Every finding on record at Crestview Nursing & Residential Living

The facility identified a census of 23 residents. The sample included 12 residents with seven residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 4 remained free from a preventable accident during a sit-to-stand mechanical lift transfer. This deficient practice resulted in a fractured finger and placed R4 at risk for further complications. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, low back pain, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),dementia (a progressive mental disorder characterized by failing memory and confusion), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R4 had limited function in bilateral extremities. The MDS documented R4 was dependent on staff assistance for toileting, bathing, lower extremity dressing and transfers. The MDS documented R4 had no falls since the MDS dated [DATE]. R4's Falls Care Area Assessment (CAA) dated 08/15/24 documented he had a fall that resulted in a fractured finger. R4's fractured finger was noted two days after his fall. R4's Care Plan dated 07/24/22 documented staff would rearrange his current room to be exactly like his previous room to avoid falls and confusion. The plan of care dated 05/22/23 documented staff were educated on bed positioning. R4's plan of care dated 07/24/24 documented staff were educated on sling and lift placement with the sling. R4's EMR under the Clinical Documentation tab recorded a Note dated 07/24/24 at 06:30 AM that documented R4 had to be assisted to the floor during a transfer with a sit-to-stand mechanical lift. The sling had become unhooked from the sit-to-stand lift on the right side during the transfer. R4 complained of pain to his ring finger on his right hand. R4 was able to complete active range of motion to the finger on his right hand without difficulty. A Note dated 07/24/24 at 09:30 AM documented R4's ring finger on his right hand started to swell and bruise. A Note dated 07/24/24 at 05:49 PM documented R4 continued to complain of pain in his fourth digit on his right hand. That finger had been caught in the sling during the fall from the sit-to stand lift that morning. R4's finger was red and swollen. R4's finger was bruised on the inner part and was bruised and swollen greater than the other finger on his right hand. The licensed nurse decided R4 would need an X-ray to rule out a possible fracture of his finger on the right hand. A Note dated 7/24/24 at 11:44 PM documented R4 continued to complain of pain in his fourth digit on right hand. R4's finger remained bruised. A Note dated 07/25/24 at 10:13 AM documented R4's ring finger on his right hand remained swollen, bruised, and he continued to complain of pain. A Note dated 07/25/24 at 03:50 PM documented R4 returned from an appointment with the physician and was waiting for the results of an X-ray of R4's right hand. A Note dated 07/25/24 at 06:06 PM documented the physician recommended to tape R4's ring finger on his right hand to the next finger to prevent bending his finger till the x-ray results came back. R4 continued to complain of pain in his finger on his right hand. A Note dated 07/26/24 at 10:59 AM documented the physician's office called with x-ray results that revealed a fracture to the fourth digit of his right hand. The physician wanted R4 to return to the clinic and be fitted for the correct splint. An undated and untitled form provided by the facility documented the sling had come loose during a transfer with the sit-to-stand lift for R4 and that resulted in a fall. The form documented the root cause was one of the hooks of the sling gave way and that caused R4 to slide out of sling. The analysis noted that it was apparent that staff did not fully loop the hooks on the sling to the right-side causing the resident to fall. On 10/24/24 at 08:44 AM R4 sat in his wheelchair on the back patio smoking. On 10/24/24 at 09:13 AM, Certified Nurse Aide (CNA) M stated she had been trained on how to safely use the mechanical lifts by another CNA. CNA M stated a resident's weight determined the size of sling and placements of the sling loops on the mechanical lifts was determined by the comfort of the resident. CNA M stated the only way she could think the sling would come loose from the lift was if it was not placed on the lift correctly. On 10/24/24 at 09:35 AM, Licensed Nurse (LN) G stated all mechanical lift transfers are always completed with two staff members. LN G stated the facility provided in-services on lifts. LN G stated the staff train each other on the transfers for each resident. LN G stated the therapy department would determine the placement of sling loops on the mechanical lift. On 10/24/24 at 10:00 AM, Consultant Staff GG stated she would train the staff on safe transfers when a resident started to use a mechanical lift. Consultant Staff GG stated she believed the sling loop had not been placed on the sit-to-stand lift correctly and that is why it had slipped loose during R4's transfer on 07/24/24. On 10/24/24 at 10:44 AM, Administrative Nurse D stated the nursing staff had received yearly skills fair to go over the mechanical lift transfers. Administrative Nurse D stated the current nursing staff did train the new nursing staff members on the resident's transfers during their training. Administrative Nurse D stated the therapy department did provide education and training on safe transfers with the mechanical lifts. The facility's Safe lift, Transfer, and Repositioning Policy last revised 07/01/24 documented it was the policy of this facility to provide safe, appropriate and timely care to each elder in accordance with the eider's comprehensive care plan. All elders would be assessed by the Interdisciplinary Team (IDT) with regard to the need for assistance with transfer activities, mobility, or repositioning in accordance with the Resident Assessment Instrument (RAI) procedures and requirements. Subject to IDT determinations regarding rehabilitation, restoration, or maintenance of functional abilities, or medical contraindications or emergencies or other exceptional circumstances. Elders identified as totally dependent or extensive assistance would be transferred by means of mechanical lift equipment and/or other assistive devices rather than by manual lift. All mechanical lifting devices always required two-person assistance without exception. The nursing supervisors would ensure that mechanical lifting devices and other equipment/aids are accessible to staff. Nursing and environmental services supervisors would ensure that mechanical lifting devices and other equipment/aids are maintained regularly and kept in proper working order. All mechanical lifting devices would be checked on a weekly basis with findings documented on the maintenance log. Nursing supervisors and staff would ensure that mechanical lifting devices and other equipment/aids are stored conveniently and safely. The facility failed to ensure R4 remained free from a preventable accident during a sit-to-stand mechanical lift transfer. This deficient practice resulted in a fractured finger and placed R4 at risk for further complications. The facility completed the following corrections by 07/24/24: The facility updated R4's Care Plan on 07/24/24. Physical Therapy (PT) provided staff education for Safety Steps when using Patient lifts to CNA staff on 07/24/24. Because the facility implemented and completed the corrections prior to the onsite survey, this deficient practice was cited as past noncompliance at a G scope and severity.

The facility had a census of 23 residents. The sample included 12 residents, with one reviewed for post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash, or physical torture). Based on observation, record review, and interview the facility failed to revise the care plan for Resident (R) 21, to provide direction to staff to ensure R21 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - R21's Electronic Medical Record (EMR) documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory and confusion), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had moderately impaired cognition, felt down and depressed for two to six days, exhibited hallucination (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and had other behaviors for four to six days. R21 was independent with eating, mobility, transfers, and ambulation. R21 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant (a class of medications used to treat mood disorders) medications on a routine basis. R21's Care Plan. dated 08/14/24, directed staff to monitor for behavior or changes in depression or thoughts of suicide using the behavior flow sheet. The care plan documented R21's mood and behaviors, which were monitored on the quarterly and comprehensive MDS and by staff. R21's Care Plan directed staff to monitor for reminders of past trauma events that resulted in the resident re-experiencing the initial trauma and reporting to the charge nurse though the care plan lacked documentation of R21's actual triggers and nonpharmocological strategies to manage related behavior. The Veteran's Administration Progress Notes, dated 04/25/23, before admission to the facility, documented R21 had flashbacks when he was in the Air Force with triggers of loud noises, crowds, and delusions of jealousy with his wife. The PTSD-Trauma Assessment, undated, documented R21 experienced trauma from a car accident, and when he was flying in the Air Force, he fired a gun, and it was a traumatic experience. The assessment noted that R21 stated he had flashbacks of the car wreck. The Physician's Order, dated 06/13/24, directed staff to administer sertraline (an antidepressant), 100 milligrams (mg), by mouth, daily for depression. The Physician's Order, dated 06/13/24, directed staff to administer aripiprazole (an antipsychotic medication), 7.5 mg, by mouth, at bedtime for PTSD. The Nurse's Note, dated 06/15/24 at 09:58 PM, documented R21 attempted to call his wife and became upset when he was unable to reach her and made repetitive statements about the situation tonight. R21 talked about having a ball of anger and becoming enraged. The Nurse's Note, doted 06/27/24, at 01:00 PM, documented R21 was upset off and on throughout the day with paranoia (a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking). R21 had delusional thoughts and was not easily redirectable. The Nurse's Note, dated 07/15/24, at 01:49 PM, documented R21 was exiting various times that day, changing clothes multiple times, putting on his housecoat, and wanting to leave. The Nurse's Note, dated 09/27/24 at 03:27 PM, documented R21 had increased wandering and pacing, looked for his wife often, was exit seeking, and set off the door alarms. R21 was redirected with conversation, food, and staff one-to-one. On 10/23/24 at 02:54 PM, observation revealed R21 ambulated down the hall and into the dining room. On 10/24/24 at 07:47 AM, Licensed Nurse (LN) G stated she thought R21 had PTSD but was unsure and did not know what his triggers might be. LN G said she thought maybe things on the television would be his triggers. LN G stated R21 did not receive mental health services as he was hard of hearing and had dementia. LN G stated R21 came from the Veteran's Administration and provided R21's preadmission paperwork to review for documentation of any triggers R21 might have. On 10/24/24 at 09:30 AM, Certified Nurse Aide (CNA) M stated R21 had behaviors and often looked for his wife. CNA M did not know if R21 had PTSD but stated the staff recently had training regarding PTSD. On 10/23/24 at 10:13 AM, Social Service X stated she spent a lot of time with R21 as she took him to a weekly appointment in town. Social Service X stated she knew R21 had PTSD but did not know what his triggers were and had talked with the family to try to find out what they were. On 10/23/24 at 11:15 AM, Administrative Nurse D stated R21 had PTSD and verified there were no triggers on the care plan. Upon request, a policy for care plan revision was not provided by the facility. The facility failed to revise R21's care plan with individualized person-centered interventions to provide direction to staff to ensure R21 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 23 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Resident (R) 6, R8, and R21. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R6's clinical record revealed the PCV13 was administered on 01/29/18 and the Pneumococcal Polysaccharide Vaccine (PPSV23) was administered on 02/19/19. R6's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. A review of R8's clinical record revealed that the PCV13 was administered on 08/28/15 and the PPSV23 was administered on 08/29/16. R8's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. A review of R21's clinical record revealed the PCV13 was administered on 02/29/15 and the PPSV23 was administered on 01/19/17. R37's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or physician-documented contraindication. Upon request for R6, R8, and R21's records of declination or administration of the PCV20 vaccine, the facility was unable to provide consent or declination for these residents. The facility was unable to provide a physician-documented contraindication for all three residents. On 10/23/24 at 01:20 PM, Administrative Nurse D stated her understanding was the PCV20 was not required if the resident had been administered PCV13 and PPSV23. Administrative Nurse D stated the local physician had not ordered or recommended the PCV20 in the past. The facility's undated Influenza, COVID, and Pneumonia Immunization Policy documented that the Advisory Committee on Immunization Practices recommends vaccinating persons who are at high risk for serious complications from influenza, COVID-19, and/or pneumonia, including those 5O years of age and older, who are residents of nursing homes. Recognizing the major impact and mortality of influenza, COVID-19, and/or pneumonia disease on residents of nursing homes; and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization , and death, this facility had adopted the following policy statements. The Centers for Disease Control and Prevention (CDC) recommended two pneumococcal vaccines for all adults [AGE] years or older. The facility would administer a dose of PCV13 first, followed by a dose of PPSV23 at least one year later. If any doses of PPSV23 have been administered, a dose of PCV13 would be administered at least one year after the most recent PPSV23 dose. The facility failed to offer and administer PCV20 or obtain informed declinations for R6, R8, and R21 who were eligible to receive the vaccination. This placed R6, R8, and R21 at increased risk for acquiring, transmitting, or experiencing complications from the pneumococcal disease.

The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for 23 residents who received meals from the facility kitchen. Findings included: -On 11/02/21 at 08:02 AM, observation revealed three half gallons of vanilla Greek yogurt with expiration date of 10/28/21 in the silver refrigerator in the main part of the kitchen. The dry storage room had 40 - 4 ounce boxes of juices with an expiration date of 07/20/21, a white grocery sack with ten (sandwich size) bags of popcorn without dates or labels, 20 - 4 ounce containers of vanilla pudding with use by date 04/07/21, four packages of hot dog buns without a received date or expiration dates. The white refrigerator in the main kitchen observed to have four half gallons of heavy whipping cream stored on the bottom shelf next to a 10-pound package of thawing ground beef. On 11/03/21 at 12:21 PM, observation revealed the facility's ice machine had blackish substance across the length of the plastic ice guide, and the freezer next to it had 2-inch frost build up on each four shelves. On 11/02/21 at 08:02 AM, Dietary Staff (DS) BB, verified the out of date foods or unlabeled foods should have been discarded in the dry storage room and refrigerators and the heavy whipping cream should not be stored on bottom shelf of refrigerator with meat products. On 11/03/21 at 12:21 PM, DS BB verified the ice machine plastic guide had blackish substance on the ice guide and the freezer next to it had two inches of ice build-up on the four shelves. The facility's undated Monitoring of Refrigerators and Freezers policy, documented foods in every refrigerator will be checked on a daily basis by the dietary staff and food will be discarded when the food has been in the refrigerator for 48 hours or when the food is past the printed expiration date, or whichever comes first. The facility's undated Kitchen Cleaning Schedule directed staff to monthly defrost and disinfect freezers. The facility's undated Food Storage policy, documented all stock must be rotated with each new order received, food should be dated as to when it was placed on the shelves. The policy further documented raw animal food will be separated from cooked foods to prevent cross contamination. All foods will be checked to assure foods will be consumed by their safe use by dates. Upon request the facility failed to provide an ice machine maintenance policy. The facility failed to store, prepare, and serve food under sanitary conditions for 21 residents who received their meals prepared in the facility kitchen, placing the residents at risk for foodborne illnesses.

- On 11/02/21 at 12:05 PM, observation revealed Licensed Nurse (LN) G put on clean gloves, gathered the glucometer and container of blood sugar test strips, entered Resident (R) 123's room and obtained a blood sugar reading. Further observation revealed LN G went back to the medication cart and placed the multi-use glucometer back in the plastic basket in the cart without disinfecting the glucometer before or after use. On 11/02/21 at 12:15 PM, LN G stated she had not used any wipes to clean the meter before she used it and verified she had not disinfected the glucometer between residents. On 11/04/21 at 01:30 PM, Administrative Nurse E stated the facility glucometer should be cleaned with disinfectant wipes before and after each resident use. The facility's undated Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment policy, documented cleaning of reusable equipment cleaning and maintenance processes will follow manufacture's recommendations for all equipment. The ForaCare blood glucose monitoring system operations and procedure manual documented the meter must be cleaned prior to disinfecting, use one disinfecting wipe to clean (the process of removing dirt) exposed surfaces of the meter thoroughly and remove any visible dirt or blood or any other bodily fluid with the Micro Kill wipe. The manual documented to use a second wipe to disinfect (the process of killing germs) the meter with Micro Kill [MEDICATION(S)] wipes. The facility failed to properly disinfect the glucometer before and after use, placing R123 at risk for communicable diseases and infections. The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain infection control principles during resident fresh water and ice pass, and glucometer (instrument used to calculate blood glucose) use. Findings included: - On 11/04/21 at 09:17 AM to 09:20 AM, observation revealed Certified Nurse Aide (CNA) M and CNA N delivered fresh ice water to Resident (R) 8 and R15. Both CNA M and CNA N held the resident's used water mugs over the ice when filling and CNA N tapped the inside top of the mug with the ice scoop when putting the ice in the mug. On 11/04/21 at 01:55 PM, Administrative Nurse D verified staff should not hold the used water mugs over the ice bin and should not touch the scoop to the inside of the mugs. The facility's undated Passing Fresh Ice Water policy directed staff to not touch the pitcher with the ice scoop. The facility failed to maintain infection control principles during resident fresh water and ice pass, placing residents at risk for cross contaminated water and ice.

The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 9's insulin (hormone which allows cells throughout the body to uptake glucose) pen with date opened. Findings included: - On 11/02/21 at 07:50 AM, observation in the medication room revealed R9's [MEDICATION(S)] (a long acting insulin that can work for around 24 hours or longer) flex pen lacked a date opened. On 11/02/21 at 07:50 AM, Licensed Nurse (LN) G, verified R9 received insulin daily and the insulin flex pen lacked a date opened and/or a name. On 11/04/21 at 10:30 AM, Administrative Nurse E stated the nurses were to date the insulin pens/vials when opened, label with the resident's name, and discard expired medications. Upon request the facility failed to provide an Insulin storage policy. The facility failed to label and date when opened R9's [MEDICATION(S)] flex insulin pen, placing the resident at risk for receiving ineffective medication.

The facility identified a census of 31 residents, which resided on two units. Based on observation, interview, and interview, the facility failed to effectively clean and sanitize resident rooms and equipment. Findings included: - On 10/11/17 at 6:05 A.M., licensed nursing staff H entered resident #22's room to obtain his/her glucose (blood sugar). He/she placed the container of test strips, glucometer (blood sugar machine), and lancet in the resident's bed prior to use. On 10/11/17 at 6:12 A.M., licensed nursing staff H placed the container of test strips, glucometer, and lancet on resident #15's bedside table without a protective barrier. He/she obtained resident #15's glucose and placed the used equipment on the bedside table. On 10/11/17 at 6:08 A.M., licensed nursing staff H stated he/she usually did not put resident equipment directly on beds or tables and should have placed the glucometer and testing supplies in a disposable cup. On 10/12/17 at 4:30 P.M., administrative nursing staff E stated he/she expected licensed nursing staff to place a clean barrier for the glucometer and testing supplies prior to obtaining a resident's glucose. The facility's undated Infection Control policy documented standard precautions would be used in the care of all residents. The facility failed to adhere to standard infection control precautions regarding reusable equipment to help prevent the development and transmission of disease and infection. - On 10/11/17 at 7:38 A.M., licensed nursing staff H entered resident #22's room to complete a dressing change. Licensed nursing staff H removed gauze from a plastic container in the resident's room and placed the unwrapped gauze on the edge of the resident's bed pad while he/she lay in the bed. Licensed nursing staff H then cleansed the resident's wound with this same gauze and wound cleanser. On 10/11/17 at 7:45 A.M., licensed nursing staff H stated he/she should not have placed the clean dressings directly on the resident's bed pad and he/she should have used a clean barrier to place the supplies on. On 10/12/17 at 4:30 P.M., administrative nursing staff E stated he/she expected licensed nursing staff to place a clean barrier for the dressings and supplies prior to completing a resident's dressing change. The facility's undated Wound Cleaning policy directed staff to establish a sterile field or disposable tray as a work field for dressing changes. The facility failed to adhere to standard infection control precautions regarding dressing changes to help prevent the development and transmission of disease and infection. - On 10/11/17 at 8:06 A.M., housekeeping staff I cleaned a resident's room. Staff I donned gloves, cleansed the inside of the toilet with a brush, sprayed the toilet with(NAME)Triple T Disinfectant at 8:07 A.M., and immediately wiped the surface. Staff I placed the toilet brush and soiled cloth in the housekeeping cart and obtained a clean cloth without changing his/her gloves. At 8:09 A.M., staff I sprayed the resident's sink with(NAME)Triple T Disinfectant and immediately wiped the surface. Staff I failed to clean all surfaces in the resident's room. Review of the manufacturer's label for(NAME)Triple T Disinfectant indicated it should remain wet on surfaces for at least 10 minutes to disinfect. On 10/11/17 at 8:19 A.M., housekeeping staff I stated each housekeeper had his/her own system to clean the residents' rooms, and he/she was not familiar with the length of time the disinfectant should remain wet on surfaces. On 10/11/17 8:28 A.M., housekeeping supervisor J stated he/she was not familiar with the length of time the disinfectant should remain wet on surfaces to fully disinfect. Staff J reviewed the manufacturer's label and confirmed it should remain wet on surfaces for at least 10 minutes to disinfect. On 10/12/17 11:35 A.M., administrative staffs A and B stated each housekeeping staff had received a training manual for housekeeping procedures and duties and had been in-serviced on proper chemical use. Administrative staff A confirmed that housekeeping staff I failed to adhere to the 10 minute disinfectant time. On 10/12/17 11:50 A.M., administrative nursing staff D stated he/she expected staff to adhere to the manufacturer's recommendations for use to disinfect, and he/she expected housekeeping staff to clean the high-use resident items, such as door knobs, call lights, and bed rails. The facility's undated Housekeeping Procedures and Duties policy documented the label instructions for(NAME)Triple Disinfectant should remain on a surface for a minimum of 10 minutes. The policy directed staff to clean surfaces, including the doorknob, walls, light switches, side tables, headboard and footboard, side rails of the bed, windowsills, and convection units. The facility failed to clean residents' rooms and reusable equipment in a sanitary manner to help prevent the development and transmission of disease and infection.

The facility identified a census of 28 residents, with 1 resident sampled for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision of 1 resident (#20), identified elopement risk, who left the facility unattended and without staff knowledge ambulated approximately 12 blocks from the facility. This failure placed the resident in immediate jeopardy. Findings included: - Resident #20's [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) dated noted resident #20 had adequate vision, wore corrective lenses, had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment), he/she had delusions, physical and verbal behaviors directed toward others on 1 to 3 days in the look back period, and had wandering behavior 4 to 6 days in the look back period. The resident required limited assistance of 1 person for transfers, supervision with setup help only for walking, required limited assistance on 1 person with locomotion, was not steady, but able to stabilize without staff assistance, had one sided lower extremity impairment, and did not use a mobility device. He/she was occasionally incontinent of urine, and always continent of bowel. The resident received scheduled and as needed pain medication, and rarely had mild pain. The resident had shortness of breath or trouble breathing with exertion. The annual MDS dated [DATE] noted the resident had adequate vision with corrective lenses, had a BIMS score of 3, had fluctuating disorganized thinking and inattention and had delusions, did not have wandering behaviors, required limited assistance of 1 person for transfers, set up supervision with walking and locomotion, and extensive assistance from 1 person with toileting. He/she was not steady, but able to stabilize without staff assistance, had one-sided lower extremity impairment and used a cane. The Care Area assessment (CAA) dated 11/9/15 for falls noted the resident had a fall in the past review period. He/she was at risk for falling due to constant walking and getting short of breath. The staff redirected him/her many times with different activities. The resident was not able to redirect, but staff would continue to try redirection. His/her pain medication was increased as he/she walked until exhausted even with staff interventions. The resident used a cane. The resident had a BIMS score of 3 and a [DIAGNOSES REDACTED]. His/her cognition was expected to decline as his/her disease process advanced. The Fall Risk assessment dated [DATE] noted the resident was disoriented at all times, had a history of [REDACTED]. The total score was 11 (a total score of 10 or above represented High Risk for falls). The Risk of Elopement & Wandering quarterly assessment dated [DATE] noted the resident was cognitively impaired, ambulated independently, had a wanderguard (personal safety alarm device), staff frequently monitored, medications were reviewed, had recreational activities, exercise, and staff were aware of the resident's wander risk. The care plan dated 8/19/15 noted the resident had no difficulties making his/her needs known or understanding others. Staff provided supervision with ambulation, and transfers. The staff completed 15 minute visual checks until there was no evidence of door exit seeking behavior. Staff would provide redirection when the resident had exit seeking behaviors, such as puzzles, TV or activities. The resident was at risk for falls due to his/her decreased muscular coordination and cognitive decline with safety measures. He/she becomes increasingly upset about not being able to leave the facility and go home. He/she often walked quickly up and down halls fatiguing him/herself during these times, and could be impulsive. The staff provided redirection when the resident was outside in the courtyard trying to pull gate stop out of the ground (dated 8/24/15). The resident had a wander guard on. The resident had a history of [REDACTED]. The staff were to continue 15 minute visual checks on the resident and provide redirection when exit seeking as the resident allowed. The care plan had hand written note dated 9/11/15 the physician changed the resident's dosage and times of Ativan (anti-anxiety medication) to prevent extreme anxiety and exit seeking. The nurse's note dated 8/13/15 at 10:05 A.M. noted the resident ambulated throughout the facility all day. The nurse's noted dated 8/24/15 at 3:10 P.M. noted the resident went out the west door into the courtyard. A staff member followed the resident out and observed the resident pulling up the gate anchor. The nurse's note dated 8/25/15 at 2:10 P.M. documented the resident was exit seeking, wondering and pacing the halls looking for a way out. He/she cried out I want to go home, why can't we go home. The staff made several attempts to redirect the resident with no luck. The nurse's note dated 9/5/15 at 11:56 P.M. documented the resident was in his/her room this evening packing his/her clothes and reported he/she was going home. Review of the facility investigation documented on 9/5/15 at 3:14 P.M. the facility received a telephone call that resident #20 was 12 blocks away from the facility. Staff began a systematic search of the building, and the nurse notified administrative staff A via telephone. Administrative staff A found the resident approximately 12 blocks from the facility and returned the resident to the facility at 3:21 P.M. At 3:00 P.M. direct care staff O talked to the resident at the nurse's station. The resident wanted to know how to get to the town he/she was in. Direct care staff O explained to the resident he/she was in that town and went about his/her duties. Staff estimated the resident was away from the facility unsupervised approximately 17 minutes. The resident left the facility via the front door of the facility and got approximately 12 blocks away from the facility. The doors were alarmed and a camera monitored the front door. The staff heard the alarms sounding. The facility reviewed the camera footage and noted that at 3:04 P.M. the resident exited the building due to the regulated delay release (the door locked when the door was closed) of the code alert system. The door was opened by visitors entering the building. The facility investigation did not note the exact route the resident took from the facility to where staff found the resident 12 blocks away was not known. Observation of the area from the facility to where staff found the resident revealed there were no sidewalks on either side of the street of the 1.5 blocks to the highway. The highway had 4 lanes of busy traffic with a posted speed limit of 35 miles per hour (mph). The distance from the facility to the highway was 1.5 blocks. Staff found the resident 7 blocks south of the highway, the resident had crossed the highway. The speed limit on the residential streets was 30 miles per hour. According to weather underground the temperature on 9/5/15 at 2:53 P.M. was 91.9 degrees F. The heat index was 96.9 F, wind speed was 13.8 miles per hour (mph), and it was partly cloudy. Review of the facility investigation submitted to the state agency included an interview with direct care staff P dated and signed on 9/7/15 recorded he/she heard the front door alarm going off. A new admission resident and family was entering the building. Direct care staff assisted the new resident into the building and turned off the alarm. He/she assumed the new resident had set off the alarm when entering the building, and failed to check for the resident outside of the facility per facility policy. Review of the facility's log for the Daily Exit Door Checks dated August 2015, September 2015, October 2015, and November 2015 documented the doors were checked and functional. The doors checked included the dining room, residential living facility, patio exterior doors, and the front entrance doors. Review of the facility's log for Wander Guard/Code Alert Weekly Checks dated August 2015 through November 2015 documented weekly checks were conducted. Review of the nursing wander guard daily placement checks dated August 2015 through November 2015 were completed. Observation on 11/30/15 at 4:22 P.M. revealed resident #20 walked toward the front door without his/her cane, the wander guard alarmed, an unidentified staff member came out of an office and redirected the resident to go the other direction toward the dining room. On 12/01/2015 at 11:45 A.M. the resident ambulated out of the dining room used a cane, with a fast gait, and told passing staff member he/she was going home. Office staff stopped the resident near the front door before he/she got close enough for the wander guard to alarm. On 12/01/2015 at 12:40 P.M. the resident ambulated to the front door, there was a visitor coming in the front door. Resident #20 was able to get through the door jam. The alarm sounded and the visitor stopped the resident from leaving. Unidentified staff responded right away. On 12/01/2015 at 12:47 P.M. observation of the front door revealed the door locked when the wander guard was close to the exit door. If the door was opened, the resident could go though the door, and a different alarm sounded. There was a sign on the door alerting visitors to let only themselves out and the door shut behind them. On 12/2/15 at approximately 3:00 P.M. observation of the front door wander guard system revealed the nursing staff's pagers activated when the alarm activated. Interview on 12/01/2015 at 3:54 P.M. direct care staff P stated resident #20 was at the doors constantly. On 9/5/15 he/she was having one of those days and staff had to redirect him/her. When direct care staff P returned to the facility from his/her lunch break, the front door alarm and the wanderguard alarm were going off. He/she went to the front door to find the new resident in the doors and he/she assisted them in. He/she did not go outside to look for any residents. There were several family members with the new resident and did not see anyone else on the sidewalk, but did not think to look for anyone else. Direct care staff P assisted the new resident to the nurse's station and then answered a call light. On 12/02/2015 at 11:53 A.M. licensed staff I stated the staff redirected the resident when he/she paced the halls. He/she had a cane that he/she forgot to use at times and staff cued him/her to use it. On 12/01/2015 at 12:47 P.M. administrative nursing staff D stated the alarm for the wander guard locks the door and alarms if someone with a wanderguard went through. Staff were expected to respond to the alarm when activated. The resident was able to get out of the door with a wanderguard because the door was open to let visitors coming into the facility, the wanderguard did not lock the door. This allowed the resident to leave the facility. On 12/01/2015 at 4:21 P.M. administrative staff A stated the facility has a video camera at the front door that monitors the front door exit at all times. Review of the camera's video tapes showed on 9/5/15 at 3:04 P.M. the resident went out the front door. Direct care staff P turned off the alarm and did not look for the resident. The new resident and family were coming into the building. On 12/2/15 at 1:02 P.M. administrative staff B stated he/she expected staff to watch and monitor the residents at risk for elopement. Staff should follow the facility's policy on elopement. Review of the facility's policy for Elopement dated 1/1/14 reviewed 12/2/15 noted the facility ensured the safety of all residents by providing a safe environment for all residents at risk for wandering or elopement. Licensed staff completed elopement assessments at admission, quarterly, and with a change of status. Annual in-services on elopement will be conducted instructing staff members how to reset alarms, as well as proper procedures for door alarms. When a door alarm was activated, staff checked to see who is entering or exiting the door and the alarm may only be reset after the door had been checked and person activating the alarm has been identified. Elopement drills will be completed monthly on rotating shifts. Review of the facility's policy for Door Alarms dated 9/8/15 noted when a code alert alarm activated, staff should insure all elopement residents were accounted for and were safe. The facility failed to provide a secure environment for the cognitively impaired, ambulatory resident who exited the facility without staff awareness. A community member sited the resident approximately 12 blocks from the facility, and notified the facility. This deficient practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 9/8/15 when all staff were in-serviced on elopement in conjunction with a full orientation of door locks, on the importance of the doors shutting properly and of notifying the Administrator and/or the Maintenance employee if they find doors not working properly, importance of not clearing a code alert alarm until resident is back in the building and/or physically laying eyes on those residents at risk for elopement after clearing the alarm, the door alarm policy, and on the elopement policy. The Staff member responsible for clearing the code alert and not checking to see why the door was alarmed, or checking the facility for those at risk of elopement after clearing the code alert, received employment counseling and disciplinary action. The facility also added a device that relays through the code alert and pager system to let staff know via their pagers when the front door code alert is activated. Monitoring of compliance and continued compliance of the process will be done by the Quality Assurance team and the safety committee.

The facility identified a census of 27 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to investigate and report to the state agency, 1 resident reviewed, (#1) that experienced a fall that resulted in a [MEDICAL CONDITION] which required surgical intervention and alleged staff abuse. Findings included: - The facility admitted resident #1 on 6/11/14 with [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 14, which indicated intact cognition. The resident required limited assistance with ambulation with a walker. Interdisciplinary notes dated 9/1/14 timed 10:30 A.M., recorded staff observed the resident exiting the front door and followed the resident outside. As staff attempted to redirect the resident, he/she swung at staff, lost his/her balance, and fell on to his/her left shoulder and hip. Staff assisted the resident up and he/she walked back into the building. Interdisciplinary notes dated 9/2/14 timed 1:18 P.M. documented facility staff took the resident to a scheduled physician appointment, after which staff transferred the resident to an acute care hospital for repair of a left [MEDICAL CONDITION]. While at the hospital, the resident reported staff at the facility a (gender) staff pushed him/her down and that his/her hip felt as if it was out of its socket. During an interview on 1/28/15 at 4:00 P.M., administrative staff A revealed staff reported the incident to Adult Protective Services and not to the state agency. Administrative staff A revealed he/she first knew of the resident ' s allegations of abuse when he/she returned from the hospital after repair of his/her fractured left hip, approximately 8 days after the incident. On 1/28/15 at 4:30 P.M., administrative nursing staff D reported the facility reported the alleged incident to Adult Protective Services. On 1/29/15 at 8:30 A.M., consultant licensed social work specialist staff JJ reported during a face-to-face interview with the resident on 10/7/14 at 10:45 A.M., the resident reported a (gender) staff member pushed him/her down. Consultant social staff JJ revealed he/she asked the facility for the investigation and received that investigation on 10/21/14 for the incident on 9/1/14. Consultant social staff JJ revealed that if the facility had called the allegation to him/her, he/she would have made the call to the state hotline. The facility provided policy Abuse and Neglect Prevention, Reporting, and Intervention dated 1/1/14 documented the facility would provide resident s, families, and staff information on how and to whom to report concerns, incidents, or grievances. The administration would investigate the concerns and provide feedback to the person bringing the concern as to what was found and report any positive findings to the appropriate regulatory agencies in a timely manner ...Within 24 hours of the start of the administrative investigation, a determination was made as to whether the unexplained occurrence would be reported to the appropriate regulatory agency. The facility failed to investigate and report to the state agency as required, this resident ' s allegation of staff abuse.

The facility identified a census of 29 residents. The sample included 14 residents. The facility identified 6 residents independently mobile with a wander guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without staff knowledge) out of a total of 7 residents with a wander guard. Based on observation, record review, and interview the facility failed to provide supervision for 1 (#29) cognitively impaired resident identified at risk for elopement to prevent the resident from leaving the facility unattended and 5 other residents at risk for elopement. This cognitively impaired resident went a distance of 0.6 miles from the facility and crossed a 4 lane highway during the approximate 25 minutes he/she was gone from the facility. This deficient practice placed the resident in immediate jeopardy. The facility also failed to ensure a safe environment free from tools for the residents for 1 of 4 days onsite of the survey. Findings included: - The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #29 revealed a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. The resident displayed signs and symptoms of delirium (sudden severe confusion, disorientation and restlessness), presented with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and displayed wandering behavioral symptoms daily. He/she required staff set up and supervision for bed mobility, transfer, dressing, eating, and personal hygiene. The resident did not require a mobility device for ambulation. The 1/8/14 Care Area Assessment for cognitive loss and dementia (progressive mental disorder characterized by failing memory, confusion) revealed the resident was impulsive and made remarks about wanting to go home and became angry when he/she was told he/she could not go home. The care plan with a revision date of 7/23/14 revealed the resident did not use a mobility device for ambulation and staff performed 30 minute visual checks for him/her. Staff applied a wander guard on the resident and had attempted several alternatives to secure the wander guard due to him/her removing it. He/she was alert to person but confused to place and time, had memory impairment, made repetitive statements, packed his/her belongings multiple times throughout the day, and had impaired decision making abilities. The resident became restless and agitated at times, especially when wanting to go to his/her home. Staff identified the resident as an elopement risk due to his/her exit seeking behaviors and multiple statements about going home. Triggers for that behavior included having visitors and the time of day, especially later in the afternoon/evening times. The wandering and elopement risk assessments dated 10/10/13, 1/9/14, 3/26/14, 6/18/14, and 7/27/14 revealed the resident was at risk for elopement. The nursing summary supporting MDS forms dated 1/8/14 and 3/26/14 revealed staff identified the resident as exit seeking, restless, wandered, and he/she paced the halls of the facility. The nurses' note (NN) dated 10/13/13 at 4:06 P.M. revealed the resident required constant staff supervision while awake due to his/her risk for elopement. The NN dated 10/25/13 at 9:06 P.M. revealed the resident requested scissors from the staff to cut off his/her wander guard bracelet. The NN dated 12/4/13 at 2:47 A.M. revealed the resident displayed sundowning (condition where a person tends to become confused or disoriented toward the end of the day) type behaviors starting prior to supper which worsen throughout the evening. The resident cried, became angry, and made statements regarding going home. He/she tried all exit doors and attempted to follow visitors out of the facility. Staff had to monitor the resident for elopement behavior closely. The NN dated 12/15/13 at 10:29 A.M. revealed the resident removed his/her wander guard. Staff replaced the wander guard and provided redirection. The NN dated 6/25/14 at 5:50 P.M. revealed the resident continued with exit seeking behaviors despite numerous staff attempts to redirect. The resident punched numbers in the coded door console in attempt to open the east and front doors of the facility. The NN dated 7/2/14 at 1:37 P.M. revealed the resident talked about going home and staff observed him/her attempting to exit the facility through the east door. The NN dated 7/13/14 at 2:35 P.M. revealed the resident continued with exit seeking behavior and attempted to follow visitors out the door. The NN dated 7/26/14 at 2:35 P.M. revealed the resident continued with exit seeking behavior and was not easily redirected. The NN dated 7/27/14 at 4:02 P.M. revealed a staff member reported he/she was unable to locate the resident for his/her 30 minute visual check. Staff performed a search of the facility and grounds. Staff was still unable to locate the resident. Several staff members were instructed to use their vehicles to search for the resident and were given the resident's previous address as an area to focus the search. Staff notified the director of nursing and the administrator. The NN dated 7/27/14 at 4:14 PM revealed staff located the resident near his/her previous home. The NN dated 7/27/14 at 4:22 P.M. revealed staff returned the resident to the facility. The nurse performed a physical assessment and did not find any evidence of injury. The wander guard bracelet was still intact on the resident's left ankle. The physician progress notes [REDACTED]. The facility's investigation failed to identify which door the resident eloped from and lacked documentation of the wander guard sounding when he/she left the facility. Observation on 8/15/14 at 6:55 A.M. revealed direct care staff T assisted a resident with a wander guard placed on his/her right ankle to the patio door near the common area of the facility and the wander guard failed to alarm. Observation on 8/18/14 at 8:25 A.M. revealed once the door code was entered and the door was opened and held opened for an extended amount of time, revealed the door code did not reset itself and alarm. Observation on 8/18/14 at 1:16 P.M. revealed this resident and his/her spouse approached the front door of the facility and asked a staff member if they would open the door for them. Interview on 8/15/14 at 9:18 A.M. with administrative staff A revealed the facility kept the wander guard sensor frequency low on the patio door because the windows near that door were the best place for residents to look outside. Interview on 8/18/14 at 8:29 A.M. with administrative staff A revealed if the front door was held opened for an extended amount of time the alarm did not reset itself and did not alarm. Interview on 8/18/14 at 8:50 A.M. with administrative staff A revealed the delay switch for the doors would sound if the door remained open for 45 seconds but staff discovered it was not functioning properly. Interview on 8/18/14 at 11:43 A.M. with administrative staff A revealed the wander guard did not need to be on the resident's left ankle for the sensor to sound. He/she stated staff based the location of the wander guard on the resident's body based on the resident's preference and physical needs, if the resident had swelling in the ankles it would be placed on the wrist. Staff A reported the alarms should sound no matter where the wander guard was on the resident's body. Interview on 8/19/14 at 9:50 A.M. with direct care staff O revealed the resident was known by staff for his/her exit seeking behaviors. Staff attempted to redirect the resident when the behavior occurred. Interview on 8/19/14 at 10:50 A.M. with licensed nursing staff H revealed he/she was the nurse working the floor at the time of the resident's elopement. Staff H reported the staff was performing 30 minute visual checks during that time. He/she reported the facility had more visitors that day due to a parade in town. He/she stated the resident was atypically quiet that day prior to the elopement and a staff member saw the resident approximately 10 minutes prior to when staff could not to locate him/her. Staff checked wander guards for placement daily and checked for functioning of the wander guards weekly. Interview on 8/19/14 at 11:52 A.M. with administrative nursing staff D revealed the resident consistently displayed exit seeking behaviors. He/she reported the day of the elopement the facility was holding a birthday party for a resident and the county fair started, therefore the facility had more visitors than normal. The facility staff believed the resident followed a visitor out the doors. Staff D reported the facility staff followed the policy for checking door alarms, wander guard placements locations, and the functioning of the wander guards. He/she also reported the resident's wander guard sounded upon his/her return to the facility after the elopement. Staff performed 30 minute visual checks on the resident prior to him/her leaving the facility. Staff D stated another staff member recalled seeing him/her approximately 10 minutes prior to direct care staff realizing the resident was not in the facility. This deficient practice placed the resident in immediate jeopardy. The 1/1/14 policy provided by the facility regarding elopements revealed the facility ensured the safety of all residents by providing a safe environment for all residents at risk for wandering and elopement. The 1/1/14 policy provided by the facility regarding wander guards revealed the night shift nurse was responsible for checking the placement of the wander guard daily and to ensure it was applied securely. The nursing staff completed weekly checks for the functioning of the wander guard by taking the resident to the door. The nursing staff signed at the beginning and end of their shift the door systems were working when they came in and when they left the building. The placement of the wander guard was specific to each resident. The facility failed to provide sufficient supervision to prevent this cognitively impaired and independently mobile resident with an extensive history of exit seeking behavior and elopement attempts from leaving the facility. The facility abated the immediate jeopardy on 8/19/14 at 1:00 P.M. when: 1. The facility would continue to keep consistent assignments for resident care, each being responsible for 8-10 residents. 2. The facility would continue to complete elopement assessments at admission, quarterly, and with a change in status. 3. For those resident identified at risk, the facility would develop care plans to include identification of walking patterns, triggers, activities, redirection techniques, and/or wander guard bracelets. 4. Residents with a potential of wandering and/or elopement would continue to be accounted for on at least an hourly basis, day and night shift. 5. Staff would account for residents who had attempted to elope on a 30 minute basis and for residents who have eloped on a 15 minute basis. 6. The facility would continue to inservice staff regarding elopements annually. 7. On 8/1/14 the facility provided an inservice for all staff regarding elopements, the new door locks, the importance of the doors shutting properly, notifying the administrator and/or maintenance if doors did not work properly, the new door alarm policy, and the elopement policy. Any staff not at the inservice were inserviced one to one when they were scheduled to work. 8. All staff were educated on how to reset alarms, as well as proper procedures for the door alarms as part of their orientation. 9. The facility would continue to perform elopement drills monthly on rotating shifts. 10. The facility purchased a coded touch pad lock for the dining room and patio exterior doors which was installed on 7/25/14. 11. The facility moved the code alert to the actual door exit for the Residential Living Facility hallway. 12. All doors would have an alarm that activated when opened and a code necessary to open, with a battery backup alarm. 13. The facility provided an all staff inservice on 8/18/14 and 8/19/14 regarding all door alarms indicating the door was opened, must remain on at all times. 14. The Residential Living Facility entrance, the front door, and the patio exit door would be alarmed with code alerts. 15. The 2 main exit doors used by guests will have signs posted on the doors notifying guests the need for them to assure that doors were shut behind them and they let no one out but themselves for resident safety. 16. The nursing staff continued to monitor the placement of the code alert bracelets daily. 17. Maintenance employees checked exit doors daily for proper functioning and in accordance with the manufacturer's recommendation. 18. The nursing staff continued weekly checks for the functioning of the code alert bracelets. 19. Monitoring of compliance and continued compliance of the process would be done by the quality assurance team and safety committee. This deficiency remained at the scope and severity of an E. - On 8/13/14 at 2:45 P.M. revealed multiple maintenance tools on the floor in the TV room. There were no staff or maintenance personal in attendance of the tools. Multiple residents were in recliners in the room. On 8/14/14 at 11:35 A.M. the exposed wall and multiple maintenance tools were on the floor, no staff or maintenance person was in attendance. On 8/13/14 at approximately 2:00 P.M. administrative licensed staff F stated he/she informed the maintenance staff not to leave the tools unattended in the TV room. The facility failed to provide a policy on protecting residents from potential hazards. The facility failed to provide a policy on securing tools from residents. The facility failed to protect the residents by leaving the maintenance tools unattended.

The facility identified a census of 29 residents. Based on record review and interview, the facility failed to use the services of a Registered Nurse (RN) coverage for 8 consecutive hours on 6 days during the period from June 2014 to August 2014. Findings included: - Review of the staffing schedule for June 2014 revealed the facility lacked 8 consecutive hours of RN coverage on June 1st, June 23rd, and June 25th. Review of the staffing schedule for July 2014 revealed the facility lacked 8 consecutive hours of RN coverage on July 20th and July 27th. Review of the staffing schedule for August 2014 revealed the facility lacked 8 consecutive hours of RN coverage on August 10th. On 8/19/14 at 11:43 A.M. administrative nursing staff F said there were times the facility did not have 8 continuous hours of RN coverage. The undated Licensed Staffing Policy provided by the facility revealed the facility would use a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility failed to provide RN coverage for 8 consecutive hours 7 days a week.

The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to handle laundry to prevent cross contamination and failed to properly cover drinking containers during transport through the facility. Findings included: - On 8/18/14 at 4:00 P.M. direct care staff carried unbagged soiled resident clothing and a chux (a washable pad used to protect the wheelchair from bodily fluids) to the soiled utility room. On 8/19/14 at 10:40 A.M. direct care staff P stated staff should bag all soiled linens prior to transporting to the soiled utility room. On 8/19/14 at 11:46 A.M. licensed staff H stated staff should bag soiled linens in the residents' rooms prior to taking to the soiled utility room. On 8/19/14 at 10:25 A.M. administrative staff F stated staff should bag heavy soiled or saturated linens prior to transport to the soiled utility room. Review of the undated laundry and linen policy and procedure provided by the facility revealed staff should bag highly soiled items and take them to the dirty utility room and place in closed hampers. On 8/19/14 at 10:00 A.M. staff transported uncovered drinking mugs filled with ice from the ice machine in the kitchen hallway to the nursing unit. On 8/19/14 at 10:40 A.M. direct care staff P stated staff should cover drinking mugs prior to transport through the facility. On 8/19/14 at 10:25 A.M. administrative staff F stated staff should cover drinking containers when they were transported through the facility. The facility failed to handle laundry to prevent cross contamination by not bagging soiled laundry prior to transport to the soiled utility room and transported uncovered drinking containers through the facility.

The facility identified a census of 29 residents. Based on record review and interview the facility failed to have a transfer agreement with a local hospital. Findings included: - Review of administrative policies revealed the facility lacked a transfer agreement with a hospital. Interview on 8/19/14 at 3:00 P.M. with administrative staff A revealed the facility did not have a transfer agreement with a hospital. The facility failed to have a transfer agreement with a hospital.

The facility reported a census of 29 residents. Based on record review and interview, the facility failed to have documentation of an active certification for 1 direct care staff (R) of 5 staff reviewed and the facility failed to incorporate the 6/17/11 Centers for Medicare and Medicaid Services (CMS) letter entitled "Reporting Reasonable Suspicion of Crime in a Long-Term Care Facility (LTC): Section 1150B of the Social Security Act" into their existing facility policy. Finding included: - Record review on 8/19/14 at 2:30 P.M. revealed an inactive certified nurse aide (CNA) certification for direct care staff R hired on 10/2/2013. On 8/19/14 at 2:35 P.M. administrative staff A stated the process to re-active a CNA's license took time and she/he should continued to check the CNA registry web site. The policy and procedure dated 1/1/2014 titled Abuse and Neglect revealed to help/attempt to prevent any abuse and neglect the facility would screen/check with the appropriate registries. The facility failed to have an active CNA certification in the personnel file of direct care staff R. - The policy and procedure dated 1/1/2014 titled Abuse and Neglect lacked information regarding the reporting of suspicious crimes to a law enforcement agency of jurisdiction, the time requirement of individual reporting, and posting conspicuous notice of employee responsibility to report on allegations of abuse. On 8/19/14 at 3:37 P.M. administration staff A stated she/he thought she/he could use the resident's postings and was aware of the reporting time and should update the abuse policy and procedure. The facility failed to fully develop written policies and procedures to prohibit mistreatment, neglect, and abuse of residents, and failed to post notice of staffs' responsibility to report an allegation of abuse.

The facility identified a census of 29 residents. Based on record review, observation, and interview, the facility failed to complete the Care Area Assessments (CAAs) for two (#4 and #1) of the 14 residents sampled. Findings included: - Record review of resident #4 revealed an annual Minimum Data Set 3.0 (MDS) with an Assessment Reference Date (ARD) of 7/30/14. The Care Area Assessment (CAA) dated 8/6/14 for the triggered areas of behavioral symptoms and psycho-social well-being revealed staff did not complete the CAAs. On 8/18/14 at 7:55 A.M. the resident sat in the dining room drinking coffee and conversed with his/her tablemate. On 8/18/14 at 2:33 P.M. administrative nursing staff D acknowledged the CAA's for behavioral symptoms and psycho-social well-being triggered for resident #4 and was not completed. He/she stated they aim to complete all triggered CAA's. The undated policy for Minimum Data Set (MDS) provided by the facility revealed the facility adhered to the policy and procedures for the federal requirements of completing the Minimum Data Set. The policy further stated the Registered Nurse MDS Coordinator oversaw the MDS completion process and the accuracy of the CAA completion for each triggered item. The facility failed to complete a comprehensive assessment for this resident. - Record review of resident #1 revealed an annual Minimum Data Set 3.0 (MDS) with an Assessment Reference Date (ARD) of 7/2/14. The Care Area Assessment (CAA) dated 7/9/14 revealed staff failed to complete the CAA triggered for mood state. On 8/18/14 at 2:33 P.M. administrative nursing staff D acknowledged the CAA for mood state triggered for resident #1 and was not completed. He/she stated they aim to complete all triggered CAA's. Observation on 8/14/14 at 3:45 P.M. revealed the resident sat in his/her recliner watching television. The undated policy for Minimum Data Set (MDS) provided by the facility revealed the facility adhered to the policy and procedures for the federal requirements of completing the Minimum Data Set. The policy further stated the Registered Nurse MDS Coordinator oversaw the MDS completion process and the accuracy of the CAA completion for each triggered item. The facility failed to complete a comprehensive assessment for this resident.

The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, interview and record review the facility failed to accurately complete the Minimum Data Set (MDS) 3.0 for 2 (#5,#37) residents. Findings included: - Review of the Admission MDS 3.0 dated 5/16/14 for resident #5 revealed the resident had an external catheter. Review of the Care Area Assessment (CAA) for incontinence dated 5/16/14 revealed the resident was incontinent prior to an emergency room visit for [MEDICAL CONDITION]. The MDS revealed the resident had a condom (external) catheter (placed over the penis to catch the urine). Review of the nurse's note dated 5/21/2014 at 5:30 P.M. revealed licensed staff H received orders for antibiotic therapy, discontinued the Foley (indwelling) catheter and monitor the resident's voiding. On 8/14/14 at 12:48 P.M. 2 direct care staff provided pericare for the resident and no catheter noted. On 8/19/14 at 10:30 A.M. administrative licensed staff D stated the resident had an indwelling catheter and not an external catheter, and it was a data entry error. On 8/18/14 at 12:17 P.M. administrative licensed staff E stated he/she did not review the MDS for accuracy, only for completion. Review of the undated Minimum Data Set policy provided by the facility revealed the Registered Nurse MDS Coordinator oversaw the MDS completion process and the accuracy of the CAA completion for each triggered item. The facility failed to complete an accurate MDS assessment regarding this resident's bladder care. - The 30-day Minimum Data Set (MDS) 3.0 dated 5/23/14 for resident #37, a closed record review, revealed the resident was in a vegetative state (comatose patient, unable to communicate or respond to stimuli). The resident required extensive assistance of two plus (2+) persons for bed mobility, transfers, walking in her/his room/corridor, locomotion on the unit, dressing, and toilet use, extensive assistance of one person for locomotion off the unit and personal hygiene, and limited assistance of one person for eating. The resident did not have functional limitations to her/his upper/lower extremities, did not use a mobility device, and received two days of physical therapy during the 7 day look back period. The nursing note dated 5/24/14 at 1:45 P.M. revealed the resident was able to take her/his self to the bathroom without asking for assistance. The resident was very alert and oriented and able to make own decisions. On 8/18/14 at 10:36 A.M. administrative nursing staff D stated the MDS was completed in error and the resident was not comatose. On 8/18/14 at 12:17 P.M. administrative nursing staff E stated she/he did not oversee the MDS for accuracy but for completion. The undated policy and procedure titled MDS revealed the registered nurse MDS coordinators oversaw the MDS completion process. The facility failed to complete an accurate MDS assessment regarding the resident's brain function.

The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to complete neurological checks for 1 (#16) resident with a history of falls. Findings included: - The 14-day Minimum Data Set ((MDS) dated [DATE] for resident #16 revealed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). The resident required extensive assistance of one person for bed mobility, transfers, walking in her/his room/corridor, locomotion on/off the unit, dressing, toilet use, and personal hygiene, and supervision with set up for eating. The resident was not steady and was able to stabilize with staff assistance for moving from seated to standing position, walking, moving on/off the toilet, and surface-to-surface transfers, had impairment on one side of her/his lower extremity with functional limitation in range of motion (ROM), and used a walker and wheelchair (w/c) for mobility. The resident did not have falls since admission/entry or reentry or prior assessment. The fall Care Area Assessment (CAA) dated 6/20/14 revealed the resident had a history of [REDACTED]. Causal factors included dementia (progressive mental disorder characterized by failing memory, confusion). The fall care plan updated 8/5/14 revealed the resident was at risk for falls due to her/his impaired mobility, decreased endurance, and cognitive decline with decreased safety awareness. The resident had a history of [REDACTED]. Nursing staff would complete a fall risk assessment quarterly and as needed (PRN), provide the resident a rest break during long distant ambulation due to decreased endurance and increased risk of falls. The resident was resistive to rest breaks and would become argumentative. The resident would work with physical therapy (PT) to return the resident to her/his previous ambulatory status when she/he became weight bearing as tolerated (WBAT) . The resident was on a scheduled toileting program at night on toileting rounds and at 7:30 A.M. for fall prevention. The pharmacist would review the resident's medications related to falls post falls with the next visit. Nursing staff placed a bolster pillow at the edge of the resident's bed to help the resident identify the edge of the bed. Nursing staff would place the controls of the easy chair lift out of the resident's lap until staff provided assistance with the chair lift to prevent the resident's elbow from accidentally pushing the controls of the chair lift. The resident would wear a body alarm for 72 hours post admission while monitoring the resident's change in condition. Staff would be educated on proper foot/cast placement with the transfer pivot wheel during transfers of the resident. The nursing note (NN) dated 9/27/13 at 5:45 P.M. revealed nursing staff heard a thud in the resident's room and observed the resident sat on the floor between the bathroom and hall doorway. The resident sat upright leaning on her/his left arm and her/his legs were half bent. The body alarm did not sound and her/his walker was near the door way entry. The resident stated she/he was going to the bathroom. Nursing staff obtained vital signs and checked the blood sugars. The resident (with dementia) denied pain and denied hitting her/his head, and had active ROM to all extremities. No injuries were obvious and nursing staff assisted the resident to the bathroom with a walker and one person assist. The resident was reminded to use the call light and not to get up on her/his own and reminded her/him not to remove the body alarm as it was a fall intervention. The resident was also reminded to use the walker when ambulating and to utilize staff assistance. Record review on 8/18/14 at 4:14 P.M. lacked documentation neuro checks were performed. A NN dated 4/7/14 at 5:00 A.M. revealed nursing staff found the resident on the floor of her/his room. Nursing staff assessed the resident and no injuries were noted, and two staff members assisted the resident to a chair. A body alarm was placed for an immediate intervention. Nursing staff checked the resident's blood sugar, notified the physician and family and neuro checks were initiated. Record review on 8/18/14 at 4:14 P.M. revealed the neuro checks initiated on 4/7/14 were incomplete in documentation for the time of every half hour for two hours (Q1/2 hour x 2), Q hour x 2, Q2 hours x 2, Q4 hours x 2 and for the first of four in the 8 hours check. NN dated 6/4/14 at 7:05 A.M. revealed a licensed nursing staff was asked by a certified nursing staff (CNA) to come to the resident's room. The resident was observed in a semi upright position on her/his right side with the upper torso supported on the right arm. The electric lift chair was in the full upright position. Staff performed ROM and some tenderness was noted in the right ankle and the resident denied pain. The resident's pupils were equal and reactive and handgrasps were equally strong. The resident was assisted by three staff members to the w/c. The resident was toileted and returned to bed upon resident request. Staff elevated the right foot on a pillow and applied ice. Nursing staff obtained vital signs and blood sugars were checked. NN dated 6/4/14 at 11:00 A.M. revealed the facility transported the resident in the facility van to the hospital for x-rays of the right foot and ankle. Record review on 8/18/14 at 4:14 P.M. lacked documentation neuro checks were performed. Observation on 8/14/14 at 12:50 P.M. revealed the resident sat in a reclined chair, wore a nonskid shoe to the left foot, controls for the electric recliner were stored in a pocket on the right side of the chair, and the call light within reach. Observation on 8/19/14 at 7:47 A.M. revealed the resident slept in a low positioned bed, with a bolster pillow along the right side of the bed, and the call light within reach. Interview on 8/19/14 at 10:30 A.M. direct care staff P stated neuro checks were initiated by the nurse and CNA's would obtain the vital signs and the nurse completed the rest of the assessment. Interview on 8/19/14 at 10:37 A.M. licensed nursing staff H stated neuro checks were completed on unwitnessed falls and the resident was not a good historian. Interview on 8/19/14 at 12:24 P.M. administrative nursing staff F stated she/he would not expect nursing staff to obtain neuro checks on the resident as she/he was in a sitting position when found, there was no evidence of injury, and the resident was sent to the emergency room . The policy and procedure dated 8/2014 titled Head Injury/Neurological Checks revealed neurological assessments would be done by the nurse in charge and documented on the Neurological Assessment Flow Sheet every 30 minutes for one hour, then every hour for four hours, then every four hours for 12 hours, and then every shift for two consecutive days (48 hours). This covered a 65 total hour period for monitoring of a head injury. The facility failed to initiate and complete neurological checks on this resident with a history of unwitnessed falls.

The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, interview and record review the facility failed to follow the plan of care for 1 (#5) of 1 residents reviewed for pressure ulcers. Findings included: - Review of the electronic record for resident #5 revealed [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) 3.0 dated 5/16/14 revealed a Brief Interview for Mental Status score of 8 which indicated moderate cognitive impairment, with inattentive and disorganized thinking. The resident required extensive assistance of 2 staff for bed mobility, and transfers, extensive assist of 1 staff for dressing, toileting, and personal hygiene and supervision with set up assistance for eating. The resident had an unstageable pressure ulcer upon admission and a pressure reducing device for the chair and bed, was on a turning/repositioning program, and received nutrition or hydration interventions to manage skin problems. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident was not on a toileting program. Review of the Care Area assessment dated [DATE] for pressure ulcer revealed the resident had a stage II pressure ulcer on admission. The resident slid forward in the chair and caused friction and shearing. The resident required 2 staff for transfers, received oxygen therapy and had a Foley (indwelling) urinary catheter. Review of the skin care plan dated 8/11/14 revealed the resident with a pressure ulcer on his/her left buttocks, the staff provided a pressure reducing mattress on the bed, pressure reducing cushion in the recliner and wheelchair, used heel float boots while in bed, and changed his/her position hourly. Review of the facility standard of care for wounds dated 7/30/14 revealed staff were to reposition the resident every hour if they had a stage II or greater. Review of the facility standard of care for skin care dated 7/30/14 revealed staff were to reposition the resident every hour if the resident had a pressure ulcer. On 8/14/14 at 11:30 A.M. the staff transferred the resident to his/her bed and positioned the resident on his/her left side. Further observation at 11:45 A.M., 12:00 P.M., 12:15 P.M., 12:30 P.M., and 12:45 P.M. revealed no change in position. At 12:48 P.M. 2 direct care staff entered the room provided pericare and repositioned the resident on his/her right side. On 8/18/14 at 4:00 P.M. the staff toileted and transferred the resident to his/her wheelchair and wheeled the resident to the activity at the nurses' station. The resident remained in his/her wheelchair at 4:15 P.M. and 4:30 P.M. At 4:35 P.M. staff took the resident by a wheelchair to the dining room. The resident remained in his/her wheelchair at 4:45 P.M., 5:00 P.M. and 5:15 P.M. At 5:40 P.M. the staff transferred the resident to the recliner in his/her room. Staff did not reposition the resident for 1 hour and 40 minute. On 8/18/14 at 5:05 P.M. direct care staff S stated he/she was not aware the resident had a pressure ulcer and would reposition the resident every 2 hours or per the resident's request. On 8/19/14 at 10:40 A.M. direct care staff P stated the staff should reposition the resident every hour due to the sore on his/her buttocks. On 8/19/14 at 11:46 A.M. licensed staff H stated the resident had a red area on his/her buttocks and should be repositioned every hour. On 8/18/14 at 10:55 A.M. administrative nursing staff E stated he/she expected staff to reposition the resident every hour due to an active wound and were to follow the care plan. Review of the facility's undated policy for prevention and management of pressure ulcers revealed the staff would reposition the resident hourly. The facility failed to reposition the resident as planned.

The facility reported a census of 29 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to monitor the supplement intake for 1 (#17) of three residents sampled for nutrition as planned. Findings included: - The significant change in status Minimum Data Set (MDS) 3.0 dated 5/29/14 for resident #17 revealed a Brief Interview for Mental Status (BIMS) score of 9 (moderately impaired). The resident required extensive assistance of two plus (2+) persons for bed mobility, transfers, and toilet use, total dependence of one person assist with locomotion on/off the unit and bathing, extensive assistance of one person for dressing and personal hygiene, and limited assistance of one person with eating. The resident did not have any swallowing disorders, was 72 inches in height and weighed 185 pounds (#), had a weight loss of 5 percent (%) or more in the last month or loss of 10% or more in the last 6 months, received a mechanically altered diet, and did not have oral/dental concerns. The Nutrition Care Area Assessment (CAA) dated 6/3/14 revealed the resident had a weight loss prior to admission, and since returning from the hospital she/he had an additional weight loss of 6.8% in 30 days. She/he was hospitalized for [REDACTED]. The SLP hoped to increase the resident's strength and coordination for bolus (a rounded mass of food) control. She/he did not cooperate with SLP and made little progress. The resident refused to let staff assist her/him. Several interventions were made for the resident's weight loss since she/he returned from the hospital. She/he was able to make her/himself understood to staff and family about wants/needs. The revised nutrition care plan dated 8/1/14 revealed the resident was on a regular mechanical soft diet and received supervision to limited staff assistance with food and fluids. The resident was at risk for weight loss do to refusal of food/fluids and had a history of [REDACTED]. The resident had frequently stated she/he would eat when she/he wanted to, and she/he wished staff would stop telling her/him to eat. The resident stated she/he did like fruit at breakfast, did not eat bread or drink milk, and enjoyed desserts of any kind. The resident was be seen by a registered dietitian annually and as needed (PRN). The resident occasionally sat at the assisted dining room table for extra staff assistance with meals. The resident received 4 ounces (oz.) of supplement three times daily (TID) and at breakfast ([MEDICATION NAME]/health shake), Prosource 30 ml daily and protein powder one scoop at each meal. The supplements were increased to 4 oz. TID with snacks and meals. 4 oz. supplement was added to the A.M. and P.M. snacks in addition to the family request of ice cream, and carnation instant breakfast twice daily (BID). The nutrition standard of care care plan dated 7/20/14 revealed staff would monitor the resident for self-feeding abilities, monitor food intake as well as likes and dislikes. Staff would refer to dietary cares/notes of likes and dislikes. Review of the kitchen's resident tray card on 8/18/14 at 1:50 P.M. revealed the resident received a mechanical soft, small portions diet, with supplements each meal, required set up assistance, would receive orange juice with breakfast and juice with each meal. The kitchen's tray card lacked documentation of the resident's food preferences or likes/dislikes. Electronic health record (EHR) reviewed on 8/18/14 at 1:58 P.M. lacked documentation of the resident's likes and dislikes on the dietary EHR. The [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) lab results dated 6/17/14 revealed the [MEDICATION NAME] level was low. Record review on 8/18/14 at 1:15 P.M. revealed the percentage of supplement/snack intake documentation for June 2014, July 2014, and from August 1, 2014 to August 17, 2014 revealed lack of consistent documentation of the supplement intake ordered three times daily (TID) and the snacks in the A.M./P.M. Observation on 8/14/14 at 11:48 A.M. revealed the resident received a 4 ounce (oz.) chocolate shake and ate three bowls of peaches. Observation on 8/18/14 at 12:20 P.M. the resident consumed 100% of the supplement and peaches. Observation on 8/18/14 at 3:31 P.M. the resident consumed half of her/his supplement. Observation on 8/18/14 at 5:02 P.M. revealed the resident received a bowl of peaches and a 4 oz. glass of supplement. The resident ate all the peaches. Family interview on 8/18/14 at 3:21 P.M. stated she/he could not remember if staff reviewed the resident's likes/dislikes with her/him. The family stated the resident liked peaches and fruit. Interview on 8/19/14 at 10:27 A.M. with direct care staff P stated the resident received a supplement at 10:00 A.M., 2:00 P.M., and at night (HS) and with meals. The certified nursing aides (CNAs) documented the % of snacks received and documentation was reviewed by the nurse. Dietary documented supplements received at meals and nursing documented the intake of snacks. Interview on 8/19/14 at 10:45 A.M. with licensed nursing staff H stated the resident received supplements at snack time and with meals and the assistant director of nursing (ADON) reviewed the meal and supplement intakes. Interview on 8/18/14 at 1:53 P.M. with dietary staff DD stated the resident's likes and dislikes for foods were documented on the resident's tray card and she/he would update the card as it did not have peaches listed as a resident food preference. Interview on 8/19/14 at 10:00 A.M. with dietary staff EE stated dietary staff DD obtained the resident's likes/dislikes and documented those on the resident's tray card. The undated policy and procedure titled Supplement Pass Policy revealed nursing staff would chart the amount of the supplement that was administered in milliliters. If the resident only consumed a portion of the supplement, the milliliters would show the difference. If the resident refused, was out of the facility, or unable to take the supplement, nursing staff would chart as such. The facility failed to document resident food preferences (likes/dislikes) and monitor the percentage of supplement intake for this resident with weight loss as planned.

The facility reported a census of 29 residents. The sample included 5 residents. Based on observation, record review, and interview the facility failed to monitor fort he effectiveness of the behavioral medications for 1 (#16) resident in the sample. Findings included: - The electronic health record (EHR) reviewed on 8/14/14 at 2:44 P.M. for resident #16 revealed [DIAGNOSES REDACTED]. The 14-day Minimum Data Set (MDS) 3.0 dated 6/13/14 revealed a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact) and the resident received antidepressant and antianxiety medications. The [MEDICAL CONDITION] drug use Care Area Assessment (CAA) dated 6/20/14 revealed the resident received antidepressant and antianxiety medications. The resident's mood/behaviors were non-stop talking and praying. Nursing staff completed a pain evaluation and pain was ruled out as cause for her/his behaviors. The resident required extensive assistance with activity of daily living (ADL) skills and required numerous verbal cues. The resident had a hearing impairment which could impact her/his ability to process information. The [MEDICAL CONDITION] medication care plan updated 6/26/14 revealed the resident received [MEDICATION NAME] for depression, withdrawal of self-care, social isolation, paranoid thought of people talking about her/him, and was on [MEDICATION NAME] for her/his daily anxiety. There was an unsuccessful attempt to reduce the dosage of both medications. Licensed staff would monitor for signs of depression via Patient Health Questionnaire - 9 (PHQ-9) (a screening tool used to monitor the severity of depression) score, would monitor the resident for side effects of the medications, pharmacy would review for a gradual dose reduction (GDR) of [MEDICATION NAME]. [MEDICATION NAME] was reduced and staff would monitor the resident for increased isolation and increased paranoid thoughts. During periods of anxiety or social isolation, all staff would encourage the resident to participate in activities, visit with her/him regarding her/his children and grandchildren, encourage participation in favorite activities, and reading. The Medication care plan dated 6/25/14 revealed the resident received [MEDICATION NAME] 20 milligrams (mg) daily for depression. [MEDICATION NAME] had a black box warning (BBW) and nursing staff would monitor for behaviors, changes in behaviors, depression, or thought of suicide via the behavioral flow sheet. The resident received [MEDICATION NAME] 1 mg three times daily (TID) for anxiety and nursing staff would monitor mood/behaviors with the quarterly and comprehensive MDS. Nursing staff would also monitor the resident for behaviors, change in behaviors, and symptom of anxiety via the behavioral flow sheet. The pharmacy consultant/doctor would review and recommend GDR's unless contraindicated. The EHR reviewed on 8/14/14 at 3:35 P.M. revealed orders for [MEDICATION NAME] 20 mg by mouth (PO) daily for depression and [MEDICATION NAME] TID for anxiety. The EHR Behavior Monitoring form for May 2014, June 2014, July 2014, and from August 1, 2014 to August 17, 2014 revealed [MEDICATION NAME] 20 mg for depression and [MEDICATION NAME] 1 mg TID for anxiety were listed together for targeted behaviors of delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), withdrawal of self care, anxiety, and attention seeking. The Abnormal Involuntary Movement scale (AIMS) dated 6/22/14 revealed no abnormal muscle movement. Observation on 8/18/14 at 4:26 P.M. revealed the resident slept in a recliner chair with her/his legs elevated. Interview on 8/19/14 at 10:37 A.M. with licensed nursing staff H stated she/he was not a doctor and could not say which medications benefited the resident's behaviors. Interview on 8/19/14 at 12:40 P.M. with administrative nursing staff F stated staff reduced the medications one at a time and staff would know which medication was affective for the resident's behavior. Administrative inuring staff F acknowledged the [DIAGNOSES REDACTED]. The facility failed to monitor for the effectiveness of the antidepressant and antianxiety medications this resident received.

The facility reported a census of 32 residents. The facility identified 8 residents at risk for elopement. The sample included 3 residents identified as elopement risks. Based on observation, record review, and interview the facility failed to provide supervision for 1 (#1)cognitively impaired resident assessed at risk for elopement to prevent the resident from leaving the facility unsupervised. This cognitively impaired resident went a distance of 1.7 miles from the facility, crossed a 4 lane highway, and a set of railroad tracks durning the approximate 50 minutes he/she was gone from the facility. This deficient practice placed the resident in immedicate jeopardy. Findings included: - The signed [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7 (severe cognitive impairment). The resident did not exhibit wandering behaviors. The resident required limited assistance of one person for bed mobility, transfers, walking in her/his room/corridor, dressing, and toilet use. She/he did not have upper/lower extremity limitations, and was not steady and was steady with human assistance with moving from a seated to standing position, walking, turning around, moving on/off the toilet, and surface to surface transfer. The Significant Change in Status MDS 3.0 dated [DATE] revealed BIMS total score of 9 (moderately impaired cognition). The resident exhibited wandering type behaviors which occurred for one to three days. The resident required setup help for bed mobility, transfer, walking in her/his room/corridor, and locomotion on/off the unit. The resident used a walker for mobility, and did not have impairments to the upper/lower extremities. The Care Area Assessment (CAA) dated [DATE] for Behavioral Symptoms revealed the resident had a [DIAGNOSES REDACTED]. There were no recent change with medications, any acute illness or environmental change which affected or caused an increase with behaviors. Factors which could cause or exacerbate behaviors were reviewed. The resident's cognitive status with a [DIAGNOSES REDACTED]. The care plan dated [DATE] and revised [DATE] for Mobility/Safety revealed the resident used a rolling walker with supervision to limited assistance with ambulation. Occasionally she/he preferred not to use the walker, but with encouragement and verbal cues she/he used it for safety. The resident wore a wander guard bracelet (a device that alerts staff that a cognitive impaired resident attempts to leave the facility). The resident was at risk for fall due to her/his cognitive decline, a history of fall at home, and used an assistive device. A Fall Risk Assessment was completed by a licensed nursing staff quarterly and as needed. The care plan dated [DATE] and revised [DATE] for Cognitive/Mood/Behaviors- revealed the resident was alert and confused to time and place. At times the resident became restless and needed multiple redirections from staff throughout the day. She/he often ambulated throughout the facility looking to go home or looking for her/his spouse. The resident refused to go to meals, especially supper, when she/he insisted she/he would make her/his meal at home. During these times staff could offer the resident a snack, a drink, get her/him involved in an activity. Staff would reminiscence with the resident regarding her/his children and the farm. The Fall Risk assessment dated [DATE], [DATE], and [DATE] revealed a score of 18 where a total score of 10 or higher indicated a high risk for falls. The Elopement assessment dated [DATE] and reviewed on [DATE], [DATE], [DATE], and [DATE] revealed the resident had a [DIAGNOSES REDACTED]. The resident did not have a history of wandering and if at risk, would be addressed in the Plan of Care. A wander guard was initiated on [DATE]. The Wander Guard, Code Alert Weekly Check Sheet revealed the resident's wander guard was checked [DATE],and [DATE], and was on the resident's right ankle. The Nursing Notes (NN) dated [DATE] at 9:00 P.M. revealed the resident became restless and very adimate she/he needed to go home, and requested information on how to get out of the facility. A snack of cookies and juice was provided and an activity of bird house painting was provided. The resident was pleased and cooperative with the activity. NN dated [DATE] at 8:00 P.M. revealed the resident was restless and looked for her/his deceased spouse. Staff provided activities and one to one. The Elopement Investigation for [DATE] revealed the resident was last seen at 5:40 P.M. at the nurse's station. After a facility search between 6:30 P.M. and 6:38 P.M. was unsuccessful by direct care staff O, P, Q, and R, licensed nursing staff H was notified the resident was missing. At 6:44 P.M. the resident returned to the facility by a family member who stated a community member informed her/him the resident was located 1.7 miles from the facility. NN dated [DATE] at 6:30 P.M. revealed nursing staff was unable to locate the resident after searching the facility and facility grounds. The search to be extended to outside of the facility. At 6:40 P.M. the Assistant Director of Nurses (ADON), the Director of Nursing (DON), and the administrator were notified. At 6:40 P.M. the resident returned to the facility by a family member. The resident's wander guard sounded upon passing the alarm. The resident was alert, oriented to person, but confused. She/he denied pain. Fluids were provided. She/his skin was warm and dry, color pale and pink. At 6:50 P.M. the ADON, DON, and administrator were notified of the resident's return. At 7:00 P.M. the resident was in her/his room with family member and the wander guard was in place on her/his right ankle. Staff initiated 15 minute checks on the resident. The approximated distance from the facility to where the resident was located was 1.7 miles. The posted speed limit on Highway 36 (a 4 lane road) was 35 miles per hour (mph) and a posted speed limit in the residential area was 30 mph. The resident also crossed a set of railroad tracks prior to reaching her/his destination. According to Weather Underground the heat temperature index on [DATE] at 5:53 P.M. was 81.7 degrees Fahrenheit, at 6:53 P.M. the temperature was 79.0 degrees, with 50 percent humidity, and with wind speed of 4.6 mph. Observation on [DATE] at 11:30 A.M. revealed the resident sat in a recliner chair, wore eye glasses; tennis shoes, and a walker parked in front of the resident. Observation on [DATE] at 5:01 P.M. revealed the resident was outside without a walker and assisted activity staff with picking up tree twigs. Resident interview on [DATE] at 11:30 A.M. stated she/he did not remember going out of the facility last month. She/he had a bracelet and nursing staff checked her/his legs but not sure how often. Family interview on [DATE] at 1:02 P.M. stated she/he received a phone call from a person stating the resident was in her/his yard and she/he picked up the resident approximately 1.7 miles from the facility. There were no signs of injury and her/his parent was cheerful. Facility staff were actively searching for the resident when she/he returned the resident to the facility. The resident wore an ankle bracelet and it sounded when the resident walked back into the facility ' s front door. The resident informed her/his family member she/he had looked both ways before she/he crossed road. Family member also stated the resident had crossed a major highway and rail road tracks. Interview on [DATE] at 1:43 P.M. with administrative nursing staff D stated wander guard alarms were checked every Thursday and documented on the Weekly Check Sheet. Nursing staff walked residents up to a door with a wander guard alarm to test the function of the resident's wander guard bracelet. Interview on [DATE] at 2:04 P.M. with direct care staff S stated special monitoring devices were listed on the resident's care plan and check for placement daily when the certified nursing aide (CNA) dressed the resident. The CNA does not document wander guard placement. The resident wore her/his wanderguard bracelet on her/his ankle. The resident was known to wander and used a walker with ambulation. The wander guard door alarms were checked weekly by walking a resident by the alarm. The resident was known to go up to the doors and pushed on them. Interview on [DATE] at 2:28 P.M. with direct care staff R stated she/he last saw the resident at approximately 4:00 P.M. in the dining room when she/he assisted with meals. She/he assisted with the resident search at approximately 5:00 P.M. and was not sure what time the resident was returned to the facility and not sure if the door and wander guard sounded when the resident entered the facility. There were no apparent injuries noted on the resident. She/he did not know what door the resident left from. Wanderguards were checked on the day shift. Interview on [DATE] at 4:45 P.M. with licensed nursing staff H stated she/he received shift report at 5:50 P.M. and the resident was not at the nursing station at that time. Nursing staff informed her/him the resident was missing at 6:30 P.M. She/he was not aware of any door alarms going off as they rang at the wall panel by the nursing station. There were four CNA's that evening and after an unsuccessful search in the facility for the resident, two CNA's performed a search around the outer facility. A family member returned the resident to the facility before she/he notified law enforcement and family. The door alarm/wander guard alarm sounded when the resident walked through the Assisted Living exit door. The resident's clothes were clean and no signs of injuries were noted. The resident appeared tired and stated she/he had walked quite a ways. The family member stated the resident informed her/him she/he went out the front door. This deficient practice placed this resident in immediate jeopardy. Interview on [DATE] at 11:13 A.M. with rail road consultant staff EE stated there were approximately four trains that traveled daily at a speed of 10 to 30 mph. The facility failed to provide supervision to prevent this cognitively impaired independently mobile resident from leaving the facility. The undated policy and procedure titled Elopement/Missing Resident revealed incidences of new potential for elopement would be evaluated at each safety committee meeting. Exterior doors without wander guard alarms would have the main door alarms activated 24 hours a day. Exterior doors that have wander guard alarms would have the main door alarms activated at 10 P.M. Four exterior doors in the facility have secondary alarms as back up. The facility abated the immediate jeopardy on [DATE] at 11:30 A.M. when the facility: 1. The facility's policies were reviewed along with residents individualized Care Plans. 2. The facility will continue to have consistent assignments of aides providing care for residents, with each aide being responsible for ,[DATE] residents. 3. A sign to the exit doors would notify guests they need to assure that doors were shut behind them. 4. The facility's main entrance doors were adjusted for proper closure and the code alert at that location sounded when a resident approached and when the door has locked down. 5. The facility will continue to do elopement assessments on admission, quarterly and with change of status. 6. Those residents at risk for elopement would have their care plans updated to include walking patterns, triggers, activities, redirection techniques and/or wander guard bracelet. 7. The facility will continue to have monthly elopement drills. 8. The facility's policy for elopement and standards of care have been updated to reflect that those at risk shall be accounted for on an hourly basis, those attempting to elope, every half hour, and those who have successfully eloped every 15 minutes. Those needing monitoring more frequently than every hour will have a flow sheet. 9. All staff were inserviced on [DATE] between 11:00 A.M. to 11:30 A.M. to the protocol to guarantee that the nursing staff knows the proper procedure for providing care for elopement. To ensure continued compliance the policy is/will continue be part of the orientation process for new employees. 10. Maintenance would continue to check exit doors daily for proper function and in accordance with manufacturer ' s recommendations and with the addition to a flow sheet for tracking. 11. Nursing staff would continue to monitor the placement of code alerts daily (flow sheet added) and their proper function at least weekly. 12. Monitoring of compliance and continued compliance is to be done by the DON and the QA (Quality Assurance) Team. This deficiency remained at the scope and severity of an D.

The facility had a census of 28 residents. The facility identified 5 residents with soft touch side rails and 4 residents that utilized an air flow mattress. Based upon observation, record review and interviews the facility failed to assess the safety of using an alternating air mattress in conjunction with side rails for a dependent, cognitively impaired resident. The staff found resident #1 with his/her lower body on the floor and the upper body on the mattress with his/her neck pressed against the side rails causing a reddened area. This deficient practice placed this confused and dependent resident in immediate jeopardy. Additionally, the facility failed to assess the use of side rails for resident #2 and also failed to ensure low loss alternating air mattress settings were individualized for 1 (#3) cognitively impaired resident at risk for falls. Findings included: - Review of resident #1's November Medication Sheet dated 10/31/12 included the resident had a safety alarm as indicated in care plan. The resident's quarterly Minimum Data Set (MDS) 3.0 dated 8/29/12 included the resident scored 4 (severely impaired cognition) on the Brief Interview for Mental Status, was totally dependent upon staff for bed mobility, transfers, locomotion on and off the unit, and toilet use, and did not walk in the room or corridor, required extensive staff assistance with dressing and eating. The MDS included the resident required two person physical assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS recorded the resident was unsteady when moved from seated to standing position, moving on and off the toilet, surface to surface transfers, and did not walk or turn around. The MDS coded the resident had an impairment on one side of his/her upper extremity and both sides of his/her lower extremity. The MDS included the resident had no falls since admission or prior assessment, and did not utilize a restraint or mobility devices. The resident's cognitive loss dementia Care Area Assessment (CAA) dated 6/13/12 included the resident at times was confused to place and time, due to a cerebral vascular accident, rapid loss of brain function(s) due to disturbance in the blood supply to the brain, and required extensive assist with all activities of daily living except eating. The fall CAA dated 6/13/12 included the resident was at risk for falls due to a balance deficit, required 2 staff or the mechanical lift for transfers, no history of falls, the resident's left hand was contracted, had limited range of motion in his/her left shoulder and both legs and he/she could not extend his/her legs due to a functional decline. The resident's care plan dated 9/5/12 included the resident had a pressure reduction mattress on bed with an air overlay and utilized a pressure relieving wedge for repositioning when in bed. The care plan included the resident had a self-care deficit related to functional limitations, had a cone in his/her left hand due to a contracture, was unable to fully straighten out his/her legs and dependent upon staff for locomotion via a wheelchair. The care plan included the resident utilized a body alarm at all times, transfer bars to his/her bed which aided in repositioning while in bed (in place since 11/10/11), and required a mechanical lift for or 2 staff assistance with transfers and utilized a high/low bed with the bed in the lowest position for fall preventions and at request of the resident's family. The care plan did not address the side rails. A nurse's note dated 1/8/12 and timed 12:05 A.M. documented the resident was on the floor by his/her bed, the resident stated he/she tried to get up and slid out and staff placed the resident's bed in the lowest position. A nurse's note dated 11/1/12 and timed 5:10 P.M. documented that at 4:20 P.M. a licensed nurse was summoned to the resident's room. Staff reported the resident was on the floor, his/her legs and hips were on the floor and the resident's upper body and neck was on the side rail, the resident's body alarm was attached to the bed and shirt and the bed was in low position. The alarm did not sound. The note included the resident's blood pressure was 123/59 pulse was 80, respirations 16, the resident's oxygen saturation rate was 90 to 91 percent (%) on room air and the facility received a physician's orders [REDACTED]. A nurse's note dated 11/1/12 and timed 7:10 P.M. documented the resident returned to facility, the resident had a congested non-productive cough which was present in the emergency room , had a reddened area to the back of his/her neck from a cervical collar (placed by the ambulance staff) due to the transfer to the hospital and continued with redness to front base of his/her neck. Review of the hospital's emergency room discharge instructions dated 11/1/12 included for the facility to apply a cool cloth to the resident's neck three times a day and to monitor the resident for any changes in level of consciousness. During interview with licensed nurse C on 11/15/12 at 9:00 A.M. staff stated the facility had not conducted side rail assessments since the facility went to 1/4 rails about 1-2 years ago. Nursing administrative staff A present during the interview stated he/she was employed at the facility since 6/12 and the facility had not performed side rail assessments since that time. During interview with activity staff D on 11/15/12 at 9:26 A.M. staff stated that on 11/1/12 at approximately 4 P.M. he/she was in the television room (directly across from the resident's room) conducting an activity and noticed the resident's blankets were on the floor, he/she entered the resident's room to ensure the resident's safety, observed the resident on the floor leaning against his/her bed and summoned licensed nurse C. Activity staff D stated the resident's body alarm was intact but did not sound. During interview with licensed nurse C on 11/15/12 at 9:40 A.M. staff stated on 11/1/12 between 4:00 P.M. and 4:15 P.M. activity staff D summoned him/her to the resident's room, he/she entered the resident's room and the resident was on the floor, the resident's legs and buttock was on the floor, the resident's legs bent and the resident was leaning on the mattress and the side rail. Licensed nurse C stated the resident had a pink area on the side of his/her neck and the left side of his/her head. Licensed nurse C stated the mark on the side of the resident's neck measured about 3 inches long and 1 ? inch wide. Licensed nurse C stated the resident was at risk for falls. Licensed nurse C stated the resident hit and pinched staff during care and if direct care staff could coach the resident to hold onto the side rail the resident could not hit or pinch the staff during cares. Licensed nurse C stated the resident was totally dependent upon staff for bed mobility and could not reposition himself/herself. Licensed nurse C stated staff repositioned the resident at least every 2 hours. During interview with administrative nursing staff B on 11/15/12 at 9:50 A.M. staff stated the facility lowered the low air loss mattress pressure after the incident on 11/1/12. Administrative nursing staff stated the facility felt the mattress had too much pressure ("air") which forced the resident out of bed on 11/1/12 and lowering the pressure allowed staff to center the resident in the bed. Administrative nursing staff stated all low air loss mattresses were set on 4 and the facility lowered the pressure to 2 after the incident on 11/1/12. During interview with direct care staff F on 11/15/12 at 9:54 A.M. staff stated he/she started placing the resident in bed at 1:00 P.M. on 11/1/12. Direct care staff F stated he/she positioned the resident on his/her left side, placed a wedge behind his/her back (right side), secured the personal body alarm and raised the side rails. Direct care staff F stated the resident used the side rails to assist the staff during care and the resident was totally dependent upon staff for bed mobility and positioning. Direct care staff stated he/she clocked out at 2:00 P.M. on 11/1/12; therefore he/she did not check on the resident after he/she left the resident's room after 1:00 P.M. Direct care staff F stated staff repositioned the resident every 2 hours. Administrative nursing staff B on 11/15/12 at 10:02 A.M. stated staff should repositioned the resident at least every 2 hours. Administrative nursing staff B stated he/she spoke with direct care staff F after the incident on 11/1/12 to see how the resident was positioned prior to the incident. Administrative nursing staff B confirmed there was no evidence to support the facility had repositioned and/or checked on the resident from the time direct care staff placed the resident in bed at 1:00 P.M. until the resident was found on the floor between 4:00 P.M. to 4:15 P.M. Review of the facility's investigation with an incident date of 11/1/12 included the resident had a half rail and that at approximately 4:20 P.M. staff observed the resident sat on the floor facing his/her bed and the resident's neck was against the side rail with his/her neck closer to the mattress and the resident's body was on the floor, the resident had an approximate 3 inch red mark across his/her anterior neck distal to the thyroid membrane, (gland in the neck) down by the notch at the tracheal (breathing tube) area and the facility transferred the resident to a local hospital for further evaluation. The facility's investigation included after incident the facility lowered the air pressure of the air flow mattress to help stabilize the resident in the center of the bed and shortened the body alarm and attached the alarm to the resident's outside shoulder. Review of the resident's clinical record on 11/15/12 at approximately 8:40 A.M. lacked evidence to support the facility had performed a side rail assessment to determine the necessity and safety of the side rail. Further review of the resident's clinical record also lacked evidence to support the facility had assessed the safety hazard of using a specialty mattress when the resident utilized side rails. Observation on 11/15/12 at 11:00 A.M. revealed the alternating pressure low air loss mattress (this mattress alternated the air from side to side) the resident utilized on 11/1/12. The mattress had pressure settings (1-8) to set the softness or firmness of the mattress, alternate pressure button (that could cycle at 10, 15, 20 or 25 minutes) and a static button (maintained the mattress at constant pressure). During interview with direct care staff E at that time staff stated the facility initially set the pressure setting for all residents at 4, the alternate pressure at 15 cycles per minute and did not use the static setting. Direct care E stated nurses could increase/decrease the pressure setting if warranted to ensure the resident did not bottom out or for patient comfort. Direct care staff E stated the facility did not set the pressure control setting based on resident's cognition or weight. Direct care staff E stated the facility had not educated staff regarding low air loss mattresses. On 11/15/12 at approximately 11:30 A.M. direct care staff E and licensed nurse C showed the surveyor the exact side rail the resident had in place at the time of the incident on 11/1/12. Observation at that time revealed the side rail was 1/4 side rail with 3 openings within the perimeter of the side rail. Measurements provided at that time by direct staff E included the side rail was 20 inches long with a height of 8 1/2 inches and the 2 outer openings within the perimeter of the side rail measured 7 1/4 inches long by 3 1/4 inches wide and the middle opening measured 2 1/2 inches long by 4 inches wide. Review of the owner's manual for the alternating pressure and limited loss air loss low mattress revealed the mattress was a flotation therapy mattress, failure to comply with all directions and warnings may result in injury or death; use only as directed and the product was not suitable for all individuals. The product was not designed to and could not replace good care-giving practices and treatment including, but not limited to adequate training for and precautions by staff personnel for bed entrapment and selection of an appropriate bed system to use with the product. The product was designed to assist in the prevention and treatment of [REDACTED]. Directions for use included after preparing the resident surface, place the resident on the system, initially set the pressure control knob to low and increase if necessary for resident comfort and immersion. Review of the facility's undated side rail policy and procedure included the facility utilized side rails on residents' beds to assist staff in repositioning or enabled residents to turn/reposition him/herself in bed. The need for side rails would be evaluated on admission and regularly thereafter. The resident fell from the bed and was found on the floor with his/her neck pressed against the side rail resulting in a red mark three inches long. By the facility's failure to assess the use of side rails and an low air loss mattress prior to using for this cognitively impaired, dependent resident with a history of falls, placed the resident, at risk for entrapment and in immediate jeopardy. The Immediate Jeopardy was abated on 11/15/12 at 5:00 P.M. based on the facility ' s written plan of correction that included: 1. Completed side rail assessments on all residents with side rails. 2. The facility developed a policy for Side Rail use which included staff would assess the use of side rails on a quarterly basis and as needed. Staff would assess for the appropriateness and safety of the side rail and the risk of entrapment, including the presence of physical, mental, behavioral, or medication impairment. The care plan committee would educate the resident and /or his/her family about the purpose and potential dangers of side rails. 3. The facility developed a policy of Air Flow Mattresses which included the interventions for setting the firmness level to the lowest setting and allow 25 minutes for the mattress to fully inflate. Increase firmness if necessary for resident comfort and support. Staff would complete quarterly assessments on residents that use an Air Flow Mattress. 4. Inserviced direct care and nursing staff on the danger of side rails and the possibility of entrapments and Air Flow Mattress use and policies. All direct care staff and nursing staff were inserviced by 11/15/12 at 5:00 P.M. 5. Staff would visually assess the mattress' functionality before placing a resident in bed. If they notice a decompression of the air mattress or widening of the gaps between the bed and/or side rail the supervisory staff would assess prior to placing the resident in the bed. 6. Director of Nursing and the Quality Assurance team would re-evaluate beds with side rails, including "gap" measurement and appropriate sizing of mattresses for bed frames. 7. The care plan committee and the nurse consultant would monitor the compliance of these tasks 8. The QA team was responsible for the setting of the firmness of the air flow mattress. 9. The QA team will do monthly reviews for continued compliance. This deficient practice remained at a scope and severity of a D - Review of resident #2's quarterly Minimum Data Set 3.0 dated 10/17/12 identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance of 2 person assistance for bed mobility, transfers, walking in the room/corridor, dressing and was totally dependent upon staff for locomotion on/off the unit, toilet use and personal hygiene. The MDS coded the resident had (1) fall with no injury since the prior assessment. The MDS included the resident was unsteady when moved from seated to standing position, walking, turning around, when moved on and off the toilet and surface to surface transfers. The MDS coded the resident had impairment on one side of his/her upper extremity and impairment on both sides of his/her lower extremity and utilized a walker and wheelchair. The resident's cognitive loss/dementia care area assessment (CAA) dated 5/9/12 included the resident was confused and had difficulty making his/her needs known to staff. The resident's fall CAA dated 5/9/12 included the resident had balance problems, history of falls prior to admission, had a very short shuffling gait related to Parkinson's, had declined in his/her activities of daily living and had several falls in the past review period. The resident's fall risk assessment dated [DATE], 7/25/12 and 10/17/12 identified the resident scored 24 (according to the legend a score above 10 represented the resident at high risk for falls). The resident's care plan dated 10/24/12 included the resident required extensive staff assistance with ambulation, had a very slow choppy gait, staff placed his/her bed in low position at night, the resident may use hand/transfer bars as needed for a stable support for repositioning and the resident utilized a personal body alarm at all times. The care plan included the resident could become confused at night which could lead to falls, bruises and skin tears. A nurse's note dated 8/4/12 and timed 5:30 A.M. included the resident's personal alarm sound, staff found the resident on the floor in his/her room and no injuries observed. On 11/15/12 at 8:05 A.M. observation revealed (2) 1/4 side rails in the up position on the resident's bed. Further observation revealed three openings/spaces within the perimeter of the bed rails. During interview with licensed nurse C at that time staff confirmed the resident utilized bilateral 1/4 side rails. On 11/15/12 at 8:15 A.M. measurements revealed the (2) outer openings/spaces had horizontal gap that measured 7 1/2 inches. Review of the resident's clinical record lacked evidence to support the facility had performed a side rail assessment to determine the necessity and safety of the side rails. On 11/15/12 at 8:20 A.M. direct care staff G & H transferred the resident from the wheelchair to the toilet. Observation revealed the resident required extensive assistance of 2 staff during the transfer. During interview with direct care G at that time staff stated the resident required extensive staff assistance for bed mobility and transfers. On 11/15/12 at 9:10 A.M. and 2:10 P.M. the resident was in bed, 1/4 side rails in the up position without gap fillers. During interview with licensed nurse C on 11/15/12 at 8:05 A.M. staff stated the resident's side rails were identical to side rails resident #1 had utilized except for the color. During interview with licensed nurse C on 11/15/12 at 9:00 A.M. staff stated the facility had not conducted side rail assessments since the facility went to 1/4 rails about 1-2 years ago. Nursing administrative staff A present during the interview stated he/she was employed at the facility since 6/12 and the facility had not performed side rail assessments since that time. According to the Food and Drug Administration, Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering and that the space be less than 120 millimeter (4-3/4 inches. Review of the facility's undated side rail policy and procedure included the facility utilized side rails on residents' beds to assist staff in repositioning or enabled residents to turn/reposition himself/herself in bed. Staff would evaluate the need for side rails on admission and regularly thereafter. The facility failed to conduct a side rail assessment to determine the necessity and safety of the side rail and failed to ensure the horizontal gap did not exceed 4 3/4 inches for this cognitively impaired resident. - Review of resident #3's October 2012 Medication Sheet included the resident had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 3 (severely impaired cognition) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use and personal hygiene. The MDS coded the resident unsteady and could only stabilize with human stability when moving from seated to standing, moved on and off the toilet, walking, and turning around. The resident did not perform surface to surface transfers and no falls since the prior assessment. The resident's cognitive loss/dementia care area assessment (CAA) dated 2/29/12 included the resident had short and long term memory problems and impaired decision making skills. The resident's fall CAA dated 2/29/12 included the resident had a history of [REDACTED]. The resident's fall risk assessment dated [DATE] and 10/24/12 identified the resident scored 16 (according to the legend a score of 10 or above represented the resident at high risk for falls). The resident's care plan dated 10/31/12 included the resident utilized an alternating air mattress on his/her bed. The resident was at risk for falls, utilized a high/low bed in low position at night and utilized a personal alarm at all times. The care plan included the resident lacked the coordination to use a walker and required hand-held assist of 1-2 people when ambulating. On 11/15/12 at approximately 8:15 A.M. staff ambulated the resident to the dining room. On 11/15/12 at approximately 11:15 A.M. the resident laid in bed and observation revealed the resident's bed had an alternating low loss air mattress. Further observation revealed the pressure control set at 4 and the mattress set to cycle every 15 minutes. During interview with direct care staff E at that time staff confirmed the resident's bed had an alternating low loss air mattress. During interview with direct care staff E on 11/15/12 at 11:00 A.M. staff stated the facility initially set the pressure setting for all residents at 4, the alternate pressure at 15 cycles per minutes and did not use the static setting. Direct care E stated nurses could increase/decrease the pressure setting if warranted to ensure the resident did not bottom out or for patient comfort. Direct care staff E stated the facility did not set the pressure control setting based on resident's cognition or weight. Direct care staff E stated the facility had not educated staff regarding low air loss mattresses. During interview with administrative staff A on 11/15/12 at approximately 3:00 P.M. staff stated the facility did not have a policy and procedure regarding low air loss mattresses. Review of the owner's manual for the alternating pressure and limited loss air loss low mattress revealed the mattress was a flotation therapy mattress, failure to comply with all directions and warnings may result in injury or death; use only as directed and the product was not suitable for all individuals. The product was not designed to and could not replace good care-giving practices and treatment including, but not limited to adequate training for and precautions by staff personnel for bed entrapment and selection of an appropriate bed system to use with the product. The product was designed to assist in the prevention and treatment of [REDACTED]. Directions for use included after preparing the resident surface, place the resident on the system, initially set the pressure control knob to low and increase if necessary for resident comfort and immersion. The facility failed to provide training regarding the use of the low loss air mattress and precautions for staff personnel to ensure control setting were properly set to prevent possible falls and/or injury for this cognitively impaired resident with an air loss alternating mattress.

The facility had a census of 30 residents. The sample included 13 residents. Based upon observation, record review, staff and resident interview the facility failed to ensure that 1 (#16) of 3 sampled residents for nutrition maintained acceptable parameters of nutritional status. Findings included: - Resident's #16's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident's significant Minimum Data Set (MS) 3.0 with an assessment reference date of 1/11/12 identified the resident scored a 10 (moderate impaired cognition) on the Brief Interview for Mental Status, required supervision with eating, and required extensive staff assistance with other activities of daily living. The MDS recorded the resident weighed 146 pounds, received a mechanically altered diet, had experienced a weight loss and was not on a physician prescribed weight loss program. The resident's nutritional status care area assessment dated [DATE] documented the resident received a mechanical altered diet, usually ate more than 75 percent (%) of each meal, had sustained a weight loss due to thrush and being resistive with food/fluid intake and the facility started the resident on a nutritional supplement. The resident's care plan dated 1/18/12 addressed the resident weighed 145 pounds, needed staff assistance with set up at meals, required staff supervision with meals only on occasion, required extensive staff assistance in the evening with meals when fatigued and received [MEDICATION NAME] (a nutritional supplement) on a daily basis. The facility's nutrition standard of care (date unknown) addressed residents received diet as ordered, the facility monitored residents' weight routinely or as ordered, monitor residents' food intake, and received nutritional interventions as ordered or suggested by the dietician. A laboratory report dated 9/27/11 recorded the resident's total protein as low 6.3 gram/deciliter (g/dL) (normal reference range 6.4-8.2 g/dL); and the resident's [MEDICATION NAME] level as low 2.7 (normal reference range 3.4-5.0 g/dL). Review of the resident's weight record revealed the following weights: 10/25/11: 167 pounds 11/08/11: 164 pounds 11/22/11: 162 pounds 12/06/11: 157 pounds 12/19/11: 155 pounds 01/02/12: 146 pounds (21 pounds in less than 3 months or 12.5%) 01/17/12: 148 pounds 02/27/12: 148 pounds A nurse's note dated 12/17/11 timed 8:20 P.M. documented the resident made a painful expression when he/she took the medications, staff asked the resident if he/she had a sore throat, the resident said no, staff asked the resident if he/she had trouble swallowing and the resident shook his/her head yes. The staff asked the resident if he/she would want to pursue a swallowing study and the resident stated no. The clinical record lacked evidence the facility had attempted other alternatives to minimize the resident's swallowing difficulties. A nurse's note dated 1/3/12 timed 9:00 A.M. documented the facility notified the physician of the resident's weight loss and received a physician's orders [REDACTED]. A nurse's note dated 1/3/12 and timed 8:30 A.M. documented the resident lost 5% of his/her body weight in less than 30 days. A nurse's note dated 1/6/12 timed 8:00 P.M. documented the resident took the night time medications and took 15 minutes to swallow the medications. A nurse's note dated 1/8/12 timed 8:45 A.M. documented the resident took the A.M. medications without difficulty, took a drink of milk and let the milk run out of his/her mouth. A nutritional assessment dated [DATE] (time unknown) and signed by a registered dietician documented the resident held the fork for a long time after taking a bite, staff stated the resident would not eat if encouraged or if someone watched, the resident was already on supplement, the resident's appetite varied, and the resident continued to receive the nutritional supplements. The clinical record lacked evidence the registered dietician assessed the resident's nutritional status until 1/30/12 (after the resident had experienced the weight loss). A registered dietician's note dated 2/27/11 timed 12:07 P.M. documented the resident refused to eat at some meals, and due to poor intake the dietician recommended increasing the juice supplement ([MEDICATION NAME]) to 4 ounces three times a day at meals. The resident's January 2012 meal intake log revealed the facility did not consistently record the resident's meal consumption. For example the facility did not record the resident's breakfast meal intake on 1/1, 1/9, 1/16, 1/27 or 1/28/11, lunch meal intake not recorded on 1/9, 1/11 to 1/13, 1/16, 1/20 and 1/24; supper meal intake not recorded on 1/20 or 1/29/11. Further review revealed the resident did not consume any of the breakfast meal 13 days, or any of the supper meal 4 days. The resident's February 2012 meal intake log revealed the facility did not consistently record the resident's meal consumption. Further review revealed the resident consumed 25% of the meals 26 times. The resident's snack/supplement record from January 19th to February 26 recorded the resident consumed 100% of the nutritional supplement each night. On 2/23/12 at 12:20 P.M. the resident sat at the dining room table with the lunch meal in front of him/her which consisted of goulash, lima beans, jello, and pie. The observation revealed the resident appeared asleep and had not consumed any of the meal. At 12:39 P.M. the resident had finished with the lunch meal and had not consumed any of the meal. The observations did not reveal staff cued/encouraged the resident or offered an alternate. On 2/27/12 at 7:50 A.M. the resident sat in the dining room, the breakfast meal in front of him/her which consisted of poached eggs, toast with jelly and a bowl of diced peaches. Observation revealed the resident nibbled on a piece of toast. At 8:32 A.M. the resident sat at the breakfast table and had not consumed any of the meal. The observations did not reveal staff cued/encouraged the resident or offered an alternate. During interview with dietary staff X on 2/27/12 at 8:40 A.M. the staff confirmed the resident did not consume any of the breakfast meal. On 2/27/12 at 12 noon the resident sat at the dining room table, the lunch meal in front of him/her which consisted of a ground beef patty, mashed potatoes and gravy, green beans, fruit slushi and a piece of cake. At 12:30 the resident had finished with the meal and had consumed 25% of the cake and 25% of the slushi, a bite of meat and potatoes and gravy, and 75% of the juice (not the nutritional supplement). The observations did not reveal staff cued/encouraged the resident or offered an alternate. On 2/27/12 at 8:50 A.M. the resident stated he/she liked the nutritional supplement and would drink more of the supplement if offered. During interview with direct care staff Q on 2/27/12 at 1:40 P.M. the staff stated the resident had not been eating well, staff had to ensure the resident chewed and swallowed foods if not the resident pocketed the food in his/her mouth. During interview with direct care staff R on 2/27/12 at 1:50 P.M. the staff stated the resident had swallowing difficulty lately, retained food in his/her mouth and last week he/she removed a large quantity of food from the resident's mouth. During interview with licensed nurse H on 2/27/12 at 1:56 P.M. the staff stated the resident consumed 25% of the lunch meal, and had not pocketed food in a while. During interview with administrative nursing staff D on 2/27/12 at approximately 3:30 P.M. the staff stated he/she was aware the resident had experienced a weight loss, and received a nutritional supplement on a nightly basis. Administrative nursing staff D stated he/she did not think the resident was pocketing food, and the facility had not explored other alternatives or causal factors for resident's refusal to eat at some meals, other than starting the resident on the nutritional supplement. Administrative nursing staff D stated the facility should record the resident's food intake as care planned. The facility's policy and procedure on weight variance included after determining a resident experienced a significant weight loss, the facility reviewed the resident's medical records to determine possible causes and started interventions to correct weight losses. The policy and procedure included the facility would monitor the resident's labs and a thorough food intake would be completed, the consulting dietitian would be notified on his/her next visit and would assess to make appropriate recommendations. The policy and procedure included the facility reviewed the resident's medical record for causes of weight variations, and would determine interventions to correct the weight problem. The facility failed to timely assess and provide timely interventions for this resident with a 21 pound weight loss in ten weeks.

The facility reported a census of 33 residents and the sample was 16. Based on record review, observation, and staff interview, the facility failed to provide assessment and bowel monitoring for 1 (#36) resident, and failed to provide assessment/monitoring for skin issue for 1 (#17) resident in the sample. Findings included: - Resident #36 had [DIAGNOSES REDACTED].[REDACTED] The hospital admitted d [DATE] and discharge date [DATE] recorded final [DIAGNOSES REDACTED]. The hospital course recorded the resident was lethargic and fell asleep easily, was just not feeling well in general, could be aroused, abdominal exam was unremarkable, had UTI, was started on intra venous (IV) fluids, oxygen, IV antibiotics, had some exacerbation of [MEDICAL CONDITION], and given additional [MEDICATION NAME] IV, also lab was checked due to history of [MEDICAL CONDITION], and computerized tomography (CT) of abdomen /pelvis was negative for tumors. The bowel/bladder assessment dated [DATE] recorded the resident was continent of bowel. The staff recorded the resident had a [DIAGNOSES REDACTED].M. when arising. The staff noted the resident had an appointment with the urologist on ,[DATE]. On [DATE] the staff recorded the resident took self to the toilet independently. The care plan last reviewed [DATE] recorded several changes done with his/her improvement in activities of daily living, able to walk alone, needed minimum assistance with dressing/grooming/toileting, the weight had stabilized, the staff noted most improvement after the physician added [MEDICATION NAME], and now the resident went out with family. The care plan for personal care dated [DATE] recorded that the resident needed limited assistance with oral care, needed limited assistance/supervision with dressing, and needed supervision with toileting. For mobility/safety the staff recorded he/she used a walker for short distances most times, wheel chair for long distance, and needed staff to walk with him/her if felt dizzy or unsteady. The care plan did not address bowel monitoring. The physician visit [DATE] recorded the resident continued on skilled care, had some mood changes still, was much more drowsy on [MEDICATION NAME], and the resident also had some problems with constipation. Plan: "will try low dose [MEDICATION NAME] 75 milligram (mg) at bedtime, and will start [MEDICATION NAME] 100 mg daily to see if that helps with the constipation, may need to change to [MEDICATION NAME] if it is not successful." Nurses notes (NN) dated [DATE] the physician was at the facility to see the resident, an order for [REDACTED]. NN dated [DATE] at 1:10 P.M. recorded the resident returned from physician visit with [DIAGNOSES REDACTED]. NN [DATE] complained of not feeling well, diaphoretic, drank glass of V8 juice, complained of stomach feeling upset, and the staff gave [MEDICATION NAME] 30 milliliter (ml). NN [DATE] MDS change of status done due to improvement in mood /behavior and improvement in activities of daily living. NN [DATE] at 2:00 P.M. the resident complained of chest pain, said it just started, vitals stable, bowel sounds (BS) hyperactive x 4, the staff gave the resident [MEDICATION NAME] 30 ml, lungs clear, complained of [MEDICAL CONDITION] tenderness with slight palpitation. At 2:50 P.M. the resident reported feeling fine now, and had no complaint of chest pain. NN [DATE] at 10:30 A.M. the resident complained of pain in left upper quadrant and radiated into the back very tender to touch, he/she was unaware of last time bowels moved. The resident came up to the nurses' station 40 minutes later and said he/she had a good bowel movement (BM) and that his/her pain was gone. NN [DATE] at 6:00 P.M. the resident vomited and complained the stomach felt "sour", and the staff gave the resident [MEDICATION NAME]. At 7:00 P.M. the resident vomited 1 time, and then reported he/she felt much better after vomiting. At 11:00 P.M. the resident vomited moderate amount of brownish liquid with few solid particles, had no fever at this time. skin cool to touch, denied pain. NN ,[DATE] at 1:50 A.M. the resident was awake vomited moderate amount of brownish liquid, the skin was cool to touch, denied pain, no fever noted, and at 2:30 A.M. the resident was asleep. At 5:30 A.M. the resident had no further nausea/vomiting. NN [DATE] at 10:55 A.M. the resident was alert/oriented times 3 and sat up in bed eating crackers and drinking water, denied pain, denied breakfast, but requested lunch consisting of soup in room. The staff recorded the resident had not vomited. NN [DATE] at 2:30 P.M. the resident complained of feeling very nauseated and started vomiting. The resident vomited several times within 15 minutes, large amount of undigested food, denied feeling weak, and was afebrile. At 6:00 P.M. received a room tray with broth and jello, consumed 100% and reported feeling better. The resident did not vomit, ambulated to the bath room without difficulty. NN [DATE] at 9:30 A.M. the resident ate a pancake and fruit for breakfast, and stated he/she felt a little better. NN [DATE] at 1:00 P.M. the staff recorded that this P.M. the resident had liquid emesis, staff reported 3 liters of emesis, watery with brown particles. The resident stated: "Ever I feel to[***] it comes up the other way." Bowel sounds times 4, last BM [DATE], resident did not remember past that. The resident did not want anything to eat for lunch, was afebrile, oxygen saturation was 86% on room air, rechecked after oxygen 2 liters given, the saturation levels was >90 %. The resident and the family was aware. NN [DATE] at 1:00 P.M. the staff gave the resident [MEDICATION NAME] and a [MEDICATION NAME] suppository. At 2:05 P.M. the resident stated feeling better, had a small formed result from suppository, denied need/want for food/drink. At 2:30 P.M. the staff recorded the physician ordered [MEDICATION NAME] suppository daily until adequate bowel movement (BM) achieved, [MEDICATION NAME] 17 gram daily. The resident's family was aware. At 7:00 P.M. the staff gave the initial dose of [MEDICATION NAME] at supper. A telephone order (TO) [DATE] at 2:20 P.M. recorded [MEDICATION NAME] suppository rectally 1 daily until adequate BM achieved, and [MEDICATION NAME] 17 gm daily. NN [DATE] at 2:05 A.M. the staff gave the suppository, the resident ambulated to the bathroom for a medium BM that was soft. The resident vomited about 200 milliliter (of brown liquid), returned to bed, vitals taken, oxygen saturation level on room air was 85%, oxygen on 2 liter was 92%. The resident took small sips of water and returned to bed. NN [DATE] at 8:40 A.M. the resident ate 3 bites of breakfast and drank 8 ounces tomato juice, continued to ask for water, was weak/alert, disoriented to time/place, oxygen at 2 liters, saturation levels down to 86%, their, speech difficult to understand, the staff transferred the resident to wheel chair for transport to the hospital via van, attended by licensed nurse, the staff received order to transfer to go to the hospital. The staff notified the family at 11:00 A.M. A TO [DATE] at 10:55 A.M. recorded an order for [REDACTED]. NN [DATE] at 3:10 P.M. the facility discharged the resident. The bowel monitoring sheet dated ,[DATE], the staff recorded R.S (resident said) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], on [DATE] and on [DATE] the staff recorded L (large), and on [DATE] the staff recorded M (medium). The MAR for ,[DATE] recorded on [DATE] and on [DATE] that the staff held the [MEDICATION NAME] due to loose stools. The [DATE]/11 on [DATE] 1430 [MEDICATION NAME] for [MEDICAL CONDITION] pain-effective The MAR indicated [REDACTED]. The bowel monitoring sheet dated ,[DATE], the staff recorded R.S on [DATE], [DATE], but did not document size, and on [DATE] the staff documented S (S-small) and L (large). The clinical record lacked evidence of consistent bowel monitoring. The MAR indicated [REDACTED]. On [DATE] the staff gave the resident [MEDICATION NAME] due to sour stomach with no relief, the resident vomited. The facility bowel monitoring policy recorded: "1) each resident will be monitored daily for BM and recorded on daily BM record and activities of daily living sheet by each shifts CNA 3) Residents who are independent and not assisted by CNA's for toileting will be asked daily by the ,[DATE] CNA staff if they have had a BM that day. 4) The ,[DATE] CNA's will give the charge nurse a list of residents who have not had an adequate BM (medium or larger) in the past 3 days. 5) Residents not having an adequate BM in 3 days span will receive treatment of [REDACTED]. If no results have occurred, she/he will advise ,[DATE] nurse of lack of results and ,[DATE] nurse will monitor for results. Lack of results will be reported to the next days shift charge nurse and steps repeated. 7) If no BM by the end of that 2nd day, bowel sounds will be assessed, and series repeated that evening till a BM occurs. Doctor will be notified if no results after 2 days of laxative TX or if no bowel sounds are heard." A hospital emergency room record dated [DATE] recorded an admission time of 11:00 A.M. with a [DIAGNOSES REDACTED]. The nursing triage/assessment recorded for history that since Tuesday the resident had vomited with no fever and no complaint of pain. The resident was becoming more lethargic, blood sugar in the 300's. On the last day the vomiting became fecal like, smelled like fecal matter. The record revealed the hospital admitted the resident the same day. A hospital physician report dated [DATE] recorded lower abdominal pain with suspected small bowel obstruction. A hospital history and physical dated [DATE] recorded the resident was failing over the last several days, today is weak, shaky but afebrile. Has had intermittent problems with vomiting, will eat something , then vomit several times and then would start eating again. This has been going on for ,[DATE] days. Also during this time has had elevation of blood sugars up into 300's. Exam revealed the resident was lethargic, speech really not intelligible, abdomen revealed bowel sounds were present, no palpable masses, no marked distention. The resident did moan with palpitation in the abdomen. Assessment: nausea, vomiting, dehydration, confusion, UTI, and possible small bowel obstruction. Plan: Do not think the resident is a surgical candidate if the resident had a persisting bowel obstruction. The radiology computed tomography (CT) scan report date [DATE] of the abdomen recorded patchy opacities present in both lung bases, imaging findings would be suspicious for [MEDICATION NAME] pneumonia. No pleural effusions present. The heart was enlarged. The small intestine was distended and fluid filled consistent with a bowel obstruction. The transition point is identified in the right lower abdomen immediately anterior to the right. The remaining distal ileum decompressed. A possible tiny right Richter's type hernia is present in the anterior abdominal wall. The hospital radiology CT scan of the pelvic recorded that the colon was decompressed, and that sigmoid diverticula was present but no [DIAGNOSES REDACTED]. The colon had normal appearance. Impression: 1) small bowel obstruction. Transition point identified in the right lower abdomen 2) possible very small Richter's like hernia in the anterior right abdominal wall containing a focal segment of small bowel 3) patchy airspace opacities are present in both lower lobes concerning for [MEDICATION NAME]. A staff interview on [DATE] at 12:53 P.M. with licensed nursing staff B stated the staff documented BM's on the activities of living sheet. The staff document the BM as small, medium or large. The staff said with residents who are independent with toileting that they expect the resident to come and tell them, and if they don't he/she made out a list of residents who had not had a BM in 3 days and the staff went to ask the residents. The staff he/she said then recorded R.S on the BM sheet. The staff said they don't ask for the size. The staff said that the resident started to throw up Tuesday or Wednesday ([DATE] or [DATE]) night, and on Thursday ([DATE]) when this staff came back to work the resident ate breakfast and then started throwing up later that afternoon. The staff said the resident's room mate was also throwing up at the same time, so they thought it was the flu. The staff said they talked to the doctor on Thursday as the resident was still throwing up and described the content and that the oxygen saturation levels were down. The resident threw up food that looked like the pancakes he/she had for breakfast with brown particles in it. The staff said they gave the resident [MEDICATION NAME] and a [MEDICATION NAME] suppository. The staff said the resident had a small BM before he/she left that day, formed but small. The staff said then the doctor called an order for [REDACTED]. Interview on [DATE] at 4:20 P.M. with licensed nursing staff C said the staff should record daily on BM monitoring sheet, the day shift nurse or direct care staff asked the resident if they had a BM that day, and should record every day. The staff said the day shift nurse went thru to see if a resident had no BM in 3 days and would make a record of those who have not had a BM in 3 days. The staff said they had heard from the doctor that the resident expired from pneumonia on [DATE]. The facility failed to assess/document bowel movements/bowel sounds in a timely manner. The facility failed to monitor, assess and promptly intervene to prevent further complications of the obstruction. - The [DATE] physician's orders [REDACTED]. The [DATE] Quarterly Minimum Data Set (MDS) noted the resident had clear speech and understood; the Brief Interview for Mental Status (BIMS) score of 14 indicated no cognitive impairment; required extensive assistance of one staff for bed mobility, dressing, toilet use and personal hygiene; required limited assistance of one staff for transfers, walking in room; was independent with set-up help only for eating and walking in the corridor. The [DATE] Care Area Assessment for Activity of Daily Living (ADL) noted the resident required limited and extensive assistance with ADLs because of weakness from [MEDICAL CONDITION], back pain from spinal stenosis, and [MEDICAL CONDITION]. The [DATE] Care Plan for Skin noted the history of an open area to the coccyx. On [DATE] the physician ordered Specolazole cream to a rash in the anal and groin area. During an observation on [DATE] at 2:00 P.M. the resident had an area on both sides of his/her mouth that was bright red from the corners of the mouth about 2 inches down towards the chin on both sides of the mouth. On [DATE] at 2:00 P.M. the resident reported that the redness appeared recently, it was painful, and he/she tried all kinds of creams on it that did not work. The resident reported the redness bothered him/her quite a bit as he/she did not know what caused it and it burned. The clinical record, reviewed from [DATE] through [DATE], lacked evidence of a physician's orders [REDACTED]. The Nursing Summary dated [DATE] for Skin noted no breakdown. The Nurses Progress Notes reviewed from [DATE] to [DATE] lacked evidence of any information about sores or redness next to the resident's mouth. A review of the Bath Sheets Record from [DATE] through [DATE] indicated the bath aide checked the skin, but lacked evidence of any skin issues. On [DATE] at 8:31 A.M., direct care staff D reported the resident had a bath on [DATE], he/she did not have any abrasions, or bruises. The the resident had the areas on his/her face for a couple of weeks. Staff D stated the nurses knew about these areas, so if the nurses knew, staff D did not chart it on the bath sheet. During an interview on [DATE] at 4:00 P.M., direct care aide C stated he/she saw the reddened area on the resident's face, but did not bring it to anyone's attention. Direct care staff C remembered the reddened area being on the resident's face for about a week and the resident took care of it him/herself so direct care staff C did not think there was any need to say anything or do anything about it. During an interview on [DATE] at 1:28 P.M., licensed nursing staff C said that they did not have any interventions planned for the redness around the mouth even though they were aware of it. Licensed nursing staff C said he/she noticed the reddened area on the resident's mouth/face and it was not noted on the bath sheets for [DATE] and said that he/she would take care of it. Licensed nursing staff B on [DATE] at 1;28 P.M. who said he/she was also not aware of any interventions the facility offered to the resident for this redness. On [DATE] at 3:32 P.M. the resident said that licensed nursing staff C came in and spoke with him/her and told him/her that he/she did not notice the red area before but would take a look at it and see what they could do and it made the resident feel better. The [DATE] facility Skin Alterations Policy noted: 1. All staff will monitor residents while they perform their daily duties with the resident. Staff will heed attention to the resident ' s skin during these times and notify the charge nurse of any skin abnormalities. Any new skin alteration noted by staff will be investigated by the charge nurse. 2. The bath aide will do skin checks during bathing times for all residents. A log will be done on the Bath Aide Report for all residents indicating their skin has been checked. A resident with any new skin alterations will have a Bath Skin Assessment filled out. This will be given to the charge nurse for review. The facility failed to assess and plan interventions to treat the redness of skin around this resident's mouth.