One nurse was assigned for resident care. Based on Nurse Progress Notes dated 7/17/12 at 7:15 a.m., the resident stated he was attempting to empty the urine container in the bathroom, the resident stated his call light was on, but he didn't want to wait any longer for staff to assist him. On 7/22/12, the resident fell at 7:15 a.m. The LTC census was absent from the staffing document, but the census on 7/23/12 was 49 residents. Two CNAs were assigned to work the units and three CNAs were allocated for baths and restorative services. Two nurses were on duty. (see F353) The Fall Investigation Worksheets dated 7/17/12 and 7/22/12 were reviewed. The worksheets did not include an analysis of the collected information or recommendations/interventions to minimize fall risk. 4. Resident #4 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The resident's medical records were reviewed. The Admission Evaluation and Interim Care Plan form was completed. The screen for fall risk identified resident #4 as a fall risk. The CNA ADL Plan of Care did not identify the resident as a fall risk. On 7/31/12 at 1:45 p.m., staff member G stated the CNA plan of care was developed off of the Admission Evaluation and Interim Care plan. The nurses' progress note entry, dated 7/17/12 at 16:50 (4:50 p.m.), revealed the resident had an unwitnessed fall and was found laying on her right side. Range of motion was checked and the resident indicated she "was in pain all over." The right leg was most painful and unable to extend. The physician order [REDACTED]. A falls investigation worksheet was completed on 7/17/12. The time of the fall was noted as 16:50 (4:50) p.m. The worksheet specified the resident was transferring self to bed-"assumed" and the fall was unwitnessed. No vitals signs were documented. On the worksheet, under the recommendations/interventions, staff wrote that the resident was sent to the emergency room for evaluation after the resident was assessed and noted the resident having right leg pain and a decrease in range of motion of the leg.