Every finding on record at El Dorado Care and Rehab

Based on observation, interview, and record review, the facility failed to provide a vegetarian diet to meet the resident's nutritional needs and failed to initiate weight loss interventions for R31, to prevent a significant weight loss of 16.30 percent (%) in 19 days. Additionally, the facility failed to provide R2 with a breakfast meal on scheduled dialysis (procedure where impurities or wastes were removed from the blood) treatment days, to meet R2's nutritional needs. Findings included:- R31's Electronic Medical Record (EMR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R31's comprehensive Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented she had behaviors of rejection of evaluation for 1-3 days in the look-back period, and she required supervision or touching for eating. R31's MDS documented she did not receive a therapeutic diet, and she received parenteral or intravenous (IV) feeding (is the administration of nutrients directly into the bloodstream through a vein, completely bypassing the digestive system) while a resident. The MDS documented a proportion of total calories the resident received through parenteral, or tube feeding, was 25 percent or less, and the average fluid intake per day by IV or tube feeding was 500 milliliters (ml) or less while a resident in the past seven days. R31's Nutritional Status Care Area Assessment (CAA), dated 03/30/26, documented R31 admitted to the facility for IV antibiotic therapy due to a recent hospitalization for urinary tract infection (UTI-an infection in any part of the urinary system). R31's MDS documented she was at risk for dehydration related to recent urinary tract infection and need for IV therapy, electrolyte imbalance, worsening infection, and decline in overall condition related to recent UTI and need for IV therapy. R31's Base-Line Care Plan, dated 03/20/26, included an intervention noting R31's food preference was vegetarian. R31's Care Plan, dated 03/25/26, included an intervention for staff to monitor and record R31's meal intakes, and to provide a Registered Dietician (RD) to evaluate and make recommendations as needed. R31's Care Plan, dated 04/02/26, included an intervention for staff to provide and serve R31's diet as ordered. R31's diet was noted as a vegetarian diet, regular texture, and thin liquids. The staff were instructed to complete weekly weights four times, then monthly, or as needed. R31's Physician Orders, documented dietary supplements may be used when determined appropriate by interdisciplinary team or RD may initiate specific order for resident, dated ordered 03/20/26. R31's Physician Orders documented an order dated 03/20/26 for R31 to receive a vegetarian diet, regular texture. R31's weights in the EMR documented:03/21/25 at 01:33 AM weighed 153.4 pounds (lbs.).03/21/26 at 11:01 AM weighed 156.2 lbs. R31's Nutrition: RD admission (Initial) Assessment, dated 03/25/26, revealed the source of the nutritional information was obtained from the medical record. The option for resident or family was not checked off. Most recent weight documented on 03/21/26 at 11:01 AM weighed 156.2 lbs. The current diet was vegetarian and the average meal intake since admission was documented as poor, less than 50 percent of meals. R31 received a vegetarian diet, and her intake was 25-50 percent. R31 appeared to be tolerating her diet consistency. The assessment included R31's admitting weight was normal, and she had a Body Mass Index (BMI is a numerical value derived from an adult's weight and height, used as a screening tool to estimate body fat and categorize individuals as underweight, healthy weight, overweight, or obese) of 25.4. The assessment noted the RD would monitor her weight trends and reassess as indicated. R31's Progress Note, dated 03/22/26 at 01:56 PM, documented R31 fed herself, had a poor appetite, and claimed to be a vegetarian. R31's Provider History and Physical Note, dated 03/23/26 at 07:00 AM, documented the resident was seen today for admission to the facility. R31 had poor intake since being on Mounjaro (medication diabetes to improve blood sugar control), had weight loss, and she reported she still has a poor appetite and was asking for small frequent portions. R31's Nutrition: Dietary Manager Initial Assessment, dated 03/30/26 at 05:27 PM, revealed the source of the nutritional information was obtained from the medical record, resident, and staff. R31's weight on 03/21/26 was 156.2 lbs. and her current diet order was a vegetarian diet, regular texture, and thin liquids. R31's intake was poor since admission, averaging less than 50 percent recorded. R31 was very particular about what she ate, and her husband brought food in for her often. Intake of meals the facility provided was poor. However, she ate what her husband brought to her, but amount she ate was unknown. R31's weights in the EMR documented:04/02/26 at 12:27 PM weighed 156.2 lbs.04/04/16 at 04:46 PM weighed 132.8 lbs. R31's Alert Note, on 04/04/2026 at 06:25 AM, revealed R31 refused her meal, and noted family brings in food. R31's EMR lacked a progress note on 04/04/26 after 04:46 PM regarding R31's weight loss. R31's Nursing Vital Signs Note, dated 04/06/26 at 09:00 AM, revealed the provider was in the facility and updated on R31's low blood pressure, however the note lacked evidence the staff updated the provider regarding R31's weight loss. R31's Progress Note, on 04/08/26 at 01:33 PM, documented the provider was in the facility, notified of the resident's weight loss and not eating well, and noted the provider would be reviewing. During a concurrent observation and interview on 04/06/26 at 10:02 AM, R31 sat up in her bed, in her room. R31 said when she admitted to the facility on a Friday evening a few weeks ago, the marketer of the facility told her the facility would be able to accommodate her vegetarian diet. R31 reported the staff did not know she required a vegetarian diet, and the facility was still having issues with following the vegetarian diet. R31's family member was also in R31's room and said the facility did not offer vegetarian food choices, when R31 gets a regular menu ticket. R31's family member said he had to bring food into the facility, so R31 would have something to eat. On 04/07/26 at 08:40 AM, R31 sat up in her bed with her covered breakfast tray in front of her. R31 reported she needed to have care provided to her ostomy (surgical opening from an area inside the body to the outside) bag before she ate. Certified Nurse Aide (CNA) P and CNA O assisted R31 with care and sat R31 on the side of the bed. At 09:05 AM, CNA O uncovered breakfast tray, revealing a piece of toast, a bowl of oatmeal, coffee, and milk. R31 stuck her finger into the oatmeal and mumbled the oatmeal was cold. Neither CNA O nor CNA P addressed R31's cold oatmeal concern and they exited the room. At 09:07 AM, R31's family member picked up the bowl of oatmeal and took it to the kitchen. On 04/07/26 at 09:09 AM, Dietary Staff DD exited the kitchen door and handed a bowl of oatmeal to R31's family member and reported she warmed the oatmeal up in the microwave in the kitchen. On 04/07/26 at 11:24 AM, Dietary Staff BB entered the kitchen during meal prep observation, she had R31's meal ticket for lunch and supper for 04/07/26. Each meal choice had a black line drawn diagonally across all the food choices. Dietary Staff BB reported she needed to review the meal ticket with R31 to see what she would like to eat. The meal ticket was observed to be labeled as a regular diet, regular texture. The meal ticket lacked the vegetarian diet and had chicken, cheeseburger, hot dog, and sloppy joe listed as choices. There was an everyday option of grilled cheese, peanut butter and jelly, or cold cut sandwich. Dietary Staff BB reported she did not have a meal ticket to offer for a vegetarian diet. Dietary Staff CC reported it was difficult to provide R31 her vegetarian diet when she did not have the choices she may need on her meal ticket. Dietary Staff BB reported she had to order the resident soy burgers and had not done that yet. During an observation on 04/08/26 at 01:06 PM, staff assisted R31 to the wheelchair scale, located by Licensed Nurse (LN) H. The staff zeroed the wheelchair scale out and pushed R31 onto the scale in her wheelchair. The weight on the display was 184.8 lbs. The staff assisted R31 back to her room, where R31's family also wrote the weight down and asked to know what the wheelchair weighed so he could know her weight loss. During an observation on 04/08/26 at 01:26 PM, CNA T brought R31's wheelchair out of her room that had the oxygen tank, seat cushion, foot pedals and lift sling on the wheelchair, as R31 had those items on the wheelchair when she was weighed at 01:06 PM. CNA T zeroed out the wheelchair scale, pushed the wheelchair onto the scaled, and the wheelchair weight displayed on scale was 56.4 lbs. CNA T wrote the weight down and gave the results to LN H, and she reported that R31's weight was 128.4 lbs. During an interview on 04/08/26 at 10:45AM Administrative Nurse F reported R31's vegetarian diet was not considered a therapeutic diet. During an interview on 04/08/26 at 11:03 AM, Consultant Staff HH said Dietary Staff BB should have changed the program when printing out R31's menus, so she could have choices for her vegetarian diet she had ordered since admission. During an interview on 04/08/26 at 12:45 PM, LN H reported she documented R31's weight in the EMR as 132.8 lbs. on 04/04/26. LN H reported she did not complete a re-weight and said the provider should have been updated and thought the provider had ordered an appetite stimulant already. LN H reviewed R31's EMR for orders and reported there was no appetite stimulant or supplements ordered. LN H reported R31 was a vegetarian and did not like the choices at the facility. LN H reported R31's family member brought food into the facility that R31 liked, but she barely eats that. LN H reported R31 was very picky. On 04/08/26 at 01:30 PM, Dietary Staff BB reported she had not looked at R31's weight documented on 04/04/26. When she reviewed the EMR she reported she did not believe R31's admission weight at the facility was correct and had no comment to R31s weight from today of 128.4 lbs. On 04/08/26 at 01:54 PM Administrative Nurse D reported she did not know R31 had a weight loss on 04/04/26. Administrative Nurse D reported the staff had difficulty getting the resident to eat and she reported that R31's family member brings her food in, all the time. Administrative Nurse D reported she did not realize R31's meal ticket choices were for a regular diet and not a vegetarian diet. On 04/09/26 at 09:42 AM, Consultant Staff HH reported he had not been updated at this time of a weight loss for R31. Weights were reviewed with Consultant Staff HH, and he reported it was a concern and would address it with Dietary Staff BB. The facility's policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated 10/2025, documented monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. As part of a nutritional assessment the interdisciplinary team will define the resident's current nutritional status through assessments. Supplementation strategies to increase a resident's intake of nutrients and calories may include fortification of foods (for example, protein added to mashed potatoes), increasing portion. Closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. - Resident (R) 2's Electronic Medical Record (EMR) revealed diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), and moderate protein-calorie nutrition (a severe nutritional deficiency caused by inadequate intake or absorption of protein and calories energy). R2's admission Change Minimum Data Set, (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R2's MDS revealed he required set up for eating; he had weight loss and no therapeutic diet. R2s Nutritional Status Care Area Assessment (CAA), dated 12/08/25, documented R2 consumed a regular diet. R2's Body Mass Index (BMI is a numerical value derived from an adult's weight and height, used as a screening tool to estimate body fat and categorize individuals as underweight, healthy weight, overweight, or obese) was higher than recommended for his height. R2 was not currently on a planned weight loss program and has not voiced a desire to lose weight. R2's Quarterly MDS, dated [DATE], documented a BIMS score of 15 indicating intact cognition. MDS documented R2 had no behaviors and required set-up assistance for eating. R2 had weight loss and received a therapeutic diet and required dialysis. R2's Care Plan, dated 12/16/25, revealed staff instructed to provide and serve diet as ordered. Regular diet and texture, and thin liquids. R2's Care Plan, dated 04/07/26, lacked documentation regarding dialysis treatment and current diet order of renal dialysis diet, regular texture, thin consistency. R2's Physician Orders documented renal dialysis diet, regular texture, and thin consistency date ordered 02/12/26. R2's Physician Orders documented dialysis treatment Monday, Wednesday, and Friday at Dialysis Center, his chair time was 06:20 AM. R2's Weights reviewed from 11/26/25 through 04/08/26, no concerns noted. R2's Progress Note, dated 02/12/26 at 03:46 PM, documented R2 had dialysis appointment on 02/13/26 and would be leaving at 05:20 AM. R2's Nutrition Assessment Note, dated 02/19/26 at 12:34 PM ,documented R2's current weight was 215.2 pounds on 02/13/2026. R2's current diet order was therapeutic renal diet and R2's meal intakes were good at averaging 76-100 percent. Per documentation, the resident required set-up or clean-up with eating. R2 completes dialysis three times per week. Will continue monitor weight trends; reassess as indicated. R2's current intakes are adequate to meet estimated needs. R2's Progress Note, dated 03/18/2026 at 04:35 AM, documented R2 up and ready for dialysis, transported per facility van, accompanied by facility staff. R2's Progress Note, dated 03/23/2026 at 08:23 AM, R2 moved to a different dialysis center and his chair time changed to 05:15 AM which started 3/25/26. R2's Nutrition Amount Eaten documented in tasks on EMR reviewed from 02/13/26 through 04/08/26 revealed for breakfast meal intake documented on 02/13/26, 02/16/26, 02/23/26, and 03/06/26 R2 was not available. The breakfast meal intake documented on 02/20/26, 02/25/26, 02/27/26, 03/02/26, 03/09/26, 03/10/26, 03/13/26, 03/18/26, 03/20/26, 03/23/26, 03/25/26, 03/27/26, 03/28/26, 03/29/26, 04/01/26, 04/02/26, and 04/08/26 breakfast meal was documented non applicable. On 04/06/26 at 02:45 PM, R2 was seated up in his bed completing a crossword puzzle. He reported that he just returned from dialysis. R2 reported that he leaves very early in the morning to be at the dialysis center by 05:00 AM and stated that he does not eat breakfast before he goes to dialysis, as he is not provided one and he is not provided a snack to eat at the center. On 04/07/26 at 07:56 AM, R2 was in bed looking at a book, he reported he did not think he would get up today and was waiting for his breakfast. On 04/08/26 at 05:42 AM, Certified Nurse Aide (CNA) V reported that R2 did not have breakfast this morning and reported that he would usually refuse the breakfast. CNA V reported that there was not an actual meal prepared for R2 to be offered to be refused on dialysis days though. CNA V said to ask CNA S, as she always worked on R2's hallway. On 04/08/26 at 05:44 AM, Licensed Nurse (LN) K reported that R2 started dialysis in February 2026 and cannot recall that he had been offered a breakfast meal before he left for dialysis when he worked those mornings. On 04/08/26 at 06:12 AM, CNA S reported the kitchen was closed at the time R2 woke up to go to dialysis. CNA S reported we do not have alternatives to give him for a meal. She reported that she did not offer any snacks, food, or drinks to take with him to dialysis. On 04/08/26 at 09:20 AM, Dietary Staff BB (Certified Dietary Manager) reported R2 refused to have breakfast before dialysis, and she reported that it was not documented in R2's progress notes or R2's care plan. Dietary Staff BB reported that R2 verbalized to her that was his preference. On 04/09/26 at 09:42 AM, Consultant Staff HH (Registered Dietician) reported that R2 should be offered breakfast in the morning before dialysis and reported it was expected that if R2 refused to have a breakfast meal prior to dialysis, it should be documented in the EMR. The facility's policy Dialysis, Care for a Resident, dated 03/2026, documented communication between the community, and the dialysis facility shall contain nutritional and fluid management, including resident's compliance with diet, and/or after dialysis. The facility's policy Frequency of Meals, dated 10/2025, documented that each resident would receive at least three meals daily, at regular times, comparable to normal mealtimes in the community or in accordance with the resident needs, preferences, requests, and plan of care. The facility will serve at least three meals or their equivalent daily at scheduled times. There will not be more than a fourteen (14) hour span between the evening meal and breakfast. The facility will provide alternative nourishing meals and snacks to residents who want to eat outside scheduled meal service or at non-traditional times.

Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) 2026 Quarter 1 and FY 2025 Quarter 3 had excessively low weekend staff.On 04/08/26 at 10:44 AM, Administrative Staff A stated she was aware there was a problem and found that the previous Business Office Manager (BOM) had submitted the information incorrectly. She stated she was working with her new BOM to make sure it was being submitted correctly.The facility's Payroll Based Journal F851 policy, dated 10/25, documented that the community would submit the payroll data in a uniform format to CMS, including staffing information for community, agency, and contract staff. The direct care staff are those individuals who, through interpersonal contact with residents or resident care management, provide care and services to allow residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Direct care staff does not include individuals whose primary duty is maintaining the physical environment of the long-term care facility. The data would be submitted electronically based upon specifications determined by CMS, and the reported information would be for direct care staff and would specify whether the individual was an employee of the facility or is engaged by the facility under contract or through an agency.

Based on interviews, observation, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing wound care to a Resident (R) 2 with a Foley catheter (tube inserted into the bladder to drain urine into a collection bag), colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and a hemodialysis port (a subcutaneous vascular access device placed under the skin to provide long-term access for hemodialysis {procedure where impurities or wastes were removed from the blood}). The facility further failed to ensure adequate hand hygiene during care for R43, R31 and R8. Findings included: - During an observation on 04/07/26 at 08:16 AM, Certified Nurse Aide (CNA) O and CNA P provided peri-care care to R43. CNA O opened R43's drawer and removed a tube of barrier cream, with the same gloved hand she used to provide R43's peri-care, then began to apply barrier cream to R43's buttocks. CNA O then removed her gloves and did not perform hand hygiene before she applied a new pair of gloves. CNA P did not change her gloves after assisting R43 with pericare, in which R43 had a small, soft bowel movement, and continued to assist R43 with clothing. CNA P then removed her gloves and walked over to the glove box, but it was empty. CNA P did not perform hand hygiene after removing her soiled gloves, grabbed the doorknob and exited the room. CNA P returned to R43's room and applied new gloves. An interview on 04/07/26 at 03:17 PM revealed CNA O and CNA P both said they did not realize they had to wash their hands when they removed soiled gloves during care. CNA O reported she did not realize she had used her soiled gloved hand to open the drawer and apply the barrier cream to the resident. CNA P reported she did not think to change her gloves after she cleansed the bowel movement from R43 and before she assisted R43 to dress. During an observation on 04/07/26 at 08:40 AM, CNA P provided ostomy care to R31. CNA P removed R31's ileostomy (surgical formation of an opening through which fecal matter empties) bag and wafer, cleansed around the stoma, used the same soiled gloves to open the box of ostomy supplies, removed a new bag/wafer from the box, and applied the device to R31's abdomen. CNA O then opened a drawer with gloved hands and removed wipes and barrier cream. CNA P applied new gloves, then opened the bathroom door and the closet door and removed a brief. CNA P cleansed R31's buttocks and applied the barrier cream to her buttocks. CNA P removed her gloves and, without performing hand hygiene, assisted R31 with her brief. CNA O removed her gloves without performing hand hygiene, applied new gloves, opened the closet door, and removed R31's clothes. An interview on 04/07/26 at 03:30 PM revealed CNA O and CNA P both said they did not realize they had to wash their hands when they removed gloves during care. CNA P reported she was able to complete ostomy care, and she said she should have washed her hands before removing a new ostomy bag from the supply box. CNA P and CNA O stated they did not realize they used their soiled gloved hands to open drawers and closets, to gather supplies. During an observation on 04/07/26 at 09:30 AM, Consultant Staff JJ provided wound care to R8. Consultant Staff JJ removed the soiled dressings from the outer right side of R8's foot and distal end of right great toe. Consultant Staff JJ removed her gloves and asked Consultant Staff KK for a measuring stick and wound wash. Consultant Staff JJ applied new gloves without performing hand hygiene. Consultant Staff KK wiped the top of the bottle of wound wash with a sanitation wipe. Consultant Staff KK then sprayed a 4x4 gauze dressing with wound wash and cleansed the open wound on R8's outer right foot. Consultant Staff KK cleansed the open wound with a 4x4 gauze a few times without flipping the gauze. Consultant Staff KK then kept her gloves on after washing the wound and gave a wet 4x4 gauze to Consultant Staff JJ. Consultant Staff KK then opened a new dressing and handed the dressing to Consultant Staff JJ, with the same gloved hands she used to clean the open wound on R8. Consultant Staff JJ placed the dressing on the barrier, then she took her phone out of her back pocket and tried to type on her phone the wound measurements. Consultant Staff JJ removed the glove off of her right hand and typed the measurements into her phone. Consultant Staff JJ applied a new glove onto her right hand but did not perform hand hygiene. Consultant Staff KK handed Consultant Staff JJ another dressing. Consultant Staff KK then opened a 2x2 dressing and handed the dressing to Consultant Staff JJ. Consultant Staff KK continued to wear the gloves she wore to clean the wound on R8, and opened and closed drawers on the treatment cart in R8's room. After she applied a dressing to the area on the distal end of R8's right great toe, Consultant Staff JJ removed her gloves, took her phone out of her pocket, and took a picture of R8's outer right foot. Consultant Staff KK then went into R8's closet with the same soiled gloves and removed a packet of 2x2 dressings. Consultant Staff JJ typed measurements into her phone and put the phone back in her pocket, without performing hand hygiene prior to applying clean gloves and then applied the dressing to R8's right outer foot. Consultant Staff KK washed off the treatment cart with a sanitation wipe, wearing the same soiled gloves she wore since she washed R8's right outer foot open wound. Consultant Staff KK and Consultant Staff JJ removed their PPE and then performed hand hygiene. During an interview on 04/07/26 at 10:14 AM, Consultant Staff KK and Consultant Staff JJ reported they should have performed hand hygiene after removing their gloves, and Consultant Staff JJ said she generally would remove both of her gloves. Consultant Staff KK stated she thought she used a different 4x4 when she cleansed the wound and confirmed she left her gloves on the entire time, touching dressing supplies, the cart, and door handles. Consultant Staff KK reported she should have removed her gloves after she cleaned the wound and performed hand hygiene. During an observation on 04/07/26 at 10:10 AM, Consultant Staff II, Consultant Staff JJ, Consultant Staff KK, and another unknown wound care team member were in R2's room (a resident on EBP). R2 was positioned on his right side facing the window as two of the Consultant Staff members assisted him. Consultant Staff II reported they were almost finished with his wound care. Observation revealed none of the Consultant Staff in R2's room performing wound care wore a gown as required; they all wore gloves only for the wound care. During an interview on 04/07/26 at 10:13 AM, Certified Medication Aide (CMA) R reported R2 was on EBP as R2 had a colostomy, urinary catheter, and a dialysis port in his left chest. CMA R reported staff were required to wear a gown and gloves when direct care was provided. During an interview on 04/07/26 at 10:14 AM, Consultant Staff II reported they should wear the required personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) if a resident was on EBP and confirmed none of the consultant staff had worn a gown when they provided wound care for R2 that morning. During an interview on 04/07/26 at 10:19 AM, Administrative Nurse E (Infectious Preventionist) stated she expected the wound care staff to use the PPE gowns and gloves for residents that have EBP. She said she expected the wound care staff and the facility staff to perform hand hygiene when gloves were removed. Administrative Nurse E reported she expected all wounds to be cleansed by standards of care. She also expected the staff and wound care staff not to wear soiled gloves to touch clean items or residents. The facility's policy Enhanced Barrier Precautions, dated 04/2025, documented expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multiple drug-resistant organism (MDRO-common bacteria that have developed resistance to multiple types of antibiotics) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities are indicated. The facility's policy Handwashing/Hand Hygiene, dated 10/2025, documented the facility considers hand hygiene the primary means to prevent the spread of infections. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions:Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice), after removing gloves, and before handling clean or soiled dressings, and gauze pads.

Based on observation, interview and record review the facility failed to store and label biologicals adequately when staff failed to date an insulin (medications used to treat high blood glucose levels) pen when opened and failed to remove or dispose of four expired bottles of stock medications. This deficient practice placed the residents at risk to receive expired, ineffective insulin and other residents at risk to receive expired ineffective stock medications. Findings included:.- On [DATE] at 08:05 AM, observation of the 100-200 hall medication cart revealed the following:R41's Novolog (long-acting insulin) pen without an open date or the discard date.On [DATE] at 08:15 AM, observation of the treatment cart revealed four expired stock medication bottles which included:ASA (pain and anti-inflammatory medication) 325 milligrams (mg), expired 01/26.Vitamin D (vitamin supplement) 100 tablets, expired 03/26.Calcium (bone building supplement) 600 mg and Vitamin D 5 micrograms (mcg), expired 07/25.Zinc (mineral supplement) 50 mg. 100 tablets, expired 01/26. On [DATE] at 8:10 AM, Certified Medication Aide M verified the stock medication had expired. On [DATE] at 08:20 AM, Licensed Nurse (LN) G verified the undated insulin pen and stated staff were to date the insulin pens when they are opened. The facility's Medication Storage policy, dated 03/2026, stated the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The facility staff shall not use discontinued, outdated, or deteriorated drugs or biologicals and shall be returned to the dispensing pharmacy or destroyed per state regulations.

Based on observation, record review, and interview the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria and illness. Findings included:- Observation of the kitchen and food storage areas on 04/06/26 at 07:59 AM revealed the following areas of concern: The kitchen prep counter had staff's personal items laid on the counter, including a purse and a tumbler with a straw. The personal items laid next to several bags of undated hamburger and hot dog rolls. Two of the bags of rolls were not sealed. One bag of the hot dog rolls had three rolls that had fuzzy green colored areas on the rolls.Two bags of unsealed and undated potato chips laid on the same counter. At 08:01 AM, temperature logs hung on the front of the refrigerator door in the kitchen, which lacked recorded temperatures on 03/03/26, 03/04/26, and 03/05/26. Dietary Staff FF looked at the temperature logs and stated staff were to record the temperatures at least daily, and said there were a lot of new staff. At 08:05 AM continued initial tour of the kitchen revealed the following areas of concern: In the Kitchen refrigerator:Wilted lettuce dated 04/04/26, in an unsealed bag.One container of beef base, which lacked an opened date.A container of mustard and relish, not dated when opened.Two packages of unsealed, undated deli meats.Two containers of opened, honey thickened liquid, one dated 02/09/26 and the other 02/10/26. The directions noted the items were to be disposed of seven days after opening.One cup of covered cottage cheese, undated.Several small single serve containers of salsa, undated. In the dry storage:One dented can of Cheese Sauce in the front rotation of big, canned items, dated 03/20/26.One box of gravy mixes and two large cans of apple pie filling, stored directly on the floor.One bag of unsealed rice cereal on the shelf.One large bag of unsealed spaghetti.One large box of lasagna noodles, unsealed, due to the lid on the box was partially open. In the walk-in cooler:No dates documented on the temperature log sheet for the walk-in cooler and walk in freezer for 03/03/26, 03/04/26, and 03/05/26.One unsealed bag of celery, and lettuce that was unsealed and wilted.One big bowl of batter covered with tin foil dated 04/04/26, not labeled.One bag of unsealed sausage patties.A large container of egg salad dated 03/28/26.A yellow pastry/cake covered loosely with a piece of tin foil, dated 03/30/26.A container of undated and unlabeled meat in brown fluid. Walk-in freezer:One box of pork laid directly on the freezer floor.One bag of chicken laid directly on the freezer floor.The internal thermometer in the walk-in freezer was found on the floor. The floor of the walk-in cooler and freezer had a lot of debris, which appeared to be old food crumbs. On 04/07/26 at 11:09 AM, the walk-in freezer internal thermometer read zero degrees Fahrenheit. Observation revealed all the temperature log sheets for the walk-in cooler, walk-in freezer, kitchen refrigerator and freezer now had documented temperatures for the dates which were not filled in on 04/06/26 initial tour. On 04/07/26 at 11:15 AM, Dietary Staff CC reported he just placed all the cooked chicken, beans, and marinara sauce on the steam table. On 04/07/26 at 11:21 AM, Dietary Staff CC started prep for the pureed diet, as he waited for the food processor container to wash in dishwasher in-between pureeing foods, Dietary Staff CC was drinking coffee from a large disposable cup and placed that cup on the kitchen counter next to an uncovered cake, cut up and ready for service. On 04/07/26 at 11:32 AM, Dietary Staff CC placed the pureed food he prepared in the fridge, covered with foil. During an observation on 04/07/26 at 11:33 AM, Dietary Staff EE walked in the back door of kitchen with a basket of clean kitchen linens and did not wear a hairnet. At 11:35 AM Dietary Staff EE entered the kitchen without a hair net and placed a bag in the trash can by the food prep area. Dietary Staff BB told Dietary Staff EE to put on a hairnet on. On 04/07/26 at 11:51 AM, Dietary Staff CC checked the temperature of the food on the steam table, and used one paper towel to wipe off the thermometer in between checking the food temperatures. On 04/07/26 at 11:54 AM, Dietary Staff BB placed sanitizing thermometer wipe packets on the counter. On 04/07/26 at 11:56 AM, Dietary Staff CC removed the prepared pureed food from the refrigerator, removed the foil, and poured the pureed noodles onto the plate. He placed the uncovered food into the microwave for one minute, then took the plate out and checked the temperature of the chicken, beans, and noodles in-between temperature checks and used the sanitation wipe to wipe off the food. He placed the plate back into the microwave uncovered for one minute, checked the temperatures of the chicken, beans, and noodles in-between temperature checks and used the sanitation wipe to wipe off the food. On 04/07/26 at 11:37 AM, Dietary Staff EE reported she should have applied her hairnet before she entered the kitchen. On 04/07/26 at 12:50 PM, Dietary Staff CC reported he generally used a paper towel to clean the thermometer in-between checking the food temperatures. Dietary Staff CC reported he has always drunk coffee in the kitchen when he works. He reported that he should have covered the plate of food before he placed it in the microwave. On 04/06/26 at 08:30 AM, Dietary Staff BB reported she expected the staff to check the temperatures of the refrigerator, freezer, walk-in cooler, and walk-in freezer and document them on the form three times a day. Dietary Staff BB expected staff to label, date, and seal all dry, cold, or frozen food and dispose of food when it was outdated, wilted, or moldy. Dietary Staff BB reported the egg salad should have been disposed by day seven on 04/04/26. Dietary Staff BB expected staff not to store any food items on the floor and to keep the kitchen areas clean. On 04/07/26 at 01:00 PM, Dietary Staff BB reported she expected the staff to apply a hairnet before they entered the kitchen, then reported she observed Dietary Staff CC use the same paper towel to wipe off the thermometer in-between food temperature checks, and said that was why she laid the wipes on the counter. She expected the staff to use one wipe after each time the thermometer was used. Dietary Staff BB reported she expected the staff to never eat or drink in the kitchen and had not seen the staff do that, she expected the staff not to have any personal food, drink or items in the kitchen. Dietary Staff BB reported she expected the staff to cover the food in the microwave. On 04/08/26 at 11:03 AM, Consultant Staff HH reported completed a monthly kitchen inspection and reported nothing was perfect. Consultant Staff HH reported he expected the staff to wear a hairnet in the kitchen. Consultant Staff HH expected the staff to never drink, eat, or have personal items in the kitchen. He expected the staff to check the temperatures of the refrigerator, freezer, walk-in cooler, and walk-in freezer and document them on the form three times a day and expected staff to label, date, store and seal all dry, cold or frozen food and dispose of food when it is outdated, wilted or moldy. Consultant Staff HH expected the staff to keep the kitchen areas clean and sanitize the thermometer the proper way. The facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 10/2025, documented food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Hair nets must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Personnel may not eat or drink in the food preparation area. The facility's policy Sanitation, dated 10/2025, documented all kitchen areas and dining areas shall be kept clean, and free from litter and rubbish. The facility's policy Food Safety Requirements, dated 10/2025, documented foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will always maintain clean food storage areas. Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents (at least 18 inches). Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements.

Based on observation and interview, the facility failed to promote dignity for one resident, Resident (R) 36, whose were exposed to other residents when his pants started to fall. Findings included:- On 0/06/26 at 11:55 AM, observation revealed during meal service, R36 stood up from the dining table. When he started to walk, his pants fell below his abdomen, and the top of his buttocks were exposed. Further observation revealed R36 grabbed onto the waistband of his pants to hold them up. An elderly female resident, R34, stated, I just saw that man's butt.On 06/07/26 at 12:10 PM, R36 was at the nurse's station on the phone. While he was standing there, the plaid pajama pants had slipped below his abdomen, and approximately a quarter of his buttocks were exposed. As R36 walked to the dining room, he kept pulling up his pants to keep them up.On 06/08/26 at 11:00 AM, Licensed Nurse (LN) I stated R36 did not have a weight loss, so she did not know why his clothes were not fitting correctly, and that she would investigate the situation.On 06/08/26 at 12:50 PM, Administrative Nurse E stated that R36 had money he needed to spend down and had already planned to buy him some new clothes with it and agreed it was a dignity issue and felt bad the other residents were in the dining room to see it.The facility's Respect and Dignity, Right to Personal Property, Including Searches and Illegal Substances policy, dated 06/25, documented residents have the right to be treated with respect and dignity, unless to do so would infringe upon the rights and safety of other residents. Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Staff shall accommodate to the fullest extent possible the use of personal possessions, including furnishings and clothing, unless to do so would infringe upon the rights or health and safety of other residents.

The facility reported a census of 43 residents; 14 residents were sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure one resident's advanced directives were honored. Resident (R) 8's completed do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) order was discontinued on [DATE]. Findings included:R8's Electronic Medical Record (EMR) revealed diagnoses of tracheostomy status (opening through the neck into the trachea through which an indwelling tube may be inserted), chronic respiratory failure (CRF - a long-term, ongoing condition where the respiratory system fails to properly exchange oxygen and carbon dioxide, resulting in persistently low oxygen), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R8's Annual Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) could not be completed as resident was rarely/never understood. Staff assessment completed and documented R8 had severely impaired cognition. R8's MDS documented that he required total assistance for all activities of daily living. R8's Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R8 was a long-term resident at the facility with a primary diagnosis of chronic respiratory failure. R8 required a tracheostomy. R8 was nonverbal and rarely communicated and was dependent on all cares. R8's Order Approving Written Certification of Treating Physician and Concurrence, dated [DATE], documented the matter that comes before the court upon guardian's (a person or entity legally entrusted with the care, protection, and management of another person typically an incapacitated adult) presentation of a physician's certificate in accordance with Kansas Statutes Annotated 59-3507 (e)(7)(C). Upon review of presented certification, the Court finds the physician's certificate and concurring certification of the second physician are in proper form and approved. The Guardian and Conservator shall have the authority to consent on behalf of the ward to the withholding of life-saving medical care, treatment, services or procedures. R8's EMR had an uploaded DNR dated [DATE] that was signed by one physician, the guardian, and two witnesses. R8's Physician Orders, documented a DNR date ordered [DATE] when he admitted to the facility, that was discontinued on [DATE]. R8's Physician Orders, documented full code, all measures date ordered [DATE]. R8's Care Plan, dated [DATE], instructed staff to initiate cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) when appropriate and continue until Paramedics arrive to take over, and review quarterly and as needed. R8's Provider Note, dated [DATE], documented code status DNR. R8's Provider Note, dated [DATE] at 11:00 PM, documented the Director of Nursing notified the provider that R8 required a DNR form in his chart. R8 was ordered a full code until two physicians can sign the form stating R8 was a DNR candidate and the durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) would work court side to get that finalized. R8's Progress Note, dated [DATE] 01:09 PM, revealed R8's code status updated to full code pending guardians completing court process for DNR. Provider notified of need for DNR letters for guardians. Message left for guardians. R8's Care Conference Note, dated [DATE], documented discussed care options with guardian and he would like to transition R8 from a full code to a DNR. Guardian reported that R8 had originally had a DNR and the state made them change him to a full code. Guardian was okay to start the process of transitioning R8 to a DNR and continue to follow up with guardian per request. On [DATE] at 09:15 AM, R8 lay in his bed with head of bed elevated, observed a red abrasion, approximate size 0.5 centimeter (cm) x 2 cm, surrounded by slight redness in color of the right forehead. R8 had a lot of facial hair, and he shook his head side to side in a no motion when he was asked if he wanted a shave. He shook his head side to side in a no motion when asked him if he had a fall. [DATE] at 11:22 AM, R8's Guardian reported that R8 used to be a DNR and reported the state did an audit last year and he had to be full code. Guardian reported he could not understand why and has asked the facility for assistance. On [DATE] at 02:45 PM, Licensed Nurse (LN) J reported she could not recall why R8's DNR was discontinued in [DATE]. On [DATE] at 02:50 PM, Social Service Designee (SSD) X revealed that a mock survey by regional staff had been completed in [DATE]. SSD X reported she was told R8's DNR was not good as it was signed after the guardianship paperwork was in effect. SSD X reported that the Director of Nursing at the time had R8's provider discontinue the DNR and reported she was a bit confused when that occurred. SSD X reported she had not spoken to R8's guardian about a request to have assistance to have a DNR completed. On [DATE] at 03:02 PM, Administrative Staff A, Administrative Nurse D, and Administrative Nurse E reviewed R8's EMR of the DNR, progress notes, orders, and guardian ship paperwork, and they all reported that they had no knowledge of the concern that the guardian had about the DNR. Administrative Nurse D reported that R8's Guardian wanted R8 to be a full code when she had spoken to guardian about hospice. Administrative Staff A reported that R8's paperwork for the DNR was accurate and directed Administrative Nurse E to contact the Guardian to see what they wanted to do with R8's code status. The facility's policy Advance Directives, dated 05/2025, documented advance directives would be respected in accordance with state and federal law and facility policy. Prior to or upon admission of a resident, the Social Services Director or designee would inquire about the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview, and record review the facility failed to identify, monitor, and respond to an injury of unknown origin/skin condition identified as and abrasion and redness on Resident (R) 8's forehead. Findings included:- R8's Electronic Medical Record (EMR) revealed diagnoses of chronic respiratory failure (CRF is a long-term, ongoing condition where the respiratory system fails to properly exchange oxygen and carbon dioxide, resulting in persistently low oxygen), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R8's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) could not be completed as the resident was rarely/never understood. Staff assessment revealed R8 had severely impaired cognition. R8 had no behaviors and required total assistance for all activities of daily living. R8's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 04/28/25 documented R8 was nonverbal, rarely communicated, and was dependent on all cares. R8's Quarterly MDS dated [DATE] documented the resident had no change in mental status, behaviors, or assistance required with activities of daily living R8's Care Plan, dated 04/26/23, revealed staff were instructed to inspect the resident's skin weekly and as needed. Staff would observe R8 for redness, open areas, scratches, cuts, bruises, and report any changes to the nurse. R8's Weekly Skin Note, reviewed from 03/28/26 and 04/02/26, revealed no documentation for an abrasion or bruise to R8's forehead. During an initial observation (on the first day of the facility's annual resurvey) on 04/06/26 at 09:15 AM, R8 laid in his bed with the head of his bed elevated. The resident had a red abrasion, which measured approximately 0.5 cm by 2 centimeters (cm) present on the right side of his forehead. R8 shook his head side to side in a motion indicating no, when asked if he had a fall. R8's progress notes lacked evidence that staff identified the abrasion to R8's forehead and/or investigated the origin of the injury until the next day on 04/07/26. R8's Progress Note, dated 04/07/26, at 05:10 PM documented R8 had a purple abrasion to the right side of his forehead. The area was closed and measured 0.3 cm by 2.5 cm by 0 cm. R8 was unable to describe how the injury occurred. Staff were questioned about the origin of the resident's injury, and no event was noted to occur. The note indicated R8's head may have hit the wall during cares. R8 recently had a room change, and his bed was placed against the wall. A fall mat was placed to the left side of the resident's bed to prevent him from grazing his head on the wall. During an interview on 04/07/26 at 09:54 AM Certified Nurse Aide (CNA) O reported she had not noticed the abrasion/redness on R8's forehead. During an interview on 04/07/26 at 02:29 PM, Licensed Nurse (LN) J reported that she was told by the night nurse on 04/06/26 that R8 had an abrasion on his forehead and she was not sure how it happened. LN J reported that she did not document the area on R8's forehead as she thought the night nurse did. During an interview on 04/07/26 at 03:33 PM, CNA O reported that any new skin issue identified on a resident would be reported to the nurse. The staff were required to write a statement for an injury such as a bruise, or skin tear. During an interview on 04/07/26 at 05:01 PM, Administrative Nurse E stated she was not aware that R8 had an abrasion on his forehead and reported that the nurse should have reported, assessed, and completed a risk management for the abrasion. Administrative Nurse E further stated a root cause analysis should have been completed to assess how R8 would have received an abrasion.

Based on record review and interviews, the facility failed to provide written notification of a bed hold for a facility-initiated transfer for Resident (R) 5 when they were transferred to the hospital and failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for R5. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), chronic kidney disease Stage 3 (moderate to severe loss of kidney function), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R5 required staff assistance with most activities of daily living (ADLs). The MDS recorded R5 received dialysis (a procedure where impurities or wastes are removed from the blood), and oxygen therapy. The Activities of Daily Living (ADLs) Care Area Assessment (CAA), dated 07/01/25, recorded R5 required substantial assistance with ADLs requiring the lower body, he is unable to ambulate and had poor balance. R5 would operate his wheelchair with set-up assistance and was a fall risk. The ADL Care Plan, dated 12/16/25, recorded staff would assist R5 with ADLs and ambulation as needed. The care plan documented that staff would monitor and report changes in mental status, lethargy, tiredness, fatigue, tremors, seizures and breathing difficulties. The care plan documented R5 had renal insufficiency due to chronic kidney disease and staff would monitor lab results, electrolytes, and report to the physician results. The Nurse's Note, dated 12/09/25 at 01:13 PM, documented the lab called the facility and stated the resident had a critical lab hemoglobin (Hgb-measure of blood that carried oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs) of 6.1 (normal 13.5 to 17.5 grams per deciliter (g/dl) for men). The Nurse's Note, dated 12/09/25 02:15 PM, documented the facility received a call from the provider to send R5 to the emergency room due to the critical lab values. The 12/09/25 at 02:40 PM, Nurse's Note documented R5 left the facility via stretcher per ambulance. The 12/16/25 at 06:06 PM, documented R5 returned to the facility from the hospital for end stage renal disease and anemia. R5 had a dialysis port on the left upper chest. R5's clinical lacked evidence of the bed hold policy and the facility was unable to provide evidence upon request. The facility was unable to provide evidence that the facility notified the LTCO of the resident's transfer/discharge from the facility. On 04/08/26 at 09:30 AM, Social Service X verified the facility lacked a bed hold notice when R5 was discharged to the hospital and verified the Ombudsman was not notified of the resident's discharge to the hospital. The facility's Bed Hold policy, dated May 2026, documented the facility staff shall inform residents upon admission and prior to a transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed-hold policy. The policy documented upon admission and when a resident is transferred for a non-emergency hospitalization or for therapeutic leave, a representative of the business office would provide information concerning the bed hold. When emergency transfers are necessary, the facility would provide the resident and the resident representative with information concerning the bed-hold policy per state law as applicable. A copy of the resident's bed hold policy would be filed in the resident's medical record. Upon request the facility failed to provide an Ombudsman Notification policy

Based on observation, interview, and record review, the facility failed to provide consistent bathing for two residents, Resident (R) 22 and R37. The facility failed to provide grooming for R43, who had facial hair and dirty fingernails.Findings included:- R22s Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated 01/ 06/26, documented a Brief Interview for Mental Status (BIMS) of 8, indicating moderately impaired cognition. R22 required substantial staff assistance with lower body dressing and showers, and partial staff assistance with personal hygiene. R22's Care Plan, dated 01/29/26, directed one staff member to assist with bathing and use a shower chair, initiated on 10/07/22. The April 2026 Shower Sheets documented R22 had not received a bath or shower during the following days: 04/01/26-04/07/26 (7 days) The April 2026 Shower Sheets documented R22 refused her shower on 04/01/26. The March 2026 Shower Sheets documented R22 had not received a bath or shower during the following days: 03/01/26-03/30/26 (30 days) The March 2026 Shower Sheet documented R22 refused her shower on 03/20/26 and 03/25/26. On 04/06/26 at 09:46 AM, R22 had stains on her pants and had multiple chin hairs. On 04/08/26 at 08:00 AM, Certified Nurse Aide (CNA) N stated there are bath sheets that are used with the skin assessment and if the resident refused. CNA N further stated that she would reapproach the resident if they refused bathing and notified the nurse. On 04/08/26 at 11:00 AM, Licensed Nurse (LN) I stated R22 refused bathing but was sure she had been provided with showers since February, but staff could not force her to take one. LN I further stated, if a resident refused, they would reapproach. Staff document on a shower sheet, given to the nurse, and placed in a basket on the desk. LN, I stated, she was unsure what happened to them after that. On 04/08/26 at 12:50 PM, Administrative Nurse D stated R22 refused her baths and that they had a lot of agency staff in and she had to hunt them down to do shower sheets so some of the showers were probably not documented. The facility's Quality of Life-Activities of Daily Living policy, dated 03/26, documented the facility assisted the residents in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. Residents are provided with services including hygiene, mobility, elimination, dining, and communication. - R37's Electronic Medical Record (EMR) documented diagnoses of benign prostatic hyperplasia (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and polyneuropathy (a chronic disorder resulting from damage to multiple peripheral nerves simultaneously). The Annual Minimum Data Set (MDS), dated [DATE], documented intact cognition. R37 required supervision with showers, lower body dressing, toileting hygiene, and transfers. The 03/25/26 Care Plan included the following interventions for R37: 10/18/22- I prefer to have staff shave him with razors. 11/04/22- I require one staff participation with personal hygiene and oral care. 11/04/22- I require one staff participation with bathing. I like to shower two times a week on Monday and Thursday mornings. 03/27/24- I can get my own clothes ready for the day and able to pick my own clothes. The March 2026 Shower Sheets and Bathing Record documented R37 requested showers on Monday and Thursday dayshift and lacked documentation R37 received the requested two showers. The March 2026 Shower Sheet lacked documentation R37 refused his showers. The February 2026 Shower Sheets and Bathing Record documented R37 requested showers on Monday and Thursday dayshift and lacked documentation R37 received the requested two showers. The February 2026 Shower Sheets and Bathing Record lacked documentation R37 refused his showers. On 04/06/27 at 10:16 AM, R37 was unshaven, and he stated that he had not received his showers as requested. R37 stated he had spoken to staff and was told that he refused his showers. R37 requested to see the shower sheets that he would have signed if he had refused his showers. but staff were unable to find those shower sheets. On 04/08/26 at 9:15 AM, Certified Nurse Aide (CNA) N stated R37 did not typically refuse his showers. If a resident refused, she would reapproach and tell the nurse. On 04/08/26 at 11:15 AM, Licensed Nurse (LN) I stated a resident can have as many baths as possible per week as they wanted. LN I further stated there had been times in the past the bath aide was pulled to the floor to work as the CAN, and stated that may be why he had not received his showers twice a week. On 04/08/26 at 12:50 PM, Administrative Nurse D stated she expected R37 to receive his showers twice a week as preferred. The facility's Quality of Life-Activities of Daily Living policy, dated 03/26, documented the facility assisted the residents in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. Residents are provided with services including hygiene, mobility, elimination, dining, and communication. - R43's Electronic Medical Record (EMR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R43's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) could not be completed as the resident was rarely/never understood. Staff assessment revealed R31 had severely impaired cognition. R4 required total assistance for personal hygiene. R43's Communication Care Area Assessment (CAA), dated 10/17/25, documented R43 relied on staff to have her needs met, daily. R43's Care Plan, dated 02/03/23, revealed R43 required one staff assistance with personal hygiene. R43's Care Plan, dated 05/08/25, revealed staff were instructed to assist the resident with grooming and hygiene to the extent needed. On 04/06/26 at 10:20 AM, R43 sat in her wheelchair, in the dining room, and had several facial hairs on her chin that measured approximately 0.25 inches long. Her fingernails had a brown substance underneath them and were jagged. On 04/07/26 at 08:16 AM, Certified Nurse Aide (CNA) O and CNA P provided morning cares to R43 who laid on her bed. R43 continued to have several facial hairs on her chin, her fingernails had a brown substance underneath them, and they were jagged. On 04/07/26 at 12:45 PM R43 continued to have facial hair on her chin, fingernails had a brown substance underneath them, and they were jagged. During an interview on 04/07/26 at 03:17 PM, CNA O reported the facility had a bath aide that was scheduled on first and second shift, Monday through Friday. CNA O stated she was taught not to shave residents and reported the nurse would shave the residents. CNA O further reported the nurse would cut all the residents' nails but noted the bath aide cleaned the residents' nails. During an interview on 04/07/26 at 03:48 PM, CNA Q reported she was the bath aide for second shift and would complete the scheduled showers. CNA Q reported she shaved residents if they requested it. She reported she would provide nail care but would not cut diabetic nails. CNA Q reported she would clean residents' nails on shower days, and if any additional nail concerns were identified the residents' nails would be cleaned then. CNA Q reported it was hard to shave R43 as she moved her head, which made it hard to shave her. CNA Q reported she could not always understand R43. During an interview on 04/07/26 at 03:53 PM, Licensed Nurse (LN) J reported the staff were expected to offer and complete facial hair removal/shaving, and nails were to be cleaned on shower days and if needed or requested. LN J reported the nurse was required to cut fingernails for all the residents and noted the CNAs did not cut any resident fingernails. During an interview on 04/07/26 at 04:10 PM, Administrative Nurse E stated she expected the CNAs to file, clean, and trim fingernails for the residents on their bath day and as needed. The nurse would cut the resident's fingernails that were diabetic. Administrative Nurse F expected the CNAs to remove facial hair on shower days and as needed. She also reported that facial hair should be removed when requested and per the resident's preferences, which would be documented on the resident's care plan. The facility policy Quality of Life-Activities of Daily Living, dated 03/26, documented the facility assisted the residents in maintaining and/or achieving independent functioning, dignity, and well-being. Residents who are unable to carry out activities of daily living received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure dependent Resident (R) 43 received staff assistance in placing his hearing aids, which placed the resident at risk for social isolation, mental decline, and loss of independence. Findings included:- R43's Electronic Medical Record (EMR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and malformation of ear causing hearing impairment. R43's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) that could not be completed as the resident was rarely/never understood. Staff assessment revealed R31 had severely impaired cognition. R43's MDS revealed she wore a hearing aide. R43's Communication Care Area Assessment (CAA), dated 10/17/25, documented R43 relied on staff to have her needs met. R43's Quarterly MDS, dated [DATE], documented no change in the resident's BIMS or hearing aid use. R43's Care Plan, dated 01/03/23, revealed staff would ensure availability and functioning of adaptive communication equipment, which included a message board and a hearing aid to the right ear. R43's Care Plan, with a revised date of 01/29/25, instructed staff to provide her hearing aid for the right ear, which was to be worn during the day and taken off at night. The case was to be left at the nurses' station and charged overnight. R43's Physician Orders documented the resident could be seen by specialists as needed including audiologist of choice and they were to provide care as needed, dated 01/30/23. R43's Activities Note, dated 08/29/25 at 11:40 AM, documented R8 was hearing impaired and wore a hearing aid in the right ear, when available. R43's Activities Note, dated 09/30/25 at 10:23 AM, documented R8 had limited communication and was hearing impaired. On 04/06/26 at 10:20 AM, R43 sat in her wheelchair with no hearing aid noted. On 04/07/26 at 12:45 PM, R43 sat in the dining room with no hearing aid observed in her right ear. On 04/06/26 at 10:20 AM, Activity Director Z reported that R43 did not have a hearing aid. The staff had to speak loudly in her right ear so she could hear. Activity Director Z reported that R43 did not speak often. On 04/07/26 at 09:47 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R reported that R43 did not have a hearing aid, and they had never seen one. On 04/07/26 at 03:17 PM, CNA P and CNA O reported that R43 did not have a hearing aid, and they did not know if she was care planned for the use of a hearing aid. On 04/07/26 at 04:30 PM, Administrative Nurse F reported that R43 required a hearing aid and was care planned for the use of a hearing aid to the right ear. Administrative Nurse F reported she was not sure if R43 had a hearing aid. On 04/07/26 at 04:36 PM, Activity Director Z reported that R43 had not used a hearing aid since they quit working some time last year. She reported the resident's hearing aid would not hold a charge. Activity Director Z stated she had informed a nurse about the residents' hearing aid. On 04/07/26 at 04:50 PM, Social Service Designee (SSD) X reported R43's hearing aid broke four or five months ago. SSD X tried to contact R43's durable power of attorney and was unable to get ahold of him about the hearing aid. She was not sure if the hearing aid would be covered or if R43 had personal funds to cover the hearing aid repair and reported that this was documented in R43s EMR. SSD X reported she did not think that R43 ever had an appointment with an audiologist. On 04/08/26 at 11:00 AM, Activity Director Z reported R43 had a hearing aid that charged at that nurse's desk. Activity Director Z then applied the hearing aid into R43's right ear and R43 smiled. On 04/08/26 at 01:54 PM, Administrative Nurse D stated that she expected staff to make sure resident hearing aids were offered and placed on the residents as ordered. Administrative Nurse D reported that an unnamed facility nurse purchased R43 a hearing aid and she was not sure when it arrived but noted that it had been at the nurse's desk charging. The facility did not provide a policy for hearing aids.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe environment for one resident, Resident (R) 22, who had multiple falls in the facility dining room, and failed to follow her plan of care. Findings included:- R22's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), atrial fibrillation (rapid heartbeat), and muscle weakness. The Quarterly 5-Day Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) of eight, indicating moderately impaired cognition. R22 required partial staff assistance for eating, mobility, transfers, and did not ambulate. R22 had no functional impairment and had no falls since the prior assessment. The Quarterly MDS, dated 01/06/26, documented a BIMS of 8, indicating moderately impaired cognition. R22 was dependent upon staff for transfers, toileting hygiene, and had partial staff assistance for mobility. R22 had no functional impairment, no falls since prior assessment, and did not ambulate. The Fall Assessments, dated 10/08/25, 01/08/26, 01/25/26, and 03/16/26, documented R22 a high risk for falls. The 01/29/25 Care Plan included the following interventions for R22:11/12/24- Ensure she is wearing non-slip footwear. If the gripper socks are too worn, remove them from her inventory and contact the family.3/24/24- Floor mat on the exit side of the bed to decrease the risk of injury when R22 gets out of bed.12/06/25- Staff are not to leave residents in the dining room after meals unattended.12/21/25- Do not transfer to the dining room chair for meals; leave her in her wheelchair to prevent falls.02/24/26- Antithrust cushion placed with Dycem (non-slip mat used for stabilization and gripping to prevent falls) to wheelchair.03/11/26- Remove Hoyer (full mechanical lift) sling from the wheelchair after transferring R22.03/16/26- PT to evaluate and treat for walk to dine to prevent falls.03/28/26- Staff educated on the interventions put into place on 12/21/25, not to leave her unattended in the dining room. The intervention would be added to an assigned task for each shift. Offer toileting and to lay her down after meals. Adjust her bed routine to fit the resident's preference to go to bed earlier, offering her to go to bed when she starts showing signs of fatigue. The Fall Investigation, dated 12/21/25 at 05:25 PM, documented staff found R22 on the floor in the dining room by a Certified Nurse Aide (CNA). The investigation documented R22 had been one-on-one all afternoon due to wanting to stand up and walk. R22 told staff she wanted to go home. R22 was assessed for injuries, and the family was notified. R21 was oriented to person, had gait imbalance, impaired memory, and was impulsive. The Fall Investigation, dated 03/11/26 at 05:00 PM, documented that another resident was heard calling for help in the dining room to inform staff that R22 had slipped out of her chair onto the dining room floor. Staff found her seated on her buttocks in front of her wheelchair with her back up against her wheelchair. The two residents at R22's table stated she had just slipped and did not hit her head. The investigation further documented R22 was oriented to person, had impaired decision-making skills, had decreased strength, and had decreased safety awareness. The root cause analysis for the fall was that the sling from the lift should be removed after the resident was transferred. The Fall Investigation, dated 03/28/26 at 11:38 PM, documented R22 was lying on the floor face down with the wheelchair at her feet. She was assessed and assisted into her wheelchair by two staff members. R22 needed to go to the bathroom after a meal and was not offered. R22 had impaired decision-making, oriented to person, impulse, and needed to go to the bathroom. On 04/06/26 at 3:27 PM, R22 was in her wheelchair, pushed by staff to the dining room with the sling still under her in the wheelchair. On 04/07/26 at 08:00 AM, CNA T placed the sling lift under R2 and attached the sling to the Hoyer lift. CNA N used the controller to lift the resident and set her into her wheelchair. After removing the sling from the lift, CNA N pushed the sling partially under R22 so it would not drag on the ground. CNA N took the sling that was behind R22 and took the black loops on the sling and wound them onto the wheelchair handles. CNA N stated R22 had a lot of falls and that she had a fall mat beside the bed, and they made observations of her several times a day. CNA N further stated that she was able to have access to the plan of care from the computer to see all her fall interventions. On 04/08/26 at 11:00 AM, Licensed Nurse (LN) I stated R22 had falls in the dining room and that they tried to keep an eye on her because she is impulsive and often resists care. On 04/08/26 at 12:50 PM, Administrative Nurse F stated that R22 should not have been left alone in the dining room, as she is impulsive and falls. Staff should follow the care plan, and she had inadvertently put on the care plan to remove the sling, as it should not have been a fall intervention, as R22 had Dycem in her wheelchair. The facility's Assessing Falls and Their Causes Guidelines policy, dated 10/25, documented staff reviewed the residents' plan of care to assess for any special needs of the resident, the resident's current medications, and conditions. After the fall, an incident report was completed by the nursing supervisor on duty at the time of the fall, and the Director of Nursing Services would be notified no later than 24 hours after the fall occurred. The staff will evaluate the chain of events or circumstances of the fall and will determine the cause. Appropriate interventions would be taken to prevent further falls.

Based on observation, record review and interview, the facility failed to facilitate the necessary dental care services for Resident (R)1. Findings included: - R1's Electronic Medical Record (EMR) recorded diagnoses of gastroesophageal reflux (GERD-backflow of stomach contents to the esophagus), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and protein calorie malnutrition (a severe form of undernutrition caused by inadequate intake of protein, calories, and essential nutrients, or by high metabolic demand). R1's admission Minimum Data Set (MDS), dated [DATE], recorded R1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed R1 was independent with oral hygiene and personal care. The assessment revealed that R1 did not have any natural teeth or tooth fragments, no inflamed or bleeding gums, and no broken or loosely fitting full or partial dentures. R1's Dental Care Area Assessment (CAA), dated 03/06/26, recorded R1 had tooth pain on her right side and started an antibiotic for a dental abscess. R1's Nursing admission Evaluation, dated 02/06/26, recorded the resident did not have her own teeth and did not have any broken or loose fitting full or partial dentures. The evaluation recorded the resident had recent weight loss. The assessment lacked any additional dental documentation. R1's Care Plan, dated 02/07/26, lacked any reference to R1's broken, decayed teeth, or the dental services to be provided. The 02/16/26 at 04:01 PM, Nurses' Notes documented R1 reported she had a tooth abscess on her tooth on the right side and reported her mouth was sore and had been hurting. The 02/16/26 at 05:22 PM, Nurses' Notes documented the nurse practitioner ordered Clindamycin (antibiotic) 300 milligrams(mg), four times a day for seven days. The 02/21/26 at 10:48 AM, Nurses Notes documented R1 continued with the antibiotics for the tooth abscess and reported decreased pain. The 02/22/26 at 12:34 AM, Nurses Notes documented the resident continued to receive Clindamycin for the abscessed teeth and denies any adverse effects at this time. On 04/06/26 at 01:30 PM, observation of R1's sitting in the side of the bed with her room tray in front of her and eating a salad. Observation revealed R1 mouth she had missing teeth, except one that was decayed and split in pieces and one that had broken off at the lower jaw. On 04/08/26 at 01:30 PM, Administrative Nuse E verified she had not visualized R1's mouth or teeth until today and verified R1 was edentulous except for the two broken teeth, and verified the resident was not currently on the facility dental services provided by an outside source. Administrative Nurse E verified R1 had not had any dental care or services since admission to the facility, and they would investigate having her see a dentist for continued dental care. The facility's Routine Dental Care policy, dated November 2025, documented that each resident would receive routine dental care. The policy documented nursing care staff would conduct ongoing health assessments to assure that each resident receives adequate oral hygiene, The attending physician would be notified of a residents' need for dental treatment and order dental consultation as appropriate The facility's routine dental care includes, but is not limited to and initial evaluation of each residents dental needs, consultation with the resident, staff, and the dental consultant, daily dental and oral hygiene plan of care, and preventative care and treatment.

The facility had a census of 43 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to meet the nutritional needs of residents in accordance with established national guidelines, placing the residents at risk for unmet nutritional needs. Findings included:- On 04/06/26 at 09:00AM, observation revealed R48 sat in a wheelchair in her room with the bedside table in front of her awaiting her breakfast tray. Continued observation revealed at 09:30 AM a nurse aide came into R48's room and R48 inquired when her breakfast would be delivered. The nurse aide stated the kitchen had not delivered the food cart to the hall and when they did, she would deliver R48's room tray. On 04/06/26 at 10:00 AM, observation revealed R48 sat in a wheelchair in her room with her bedside table in front of her awaiting breakfast to be delivered to her room On 04/06/26 at 10:05 AM, Administrative Nurse D and Administrative Nurse E were summonsed to R48's room and the surveyor inquired when R48 would and should receive her breakfast and they stated they would check into it and verified the resident should have had her breakfast before 10:00 AM. On 04/06/26 at 10:10 AM R48 received her room tray that consisted of cream of wheat and one piece of toast. R48 stated they did not provide sugar, butter or jelly when they delivered her meal. R48 states she had asked for eggs and orange juice and the staff stated they were out of those items, and this is what they had available. On 04/06/26 at 10:15 AM, Administrative Nurse E verified the kitchen did not print a breakfast ticket for the residents and that is why she did not receive her meal. On 04/08/26 at 11:10 AM, Dietary Staff BB verified R48 had not received her breakfast meal tray because the meal ticket did not print, and staff did not know she had not received her meal and verified the supper meal on 04/05/26 her meal ticket had not printed and that is why she did not receive that supper meal until late. Dietary Staff BB verified they have corrected the issue, and they will have three check offs to be sure every resident receives their meals and they are served timely. The facility's Food Preparation and Service policy, dated 10/2025, documented residents are to be provided with food that is palatable, attractive and at a safe and appetizing temperature. The policy documented that the food service employees should prepare and serve food in a manner that complies with safe food handling practices.

The facility reported a census of 37 residents. The sample included eight residents who were reviewed for misappropriation. Based on observation, interview, and record review, the facility failed to ensure Resident (R)1, R2, and R3 remained free from misappropriation when staff wrote checks and forged signatures to cash the checks without appropriate authorization.Findings included:- R1's Electronic Health Record (EHR) revealed diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion), cognitive communication deficit, generalized muscle weakness, and a need for assistance with personal care.R1's Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment documented that R1 had minimal difficulty hearing but did not have hearing aid devices. R1 required supervision or setup assistance with most activities of daily living (ADL).R1's Quarterly MDS dated [DATE] documented a BIMS score of nine, which indicated moderately impaired cognition. The assessment documented R1 had minimal difficulty hearing but did not have hearing aid devices. R1 was dependent on staff for lower body dressing, including shoes, and required substantial or maximal assistance for most other ADL; she required partial or moderate assistance for eating and oral hygiene.R1's Cognitive Loss / Dementia Care Area Assessment (CAA) documented R1 had a diagnosis of dementia.R1's EHR lacked evidence of authorization from R1 or R1's representative to manage R1's personal funds.Review of facility investigation notes revealed the following information: On [DATE] at approximately 04:45 PM, R1's representative called Administrative Staff A to Administrative Staff B's office. R1's representative informed Administrative Staff A that R1's bank notified her of two suspicious checks that were deposited into Administrative Staff B's personal account. Administrative Staff B gave a written statement of the incident and was placed on suspension pending the outcome of an investigation by the facility. The facility informed Law Enforcement ([NAME]) regarding the suspicion of a crime. On [DATE], the facility terminated Administrative Staff B's employment.Administrative Staff B's undated and unnotarized Witness Statement noted Administrative Staff B started employment at the facility in [DATE]. Administrative Staff B noted that at that time, she received permission from R1's representative to take full responsibility for R1's financials and to pursue the facility being the representative payee for R1. Administrative Staff B stated in [DATE] she wrote a check for around $15,000, but she had to sign for R1 since R1 was unable to sign. The amount of the check was applied to R1's liability towards the facility. Administrative B stated in [DATE], in order to do a spend-down required to get R1's Medicaid application approved, she wrote two checks, one for $764.00 and one for $1800.00, made out to the facility, in care of herself. She stated she took the checks to her personal bank and cashed them. Administrative Staff B documented that she brought the money to the facility and put it in the safe. When the bank called to inquire, she attempted to explain the situation, but the bank recalled the checks, which dropped the balance of Administrative Staff B's personal account for the amounts of the checks, so Administrative Staff B took the cash and deposited it in her personal account. Administrative Staff B documented R1's representative took R1's checkbook.R1's representative's notarized statement, dated [DATE], documented that the bank's fraud department contacted her about checks that had been written on R1's account. The bank advised her to go talk with whoever oversaw R1's accounts at the facility and to try to find out what was happening. The bank notified R1's representative that they had contacted Administrative Staff B, so that is whom she talked to when she came to the facility. R1's representative stated that Administrative Staff B reported the bank had called, so she had returned the money, so it should not be a problem. R1's representative noted that Administrative Staff B said that she put the money in the closet because R1 would not have any spending money once she went on Medicaid. Administrative Staff B indicated she planned to put the money back into R1's account after Medicaid was started. Administrative Staff B wanted R1's representative call the bank back to tell them everything was okay, so R1's representative left the facility, went home, and called the bank to relay the message. The bank then directed R1's representative to go back to the facility, get the checkbook, and get Administrative Staff A involved. R1's representative returned to the facility and met with Administrative Staff A and Administrative Staff B. Administrative Staff B admitted she had deposited R1's checks into her personal account, then Administrative Staff A immediately took Administrative Staff B to another office to write a statement.During an observation on [DATE] at 12:45 PM, R1 sat in a wheelchair in a common area near the front door with peers and staff present.During an interview on [DATE] at 09:32 AM, Administrative Staff A stated that on [DATE] at approximately 04:45 PM, she was contacted by R1's representative, who was at the facility and was visibly upset. R1's representative alleged that Administrative Staff B had deposited two checks from R1's private account into her personal account. R1's representative reported that they were contacted by the bank's fraud department about suspicious activity. The bank's fraud department had marked a check for $768.00 and a check for $1,800.00 as suspicious, as they were deposited into Administrative Staff B's personal account rather than the facility's business account. Administrative Staff A reported that Administrative Staff B had received permission from R1 and R1's representative to spend down the balance of R1's account so R1 would meet Medicaid's asset requirements. Administrative staff A revealed that Administrative Staff B's rationale was to deposit monies from R1's account into Administrative Staff B's personal account, then withdraw the cash and bring it to the facility to place in the facility's safe for R1 to use after the authorization or start of Medicaid. Administrative Staff A stated the facility's expectation was that the monies should have been placed either in the resident's trust account or applied to the resident's outstanding bill to the facility. Administrative Staff A reported that Administrative Staff B was taken to Administrative Nurse D's office, where she provided a written statement, then was suspended pending the outcome of the facility's investigation and was terminated on [DATE]. Administrative Staff A reported the incident to local [NAME] for them to investigate.During an interview on [DATE] at 12:57 PM, R1's representative confirmed she was R1's representative and stated she received a telephone call from R1's bank's fraud department, which perceived that there were irregularities with the approved signatures on R1's checks; the bank advised her to go to the facility and retrieve R1's checkbook. R1's representative stated she went to the facility on [DATE] and confronted Administrative Staff B. She said Administrative Staff B appeared nervous and confirmed she had deposited checks from R1's checkbook into her personal account so that R1 would have money after Medicaid was initiated. R1's representative said that Administrative Staff B said she planned on putting the money in a closet and planned to return the money to R1 after Medicaid started. She said Administrative Staff B reported receiving a call from R1's bank informing her that they had returned the money to R1's account. Administrative Staff B told her to go home and call the bank because the money had already been returned to R1's account. R1's representative said she then left the facility without R1's checkbook, went home, and called the bank, which then advised her to go back to the facility and demand that R1's checkbook be returned to her. R1's representative said she returned to the facility and contacted Administrative Staff A. R1's representative provided a document from R1's bank that documented the check for $769.00 and the check for $1,800.00 were returned to R1's account.In an email on [DATE], Administrative Staff A stated the facility's ongoing investigation revealed two additional instances where Administrative Staff B forged her signature to cash checks. The issue resulted in misappropriation of $10.56 for R2 and $115.07 for R3. Administrative Staff A stated the facility had returned the monies to those deceased residents and updated [NAME].The facility's Abuse Prevention Program F600 policy, dated 08/2025, documents that residents have the right to be free from misappropriation of property and exploitation.The facility's Management of Residents' Personal Funds F567 policy dated 08/2025 documented that the facility would manage the personal funds of residents who request the facility to do so. The authorization from the resident or their representative would be in writing, and a copy of such authorization must be in the resident's EHR.

The facility reported a census of 34 residents with 14 residents selected for review, which included one resident reviewed for self-determination. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)5, received appropriate preparations for his scheduled surgery. Findings included: - Review of Resident (R)5's diagnoses included paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk) due to demyelinating (a disease of the spinal cord, nerves and brain causing paralysis and weakness) disease of the central nervous system, and cutaneous (in the skin) abscess (cavity containing pus and surrounded by inflamed tissue) of the abdominal wall. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15, which indicated normal cognitive function. The resident had impairment in both lower extremities and no impairment in upper extremities. The Activities of Daily Living Functional (ADL) /Rehabilitation Care Area Assessment (CAA), dated 03/20/24, assessed the resident was dependent on staff for ADLs due to paraplegia, weakness, infections, and risk factors included unresolved skin issues. The Return to Community Referral CAA dated 03/20/24, assessed the resident wanted to return home, with barriers related to paralysis, wounds and inability to care for self. The pressure ulcers Care Plan reviewed 09/18/24, revealed cares related to the resident's old PEG (percutaneous endoscopic gastrostomy: a feeding tube that is inserted through the abdominal wall directly into the stomach) tube site had MASD (moisture associated skin damage) and staff were to cleanse the area with normal saline and apply skin prep and zinc oxide paste. A Physician's Order dated 07/20/24, instructed staff to administer ferrous sulfate (an iron supplement), 325 milligrams (mg), daily. A Physician's Order dated 08/28/24, instructed staff to administer Eliquis (a medication used to prevent blood clots), 2.5 mg, twice a day. A Nurse's Note dated 09/25/24, documented the lack of preoperative orders, realized by nursing staff when the resident refused to take his blood thinner for the planned surgery. Observation on 09/30/24 at 02:35 PM, revealed the resident had a gauze pad covering the PEG tube site, with dark brown drainage on it. The resident stated the drainage was gastric acid and caused the skin damage to the surrounding skin. Interview, on 09/30/24 at 02:35 PM, R5 reported he desired to return home but had to overcome many obstacles. He stated he was self-sufficient in the past with paraplegia but now had multiple medical issues that needed treatment but was determined to overcome the obstacles and return home. He stated his PEG tube had been surgically closed in August 2024, but failed, and he was scheduled for another attempt at closure in September 2024, but staff did not hold his blood thinner and iron, and surgery had to be canceled. He stated the surgery had to be rescheduled for 10/23/24, which he felt further delayed his plans to return home. Interview, on 10/02/24 at 08:45 AM with Certified Nurse Aide (CNA) N, revealed she was notified of the need for transportation for the resident on 09/26/24 , for surgery and knew the time of arrival. She thought the nursing staff had the orders for the surgery. Interview, on 10/02/24 at 02:01 PM with Administrative Nurse E, revealed the resident set up the surgery for closure of the PEG tube site on 09/26/24 and notified nursing staff that the physician's office would send the preoperative orders to the facility. Administrative Nurse E stated nursing staff did not receive the orders and did not follow up with the physician's office for preoperative instructions. Interview, on 10/02/24 at 02:30 PM with Administrative Nurse D, confirmed the nursing staff did not prepare the resident for surgery, by not ensuring preoperative orders received, which resulted in the surgery delayed and required to be rescheduled for 10/23/24. The facility lacked a policy staff to ensure components of planned operative procedures were in place. The facility failed to ensure preoperative orders were obtained for this resident's planned procedure which resulted in the rescheduling of the procedure for 27 days, which further delayed the resident's progress toward his goal of returning to his home.

The facility reported a census of 34 residents. The sample of 14 residents included three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide two Residents (R), R27 and R 3, who required respiratory care, including tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care and tracheal suctioning, provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences related to the storage of suctioning cannulas/tubing to when not in use to prevent infection and cross contamination to prevent infection. Findings included: - Review of Resident (R)27's Physician Orders, dated 08/07/24 revealed the following diagnoses that included spastic quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), with tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), chronic respiratory failure with hypoxia (inadequate supply of oxygen), abnormalities of breathing, disorders of lungs, pneumonia (inflammation of the lungs), due to pseudomonas aeruginosa mallei psuedomallei (type of microorganisms/bacteria related to infection) , and developmental disorder of speech and language. The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognition. R27 rarely/never understood. She received special care and treatment which included oxygen, suctioning, and tracheostomy. R 27 received antibiotic medication. The Care Plan dated 07/24/24, directed staff the resident with a tracheostomy related to impaired breathing mechanics. Staff were to monitor the resident for potential for respiratory infection. The suctioning tubing should be put away properly to prevent infection/ related to contamination. The Physician Orders, dated 08/07/24, documentation included: 1. When tracheostomy suctioning, the suctioning tubing is to be put away properly to prevent infection/contamination. Suctioning every two hours related to chronic respiratory failure with hypoxia. 2. Ciprofloxacin HCl Tablet (antibiotic used to treat infection), 500 milligrams (MG), give 1 tablet via gastrostomy tube every 12 hours for pneumonia, for seven days, ordered 09/25/24. On 10/01/24 at 08:29 AM, R27 was in bed with the head of bed elevated and the tube feeding infusing via pump. The resident had white frothy secretions at her mouth and bubbling film at her tracheostomy opening. She made raspy gurgling sounds while inhaling and exhaling. Licensed Nurse (LN) H entered R27's room, put on gowns and gloves, assessed the resident, opened in line suction cannula, attached to suction machine connection tubing, and suctioned the resident's tracheostomy twice, clearing the line with sterile water with each pass. LN H provided mouth care/oral care. LN H reported the resident had infection in her sputum which was sent to laboratory for analysis. R27 received intravenous (IV) antibiotics. R27 has frequent congestion and required suctioning every two hours. On 10/01/24 at 10:07 AM, LN G verified R27's suction tubing in a drawer with the end of the suction connective tubing uncapped and stored directly on the bottom of the drawer,surrounded by various other medical supplies. LN G stated the tubing should be capped and stored when not in use to prevent contamination of the cannula and connective tubing. On 10/02/24 at 11:00 AM, Administrative Nurse F noted an uncapped and uncovered suction tube stored directly on the drawer bottom surrounded by various other medical supplies. She stated the tubing should be capped and stored when not in use to prevent contamination of the cannula and connective tubing. Administrative Nurse F reported she expected staff to follow orders and the suction tubing placed back into the wrapper should be labeled and dated. Cannulas should be capped when not in use. Storing cannula without caps when not in use is not appropriate. She confirmed the resident received antibiotic therapy for upper respiratory infection. On 10/02/24 at 12:30 PM, Administrative Nurse D reported staff should cap and store suction cannulas/ tubing when not in use in a manner to prevent cross contamination and infection. She confirmed storing a suction machine connective tubing and cannulas used for suctioning the resident's tracheostomy directly in the drawers was not appropriate to prevent infection. The facility's policy for Suctioning the Lower Airway (Endotracheal (ET) or Tracheostomy Tube), dated 05/2024, documentation included staff were to use sterile equipment to avoid widespread pulmonary and systemic infection. Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile. The facility failed to provide required respiratory care to this resident, which included tracheostomy care and tracheal suctioning, consistent with professional standards of practice related to the storage of suctioning cannulas/tubing to when not in use to prevent infection and cross contamination to prevent infection. - Review of Resident (R)3's Physician Orders, dated 08/07/24 revealed the following diagnoses that included chronic respiratory failure, extended spectrum beta lactamase (ESBL) resistance infection (microorganism/bacteria), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), carrier, or suspected carrier of methicillin resistant staphoccocus aureus (MRSA-microorganism/bacteria type infection), and tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating not able to complete interview, related to the resident rarely/never understood. He received special care and treatment which included oxygen, suctioning, and tracheostomy. The Care Plan dated 07/03/24, directed staff the resident with a tracheostomy (trach) related to impaired breathing mechanics. Staff were to monitor the resident for potential for respiratory infection. The suctioning tubing is to be put away properly to prevent infection/ related to contamination. The Physician Orders, dated 08/07/24, documentation included when trach suctioning, suctioning tubing is to be put away properly to prevent infection/contamination. Suctioning every two hours related to chronic respiratory failure with hypoxia (inadequate supply of oxygen). On 10/01/24 at 10:07 AM, Licensed Nurse (LN) G verified the suction tubing in R 3's drawer with the end of the suction connective tubing uncapped and stored directly on the drawer bottom surrounded by various other medical supplies. LN G stated the tubing should be capped and stored when not in use to prevent contamination of the cannula and connective tubing. On 10/02/24 at 12:30 PM, Administrative Nurse D reported staff should cap and store suction cannulas/ tubing when not in use in a manner to prevent cross contamination and infection. She confirmed storing suction machine connective tubing and cannulas used for suctioning the resident's tracheostomy directly in the drawers was not appropriate to prevent infection. The policy Suctioning the Lower Airway (Endotracheal (ET) or Tracheostomy Tube), dated 05/2024, documentation included use sterile equipment to avoid widespread pulmonary and systemic infection. Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile. The facility failed to provide required respiratory care to this resident, which included tracheostomy care and tracheal suctioning, consistent with professional standards of practice related to the storage of suctioning cannulas/tubing to when not in use to prevent infection and cross contamination to prevent infection.

The facility reported a census of 34 residents. The sample of 14 residents included five residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure medications monitored and administered to treat Resident (R)19's heart failure. Findings included: - Review of Resident (R) 19's Physician Orders, dated 08/07/24, revealed diagnosis that included congestive heart failure. The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. The resident rejected evaluation of care one to three days a week. The Quarterly MDS, dated [DATE], documented changes in the resident status which included a BIMS score of 13, which represented a decline in his cognition. R 19's Care Plan dated 08/29/24, directed staff the resident received multiple medications to treat his diagnoses. The staff should administer medications as ordered, monitor for side effects and effectiveness, notify the physician as ordered, consult with pharmacist, and discuss with the physician regarding ongoing need for use of medication. Staff were to educate the resident of risk of refusal of care. Review of R 19's Physician Orders, dated 08/07/24, included Metoprolol Succinate ER (Extended Release) Tablet 50 milligrams (MG), give one tablet, by mouth in the morning, related to heart failure. Hold medication and notify the Physician for a pulse of less than 60 and/or systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) of less than 110. Review of the Medication Administration Record, (MAR) dated 09/01/24 through 09/30/21, revealed R19 received Metoprolol medications outside of the physician prescribed parameters on 09/02/24 with SBP of 108, on 09/10/24 with SBP of 103, on 09/12/24 with SBP of 103, on 09/19/24 with SBP of 106, and 09/20/24 with SBP of 106, a total of five occasions. The MAR and electronic medical record (EMR) lacked documentation of R 19's physician notification of medications administered outside of the prescribed parameters. Additionally, the documentation revealed the resident refused Metoprolol on five occasions on 09/03/24, 09/05/24, 09/11/24, 09/26/24, and 09/28/24, and lacked physician notification, or documented evidence of education provided to the resident regarding benefits verses risks related to not taking his heart medication. On 10/01/24 at 03:10 PM, Licensed Nurse (LN) J verified the resident frequently refused his medication. She reported the resident stayed up late and became agitated when staff woke him to give him his medication. The anti-hypertensive medications had parameters for administration. LN J reported the physician orders indicated the resident the medication should be held if the resident's SBP less than 110, and/or pulse less than 60. She confirmed that if the resident's vital signs were outside of the parameters the medication should be held and the physician notified. On 10/02/24 at 02:57 PM, Administrative Nurse D reported staff should follow physician orders when they administer medication. She stated the staff should hold the medication when vital signs were outside of the prescribed parameters and notify the physician. The facility lacked a policy to address administering medications as the physician orders and/or staff notifying the physician of parameter outliers and resident refusal of medication. The facility failed to ensure medications monitored and administered to treat Resident (R)19's heart failure.

The facility reported a census of 34 residents. Based on observation, record review, and interview, the facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents. Findings included: - Observation, on 09/30/24 at 10:02 AM, revealed the kitchen refrigerator contained six squirt bottles of condiments (salad dressings) that lacked coverings over the tips of the squirt bottles. Observation, on 10/02/24 at 10:57 AM, during environmental tour of the kitchen with Dietary Staff BB, revealed the following areas of concern: 1. The kitchen refrigerator contained six squirt bottles of condiments (salad dressings) that lacked coverings over the tips of the squirt bottles. 2. The kitchen handwashing sink contained a black substance along the back edge caulking and brown/yellow discolorations on the sink back edges. 3. The air fryer/convection oven contained splatters of a black substance on the upper interior surface. 4. The ice machine drain laid directly in the drain without a two-inch air gap. Interview, on 10/02/24 at 11:15 AM, Dietary Staff BB confirmed the above issues and Maintenance Staff U, confirmed the ice machine drain did not have a two-inch air gap between the drain. The facility policy Food Safety Requirements reviewed 10/2023, instructed staff all foods stored in the refrigerators will be covered, labeled and dated. The facility policy Sanitation instructed staff to maintain the food service area in a clean and sanitary manner. Equipment, food contact surfaces and utensils shall be washed to remove or completely looses soils by using manual or mechanical means. The facility failed to ensure foods were stored, prepared, and distributed in a manner to prevent foodborne illness to the residents.

The facility reported a census of 34 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure staff provided incontinence care in a manner to prevent the spread of infection for one Resident (R)13 with an open wound on her sacrum (large triangular bone between the two hip bones). Findings included: - Review of Resident (R)13's medical record revealed diagnoses that included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, cerebral infarction (CVA/stroke) - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and sacral (large triangular bone between the two hip bones) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. R13 had impairment on one side of her upper extremities and required substantial to dependent assistance on staff for activities of daily living, incontinent of bowel and bladder and had a stage two pressure ulcer (a partial loss of skin resulting in a shallow open ulcer. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 05/26/24, assessed the resident with skin breakdown, incontinence of bowel and bladder and a pressure ulcer to her coccyx (small bone at the end of the spine in the sacrum). The Care Plan reviewed 08/21/24, instructed staff the resident required total assistance with personal hygiene. Observation, on 10/01/24 at 10:19 AM, revealed Certified Nurse Aide (CMA) M and Administrative Nurse E, provided incontinence care to the resident. The resident was incontinent of stool, and the stool was on the lower edge of the dressing on her sacrum. CNA M used peri wipes to cleanse the rectal area of stool, and Administrative Nurse E instructed CNA M to remove the soiled dressing. The sacrum contained an open wound, and CNA M then used a peri wipe to further cleanse the rectal area and wiped the resident from her rectum over the wound. Administrative Nurse E then cleansed the wound with wound cleanser and provided wound care. Interview, on 08/21/24 at 10:30 AM, with Administrative Nurse E, revealed staff should wipe incontinent residents from the front to back, but in this case, it would be appropriate to wipe away from the wound, so as not to contaminate the wound with stool. The facility policy Wound Care Guidelines reviewed 04/2024, instructed staff to provide care of wounds to promote healing. The facility failed to ensure staff provided this resident with bowel incontinence with appropriate incontinence care to prevent the spread of infection.

The facility reported a census of 35 residents, with 5 identified at risk for elopement and 3 reviewed for elopement. Based on record review and interviews, the facility failed to provide adequate supervision and assistive devices to prevent Resident (R) 1 from leaving the facility without staff knowledge. R1 removed a screw from his window, removed the screen, crawled out of the window, and left the facility. He walked to a grocery store on a highway 1 and ,[DATE] miles from the facility at night. The city police picked him up and could not determine where he belonged. They transported him to a homeless shelter. He had an expired identification which led the police to call a family member. The facility received a phone call at 12:45 AM from the family member and were informed the police picked R1 up at the grocery store at approximately 10:00 PM. The facility staff were unaware the resident exited the facility four hours and 39 minutes earlier, without their knowledge. This deficient practice placed the resident in immediate jeopardy. Findings included: - The Admission Record in the Electronic Medical Record (EMR) verified the facility admitted R 1 on [DATE]. The PCP (primary care physician) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), dated [DATE], revealed the resident with a Brief Interview for Mental Status (BIMS) score of 03 indicating severely impaired cognition. The resident was independent with mobility and experienced hallucinations (sensations such as hearing or seeing created in a person's mind) and wandering behavior. The Cognitive Care Area Assessment (CAA), dated [DATE] included the resident had a memory and recall deficit. The Behavior CAA, dated [DATE], verified the resident with hallucinations and wandering, including a significant risk of getting to a dangerous place. The Activities of Daily Living (ADL) CAA, dated [DATE], included the resident was independent with transfers and walking. The Elopement Risk Assessment, dated [DATE], scored the resident as a 3 indicating low risk. The Care Plan initiated on [DATE] included, An elopement risk/wanderer with wandering through the facility and asking staff to leave. Interventions included, to ensure the wanderguard (a device put in place to detect and make a sound when a resident opens an exit door) was in place and distract resident from wandering with diversional activities, conversation and food. The Facility Investigation with staff interviews, dated [DATE], revealed on [DATE] at 07:55 PM, R1 ate a snack while standing at the nurse's station. At 08:00 PM, he returned to his room and initiated his call light at 08:06 PM. Following that time, the facility staff failed to observe the resident and failed to realize he exited the building, until [DATE] at 12:45 AM (4 hours and 39 minutes later). At that time, a family member called and notified the facility staff the resident was found by the police 1 and ,[DATE] miles from the facility at 10:00 PM. The police took the resident to a homeless shelter. On [DATE], at 10:40 AM, Administrative Nursing staff B acknowledged the resident wore three layers of clothing, with flannel pajamas as the outer layer and slipper socks. The temperature was 47 degrees Fahrenheit (F) and clear. However, the resident was at risk for serious injury or harm due to the time of night, the cold, and the path that he took along the highway. Progress notes, dated [DATE] at 01:45 AM, revealed upon return to the facility at 01:30 AM on [DATE], Licensed Nursing Staff C evaluated the resident head to toe and noted no injury. On [DATE] at 01:10 PM, Licensed Nurse D reported on [DATE] (the day of the elopement) R 1 went to the front door and a side door several times and expressed his desire to go home and stated, I need to get out of here. At that time Licensed Nursing Staff B also reported he was easy to redirect. At 01:20 PM, Administrative Staff A reported the facility had video footage that verified the resident went into his room at 08:00 PM and did not come out of his room on [DATE]. [DATE] at 2:10 PM, CNA F stated she was aware of the facility policy that staff were to check on residents at least every two hours or more often if it was on the plan of care. On [DATE] at 03:05 PM, Maintenance Director E verified the door alarms were all checked following the return of R1 and worked properly. He then investigated R 1's room and determined the resident removed a screw from his window, which allowed the resident to raise the window, remove the window screen, and exit through the window. The facility policy, Resident Supervision, dated ,[DATE], included, All residents will be visually seen by the assigned certified nurse aide (CNA) at least every 2 hours and during shift change. If a resident was not accounted for, the CNA will notify the charge nurse immediately and a search will begin. Staff will also notify the Director of Nurses and the Administrator. The facility failed to follow their policy to check on residents at least every two hours. The resident left the facility and was out of the facility for at least 4 hours and 39 minutes. This deficient practice placed the resident at immediate jeopardy and at risk for serious injury or harm due to the time of night, the cold, and the path that he took along the highway. This deficiency was cited as past non-compliance as of [DATE] at 10:00 AM when the facility took the following action: 1. Completed head count of all residents. 2. All exit doors were checked to ensure locked and working properly. All resident windows were audited. 3. One on one supervision by staff with R1 until physician notified and order received for transfer to the Behavioral Health Unit on [DATE] at 5:00 PM. 4. Education of all staff regarding elopement and elopement procedures, and staff to visually observe residents every 2 hours during rounds, shift change and as directed by the residents plans of care, completed [DATE] at 10 PM. 5. New elopement assessments for residents at risk for elopement (4 others). 6. QAPI meeting including the medical director held on [DATE] at 10:00 AM.

The facility reported a census of 45 with 14 residents sampled including 5 residents sampled for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision or assistive devices to prevent accidents, for 2 of the sampled residents reviewed, including failure to provide appropriate interventions to prevent a fall for resident #36, resulting in a fractured femur (a break in the thigh bone), and failure to provide immediate, appropriate interventions to prevent repeated falls for resident #32. Furthermore, the facility also failed to ensure the environment remained free of accident hazards for 4 identified residents with confusion and self-mobile when the facility staff left a hydroculator accessible/unattended in the therapy room. In addition, the facility failed to ensure the environment remained free of accidents when it failed to ensure no unsafe hot water temperatures in hand-washing sinks in resident rooms. Findings included: - The POS (Physician order [REDACTED].#36 had [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 5-20-19, documented the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating the resident had moderately impaired cognition. He/she required limited assistance of 1 person for toileting and personal hygiene. His/her balance while moving from seated to standing, was not steady, but he/she was able to stabilize without staff assistance. His/her balance while moving on and off of the toilet was not steady and he/she was only able to stabilize with staff assistance. The resident had no impairment in functional range of motion and ambulated with a walker. The resident had occasional bladder incontinence and frequent bowel incontinence. He/she had falls prior to admission to the facility. The CAA (Care Area Assessment) for cognition, falls and ADLs (Activities of Daily Living), dated 5-20-19, documented the resident was at risk for cognitive loss. The resident required limited assistance with personal hygiene and was at risk for falls due to impaired memory, impaired mobility and [MEDICAL CONDITION]. Staff were to encourage the resident to use the call light for assistance. (The resident with moderately impaired cognition, per MDS, 5-20-19). The care plan, dated 5-13-19, instructed staff the resident was at risk for falls due to the [DIAGNOSES REDACTED]. Staff were to limit the resident's fluids 2-3 hours before bedtime. The plan of care lacked a toileting plan for the resident. review of the resident's medical record revealed [REDACTED]. A progress note, dated 5-28-19, documented the resident had a fall on 5-27-19 while in his/her bathroom. Staff discovered the resident on the bathroom floor with his/her pants around his/her thighs, with legs spread apart, in front of the toilet. Emergency medical services transported the resident to the emergency room where he/she admitted to the hospital for a right femur fracture (a break in the thigh bone). The resident forgot to use the call light before ambulating to the restroom with the use of a front-wheeled walker. Review of the hospital records, dated 5-28-19, documented a right distal femur fracture, displaced. The femur was surgically corrected on 5-29-19, and the resident readmitted to the facility on [DATE]. On 6-25-19 at 1:28 p.m., direct care staff R and office staff/direct care staff X, transferred the resident from the wheelchair to the bed with the use of a full body lift. The resident had an immobilizer (brace worn on the leg to prevent motion) to the right leg extending from the upper right thigh to below the knee. The resident showed no evidence of pain or discomfort during the transfer. On 6-25-19 at 10:17 a.m., direct care staff R stated the resident fell and fractured his/her right femur while toileting him/herself. Staff encouraged the resident to use the call light, but he/she did not always remember to do so. He/she required help with toileting, but was able to ambulate in the hall on his/her own. On 6-26-19 at 5:08 p.m., direct care staff Y stated the resident would ambulate in the hall with his/her walker, but required assistance with toileting. The resident had confusion and would not remember to utilize the call light before getting up. There were no interventions in place at the time of the fall to prevent this fall. On 6-26-19 at 11:23 a.m., licensed staff [NAME] stated he/she could not recall any fall interventions in place at the time of the resident's fall, but there should have been as the resident was at a high risk for falls. On 6-27-19 at 10:48 a.m., licensed staff D stated, the resident required limited assistance for toileting, personal hygiene and dressing, but at times would toilet him/herself. Since the fall, he/she required more extensive assistance with ADLs due to the fractured femur. On 6-27-19 at 10:02 a.m., administrative staff A stated, the resident was at a high risk for falls. The staff were to remind him/her to use the call light before toileting, but the resident did not always remember. It was unclear how long it had been since the resident last toileted as he/she would at times take him/herself. The resident failed to utilize the call light, at the time of the fall. On 6-27-19 at 1:44 p.m., physician F stated, the facility staff often reminded the resident to use the call light when he/she needed assistance, but the resident would not remember. The facility policy for Falls Management, revised 5, (YEAR), included: The interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls. Upon admission, staff will assess and review the resident risk factors for falls and implement interventions. The facility failed to implement appropriate interventions to prevent a fall with leg fracture for this resident with Alzheimer's, and at high risk for falls. The resident failed to use the call light and attempted to self toilet, fell and experienced a femur fracture. - The POS (Physician order [REDACTED].#32, documented the resident had [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set), dated 8-07-18, documented the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating severely impaired cognition. The resident required limited assistance of 1 for bed mobility, transfers, walking in the room, dressing, toilet use and personal hygiene. The resident's balance while moving from seated to standing and moving on and off of the toilet was not stable, but he/she was able to stabilize with staff assistance. The resident had functional limitation on one side of the lower extremity and used a walker and a wheelchair. The CAA (Care Area Assessment) for falls, dated 8-07-18, documented the resident had fallen while in the facility while trying to toilet. The CAA for ADLs (Activities of Daily Living), dated 8-07-18, documented the resident had multiple falls before being admitted to the facility. The CAA for cognition, dated 8-07-18, documented the resident showed disorientation, confusion and inattention. The quarterly MDS, dated [DATE], documented the resident had a BIMS score 1, indicating severely impaired cognitive. The resident required limited assistance with bed mobility, transfers, ambulation in the room and hallway, and toilet use. The resident's balance was not steady, and he/she was only able to stabilize with staff assistance. He/she had no limitation in functional ROM (range of motion) and used a walker. The care plan for falls, dated 5-28-19, instructed staff to encourage proper footwear and for the resident to ask for assistance before attempting to transfer. The resident had a motion sensor in his/her room to alert staff when he/she would stand up. review of the resident's medical record revealed [REDACTED]. Review of the medical record revealed the resident had non-injury falls on 6-17-19, 3-29-19, 3-18-19, 3-17-19 and 2-16-19. None of these falls had an immediate intervention initiated to prevent further falls. On 6-24-19 at 2:39 p.m., the resident got up from his/her recliner and walked with his/her walker into the hallway. The sensor alarm sounded as the resident stood. Staff responded to the room and assisted the resident to sit down in his/her recliner. On 6-25-19 at 3:48 p.m., direct care staff S stated, the resident had a call light to use when he/she needed assistance. The resident got up on his/her own all of the time. On 6-26-19 at 8:39 a.m., direct care staff R stated the fall interventions for the resident included the sensor alarm. On 6-26-19 at 11:23 a.m., licensed staff [NAME] stated, fall interventions were to be initiated immediately following a fall in order to prevent further falls. The interventions would be communicated to the direct care staff by word of mouth or checking the care plan. The director of nursing was responsible for updating the care plan. On 6-26-19 at 10:57 a.m., administrative staff A stated, staff did not initiate appropriate interventions for this resident's falls. All falls were to have an immediate intervention, and they did not. The facility policy for Falls Management, revised 5, (YEAR), included: Following a fall, the staff will immediately implement appropriate measures to prevent further falls. The facility failed to provide immediate, appropriate interventions following falls for this resident with repeated falls. - Observation, on 6-23-19 at 2:45 pm, revealed water temperatures in 4 resident room sinks registered 131.8, 129.8, 134.1, and 128.5 degrees Fahrenheit. Maintenance staff K confirmed the water temperature in 1 resident room [ROOM NUMBER] as 131 degrees Fahrenheit. Interview, on 6-23-19 at 2:45 pm, with maintenance staff K, revealed he/she checked the water temperature daily, Monday through Friday with the last day checked on 6-21-19, in resident room [ROOM NUMBER], and documented as 121.8. Staff K stated he/she did random checks in various resident rooms to ensure safe water temperatures. Staff K stated the temperature rises above 120 degrees Fahrenheit at times, and he/she needed to adjust the water heater. Staff K turned the hot water off in the resident rooms on hall 100 to adjust and stabilize the temperature. Observation, at 3:25 pm, revealed the water temperature down to 127 degrees Fahrenheit in room [ROOM NUMBER]. Observation, at 4:45 pm, revealed the water temperature at 112.8 degrees Fahrenheit. in room [ROOM NUMBER]. The facility undated policy for the physical plant, daily inspections, advised staff to take water temperatures in specific identified locations, twice daily and to document it on the building temperature log. The facility failed to maintain safe water temperatures in 4 resident rooms on the hall 100, to prevent [MEDICAL CONDITION] exposure to water temperature above 120 degrees Fahrenheit. - Observation, on 6/26/19 at 9:05 a.m., revealed the therapy room door unlocked. The [MEDICATION NAME] (a temperature-controlled unit that holds heating pads in a water bath) sat on a counter, and no staff present in the room. While in the therapy room, direct care staff T entered the room with a resident, to provide restorative services. Interview, on 6/26/19 at 9:09 a.m., with direct care staff T, revealed that he/she routinely unlocks the therapy room door when he/she comes in at 6:00 a.m., and locks the door before leaving. Otherwise, he/she just kept the door shut during the day, including when he/she was not in the room. Observation, on 6/26/19 at 9:21 a.m., with administrative staff K, responsible for facility maintenance, revealed the temperature of the water inside the [MEDICATION NAME] to be 160 degrees Fahrenheit, and the outside of the unit to be hot. A water temperature of 155 degrees Fahrenheit can cause a third-degree burn in 1 second. Interview, on 6/26/19 at 11:49 a.m., with administrative nursing staff A, identified that 19 residents were independently mobile in the facility and had a BIMS (brief interview of mental status) of 12 or lower, indicating moderate to severe cognitive impairment. The facility also identified are 4 residents in the facility that wandered, 3 residents that ambulated independently, and 1 of the 4 that used a wheelchair independently. The facility failed to maintain an environment free of accident hazards for 4 residents with impaired to severe cognitive impairment that wandered.

The facility reported a census of 45 residents with 14 selected for review, including 6 residents selected for review of unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one of the 6 residents (#41) remained free of significant medication errors when the resident received another resident's medication, which resulted in a change in condition; low oxygen saturation (the amount of oxygen in the blood) of 85% (norm >90%) and lethargy (sluggishness) which required acute care treatment in the intensive care unit and administration of [MEDICATION NAME] (a medication to reverse the effects of an opioid overdose). Findings included: - Review of resident #41's physician order [REDACTED]. The annual MDS (minimum data set), dated 10-18-18, assessed the resident with a BIMS (brief interview for mental status) score of 15, received 7 days of insulin, antianxiety, diuretic (a medication to remove fluid from the body), anticoagulant (a medication to prevent the formation of blood clots) and 3 days of opioid medications in the 7 day look back period. The CAA (care area assessment), dated 10-18-18, for pain, assessed the resident had pain in his/her legs and required compression wraps. The care plan, updated 4-9-19, advised staff the resident received [MEDICATION NAME] (an opioid medication for pain) 50 mg (milligram), every 4 hours as needed for pain and [MEDICATION NAME] 50 mg, 2 tablets at night for pain, and [MEDICATION NAME] HCL (a muscle relaxer), 5 mg, twice a day, for spasms. The care plan advised staff to monitor for effectiveness and side effects of [MEDICAL CONDITION] (slow heart rate), confusion, drowsiness, [MEDICAL CONDITION] (low blood pressure), and fatigue. The physician order, dated 2-28-19, instructed staff to administer [MEDICATION NAME] 50 mg, every 4 hours as needed for pain and [MEDICATION NAME] 50 mg, 2 tablets, at night for pain. Further review of the physician orders [REDACTED]. Review of resident #27's physician's orders [REDACTED]. Review of resident #27's MAR (medication administration sheet) for (MONTH) 2019, revealed administration times for the [MEDICATION NAME] as 9:00 am, 3:00 pm, and 9:00 pm. Review of the controlled substance accountability sheet, for resident #27's [MEDICATION NAME], dated 6-18-19, revealed a discrepancy of 3 missing pills, in the count of [MEDICATION NAME]. Review of the controlled substance accountability sheet for resident #41's [MEDICATION NAME] 50 mg, 2 tablets, at 9:00 pm, dated 6-16-19, lacked an entry for the 6-17-19 administration (the MAR, for (MONTH) 17,2019, documented the dose given, but the [MEDICATION NAME] count did not reflect this). Licensed administrative staff A, concluded that this discrepancy indicated resident #41, received the [MEDICATION NAME] instead of the [MEDICATION NAME] at 9:00 pm. Review of a nurse's note, dated 6-18-19 at 8:17 am, revealed resident #41 as alert and oriented to person, but lethargic and unable to answer questions. The resident had labored breathing (respiratory rate of 16, pulse 86 and blood pressure 106/57) and on 3 liters of oxygen, with an oxygen saturation level of 85%. Licensed nursing staff G notified the physician of the resident's change in status, and the physician instructed staff to transfer the resident to acute care for evaluation. A nurse's note, dated 6-18-18 at 1:30 pm, (time of the documentation) documented licensed nurse G requested the acute care facility perform a urine drug screen for [MEDICATION NAME] on the resident. Licensed nursing staff G documented he/she contacted physician F and requested him/her to contact the acute care facility to run a [MEDICATION NAME] drug screen on the resident as it was possible the resident received [MEDICATION NAME]. A urine drug screen, dated 6-18-19 at 10:30 am, revealed a positive level of [MEDICATION NAME], for resident #41. Interview, on 6-24-19 at 4:42 pm, with licensed nursing staff I revealed he/she worked from 6:00 pm on 6-17-19 through 6:00 am on 6-18-19. Staff I stated he/she passed medications and acted as the charge nurse. Staff I stated he/she was new to the facility and worked approximately 8 shifts and became distracted by a high risk for fall resident during the bedtime (8-9 pm) medication pass. Staff I inadvertently administered resident #27's [MEDICATION NAME] 10 mg, 3 tablets, to resident #41. (instead of the [MEDICATION NAME] 50 mg, 2 tablets, as ordered by the physician). Interview, on 6-24-19 at 4:42 pm, with licensed nursing staff G confirmed he/she completed the narcotic count with licensed nursing staff I, and found the discrepancy with 3 missing [MEDICATION NAME] pills on 6-18-19 at 6:00 am and notified the director of nursing. Staff G stated he/she assessed resident # 41 and noted the above mentioned change in status, notified the physician of the change in status and subsequent transfer of resident #41 to acute care. Interview, on 6-24-19 at 4:00 pm, with administrative nursing staff A, revealed he/she investigated the [MEDICATION NAME] discrepancy on 6-18-19 at approximately 8:30 am. Staff A stated he/she noted the count for the [MEDICATION NAME] 50 mg, 2 tablets indicated the last dose administered on 6-16-19 and was signed for on 6-17-19 at 9:00 pm, on the MAR. Staff A interviewed licensed nursing staff I and determined the [MEDICATION NAME] dose most likely was the [MEDICATION NAME], as this count was off. Staff A stated he/she discussed the missing doses with the facility's medical director (resident #41's physician) on 6-18-19 at approximately 8:45 am and related the possibility that resident #41 received the [MEDICATION NAME] instead of [MEDICATION NAME]. Staff A stated, residents #41's positive urine [MEDICATION NAME] level confirmed the suspicion. Interview, on 6-25-19 at 8:55 am, with nursing staff A, notified him/her of the medication discrepancy on 6-18-19 in the morning and suspicion that resident #41 received [MEDICATION NAME] on 6-17-19 at 9:00 pm. Staff notified him/her of the resident's change in condition, noted at 6-18-19 at 8:17 am, and he/she instructed staff to send the resident to acute care. The facility policy for medication administration, dated 5-2017, advised staff to verify the pharmacy prescription label and the MAR matches and verify the correct resident, medication, dose, route, and time with the MAR before administering. The facility failed to ensure resident #41 remained free of significant medication errors and received only medication as ordered by the physician. The resident received another resident's narcotic medication which resulted in a change in status, low oxygen saturation levels, requiring admission to the acute care intensive care unit for administration of [MEDICATION NAME] and monitoring.

The facility reported a census of 39 residents with 5 selected for review of accidents. Based on observation, interview and record review, the facility failed to ensure 1 resident (#3), of the 5 reviewed, received care and services to ensure a safe environment, related to the resident climbing over the top of full side rails and fell to the floor. Additionally, the facility failed to ensure staff utilized foot pedals on the wheelchairs, as needed, for 3 residents (# 2, 5, and 6) of the 5 reviewed. Findings included: - Resident #3's physician order [REDACTED]. A significant change Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status score of 5/15, indicating severely impaired cognition. The assessment documented the resident required extensive assistance of 2 staff for bed mobility, transfers, and toileting. Additionally, the assessment identified the resident experienced falls since admission with 2 or more without injury, 2 or more with injury (not major) and none with major injury. The assessment lacked identification of side rail use. The cognition and fall Care Area Assessments, dated 6/26/17, included an acute onset of mental status change from the resident's baseline, with inattention, disorganized thinking, and behaviors, which placed the resident at risk for injury. Fall risk assessments, dated from 5/9/17 to 6/23/17, included scores from 15 to 21. The risk assessments identified that scores of 10 or greater identified the resident at high risk for fall potential. Side rail assessments, dated 3/14/17, included a determination that the resident preferred ½ rails bilaterally to enable the resident in bed mobility and to promote independence. An assessment, dated 5/9/17, was the same as the 3/14/17 assessment. The staff failed to assess the appropriateness of the full rails when added to the bed on 6/4/17. On 6/16/17, an assessment determined side rails were no longer necessary. The residents care plan, dated 4/26/17, included a plan for the prevention of falls, related to the use of side rails: Encourage the resident to use the call light and to wait for assistance for safety, added 12/24/16. Encourage the resident to wear non-skid socks, added 12/24/16. Staff observed resident slide off the bed, lowered the transfer bar to a ¼ rail to better define the edge of the bed, and added 6/1/17. Requested hospice to provide a bed with longer (full) rails, added 6/4/17. Ensure oxygen in place and side rails remain in raised position, added 6/4/17. Right side rail padded and in raised position for comfort, allowing the resident to exit at the foot of the bed, where a transfer pole is within easy reach for the resident to use the bedside commode, added 6/4/17. Resident can notify staff if he/she wants the side rail left up or not, added 6/4/17. Removed full rail on left side of the bed, when the resident climbed over the bedrail and fell . The right sided padded rail remains in place with the bed against the wall, added 6/15/17. A fall on 6/16/17 at 6:45 AM identified the staff found the resident on the floor in his/her room. The resident held his/her head in his/her hands, with a 1.8 centimeter laceration to the left eyebrow and a hematoma, 3 centimeters by 1.8 cm, to the left side of the resident's forehead. Additionally, a 0.4 centimeter abrasion was noted to the resident's left cheekbone. The staff steri-stripped the laceration, completed neurochecks and notified hospice. An investigation of the fall, dated 6/19/17, identified another staff member observed the resident crawling over the top of the rail, caught his/her self on the rail and then fell over the rail onto his/her face. The staff member was not able to reach the resident in time to prevent the fall. Observations of the resident, on 6/28/17 at 2:45 PM, identified the resident seated in a wheel chair with staff member T, supervising the resident's meal intake, in his/her room. Noted fading bruising to the resident's left eye area. On 6/28/17 at 3:10 PM, the resident rested in bed, with a full rail up on the right hand side of the bed, against the wall, with padding over the rail. The left side of the bed exhibited an overbed table beside the bed, with personal items on it, within the resident's reach. The bed appeared at a regular height, and lacked any fall mat on the floor. The oxygen concentrator, placed at the head of the bed, identified normal length tubing and the resident's call light rested on the concentrator. At 4:10 PM the resident remained in bed, however, had awakened and reached for a cover at the foot of the bed. The call light remained out of the resident's reach. Continued intermittent observations identified the resident remained in bed at 4:15 and 4:30 PM, with the call light out of reach. At 4:45 PM the resident sat on the edge of the bed, holding a television remote control and visited with staff member L. Staff L reported, at that time, the resident required one on one staff attendance when the resident was awake, due to the resident's high fall risk. On 6/29/17 at 8:00 AM, the resident slept in the bed, with the call light within the resident's reach, the bed at regular height, and the overbed table placed next to the exit side of the bed. The resident remained in the same position during observations at 8:30 AM and 9:00 AM. At 9:15 AM the resident appeared to move about in the bed, minimal movements. An overbed table exhibited the resident's breakfast meal atop the table. No staff were present. The tray and table remained in place with the resident asleep at 9:30 AM; however, at 10:00 AM the tray was remained with the table remaining in place. At 10:45 AM the resident sat in a high fowler's position in the bed, was alert and talkative and requested coffee. Direct care staff J entered the room during the conversation, delivering coffee, cereal and milk for the resident. The resident lacked any staff present at 11:00 AM upon observation. At 11:45 AM, a hospice nurse sat with the resident. The resident remained in bed, with the overbed table in front of the resident until 1:15 PM, in the high fowler's position. At 3:10 PM direct care staff K assisted the resident with standing up, using a gait belt and non-skid socks on his/her feet. The resident stood for several minutes at the edge of the bed, supported by the staff and the resident holding onto the bed. On 6/28/17 at 1:03 PM direct care staff J reported the resident used a bedside commode for toileting, cognition varied from very alert to very confused, and the resident had experienced falls as a result of the confusion. The last fall the resident had a cut above his/her eye. Interventions to keep the resident safe included one on one when awake, try to keep the resident calm, no rail on the outside of the bed now, but did have one and climbed over it and fell . On 6/29/17 at 12:40 PM, consulting nurse M reported the resident had declined as a result of his/her disease process and experiencing increased confusion, most likely due to hypoxia (inadequate supply of oxygen). The resident does seem to get an occasional spurt of energy, thinking he/she can walk without assistance and falls. The facility and hospice along with the medical director for hospice all brainstormed on what to do for the resident, however, that is difficult while maintaining his/her dignity and respect the resident's wishes. A private sitter seems to work the best, but even then he/she becomes upset with the lack of privacy. The nurse reported hospice provided the full rails in the attempt to keep the resident from rolling out of bed. On 6/29/17 at 12:53 PM direct care staff I reported that the most recent interventions included providing one on one with the resident, when awake and removal of the full side rails. Staff further noted the resident had crawled over the rails, prior to the fall with head injury. On 6/29/17 at 2:30 PM direct care staff G reported the resident needed one on one observation when up and out of bed, with the bed in the lowest position, and the right side rail padded, against the wall. The bed had full side rails on the outside of the bed; the resident crawled over the rails and fell and the staff then removed the rail. On 6/29/17 at 4:17 PM, administrative nursing staff B, reported the resident had been a challenge, in relation to falls. The staff verified the resident had fallen numerous times and each time the staff reviewed the fall to find out the root cause and attempt to prevent further falls. The staff further noted that the attempt to place full side rails on the bed, as a result of a fall when the resident rolled out of bed, while asleep. The staff reported the end of the bed, at that time had a transfer pole with enough space for the resident to exit from the end; instead the resident crawled over the top of the rail and incurred a head injury. Administrative nursing staff B, reported on 7/5/17 at 7:45 PM, reported the residents full side rails were placed as an intervention to prevent the resident from rolling out of bed, and then he/she climbed over the rail and fell on to the floor. The staff verified the facility failed to fully assess the resident for full side rail use. The facility failed to provide adequate supervision and/or assistive devices to prevent an injury fall for this resident, with multiple falls. The resident climbed over a full side rail, fell and incurred a head injury requiring steri-strips. - The 8/13/16 admission MDS (minimum data set) documented resident #2 with a BIMS (brief interview for mental status ) score of 2 which identified severe cognitive impairment, (0-7= severe cognitive impairment). The resident required extensive assistance with most ADLs (activities of daily living) , and used a wheelchair with mobility. The 8/13/16 Fall CAA (care area assessment) documented he/she was at risk for falls related to a new environment, use of medication, reduced ability to communicate, incontinence, and history of elopement attempts at a prior facility. The 5/15/17 quarterly MDS documented a BIMS's score of 4, and the resident remained with the same required extensive assistance required for ADLs and used a wheelchair for mobility. The 5/22/17 care plan instructed staff the resident was mobile via wheelchair; propelled by the resident and the staff and used no footrests on the wheelchair. The 12/14/16 fall risk assessment documented a score of 13. A score of 10 or above represented high risk, and the resident had many falls at the previous facility. The 6/16/17 fall risk assessment documented a score of 7. On 6/29/17 from 9:00-11:20 AM, intermittent observations revealed the resident in the dining room sitting in a wheelchair without foot rest pedals. The resident moved the wheelchair with his/her feet. Activity staff N entered the room, talked to the resident, and set up items for an activity. The resident continued to move the wheelchair back and forth with his/her feet, as activity staff N continued, reading and singing with the group. On 7/5/17 at 1:35 PM, direct care staff L and V pushed the resident, in the wheelchair, from the dining room to his/her room. The wheelchair lacked foot rest pedals. The resident's feet, with nonslip socks on, touched the floor as the staff propelled the wheelchair forward. Direct care staff L brought a stand-up lift into the room and began to attach the sling to the resident, who sat with his/her head down and eyes closed. The resident would not arouse as staff tried to get him/her to hold onto the bars of the lift, and just left his/her arms fall down. Direct care staff L reported not comfortable with using the lift with the resident so lethargic, and went to get the full lift. Staff got the Hoyer lift, used a sling that went around the resident's legs, and transferred the resident to the bed. On 6/29/17 at 9:42 AM, direct care staff L reported the resident was able to propel him/her self in the wheelchair and did not use foot pedals. The staff added the resident did have pedals for the wheelchair but the staff did not use the pedals, since the resident used his/her feet to move about. On 7/5/17 at 3:45 PM, direct care staff L verified the resident's wheelchair lacked foot pedals as staff pushed the lethargic resident from the dining room to the bedroom. Staff L explained not using the foot pedals because the resident used his/her feet to move about in the wheelchair at times. Direct care staff L verified that at other times the resident was lethargic as today, and added maybe the staff should use foot pedals when the resident was like this. On 7/5/17 at 4:00 PM, licensed nursing staff E reported staff should use foot pedals when the resident was so lethargic. Staff E further verified the resident's care plan lacked instruction for the staff do this. Licensed nursing staff E added that the resident did have days of being very lethargic. On 7/5/17 at 4:20 PM, administrative nursing staff C verified the care plan lacked instruction for the use of the foot pedals when the resident had lethargic days, and reported the resident had these days these periodically. The facility failed to provide a policy for the use of wheelchair foot pedals when requested. The facility failed to ensure safe wheelchair transportation for this resident, when the staff failed to utilize foot pedals for this cognitively impaired resident who was very lethargic with feet touching the floor. - Resident #5's [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], included a Brief Interview for Mental Status score of 7/15, indicating moderately impaired cognition, and the resident required extensive assistance of staff for transfers with range of motion impairment to 1 side of the resident's body, to the upper and lower extremities. Therefore, the resident used a wheelchair for mobility. The assessment identified the resident had a fall in the 2-6 months prior to entry to the facility, and without fracture or falls since admission. The Care Area Assessment for falls, dated 4/12/17, identified the resident at risk for falls due to weakness on the resident's dominant (right) side, along with confusion and reduced safety awareness. 1. The care plan, dated 4/17/17, lacked inclusion of wheelchair foot pedals to the plan of care, as needed. 2. Do not leave the resident in the wheelchair alone in his/her room. Added 4/12/17. 3. Take the resident to his/her room as soon as he/she finishes meal intake. Take the resident to the bathroom and then assist into the recliner or bed. Provide the resident all items he/she wanted, and place these items within reach of the resident. Place the call light within reach. Adjust the television and lighting, as desired. Leave the door open and check on the resident's needs at intervals. Added 4/25/17. On 6/28/17 at 5:09 PM, direct care staff K propelled the resident's wheelchair in the hallway. The staff instructed the resident to hold his/her feet up. An unidentified family member inquired about foot pedals for the resident. Staff K responded, some residents need them and some did not. The staff continued to propel the resident outside the building, while the resident held his/her legs elevated. On 6/29/17 at 3:40 PM the resident returned with family via wheelchair, without foot pedals, to the facility. On 6/28/17 at 1:03 PM, direct care staff J reported the resident required extensive assistance of staff for most ADL's (activities of daily living). On 6/28/17 at 4:50 PM, direct care staff K reported the resident required extensive assist with most ADL's. On 7/5/17 at 11:43 AM, direct care staff H reported the resident required assistance with toileting. Staff H further reported that sometimes the resident self-propelled the wheelchair independently, but usually staff propelled the resident where he/she chose to go. On 7/5/17 at 7:45 PM, administration staff A, reported the residents using wheelchairs, and sometimes requiring assistance with propelling of the wheelchairs, needed to be assessed and a determination of the use of foot pedals considered. The facility failed to provide a policy for foot pedal use on wheelchairs, when requested. The facility failed to provide wheelchair foot pedals for this resident, when the staff propelled the wheelchair, placing the resident at risk for an accident if unable to hold feet up for extended periods of time. - Resident #6's physician's orders [REDACTED]. The resident lacked a completed comprehensive Minimum Data Set assessment, due to the length of stay. The resident's care plan, dated 6/22/17, lacked any instructions to staff regarding the resident's use of foot pedals. 6/26/17 I slid out of my wheelchair to sit on the floor, therapy looking at my wheelchair cushion to reduce the risk. On 6/29/17 at 12:15-12:30 PM, the resident self-propelled the wheelchair, in the dining room without foot pedals in place. The resident seemed groggy, and with his/her eyes closed most of the time. At 1:15 PM, direct care staff T assisted the resident to his/her room, in the resident's wheelchair, without foot pedals in place. The resident remained very sleepy and staff continually asked the resident to hold his/her feet up. The resident's feet touched the floor, and at times the resident took tiny steps, when instructed to do so. On 7/5/17 at 11:22 AM, direct care staff H returned the resident from the dining area to his/her room without any foot pedals in place on the wheelchair. The resident took steps during the propelling, as though self-propelling, but with staff continuing to push the wheelchair. At 11:26 AM, the staff and resident returned to the dining room from the resident's room, still without any foot pedals, with the resident's feet barely raised off the floor. On 6/28/17 at 1:03 PM, direct care staff J reported the resident was a fall risk and did not walk at this time. The staff reported the resident did not use foot pedals. On 6/29/17 at 12:53 PM, direct care staff I reported the care plan directs care needs for the residents. In addition to the care plan, a kardex (list of care needs) are available in the kiosk (a computer screen). When asked about safety interventions for the resident, the staff lacked knowledge of wheelchair foot pedal use. Direct care staff G reported, on 6/29/17 at 2:30 PM, the resident was a fall risk and required one on one attention when up in his/her wheelchair, however, lacked knowledge of wheelchair foot pedal use. On 7/5/17 at 11:37 AM, direct care staff H reported the resident was a fall risk, and needed one on one attention, when awake. The staff added the resident often propelled him/herself into other resident rooms. The staff further indicated the resident did not use wheelchair foot pedals as he/she did self-propel. On 7/5/17 at 7:45 PM, administrative staff A reported the residents who required wheelchairs and sometimes self-propelled and sometimes staff propelled, required assessment and care planning to instruct staff in the residents safety needs. The facility failed to provide a policy for foot pedal use on wheelchairs, when requested. The facility failed to provide wheelchair foot pedals for this resident, when the staff propelled the wheelchair, placing the resident at risk for an accident if unable to hold feet up for extended periods of time.

The facility reported a census of 37 residents, with 3 residents sampled and reviewed for accidents. Based on observation, interview and record review, the facility failed to provide interventions to prevent a fall for resident #1, when the resident repeatedly rocked backwards onto the back two legs of the dining room chair, falling backwards and hitting his/her head, causing a laceration on the back of the head that required transfer to the hospital and 6 staples for closure of the wound. Findings included: - The physician's orders [REDACTED].#1 re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 9/9/15, documented the resident's BIMS (brief interview for mental status) score of 2, indicating severely impaired cognition. The resident required extensive assistance of 1 staff for bed mobility, transfers, walking in room/corridor, locomotion on/off unit, and toileting and was not steady walking, but able to stabilize with staff assistance. The resident used a wheelchair for mobility. There were no falls noted since admission or readmission to the facility. The quarterly MDS, dated [DATE], documented the resident's BIMS score of 1. The resident required limited assist of 1 for bed mobility and transfers, supervision for walk in room/corridor and locomotion on/off unit. There were no assistive devices used for mobility. The resident had one non-injury and one minor injury fall noted since the prior assessment. The CAA (care area assessment) for falls, dated 9/9/16, documented the resident at was risk for falls due to the following: dementia with cognitive loss and reduced safety awareness, incontinence issues, potential effects of medications, mood changes, behaviors of wandering, delusions, unsteady gait, and a history of falls. The care plan, last updated 1/18/16, documented the resident forgets things and makes poor choices which creates possible safety risks. The resident was at risk for falls. Staff directed to attempt to redirect the resident to common areas for closer supervision when up, assist with transfers and ambulation as appropriate, keep the environment free of obstacles, apply foot wear to prevent slipping, and use the grab bar for repositioning. The update, on 2/9/16, documented the resident tipped the chair back in the dining room, falling straight back and receiving a 4 cm (centimeter) laceration to the back of the head. It may be safer to sit him/her in the assisted area of the dining room so staff can more closely monitor his/her safety. The update, on 3/1/16, directed staff to provide frequent visual checks for safety, redirect/toilet the resident as needed and help engage him/her in activities as tolerated. Place a mattress on the floor, with a fall mat next to the bed, due to witnessing the resident's attempt to roll out of bed and off the couch in the library. The resident prefers to sleep in the library on the couch so staff will continue to do frequent visual checks for safety and redirect the resident if observed attempting to roll off the couch. The fall risk assessment, dated 9/2/15, documented a score of 20. A score above 10 deems at risk for falls. The nurse's note, dated 2/9/16 at 3:42 PM, documented the resident sat in a regular dining room chair at lunch. Staff witnessed the resident fall backwards in the chair hitting the back of his/her head. The staff were unable to reach the resident in time to prevent the fall. A 4 cm laceration noted to the back of the resident's head. The physician ordered to send the resident to the hospital for possible closure of the laceration and for evaluation. The nurse's note, dated 2/9/16 at 4:54 PM, documented the resident returned from the hospital with 6 staples to the back of the head. The resident was to follow-up with the physician in 7 days for suture removal. Observation of the resident, on 3/1/16 at 9:45 AM, revealed the resident asleep on the couch in the library room, covered with a blanket. At 11:28 AM, the resident independently ambulated in the hallway, with an unsteady gait. At 11:43 AM, the resident sat at a dining room table eating a snack, while a staff member provided a craft activity for the other residents at the table. At 1:09 PM, the resident returned to the couch in the library room and fell asleep. At 1:20 PM, 1:42 PM, 2:00 PM, 2:14 PM, 2:23 PM, and at 2: 54 PM, there was no change. On 3/1/16 at 10:12 AM, direct care staff C reported the day the resident fell , he/she rocked the chair and tipped it backwards and hit his/her head. The resident tips the chair back onto just the back two legs of the chair and rocks. Staff C stated he/she observed the resident rock the chair on and off for the last month. Staff C stated the nurses knew about it too, because sometimes they would come and talk with the resident and tell him/her, Hey, you can't be rocking like that, you are going to fall. Staff C was never told anything specific to do to stop the resident from rocking the chair. Staff C would redirect the resident, and give him/her something to eat or a cup of coffee to distract him/her from the rocking. Sometimes it worked for a little bit, then the resident would go back to rocking the chair. The resident was very forgetful. On 3/1/16 at 11:20 AM, direct care staff D reported he/she had seen the resident rock back in the dining room chairs on and off since last November. Staff D had frequently heard kitchen staff tell the resident not to rock in the chairs. Staff D had talked with administrative nursing staff B several months prior to the fall about how the resident rocked in the chair in the dining room, but nothing specific was ever put into place to stop it that staff D was aware of. On 3/1/16 at 1:32 PM, licensed nursing staff E reported the resident was at risk for falls and had occasionally seen the resident rock the chair in the dining room onto the back two legs of the chair. Staff E stated the resident had done that for as long as staff E could remember. Staff E stated there was not anything specific done to address the rocking in the chair. If an unsafe behavior is seen in a resident, such as rocking the chair, interventions should have been placed in the care plan to prevent an accident, but we did not do that. On 3/1/16 at 1:56 PM, licensed nursing staff F reported the resident fell and was injured when he/she rocked the chair back and forth on the back legs of the chair. Staff F had seen the resident do this before that day, but stated there was nothing in the care plan regarding the rocking in the chair prior to the fall. On 3/1/16 at 3:00 PM, dietary staff G stated the resident frequently rocked the chair on the back legs when he/she sat in the dining room. Staff G had frequently heard and seen the nurses and CNAs (certified nursing assistants) tell the resident he/she was not in a rocking chair and needed to stop rocking before he/she fell out of the chair, it was not safe. Staff G stated that when the staff did this, it did not usually work and the resident would continue to rock the chair. On 3/1/16 at 3:17 PM, licensed nursing staff H stated the resident rocked the dining room chair all the time before the fall. There were no specific interventions in place to address that safety concern. Staff H would just redirect the resident, which did not always work. On 3/1/16 at 3:27 PM, administrative nursing staff B reported the resident had a fall from the dining room table because he/she tipped the chair back and fell over. The resident received a laceration to the back of the head which required 6 staples for closure of the laceration at the hospital. Nobody had ever reported the rocking of the chair to staff B. If staff B had been aware, interventions would have been put in place to try and prevent the fall. The facility provided falls management policy, dated 10/21/15, documented the falls prevention and intervention program includes residents at risk for falls will have a fall risk care plan initiated with appropriate and individualized interventions in place. There will be ongoing assessment and documentation by licensed nurses and a communication system to identify residents at risk for falls. The facility failed to identify the resident's repeated unsafe behavior of rocking the chair on the back legs, and develop appropriate interventions to prevent a fall. The resident fell backwards while rocking the chair in the dining room and received a 4 cm laceration, which required transfer to the hospital where the resident received 6 staples to close the head wound.

The facility had a census of 43 residents. The sample included 7 residents. Based upon observation, record review and interviews, the facility failed to develop and implement timely interventions to prevent development of and promote healing of pressure ulcers for 1 (#77) of 1 residents sampled for skin. Resident #77 developed an unstageable pressure ulcer to the spine and two stage II pressure ulcers to the buttocks. Findings included: - The Physician order [REDACTED].#77, dated 10/21/15, includes a [DIAGNOSES REDACTED]. Review of resident #77's admission Minimum Data Set (MDS), dated [DATE], recorded the resident admitted to the facility on [DATE]. He/she had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe impairment in cognition. The resident required extensive assistance of one for bed mobility, dressing, eating and personal hygiene. Transfers and toilet use required extensive assistance of 2. He/she had impaired range of motion (ROM) on one side of the upper and lower extremities. The resident had scheduled and as needed pain meds with no pain reported on the MDS. The resident was at risk for development of pressure ulcers with no unhealed pressure ulcers at the time of the assessment. The resident was to be placed on a turning and repositioning plan. The Care Area Assessment (CAA), dated 10-08-15, documented the resident was at risk for pressure ulcers related due to low Body Mass Index (BMI) and reduced mobility due to effects of a past stroke. The Braden assessment, completed 10-01-15, recorded the resident was at risk for development of pressure ulcers. The temporary care plan, dated 10-01-15, instructed staff to turn and reposition the resident every two hours. The care plan for altered skin integrity, dated 10-06-15, updated from the original temporary care plan, documented that although the wound on the resident ' s back started as a shear, it was now a pressure ulcer. Staff were to provide pressure reducing wheelchair cushion for the resident ' s wheelchair and recliner. The care plan included interventions of a pressure redistributing mattress and for the resident to be turned and repositioned by staff. The resident ' s admission skin assessment, completed on 10-01-15, documented no open areas on the resident. Review of the nurses notes revealed an entry on 10-12-15 at 4:14 p.m., which included the nurse had noted a red/blanchable (reddened area of the skin that temporarily turns white or pale when pressure is applied with a fingertip ) area to the resident's mid spine with a dime-sized open area distal to the redness. The resident also had a nickel-sized open area to his/her bilateral inner buttock. The nurses note also revealed the areas had a shear-like appearance with 100% granulation (collagen-rich tissue which forms at the site of an injury) tissue. Review of the resident ' s chart revealed a physician telephone/verbal order on 10-12-15, from physician E for staff to initiate gel cushions for the resident ' s buttock/coccyx and spine to be placed in the resident ' s recliner and wheelchair related to increased risk of skin breakdown. Staff were to use skin prep to the red area on the resident ' s spine, off-load with hydrofoam to the open area of the spine and change dressing every three days and as needed (PRN). The Wound Evaluation Flow Sheet, dated 10-28-15, by direct care staff C, identified an unstageable pressure ulcer, acquired in-house, on the resident ' s upper-mid spine. The wound measured 4.0 X 3.0 centimeters (cm), had no depth, odor or drainage. The wound had 80% necrotic (pertaining to the death of tissue in response to disease or injury) tissue and 20% granulation tissue with defined wound margins. The surrounding tissue was clean, dry and intact. The treatment order received on that date was for xeroform to the open area and off-load with hydrofoam. Dressing was to be changed daily. The wound had no signs or symptoms of infection. Current preventative interventions already in place included, pressure redistribution mattress, wheelchair cushion and positioning pillows in chair to aid in off-loading spine. The Wound Evaluation Flow Sheet, dated 10-29-15, by direct care staff D, documented the measurements of the unstageable wound to be 5.0 X 3.5 cm with no depth. The wound had 85% necrotic tissue and 15% granulation tissue with defined wound margins. The surrounding tissue had erythmia (redness or inflammation of the skin). The treatment order was changed that date and instructed staff to wash the wound with wound wash, pat dry with gauze, then apply hydrogel to the wound and cover with hydrofoam. Off-load the wound with ABD (a type of dressing used for wounds) pad and secure with tape. Change every day and PRN due to drainage. Further review of the resident ' s chart revealed communication on 10-29-15, from licensed staff C to physician E requesting the physician visit the resident in the facility to assess the spinal wound due to rapid changes. The wound had increased in size 1 cm in length and had developed inflammation around the wound within the past 24 hours. An air mattress was placed on the resident ' s bed and off-loading pillows while in the recliner as interventions. The measurements of the wound at the time of assessment on that date at approximately 5:00 p.m., were 5.0 cm in length, 3.0 cm in width, with 5 cm of inflammation surrounding the wound. Eschar (dead tissue) to the wound measured 5.0 X 3.0 cm. On 10-28-15 at 9:00 a.m. and 9:15 a.m., the resident was sitting in his/her recliner watching television in their room. At 9:30 a.m., direct care staff H entered the resident ' s room and assisted him/her to toilet. After toileting, staff assisted the resident back to his/her recliner where the gel cushion was in place. On 10-29-15 at 8:03 a.m., direct care staff H assisted the resident to the dining room for breakfast. The resident was reclined in the geri-chair and had no pillows off-loading his/her spine. The resident ' s spine was resting directly on the back of the geri-chair. On 10-29-15 at 8:43 a.m., administrative nursing staff B, asked direct care staff H why the resident did not have positioning pillows with him/her in the wheelchair. At that time, staff H retrieved the positioning pillows from the resident ' s room and with assistance from staff B, placed the pillows appropriately for the resident. On 11-02-15 at 1:24 p.m., licensed staff D and hospice licensed staff G went into the resident ' s room to change the dressing to his/her spine. A small amount of drainage was present when staff removed the existing dressing. Wound measured 5.3 X 3.4. The reddened area, including the open wound measured 11.5 X 5.2 cm. Licensed staff D treated the wound and covered per current orders. On 10-28-15 at 12:37 p.m., direct care staff H stated, the resident had a pressure ulcer on his/her spine. The area had a bandage on it at times, but not always. The first time staff H had seen a bandage on the resident ' s back was approx. 10-21-15. The resident also had pressure ulcers on his/her bottom. Staff H stated staff repositioned the resident at least every two hours. On 10-29-15 at 12:14 p.m., direct care staff H stated, the positioning pillows had not been put in place with the resident in the geri-chair that morning because he/she had not been informed the resident needed them. Staff H stated staff used a Communication book for new interventions. The book helps to make sure other staff and shifts are aware of changes going on with the residents. Staff H stated that administration, nurses, aides and therapy are all able to write in the book to pass new information along to other shifts. Staff are to look at the book at the beginning of each shift. Upon review of the communication book on the date and time, the intervention for the positioning pillows was not there. Staff H also stated that there are also cheat sheets available for the staff. Staff H stated the resident did not have an air mattress because those are only for residents who are prone for skin break down and stay in bed most of the day. On 10-28-15 at 3:26 p.m., hospice direct care staff I stated, he/she had noticed a bandaged area to the resident ' s spine. Staff I stated the area has been bandaged since about a week following the resident ' s admission to the facility. When staff I had given the resident a bath on 10-23-15, he/she had noticed the area on the lower spine had a dressing at that time. On 10-28-15 at 3:43 p.m., licensed staff C stated, the area on the resident ' s back was first noticed on 10-12-15 and staff documented the area as a sheer. At that time, staff were using skin prep on the area and off-loading. On 10-27-15, staff C noticed the area was open and had eschar. Staff C had not notified the primary care physician was not notified of the area until 10-28-15, because he/she stated they were waiting on hospice to be notified. Staff C considered this area to be an unstageable pressure ulcer due to the necrotic (dead) tissue, and this was the resident ' s only current pressure ulcer. Staff C stated the resident had gel cushions in his/her wheelchair and recliner and staff would stand and reposition him/her at least every two hours. The resident is able to reposition him/herself slightly. The resident is currently not on any supplements for the pressure ulcer, though usually residents with pressure ulcers do receive supplements to help promote healing. On 10-29-15 at 9:03 a.m., off duty licensed staff J stated over the phone, that a full body skin assessment was done by him/her at the time of the resident ' s admission on 10-01-15. The resident had no open areas to his/her spine at that time. On 11-02-15 at 2:55 p.m., hospice licensed staff K stated, the area to the resident ' s spine was a pressure ulcer that came on very quickly. The wound will be difficult to resolve due to the resident ' s poor nutrition. Staff K stated the resident has extremely fragile skin. On 11-02-15 at 2:44 p.m., administrative staff B stated, the air mattress was not put on the resident until 10-29-15 because the wound on the spine started as a sheer and it is not common practice for the facility to use air mattresses for sheers. Furthermore, staff B stated the resident does not receive supplements because this is not something that has been ordered for him/her. On 11-02-15 at 10:57 a.m., physician staff E stated, the size of the pressure ulcer will get bigger before it gets better and believes it will gain approximately 5 cm in size before beginning to heal. The nurse had notified staff E of the area on 10-27-15. Staff E continued to state that the resident does not eat well so it will be difficult to heal. If the resident had been turned and repositioned more often and if more interventions had been in place to prevent skin breakdown, it would have delayed the occurrence of this pressure ulcer. The resident is unable to reposition him/herself without assistance. The facility policy for skin integrity, undated, documents the residents will be assessed for risk of skin breakdown within 24 hours of admission, quarterly, before transfer or discharge and as necessitated by change in condition. The interdisciplinary plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. The facility failed to implement interventions for this dependent resident to prevent the development of and promote healing of pressure ulcers.

The facility had a census of 47 residents. The sample included 17 residents, with 3 residents sampled for nutrition. Based on observation, record review and interviews the facility failed to develop and implement timely interventions to prevent significant weight loss for 1 (#55) of the 3 residents reviewed. The resident experienced a significant weight loss of a loss of 5 pounds (4%) in one month without intervention and lost 13 pounds (7.7%) in 2 months without intervention. The resident's weight continued to decline to 91 pounds (16.51%). Findings included: - Review of resident #55's POS (physician order [REDACTED]. [DIAGNOSES REDACTED]. Review of the admission MDS (minimum data set), dated 4-16-15, identified the resident with a BIMS (brief interview for mental status) score of 11, indicating the resident was moderately cognitively intact. The resident required extensive assistance of one for eating. The resident had no impairment in ROM (range of motion) in his/her upper extremities. The resident had no natural teeth or tooth fragments. The resident's weight was 120 pounds. The MDS documented that it is unknown if the resident has weight loss/gain. The quarterly MDS, dated [DATE], identified the resident was able to eat independently with set up help. The weight documented was 104 pounds. Weight loss/gain was no or unknown. BIMS score was 10, indicating the resident continued to have moderately impaired cognition. The nutritional CAA (care area assessment), dated 4-16-15, documented the resident was to have a dysphasia (pureed) diet, which he/she refused, and the resident was on a regular diet. The resident required supplements for wound healing and was at risk for weight loss. The care plan, dated 6-03-15, revealed the resident chose to have a regular diet. Staff were instructed to monitor for and report significant findings in weight loss among other indications of fluid deficit. No other nutritional interventions were initiated and the resident did not have a nutrition care plan. Review of the resident's physician orders, dated 8-05-15, documented the resident was to receive 2 cal supplement (a high calorie liquid supplement), 120 cc's (cubic centimeters) two times a day starting on 4-20-15 and Pro Pass (a protein liquid supplement) 30 ccs every day for wound healing starting on 4-30-15. Review of the resident's labs revealed an [MEDICATION NAME] level of 3.5 (normal range 3.5-5) and a total protein level of 7.2 (normal range 6.0-8.5), both within normal levels. Both labs were drawn on 4-07-15, before the resident's admission to the facility. Review of the resident's weights in Point Click Care included: 5-01-15: 108 pounds 6-01-15: 109 pounds 7-05-15: 104 pounds (5#/4% weight loss from 6-01-15) 7-26-15: 102 pounds 8-02-15: 96 pounds (7.7% weight loss in 30 days) 8-18-15: 91 pounds (11.92% loss in 2 months; 16.51% weight loss in 2 months and 18 days). Further review of the resident's chart revealed the resident received [MEDICATION NAME] 40 mg (milligrams) as a one time order of 4-09-15 due to [MEDICAL CONDITION] on admission. On 4-10-15, staff notified the resident's physician of continued [MEDICAL CONDITION] and a new order for [MEDICATION NAME] 40 mg twice a day for three days then [MEDICATION NAME] 40 mg every day for seven days. On 5-02-15, nurses notes revealed the resident's [MEDICAL CONDITION] resolved. Review of the registered dietician's (RD) nutritional assessment, dated 6-22-15, documented the resident's nutritional intake met his/her estimated needs. Staff were to continue with the regular diet and supplements. It continued to document that the resident's weight was stable and trending upwards. No current [MEDICAL CONDITION] noted. Review of the RD's assessment, dated 7-06-15, documented the resident's current weight as 104. The RD's comment included the resident's weights remain stable over the last 60 days and continues on weekly weights for monitoring. No [MEDICAL CONDITION] noted and no new labs to review. Review of the RD's assessment, dated 8-17-15, documented the resident's estimated nutritional needs were not being met with total nutritional intake. Staff were to continue the regular diet and encourage supplement intakes. The resident triggered for a significant 30 day weight loss. Staff recorded meal intakes were recorded as 42%. The clinical record lacked evidence the physician was consulted after 7-05-15 when the resident's weight had decreased by 5pounds, on 7-26-15 when the resident's weight was down by 7 pounds at 102, or on 8-02-15 when the resident's weight was 96 pounds. Nor is there evidence the RD was notified following the decrease in weight on 7-26-15 and 8-02-15. Review of the MAR (medication administration record), for July and August, 2015, revealed the resident consumed 100% of the 2-cal supplement 9 times in August and 22 times in July. The resident consumed the supplement 25-99% 4 times in July and 1 time in August. In August the resident consumed 1-24% of supplement 8 times and in July 5 times. The supplement was refused by the resident the rest of the days. The resident's meal intake percentages ranged from 15-77% during the months of July and August. On 8-19-15 at 8:00 a.m., direct care staff K, brought the resident breakfast to his/her room which consisted of 2 small containers of yogurt, and juice, which the resident had requested. The resident's breakfast tray was left on the table next to the bed. The resident consumed 1 container of yogurt and 50% of the orange juice per self. Staff failed to encourage the resident to eat more or offer the resident something different. No supplement was given with the meal. On 8-24-15 at 8:30 a.m., two untouched cookies and a cup of juice were on the bedside table within reach of the resident. These were given to the resident for bedtime snack on 8-23-15 per interview with direct care staff K. On 8-24-15 at 12:30 p.m., the resident informed licensed nursing staff E that he/she would eat some macaroni and cheese for lunch. Staff took macaroni and cheese, sliced ham and a roll into the resident's room on a tray. The resident ate 25% of the meal on his/her own before stopping. Staff failed to encourage the resident to eat more or offer the resident something different. No supplement was given with the meal. On 8-24-15 at 7:41 a.m., direct care staff K stated the resident does not eat very well anymore. He/she enjoyed cheeseburgers and will eat 1/4-1/2 of one if it is brought to him/her. The resident also enjoyed milk and cookies and will choose this over a regular meal at times. He/she does a good job of consuming the supplements given to him/her. On 8-24-15 at 4:25 p.m., licensed nursing staff E stated the resident had not been eating well lately. It is difficult to get him/her to eat because the resident had a difficult time hearing, he/she doesn't hear staff if they try to encourage him/her. On 8-25-15 at 12:29 p.m., administrative nursing staff B stated that the resident's initial weight loss of 138 pounds to 108 pounds was expected when he/she admitted due to fluid overload. The family told staff B that the resident's normal weight were between 105-110. Weights were obtained on shower days by the nurse aides. Each morning there was a clinical stand up meeting where weights are discussed, among other clinical things. When a weight loss is noted, the RD is informed. He/she stated the resident's weights were stable between the dates of 4-18-15 and 8-02-15, and no notification of the physician was necessary. Staff notified the doctor of the weight loss on 8-04-15 and the significant loss was first known to the facility on [DATE]. The doctor did not order anything new for the resident at that time. The facility only figured weights from the first of the month to the first of each month and do not figure weights which staff obtained in the middle of the month. This was the reason they did not notice the significant weight loss until August. On 8-26-15 at 8:35 a.m., consultant R stated the resident had been resistant to interventions attempted by the facility and his/her weight had been monitored. Staff R stated they did not believe anything else could have been done for the resident because the 2-cal supplement was the highest calorie supplement available to the facility. On 8-26-15 at 9:39 a.m., licensed nurse S for physician Q stated, the doctor was not informed of the resident's significant weight loss at 96# or 91#. Had the doctor been informed, they would have given the resident something to help improve his/her appetite and to gain weight. The facility's policy for weight monitoring instructs a weight loss of 5% in one month is a significant loss. When weight change was significant, the licensed nurse would notify the resident's physician and obtain and carry out orders if given. The facility failed to identify the resident's weight loss in a timely manner, and notify the physician for further orders resulting in a significant weight loss as the resident lost 5# in one month without intervention and lost 13# in 2 months (11.92%) without intervention. The resident's weight continued to decline to 91 pounds for a total weight loss as of 8-18-15 of 16.51% in 2 month.

The facility had a census of 46 residents, with 21 residents reviewed. Based on observation, interview, and record review, the facility failed to adequately assess and provide treatment for 3 of the 21 sampled residents (#52, 10, and 37) including, the pain and swelling of resident #52's right wrist, the lower extremity swelling for resident #37, and adequate and/or thorough skin assessment for resident #10. Resident #52 experienced harm from a fractured right wrist following a fall. Staff notified licensed staff of swelling to the resident's right wrist, but staff failed to assess and/or provide medical treatment of [REDACTED]. ordered an x-ray of the right wrist. The x-ray report revealed a [MEDICAL CONDITION]'s right wrist. Findings included: - Resident #52 had a [DIAGNOSES REDACTED]. Review of the resident's fall log revealed the resident fell on [DATE], at 11:15 AM, while ambulating without assistance. Staff recorded, on the 10/17/10 change of condition report, staff found the resident on the floor in the bird room, sitting on the floor in front of a chair. Notation on the form read, "Appears that (the resident) attempted to sit in a chair, missed the chair, and landed on the floor. Ambulates independently, unsteady gait, and alert at times. Bump on head..." Staff recorded on the report the resident's vital signs within normal limits and neurological checks initiated. Fall interventions used prior to the fall, according to the record, included bed/chair alarm, bed in the low position, and call light in reach. New fall interventions recorded on the form included a wheelchair for mobility and obtain a dip UA (urine analysis) to rule out an urinary tract infection. Staff recorded in the 10/17/10 nursing notes, "Resident discovered in bird room at 11:15 AM lying on back on floor with legs bent and feet in air. Unable to explain what happened. Appeared as if was going to sit down raised area to back of head, approximately nickel-sized, tender to touch. Denied any other pain...Assessment completed and assisted to chair. There were no witnesses present. Resident had tennis shoes and laces were tied..." The resident's care plan had an intervention, dated 10/17/10, to use the wheelchair for mobility and obtain an urine analysis to rule out an urinary tract infection. Review of the resident's clinical record lacked evidence staff obtained an urine specimen to rule out an infection. Review of the resident's 11/9/10 bath sheet revealed the bath aide identified no problems. Review of the resident's 11/12/10 bath sheet revealed the bath aide recorded the resident's right hand swollen. Review of this bath sheet revealed a licensed staff signed the bath sheet as verification of reviewing the information on the bath sheet. On 11/12/10, staff faxed the physician for an order for [REDACTED]. Review of the resident's clinical record revealed a physician's phone order, dated 11/14/10 (2 days after the bath aide identified the swelling of the resident's right hand), for a x-ray of the right wrist due to swelling, tenderness, and bruising. Review of the resident's clinical record revealed a physician's phone order, dated 11/14/10 (2 days after the bath aide identified the swelling of the resident's right hand), for a x-ray of the right wrist due to swelling, tenderness, and bruising. Review of the resident's clinical record between 11/12/10 and the 11/14/10 physician's phone order lacked evidence of any type of resident injury, fall, or any swelling, tenderness, or bruising of the resident's right wrist. The 11/14/10 preliminary right wrist x-ray report, at 1:06 PM, recorded, a probable undisplaced [MEDICAL CONDITION] of the scaphoid. The x-ray revealed no further significant abnormalities. The radiologist recommended follow-up in 7 to 10 days to verify undisplaced navicular fracture versus a chronic change. The 11/14/10 final x-ray report revealed a probable undisplaced [MEDICAL CONDITION] of the scaphoid, with no further significant abnormalities. Review of the nursing notes from 11/14/10 to 11/16/10 lacked any type of documentation regarding an assessment of the resident's right wrist and/or the reason for the right wrist x-ray. Review of the resident's record revealed a physician's phone order, dated 11/15/10, for the resident to see the physician regarding right wrist swelling and pain. The next nursing documentation found in the record, dated 11/16/10, at 4 AM, revealed staff obtained an order for [REDACTED]. Staff recorded in the next nursing notes, dated 11/16/10, at 11:12 AM, the resident's son notified of the right wrist fracture. Staff recorded in the next nursing notes, dated 11/19/10, at 7:32 PM, the resident reported complaints of pain when asked if the resident's wrist/arm hurt. Staff recorded in the next nursing notes, dated 11/21/10, at 9:51 AM, the resident's right arm in thumb spica cast and sling. Cast was clean and dry, fingers to right hand warm and pink, and no complaints of pain or discomfort. Staff recorded in the next nursing notes, dated 11/23/10, at 10:49 AM, the resident's right arm remained in a cast, and the resident's right fingers pink and warm, swollen, with no bruising noted. Review of the 11/23/10 bath sheet revealed the bath aide recorded the resident with a right cast in place and right hand and fingers swollen. Review of the resident's clinical record lacked evidence of any type of assessment of the resident's swelling to the right hand and fingers for 7 days. On 11/30/10, at 10:33 PM, staff recorded the resident with 1 to 2 plus [MEDICAL CONDITION] to the right hand, with capillary refill of less than 3 seconds. Staff notified the resident's physician and obtained an order for [REDACTED]. On 12/1/10, at 5:36 PM, staff recorded the resident's right arm in a cast and right hand [MEDICAL CONDITION]. Staff documented to try to encourage the resident to elevate the arm with a sling. The clinical record reviewed from 12/1/10 through 12/14/10 lacked documentation of any type of ongoing assessment of the resident's right hand swelling. The resident's significant change 12/1/10 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with bed mobility and transfers, and had experienced 2 falls without injury and 2 falls with injuries. On 12/1/10, staff recorded on the resident's clinical health status form the resident had short and long term memory problems, sometimes understood, resisted cares, and could not transfer or ambulate independently. On 12/1/10, staff completed a resident fall assessment and scored the resident with a 13 (10 or above deemed the resident at risk for falls). Staff documented on the fall assessment the resident had experienced 2 falls in the past 6 months. On 12/2/10, no time, staff recorded the resident out of the facility for a doctor's appointment and returned with instructions to keep the right arm in a sling and elevated with 1 to 2 pillows when in bed or in a chair. Staff recorded the resident needed a follow-up appointment with the physician in 3 weeks. The resident's 12/2/10 right wrist x-ray report documented the resident's right wrist encasted, with alignment intact. On 12/2/10, staff implemented a new intervention on the resident's care plan to elevate the resident's right lower extremity on 1 to 2 pillows when in bed and in the wheelchair. Staff recorded on the care plan the resident often removed the pillows. The resident's care plan, reviewed on 12/9/10, directed staff to ensure the resident's bed in the low position, ensure the call light and personal items available and in easy reach, ensure non-skid footwear in place to prevent slipping; assist of 1 staff with transfers, as needed, with a gait belt, fall mat beside the resident's bed when occupied, assist to sit in areas where staff has view of the resident, and use a bed alarm when occupied. Staff recorded in the resident's 12/14/10 CAAS (Care Area Assessment Summary) the resident with [DIAGNOSES REDACTED]. The resident with difficulty making needs known, follow simple directions, and understanding others. The resident had fall on 10/17/10 and received physical therapy and occupational therapy intervention due to history of falls. Fall risk score of 13 which indicated high risk for falls. Wheelchair used for mobility. Proceed to care plan. The resident's 12/22/10 right wrist x-ray report documented bony alignment about the wrist was anatomic. Wrist remains intact. No definite recent or healing injuries were apparent. Advise a follow-up study of the wrist without the cast for better detail. On 12/28/10, at 11:05 AM, observation revealed the resident in a wheelchair in the dining room, with a pink cast and sling in place to the resident's right lower arm. Observation revealed no pillow in place under the resident's right arm. At 12:45 PM, observation revealed CNA (Certified Nurse Aide) AA assisted the resident with the noon meal. At that time, the CNA failed to offer placement of a pillow under the resident's right arm. On 12/29/10, at 7:30 AM, observation revealed the resident in the wheelchair in the dining room, with no pillow under the resident's right arm. On 12/29/10, at 9:40 AM, observation revealed the resident in a wheelchair in the resident's room. Observation revealed the resident had a fall mat on the floor beside the bed and a sensor bed alarm in place with a green light flashing on the alarm box. On 12/29/10, at 9:50 AM, observation revealed CNAs T and CC transferred the resident from the toilet to the wheelchair, then to the resident's bed. The CNAs assisted the resident to stand and the bed sensor alarm failed to sound. On 12/29/10, at 10:00 AM, CNA T stated, "We just tell the nurse if the alarms are not working." On 12/29/10, at 10:00 AM, CNA CC stated, "I got (the resident) up this morning and come to think of it, (the resident's) alarm did not go off when I got (the resident) up." On 12/29/10, at 10:53 AM, licensed staff B stated, "We don't have a policy regarding proper functioning of alarms..." On 12/29/10, at 1:54 PM, licensed staff B stated, "It is the CNAs responsibility to make sure alarms are in place and functioning properly." On 12/29/10, at 2:01 PM, CNA S stated, "(The resident) is a Tuesday and Friday shower...Noticed (the resident's) right hand was more swollen than the other, noticed it on the Friday shower. I put that on my shower sheet. I come over weekend and it was in pink cast...(The resident) wouldn't move the wrist, it was really red and swollen. Kept the right hand straight out. I give my bath sheets to the nurse and then they go to medical records." On 12/29/10, at 2:45 PM, licensed staff B reported no documentation found to indicate a dip urine analysis done on 10/17/10 after the resident fell . On 1/10/11, at 10:50 AM, observation revealed CNAs L and T transferred the resident from the bed to the resident's wheelchair. At that time, the resident's bed sensor alarm failed to sound. At 10:53 AM, CNA T stated the green light flashing on the bed alarm box meant the alarm functioned correctly, and added, "The bed alarm should sound when (the resident) gets up off the bed." On 1/10/11, at 10:50 AM, observation revealed CNAs L and T transferred the resident from the bed to the resident's wheelchair. At that time, the resident's bed sensor alarm failed to sound. At 10:53 AM, CNA T stated the green light flashing on the bed alarm box meant the alarm functioned correctly, and added, "The bed alarm should sound when (the resident) gets up off the bed." On 1/10/11, at 3:10 PM, observation revealed CNAs K and L assisted the resident to a sitting position on the side of the bed and then transferred the resident to the wheelchair. At that time, the bed sensor alarm failed to sound. At that time, CNA K verified the resident's bed alarm failed to create a sound when the resident stood up from the bed. The facility failed to provide adequate supervision and assistive devices to prevent accidents. The resident experienced harm as the facility staff failed to adequately assess and/or provide treatment for 2 days after the bath aide identified swelling to the resident's right wrist. The x-ray report of the resident's right wrist revealed a [MEDICAL CONDITION] wrist which required a cast application. Also, staff failed to adequately assess and/or provide treatment to the resident's right hand for 7 days after staff identified swelling to the resident's right hand and fingers, with a cast in place. In addition, the facility failed to provide interventions, as care planned, to prevent additional injury to the resident, as the bed sensor pad failed to alarm when the resident stood on 3 different occasions, and staff failed to obtain a dip urine analysis after a fall on 10/17/10. - Resident #10 had [DIAGNOSES REDACTED]. The resident's 12/22/10 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with bed mobility and transfers, used a mechanical lift for transfers. The assessment did not identify any skin disorders to the resident's feet. The resident's 1/6/11 care plan directed staff the resident required a reclining wheelchair for positioning, dependent on staff for mobility, required a mechanical lift for transfers with the assistance of 2 staff, staff to observe the resident's skin daily and report areas of breakdown or redness to the charge nurse, float the resident's heels, weekly skin assessments by the licensed nurse, and keep the resident from crossing the resident's legs while in bed and when up in the wheelchair with a pillow or blanket between the resident's lower legs. Review of the resident's weekly skin assessments from 11/11/10 through 1/7/11 revealed a treatment ongoing to an area on the resident's right foot. The 1/7/11 skin assessment identified the cyst on top of the resident's left foot. The 1/7/11 skin assessment identified no other skin areas on the resident's feet. The resident's clinical record had a fax to the resident's physician, dated 1/7/11, to inform the physician staff identified a new cyst found on top of the resident's left foot. Staff documented the cyst measured approximately 2 cm (centimeters) and appeared red in color. The physician ordered staff to treat the area with triple antibiotic ointment and cover daily, and notify the physician if the area worsened. On 1/10/11, at 11:45 AM, observation revealed the resident had a scabbed area on the resident's left cheek which measured approximately 0.5 cm (centimeter) in diameter. At that time, CNAs (Certified Nurse Aides) L and T stated, "The area on the left cheek has been present for a while. Sometimes it is better than others." In addition, CNA L stated, "(The resident) doesn't use the foot support on Broda chair as (the resident) has sensitive feet." On 1/10/11, at 11:58 AM, observation revealed CNAs L and T transferred the resident from the resident's bed to the Broda chair with a mechanical lift. At that time, the CNAs removed both the resident's socks which revealed no open areas to the resident's feet. The CNAs placed a pillow under the resident's lower legs while in the Broda chair. Observation revealed no foot support in place, and the foot support to the Broda chair folded under the resident's lower legs. Observation revealed apparent foot drop to the resident's feet, as the resident's toes pointed toward the floor. On 1/11/11, at 8:00 AM, observation revealed the resident in the dining room in the Broda chair. Observation revealed the resident's feet extended off the end of the Broda chair, with the resident's toes pointed toward the floor. Observation revealed a dressing in place to the heel of the resident's left heel. Observation revealed the resident's left foot crossed over and resting on top of the resident's right foot. On 1/11/11, at 8:00 AM, CNA CC stated, "The reason (the resident) doesn't use the foot rest of Broda chair is that (the resident) slids down in chair and the foot rest hurts (the resident's) feet when it is used." On 1/11/11, at 10:21 AM, observation revealed the resident asleep in bed with the resident's feet crossed, with the left foot resting directly on top of the resident's right foot On 1/11/11, at 1:34 PM, observation revealed the resident resting in bed with the resident's left foot resting on top of the resident's right foot. . On 1/11/11, at 1:47 PM, licensed staff D stated, "I didn't know staff were not using the foot support when the resident is up in the Broda chair." On 1/11/11, at 2:41 PM, observation revealed licensed staff H removed the dressing from the resident's left foot. Observation revealed a 1 cm triangle shaped skin tear to the resident's left outer ankle, with bright red drainage on the dressings. Observation revealed a cyst like area on top of the resident's left foot, in the area between the third and fourth toes. Also, observation revealed an approximately 1 cm scabbed area present on the resident's right lower leg. At that time, licensed staff H cleansed the open area to the resident's left ankle with wound cleanser, applied triple antibiotic ointment, and applied a dressing. In addition, this licensed staff applied triple antibiotic ointment to the cyst on top of the resident's left foot and applied a bandaid. On 1/11/11, at 2:44 PM, licensed staff H stated, "I didn't get anything in report about the new area on the left outer ankle. Did not know anything about the area to right lower leg." The facility failed to adequately assess this resident's skin, on a weekly basis, for open areas and new skin concerns. In addition, the facility failed to place protective devices between the resident's lower legs, and the resident had a scabbed area to the right lower leg. Also, the facility failed to provide adequate assistive devices to the resident's feet to support the resident's feet, to maintain the resident's body in good alignment, when up in a Broda chair. - The 12/1/10 quarterly MDS (minimum data set) assessment documented resident # 37 with adequate memory skills, needed extensive assistance from one care staff for ADL's, (activities of daily living), no pressure ulcers or other skin issues, applications of ointments and medication, and no dressings. The 12/1/10 nursing skin assessment lacked documentation regarding any skin problems. The 12/9/10 care plan instructed the staff to monitor the resident's skin daily with ADL's, administer treatments to bilateral lower extremities as ordered, for [MEDICAL CONDITION], and encourage the resident to elevate bilateral lower extremities when up in the wheelchair. The care plan documented the resident is resistive to sleeping in the bed and prefers to sleep in the wheelchair, and the staff needed to encourage the resident to sleep in the bed. The nurses notes documented the following information: On 12/29/10 at 6:41 PM, "Resident has pain in bilateral lower extremities, possible exacerbation of [MEDICAL CONDITION]. (The resident's) doctor was notified and ordered [MEDICATION NAME], PRN (as needed), until [MEDICATION NAME] arrives. (The resident) is to restart Unna boots protocol [MEDICATION NAME] mg. ( milligram), orally, BID (twice a day), for 7 days..." On 1/2/11 at 4:36 AM, " Continues on antibiotic related to [MEDICAL CONDITION] to bilateral lower extremities...Denies pain or discomfort..."" On 1/6/10 at 10:05 AM, "Resident has two different orders for lower extremities, both can not be completed as ordered. Faxed doctor for clarification as to which the doctor wishes to be done." The physicians fax report documented the following: A fax report to the physician, on 12/29/10, 8:30 AM, documented, "Resident has 3 plus [MEDICAL CONDITION] to bilateral lower extremities, skin very tight, shiny, and tender to touch on lower extremities. (Resident) has long history of [MEDICAL CONDITION], may benefit from antibiotic..." The physician replied with an order documenting, "Please use Unna boots again, Cipro, 500 mg, one, po, BID, # 14 (tablets)." A fax from the physician, on 1/6/10 no time noted, documented, "Una boots." The December, 2011 TAR (treatment administration record) documented a "Tenderwrap Unna Boot applied, on 12/31/10." The order on the TAR, further documented, "Once daily, may leave off on Sundays for entire day...Change Unna boots following baths." The January, 2011 TAR documented a [MEDICATION NAME] Propionate treatment provided to the lower extremities, on 1/2/10, also the last treatment documented in the TAR. The nursing staff provided this treatment, instead of the Unna boot treatment, ordered on [DATE]. On 1/5/10 at 11:30 AM, observation revealed the resident in a wheelchair with without the Unna boot wraps. Both of the resident's lower legs remained swollen, deep pink in color. The resident reported the staff removed the wraps on the morning of 1/4/10 to during the resident's shower, and the staff failed to reapply the Unna boot wraps. Further observations, on 1/5/10 revealed the resident remained without the Unna boot wraps, at 12:15, 1:45, and 3:00 PM. . On 1/6/10 at 9:00 AM, observation revealed the resident in a wheelchair, with feet and legs down, in the room, with both legs unwrapped. The lower legs remained swollen, red, shiny with peeling skin. On 1/6/10 at 1:00 PM, licensed nursing staff G reported the resident's legs remained unwrapped, at this time, as the TAR had 2 conflicting orders and she/he had a call in to the physician for clarification of the orders. On 1/10/11 at 9:40 AM, observation revealed the resident in the wheelchair near the nurses station, the resident's legs remained red and swollen, and without the Unna boot wraps. At this time, the resident stated, "The wraps were removed on Sunday (1/9/10), the doctor ordered the wraps could be off, on Sundays. Further observations, on 1/10/11 revealed the resident's legs remained unwrapped at 12:45, 3:00, and 4:00 PM. On 1/11/10 at 7:45 observation revealed the resident in the dining room, and the resident reported her/his legs were still unwrapped, and the nurses did not get around to wrap the legs, the previous day. The facility failed to provide the Unna boot wraps, as the physician ordered, creating the potential for increased swelling, and delay of the healing process.

The facility reported a census of 50 residents with 13 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide pain medication as ordered by the physician, for resident # 101 and failed to adequately assess and identify skin issues for resident #110. Findings included; - Resident #101 admitted to the facility on 02-04-11 with [DIAGNOSES REDACTED]. The resident transferred to the hospital on 2-12-11, for change in status/ [MEDICAL CONDITION]. The resident returned to the facility on [DATE]. The resident transferred to acute for evaluation on 03-02-11, for change in status, and returned to the facility on [DATE] with the [DIAGNOSES REDACTED]. The pain assessment in advanced dementia, dated 2/23/11, for use in cognitively impaired residents, rated the resident pain as a 4 on a scale of 1-10 with a rating of 10 indicating highest intensity. The care plan for pain, dated 2-23-11, advised staff to assess the pain level and monitor the response to the medication. Further more the plan advised staff to ..."Evaluate the need for medications and provide the medications before the resident requests pain medication and offer it to the resident at frequencies indicated in the physician order." The care plan indicated other interventions such as gentle soothing massage, aromatherapy and relaxing music. The admission MDS (minimum data set), dated 3-2-11, assessed the resident with severe cognitive deficits and unable to answer questions regarding pain. The staff assessment for pain indicators included facial expressions and protective body movements or postures. Pain frequency assessed as occurring 3-4 days in the last 5 days. Physical therapy note, dated 3-3-2011 indicated the resident had clinically worsened and recommended ..."Range of motion, and comfort care to ease any pain he may have in the near future." Observation, on 3-8-11 at 7:45 am, revealed the resident laying in bed attempting to pull themselves up using the over bed trapeze. Observation also revealed the television on and sound turned off with the resident sighing and grimacing. The resident responded appropriately to simple questions. The resident responded feeling sick and pain all over. Interview, on 3-8-11 at 7:45 am, with certified nursing staff O, reported the resident as the last to get up in the morning as the resident could not tolerate sitting up due to weakness and pain. Observation, on 03-08-11 at 7:45 am while staff O assisted the resident to dress, revealed the resident could not balance in a sitting position on the side of the bed and leaned back and sideways, with moaning and facial grimacing accompanying movements. Staff propelled the resident in their wheelchair to the dining room table for breakfast. The resident sat at the table and held their head, without eating. The resident received [MEDICATION NAME] at 8:25 am and staff returned the resident to their room and transferred the resident into bed. Interview, on 3-8-11 at 8:45 am, with licensed nursing staff H revealed the resident will hold their head when having a headache and staff medicate the resident for pain. Staff H indicated the resident ' s family member will come to the nurse to request pain medication for the resident when they visit the resident. Review of the MAR (medication administration record) revealed the physician orders, dated 2-23-11, instructed staff to administer [MEDICATION NAME] 2.5/500 mg (milligram) 1 tab ,every six hours as needed for pain. Physician orders, dated 3-3-2011, instructed staff to administer [MEDICATION NAME] 5/325 mg every 4 hours as needed for pain. Physician orders, dated 03-06-11, instructed staff to increase the dosage of [MEDICATION NAME] to 5/500 mg every 8 hours, scheduled routinely. Review of the MAR for March 2011, revealed the physician order [REDACTED]. The MAR, for March 2011 revealed the resident received [MEDICATION NAME] 5/325 mg on 03-06-11 at 8:00 am, 12:00 pm, and 4:00 pm. No follow up documentation noted on the PRN sheet The nurse's note, dated 03-06-11 at 3:10 pm, revealed...."PRN meds given as ordered, relief noted after each use." The MAR failed to evidence the scheduled dosage of [MEDICATION NAME] given as ordered. The MAR, dated 03-07-11 revealed [MEDICATION NAME] 5/325 mg given at 8:00 am and 3:45 PM, with no follow up documentation on the PRN sheet. The nurse's note, dated 03-07-11 4:18 am, documented ..."pain med x 1" The MAR failed to evidence the scheduled dosage of [MEDICATION NAME] given as ordered. The MAR, dated 3-8-11 revealed [MEDICATION NAME] given at 2:00 am, 8:25 am, and 3:10 PM. No follow up documentation noted on the PRN sheet. The nurse's notes dated 3-8-11 at 5:16 am documented ..."medicated for pain x 1" The MAR failed to evidence the scheduled dosage of [MEDICATION NAME] given as ordered. The MAR dated 03-09-11 revealed the dose of [MEDICATION NAME] 5/500 mg scheduled to be given at 7 am, circled and not given, and a dose of [MEDICATION NAME] 5/325 mg administered at 6:30 am. Interview with administrative nursing staff B, at 03-09-11 at 8:45 am, revealed the 7:00 am dose of [MEDICATION NAME] should have been given at 6:30 am instead of the [MEDICATION NAME] in keeping with the intent of the physician's orders [REDACTED]. The follow-up notation on the PRN schedule, 03-09-11 6:30 am, indicated the reason for the [MEDICATION NAME] given as increased headache with follow up documentation at 7:30 am, as "resting quietly". The nurse's note, dated 03-09-11 at 2:52 am ,described the resident as "On routine [MEDICATION NAME] with effect". Nurse's note dated 3-9-11 at 11:34 PM, described the resident ... "No distress at this time." Interview, on 03-08-11 at 11:30 am, with the resident's family member, revealed the family's goal of keeping the resident comfortable and pain free. The family member stated ..."if the pain gets intense it takes a long time for the pain medication to work". The family member stated they notify staff when the resident starts getting anxious and in pain. The family member states they have decided to start hospice care for the resident. Interview, on 3-08-11 at 3:45 PM, with licensed staff G, revealed the physician order [REDACTED]. Observation, on 03-09-11 at 7:15 am, revealed the resident positioned in bed on the right side, requesting help, stating It's killing me", while attempting to reposition themselves in the bed by reaching for the over bed trapeze. Staff B informed of the resident's condition and assessed the resident. Nursing staff B stated hospice will be notified to make adjustment in the pain medication. Interview, on -3-09-11 at 9:45 am, with the resident's family member, revealed no alternative measures for pain relief or additional comfort utilized by the staff. Interview, on 03-09-11 at 11:15 am, with certified staff O, revealed repositioning and pillow placement as methods to provide comfort. Interview, on 03-09-11 at 1:58 PM, with certified staff Q, revealed the resident usually is comfortable early in the 2 PM -10 PM shift and the resident's family requests pain medication. Staff Q stated the resident moans when in pain, but does not verbally request pain medication. Staff reposition the resident with pillows, but no other measures utilized to promote comfort. The facility's Pain Management Guideline revised 4-24-06, advised staff to intervene to treat pain before the pain becomes severe and use non drug interventions to assist in pain management. The guideline advises staff to document pain assessment, intervention and evaluation activities in a clear and concise manner per the plan of care. The facility failed to assess, monitor and follow the plan of care to provide optimal pain relief and comfort to the resident. The facility failed to administer scheduled and PRN pain medication at intervals prescribed by the physician, and failed to provide the interventions of gentle soothing massage, aroma therapy and relaxing music as planned. The resident continued to experience ongoing pain without optimal relief as evidenced by facial expressions, verbal moans and groans, and holding of (the resident's) head. - Resident #102's quarterly MDS (minimum data set) assessment, dated 12/22/10, documented cognition as moderately impaired, required extensive assistance of 2 staff for bed mobility/transfers/and toileting, without history of falls, and without any open skin areas. The resident's medical record documented re-admission to the facility on [DATE], from a hospital with [DIAGNOSES REDACTED]. The plan of care, dated 1/10/11, included interventions, "Observe skin daily while providing cares and notify charge nurse of any open areas or areas of redness. Skin assessment to be completed by licensed nurse weekly. Treatments as ordered." Nurses notes, dated 2/10/11 at 12:02 PM, documented, "Skin assessment/Weekly summary:... Skin P/W/D (pink/warm/dry) check scab with healing progressing, no signs & symptoms of infection. No other areas of concern at this time. Continues with plan of care... " On 3/7/11 at 10:45 AM, observation revealed the resident sat in a wheelchair in the dining room area in a short sleeved shirt. The resident's left outer elbow contained a clear dressing, approximately 4 by 4 inches. The dressing contained a large amount of serous fluids, yellow, dark black, and red, over approximately 85% of the dressing. The resident's [MEDICATION NAME] shirt contained 4 areas, approximately 2 cm (centimeters) each of a darkened red/black dried substance on the lower left side. On 3/7/11 at 11:45 AM, the resident returned in the wheelchair to sit in the resident's room. When questioned, at this time, related to the incident of the clear dressing on the resident's left out elbow area, the resident reported he/she noted it yesterday at noon time. The resident looked down and saw blood running down. The resident further reported he/she gets these, bruises and such, on him/her a lot. The resident's short sleeved shirt revealed both forearms contained various smaller bruises, less than 2 cm each. 3/7/11 at 12:30 PM, the resident sat in the wheelchair in the dining room with the same short sleeve shirt on without any protective covering over the resident's arms. A sweater hung over the resident's shoulders/back, without the sleeves on to cover the resident's fragile arms. On 3/7/11 at 2:15 PM, the resident sat up in the wheelchair at the bedside and watched the television. The resident's sweater removed, and the resident wore the same short sleeved shirt with the skin area exposed to view through the clear dressing. The clear dressing lacked a date. On 3/7/11 at 2:40 PM, the resident rested on the back on the bed, in the same short sleeved and blood stained shirt, without any protective covering on the resident's arms. On 3/7/11 at 3:05 PM, and again on 3/8/11 at 7:45 AM, review of the resident's March, 2011, TAR (Treatment administration record) evidenced no current treatments for any skin tears on the resident. Furthermore, the nurses notes lacked any mention of the open draining skin area under the clear dressing. On 3/7/11 at 5:02 PM, a family member entered the resident's room to visit. Certified nurse aides R and U assisted the resident from the bed into the wheelchair. The family member requested the nurse aides change the resident's shirt, due to the stains on the lower left side. The family member noted the clear dressing to the resident's left outer elbow with large amount of drainage. The family member explained the resident received bruises and skin tears easily. On 3/8/11 at 7:10 AM, the resident sat up in the wheelchair at dining room table and wore a long sleeved sweat shirt. On 3/8/11 at 10:30 AM, certified nurse aide D searched the facility records and failed to obtain any weekly skin assessments, completed by the licensed nurses of the facility, for this resident. On 3/8/11 at 10:45 AM, certified nurse aide D provided a record for the resident, dated 3/7/11, "Resident Physical Assessment During Bathing," completed by a certified nurse aide. This skin assessment, documented, "No" beside all skin area questions, indicating the resident without any skin issues. On 3/8/11, at 11:10 AM, the nurses notes and the March TAR, continued to lack any evidence of the skin area to the resident's left outer elbow. The resident sat in the bedside recliner resting. The surveyor at this time, questioned administrative licensed nurse B about the skin area on the resident's outer elbow. Nurse B lacked knowledge of the resident's skin area or the clear dressing which continued to contain approximately 85% serous fluid under it without change for an unknown period of time. Nurse B observed the area and questioned the resident about the incident. The resident reported sitting at the dining room table and a lady came by and told the resident blood ran down the resident's arm. The resident couldn't remember who told her about the area or who placed the clear dressing over the site. 3/8/11 At 11:20 AM, administrative licensed nurse B returned to the resident's room with treatment and measuring supplies. The nurse removed the clear dressing to reveal the largest open area which measured at 0.9 by 0.5 cm., and 2 to 3 smaller open areas around the edge of the larger area. The entire skin area under the dressing appeared very moist and light pink in color from the serous drainage held under the clear dressing. Nurse B completed a dressing change following measurements obtained. Nurse B reported the facility in-serviced the staff related to skin treatments and the use of standing orders. Nurse B verified whichever staff member that placed the first clear dressing on the open area, failed to document the area, failed to obtain a physician order [REDACTED]. On 3/9/11 at 11:00 AM, administrative licensed nurse B verified the nurse investigated to see how long, and which staff applied the clear dressing to the resident's elbow. Nurse B explained none of the licensed nurses that worked reported they applied the dressing without documentation. Furthermore, the nurse verified with investigation, the bath aide who completed the bathing skin assessment, failed to document the area on the resident's elbow, and that when the staff provided the bath to the resident, the resident's elbow already contained the clear dressing. The certified bath aide, failed to document any skin issues and report to the charge nurse, when the clear dressing visibly revealed the resident's skin issue. The facility's undated change of condition/clinical assessment policy recorded, "...Statement Change of Condition...The process for identification of change of condition includes gathering or objective data and documenting assessment findings, resident response...Process assists in coordinating change of condition information for concise communication with the Physician/Physician Extender..." The facility failed to provide the necessary care and services to maintain this resident's physical well-being, as the facility failed to adequately assess, monitor, and document this resident's abdominal fold skin condition. This created the potential for a decline in this resident's skin condition. - Resident #110's clinical record identified the resident with [DIAGNOSES REDACTED]. Staff recorded on the resident's 12/21/10 clinical health status form the resident with no skin issues. The resident's 12/22/10 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with all activities of daily living, and with no skin issues identified. The resident's 1/6/11 care plan directed staff to observe the resident's skin daily and report any areas of breakdown or redness to the charge nurse. Review of the licensed staffs' documentation on the resident's weekly skin assessment sheets, from 1/27/11 to 2/24/11 revealed no new skin issues and no skin redness identified. On 3/3/11, staff recorded on the skin assessment sheet the resident's right lower abdominal quadrant under the abdominal fold with reddened area. Staff recorded moisture barrier applied to the area. Review of the CNA's (Certified Nurse Aides) bath sheets, dated 2/11, 14, 17, 21, and 24/11, revealed no skin issues identified. Staff recorded on the resident's 2/28/11 bath sheet an abrasion, cut, or scratch marked on the right abdominal fold area. Review of the 2/28/11 bath sheet lacked evidence a licensed staff signature on the bath sheet to indicate any licensed staff reviewed the bath sheet. Review of the resident's 3/11 TAR (Treatment Administration Record) lacked evidence of any treatment ordered for the area under the resident's abdominal fold. On 3/7/11, at 2:18 PM, observation revealed CNAs Q and R transferred the resident to the resident's bed with a mechanical lift. At that time, observation revealed a clear dressing in place on the resident's right lower abdomen. On 3/8/11, at 9:15 AM, observation revealed CNAs L and K transferred the resident from a broda chair to the resident's bed with a mechanical lift. At that time, observation revealed a clear dressing remained in place on the resident's right lower abdomen. On 3/8/11, at 1:52 PM, licensed staff G provided a treatment to the top of the resident's left foot. Upon completion of this treatment, upon request, this licensed staff looked at the resident's abdominal area, removed the clear dressing, smelled the dressing, and stated, "(The resident) has a yeast infection. (I) will notify the doctor. We have a standing order to treat yeast." At that time, licensed staff G assessed the resident's entire abdominal area, including under the abdominal fold, and found an approximately 0.5 cm (centimeter) open area under the right lower abdominal fold. During the assessment, staff did not identify any other open areas. Observation revealed the resident had slight redness under the left side of the resident's abdominal fold and had a healed area, which measured approximately 3 cm, at the right outer side of the resident's right abdominal fold. On 3/8/11, at 2:22 PM, licensed staff B stated, "I didn't know about (the resident's)area on (the resident's) abdominal fold. I will call the doctor and take care of it myself." On 3/8/11, at 4:42 PM, licensed staff G looked in the facility's computer to try to locate any documentation from 3/3/11 to 3/8/11, related to the clear dressing and the areas under the resident's abdominal fold. At that time, this licensed staff verified the resident's computerized clinical record lacked any documentation about these areas. On 3/9/11, at 10:30 AM, licensed staff B stated, "I have talked to all my nurses and they don't know who put the OpSite (clear dressing) on the resident's abdominal fold. I know we did use some agency nurses as we had let some other nurses go. I looked in (the resident's) chart and couldn't find anything about the OpSite on (the resident's) abdominal fold. The charge nurse is supposed to sign off on the bath sheets to indicate they had reviewed them." The licensed nurse verified the charge nurse failed to review or sign the bath sheet. The facility's undated change of condition/clinical assessment policy recorded, "...Statement Change of Condition...The process for identification of change of condition includes gathering or objective data and documenting assessment findings, resident response...Process assists in coordinating change of condition information for concise communication with the Physician/Physician Extender..." The facility failed to provide the necessary care and services to maintain this resident's physical well-being, as the facility failed to adequately assess, monitor, and document this resident's abdominal fold skin condition. This created the potential for a decline in this resident's skin condition. - Resident #104 admitted to the facility, on 1/31/11, after a hospital stay with a [DIAGNOSES REDACTED]. The admission RAI (resident assessment instrument), with a reference date of 2/7/11, identified the resident as alert and orientated, receiving physical and occupational therapy, non weight bearing on left lower extremity, and requiring assistance of one to two for transfers. Review of nurses notes identified the following: 1) 2/23/2011 at 11:52 a.m., identified the resident as alert and oriented, independent in wheelchair and verbalizes needs well. " Reports some discomfort to LLE (left lower extremity). LLE noted to be [MEDICAL CONDITION] +3 (with 3+ [MEDICAL CONDITION]) and pink from hip to pedal-- Peripheral pulses intact, skin warm to touch. " Vitals recorded and within normal limits. " ...(The resident) is aware of NWB (non weight bearing) on LLE at this time. Will call doctors office r/t concern over swelling and discoloration to LLE. " 2) 2/24/2011 at 7:42 a.m. , revealed " ...(Physician) returned call on 2/23/11 today charge nurse and new orders for Doppler to lower ext. RP (responsible party)/transportation notified per charge nurse. Review of nurses notes failed to document any further assessment of the left lower extremity until 3/1/2011 at 9:38 p.m. 3) 3/1/2011 at 9:38 p.m. , revealed vital signs obtained and within normal limits. " Patient able to clearly make needs known, verbalized concern to LLE swelling, mobile radiology notified to come out and do venous Doppler as ordered, paper work on nursing station, patient made aware, patient cont of B & B (bowel and bladder), self propel in w/c (wheelchair) throughout facility this day, good appetite and fluid intake noted this day, no further concerns noted this day, call light in reach, continues to receive skilled services. " Review of nurses notes failed to document any further assessment of the left lower extremity until 3/2/2011 at 9:38 p.m. 4) 3/2/11 at 10:49 p.m., " LLE 3+ swelling with pink discoloration, venous Doppler done this am, with positive DVD LLE. Doctor called for direct admit to ...(hospital) for TX of [MEDICAL CONDITION] ([MEDICAL CONDITION]. Pt. sent by acts transport for safety. Report given to ems (emergency medical services) and staff to follow for admission process. .... Transfer paperwork sent with ems. " 5) 3/4/2011 at 1:45 p.m., the resident returned to the facility after hospitalization for lower left extremenity [MEDICAL CONDITION] with [MEDICAL CONDITION], and on anticoagulant therapy. Review of the Diagnostic Ultrasound Service report, dated 3/2/2011 faxed to the facility on [DATE] at 4:41 p.m., identified a " Extensive acute [MEDICAL CONDITION] involving the common femoral vein, superficial femoral vein, and popliteal vein on the left. " Interview with Licensed staff member B, on 3/17/2011 at 9:30 a.m., revealed the licensed staff nurse received the order after 5:00 p.m., on 2/23/11. She/he told the nurse coming on duty to report this to the nurses coming on duty at 6 am, on 2/24/11. The nurse should have told the transportation aide to schedule the appointment. Apparently that did not happen. "I personally told the CMA/transportation aide to schedule the appointment, while she/he was at the medication cart. Our transportation aide has been scheduling appointments. I have now initiated a new policy in regards to scheduling appointments. " The policy provided by the facility, stated, " Additional Duty: Van Driver, to transport residents to appointments that may scheduled. To provide transportation for new admissions and therapy home visits, and to provide basic Nursing Administration support. ..... BASIC FUNCTIONS: Duties: To transport residents to appointments that may be scheduled; to provide transportation for new admissions and therapy home visits; and provide basic nursing administrative support. " The policy failed to identify the transportation aide responsible for scheduling appointments. The facility failed to provide services as ordered for 6 days, after identifying a swollen [MEDICAL CONDITION] left lower extremity with 3+ [MEDICAL CONDITION]., including failure to schedule the venous Doppler study in a timely manner and as ordered by the physician and failure to perform ongoing assessments of the resident ' s leg, after identification of the [MEDICAL CONDITION] and redness. The resident admitted to the hospital 6 days after the initial identification , with a [DIAGNOSES REDACTED].

The facility reported a census of 50 residents. The 13 residents reviewed included 10 who required assistance to reposition. Based on observation, interview, and record review, the facility failed to provide timely assistance to reposition for 4 (#136, #110, #152, and #116) of these 10 residents. Findings included: - The medical record of resident #136 documented [DIAGNOSES REDACTED]. The care plan, dated 1/27/11, instructed staff, "Requires extensive assistance x 1-2 with most ADL (activities of daily living needs)tasks. Monitor skin when providing cares and report any changes or areas of redness to the charge nurse. Keep skin clean, dry and moisturized with lotion. Utilize moisture barrier cream with peri care. Weekly skin assessment by licensed nurse. Pressure relieving mattress on bed. Pressure relieving cushion in wheelchair. Assist with repositioning every 2 hours as she allows. Check for incontinence every 2 hours while awake and provide pericare prn (as needed) incontinent episodes. May assist to toilet prn when not agitated." On 3/7/11 at 11:50 AM, 12:20 PM, and 12:40 PM, the resident remained in a wheelchair at the dining room table, with noted urine odors around the resident. Continued observations from 12:40 PM until 2:29 PM, revealed the resident remained in the wheelchair without assistance to reposition, for at least 2 hours and 39 minutes. On 3/7/11 at 2:29 PM, CNA (certified nurse aide) I and T assisted the resident onto the bed. The staff removed a incontinent brief with bowel movement and very heavy of urine. Following perineal hygiene the staff applied barrier cream to the resident's buttocks, and a incontinent brief. On 3/7/11 at 4:11 PM, CNAs R and U assisted the resident with incontinent hygiene and transfer from the bed into the wheelchair for the evening meal service. The staff removed an incontinent brief and rolled the resident onto the side for perineal hygiene. Staff noted 2 open area to the resident's left lower buttocks crease. One area approximately 1 cm and other approximately 1 by 2 cm and bright pink. CNA U reported they worked the evening shift yesterday and the resident's buttocks contained red areas but without any open areas at that time. The resident's incontinent brief contained incontinent bowel movement and urine. The staff used perineal hygiene wipes to cleanse the backside of the resident and went out to get the nurse to assess the areas. Licensed nurse B entered the resident's room and measured the upper left area as 0.5 by 0.5 cm (centimeter), and the lower left area as 3 cm by 0.6 cm. Following the nurse's assessment, CNAs R and U continued with perineal hygiene to the resident's rectal/buttocks region, rolled the resident onto the back and pulled the incontinent brief up through the resident's thighs. As the staff attempted to tape the incontinent brief into place, the surveyor stopped the staff and questioned the staff about the failure to provide any personal hygiene to the resident's frontal perineal regions. CNA U verified the failure to provide adequate personal hygiene for the resident. The facility failed to provide adequate personal hygiene to all of the resident's skin areas that came into contact with the incontinent urine/bowel movement. 3/8/11 at 7:10 AM, observation revealed the resident up in the wheelchair in the dining room. The resident slowly propels the wheelchair about the room with jerking movements of the feet and with hands on the wheels. Frequent observations of the resident from 7:10 AM, through 9:50 AM, revealed the resident in the dining room in the wheelchair for the morning meal service, and then self propelled the wheelchair about the dining room and the hallways. At 9:50 AM, after 2 hours and 40 minutes without change in position from the wheelchair, the resident continued to self propel the wheelchair down the hall 4 and attempted to go into other resident rooms. Administrative staff A assisted the resident from another resident's doorway and into the dining room where an activity group started to gather. The facility staff failed to provide position change for this dependent resident from the wheelchair for at least 2 hours and 40 minutes. On 3/8/11 at 11:00 AM, observation revealed the resident again in the wheelchair, in the dining room area, with different clothing on. At this time, CNA L reported the staff just finished taking the resident to the resident's room to provide incontinent cares and to change the resident's clothing. CNA L explained the resident's incontinent brief as a little wet and a small bowel movement. The facility failed to timely provide assistance to this dependent resident to reposition while up in the wheelchair on 2 occasions observed, and failed to provide incontinent hygiene following incontinent episode to all skin areas in contact with the incontinence on 1 occasion observed. - Resident #152's clinical record identified the resident with [DIAGNOSES REDACTED]. The resident's 2/9/11 MDS (Minimum Data Set) scored the resident with a 1 (0-7 severely impaired) on the brief interview for mental status, required extensive assistance of staff with transfers, identified at risk for the development of a pressure ulcer, and on a turning and/or repositioning program. The resident's 2/17/11 care plan directed staff to assist the resident with a position changed as needed. Staff recorded on the 2/23/11 CAAS (Care Area Assessment Summary) the resident had urinary incontinence which increased the risk for skin breakdown. Also, the resident's Braden scale (tool used to assess for the potential for the development of a pressure ulcer) was 14 which shows the resident at risk for skin breakdown. On 3/7/11, at 11:37 AM, observation revealed the resident in a wheelchair in the living area. At 11:38 AM, observation revealed CNA (Certified Nurse Aide) V pushed the resident in the wheelchair to the dining room. Observations, at 12:05 PM and 12:08 PM, revealed the resident in the wheelchair in the dining room. At 1:15 PM, observation revealed CNA Y pushed the resident in the wheelchair into the bird room. At 1:45 PM, CNA V pushed the resident in the wheelchair to the resident's room. Observations, at 2:04 PM, 2:22 PM, and 2:37 PM, revealed the resident remained in the wheelchair in the resident's room. At 2:52 PM, observation revealed CNAs T and R transferred the resident from the wheelchair to the toilet. Staff failed to provide a position changed for 3 hours and 15 minutes. On 3/7/11, at 1:46 PM, CNA P stated, "We have to reposition residents every 2 hours." On 3/7/11, at 2:51 PM, CNAs T and R stated, "Don't know if (the resident) was toileted and repositioned after lunch." The facility's 2006 positioning the resident policy recorded, "...To relieve pressure and prevent skin breakdown..." The facility staff failed to assist this dependent resident with a change in position for at least 3 hours and 15 minutes - Resident #110's clinical record recorded [DIAGNOSES REDACTED]. On 12/21/10, staff recorded a score of 12 (10 to 12 high risk) on the resident's Braden scale (tool used to assess for the potential for the development of a pressure ulcer). The resident's 12/22/10 MDS (Minimum Data Set) identified the resident with short and long term memory problems, severely impaired decision making skills, required extensive assistance of 2 staff with transfers, at risk for the development of pressure ulcers, and on a turning and/or repositioning program. The resident's 1/6/11 care plan directed staff to turn and reposition the resident every 2 hours and as needed. On 3/7/11, at 11:35 AM, observation revealed the resident in a broda chair in the dining room. At 1:24 PM, observation revealed the resident remained in the dining room in the broda chair. At 1:39 PM, observation revealed the resident remained in the broda chair at the hallway entrance of hall 4. At 2:13 PM, observation revealed CNAs (Certified Nurse Aides) Q and R pushed the resident in the broda chair to the resident's room. At 2:18 PM, observation revealed the CNAs transferred the resident from the broda chair to the resident's bed. Staff failed to provide a position change for 2 hours and 43 minutes. On 3/7/11, at 1:46 PM, CNA P stated, "Residents should be repositioned every 2 hours." On 3/7/11, at 2:15 PM, CNA R reported, "Residents who need help with a position change should be repositioned every 2 hours. I don't know when they (day shift aides) got (the resident) up for lunch..." The facility's 2006 positioning the resident policy recorded, "...To relieve pressure and prevent skin breakdown..." The facility failed to provide the necessary services to prevent the development of pressure ulcers for this resident identified as risk for the development of pressure ulcers. Staff failed to position the resident for 2 hours and 43 minutes. - The facility admitted resident #103, on 1/27/11. The physician's orders [REDACTED]. The 2/3/11, admission MDS (minimum data set) assessment, revealed a BIMS (brief interview of mental status) score of 99, and indicated not able to complete. The staff further assessment for mental status recorded short and long term memory problems, severely impaired cognitive skills for decision making, required limited assistance for bed mobility and transfers. The assessment further recorded the need for a formal pressure ulcer skin assessment, and revealed no pressure ulcers or history of pressure ulcers. The Braden pressure ulcer risk assessment, dated 1/27/11, revealed a score of 21, indicated as not at risk for skin breakdown. However, the 2/10/11, care plan listed, " Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse. Complete Braden scale per policy. Observe skin while providing cares. Provide pressure reducing wheelchair cushion, and mattress. Skin assessment to be completed by licensed nurse weekly. Assist with re-positioning as needed. The staff failed to determine how often the resident required repositioning based on their individual need. On 3/8/11, at 08:15 am, observation revealed the resident, positioned in the wheelchair, without a pressure relieving device as planned. On 3/8/11, further observations at 9:00 am, 9:45 am, 10:00 am, 10:15 am, 10:30 am, 10:50 am, and 11:00 am, observation revealed the resident remained without a position change provided, for a time period of two hours and forty five minutes. On 3/8/11, at 11:00 am, the surveyor requested a skin check of this resident. Licensed nurse H, stated, " I will get the aides to do it immediately. " However, staff failed to return to complete this skin assessment, at this time. On 3/8/11, at 11:30 am, observation revealed the resident remained without position change. On 3/8/11, at 11:35 am, certified nursing assistant L, verified a failure to provide the resident with a position change this morning. The certified nursing assistant explained, "I will get to (the resident) in a few minutes. " On 3/8/11, at 11:50 am, observation revealed the resident remained without opportunity to toilet or change position. On 3/8/11, at 12:02 pm, observation revealed certified nursing assistants, O and T, as they transferred the resident to the toilet from the wheelchair. The resident stood with extensive assistance of both staff. The facility staff failed to provide this resident with assistance to reposition from the wheelchair, without a pressure relieving device, for at least three hours and forty seven minutes. On 3/8/11, at 12:02 pm, certified nursing assistant O, stated, "The resident doesn't have a cushion (pressure relieving device), never has had one. (The resident) was able to walk, but just quit. (The resident) can get up and down unassisted, but just does it when sometimes." On 3/8/11, at 12:05 pm, certified nursing assistant T, stated, "The resident doesn't need a cushion (pressure relieving device). The resident can stand up and walk, if desired." On 3/8/11, at 1:15 pm, observation revealed the resident positioned onto his/her back on the bed. On 3/8/11, at 2:15 pm, 3:00 pm, 3:30 pm, 4:00 pm, 4:15 pm, 4:30 pm, 4:40 pm, revealed the resident remained in the same position, without change. On 3/8/11, at 4:05 pm, certified nursing assistant J, stated, "The resident doesn't have a cushion (pressure relieving device). I didn't know one was needed. The resident was able to walk when admitted , but then just quit. So now, (the resident) just uses the wheelchair. " On 3/8/11, at 4:15 pm, certified nursing assistant R, stated, "No, I haven't turned (the resident) this afternoon. (The resident) doesn't have a cushion (pressure relieving device) in the wheelchair. I am pretty sure there never was one, in that wheelchair. " On 3/8/11, at 4:25 pm, certified nursing assistant S stated, "The resident doesn't have a cushion (pressure relieving device) in the wheelchair. I didn't know one was needed for this resident." On 3/8/11, at 4:45 pm, licensed staff H, stated, "(The resident) walked when admitted . Now, (the resident) can walk, but doesn't. (The resident) doesn't have any cushion (pressure relieving device) for the chair, because he/she can walk. (The resident) hasn't needed the wheelchair for too long, maybe a month." The nurse verified the resident's mobility status declined which required the use of a wheelchair, for approximately one month. On 3/8/11, at 4:55 pm, final observation on this date, revealed the resident remained without a change in positron. The resident remained without a change of position for a period of at least three hours and forty minutes. On 3/9/11, at 7:35 am, observation revealed the resident up in the wheelchair, at the dining room table, with a pressure relieving device in place. On 3/9/11, at 9:00 am, staff V, assisted the resident, in the wheelchair, from the dining room into the library area. On 3/9/11, at 9:55 am, observation revealed the resident remained in the wheelchair, without a position change. Certified nursing assistant N, at this time, verified, " I haven't done anything with him/her since breakfast." On 3/9/11, at 9:58 am, certified nursing assistant K, stated, "I haven't taken care of him/her. I went to lunch and I haven't done anything on the resident's hall yet. " On 3/9/11, at 10:00 am, certified nursing assistant N, and licensed staff G, transferred the resident onto the toilet. During this time, certified nursing assistant N stated, "I usually work this hall. This resident hasn't had a cushion (pressure relieving device) in the wheelchair." The facility staff failed to assist the resident to reposition from the wheelchair for at least two hours and thirty minutes. On 3/9/11, at 10:01 am, licensed nursing staff G, stated, " I don't know about the cushion (pressure relieving device). He/She didn't have it yesterday. Maybe they did it last night. " Lippincott Manual of Nursing Practice, 8th edition, Care of the Older Adult, Preventing complications of Immobility, "The goal of frequent position changes is to prevent contractures, stimulate circulation, and prevent pressure sores...recommendations is to change body position at least every 2 hour, and preferably more frequently in patients who have no spontaneous movement..." The facility failed to provide the planned pressure relieving device to the resident's wheelchair and failed to provide assistance to reposition the resident on three occasions, observed, in two days, placing this resident at risk for skin breakdown.

The facility had a census of 46 residents, with 21 residents reviewed. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents to 5 of the 7 sampled residents (#35, 21, 36, 49, and 71) reviewed with accidents. Resident #35 experienced harm from a head laceration when the resident rolled out of the resident's bed, which was not in the low position. This head laceration required medical treatment at the local hospital. Findings included: - Resident #35 had [DIAGNOSES REDACTED]. The resident's 10/27/10 MDS (Minimum Data Set) identified the resident during the brief interview for mental status with a score of 6 (a score of 0-7 indicated severely impaired cognition), required extensive assistance of staff with bed mobility, transfers, and all other activities of daily living, and lacked coding for experiencing any falls. On 10/26/10, staff completed a fall assessment and scored the resident with a 12 (a score of 10 or above indicated at high risk for falls). The resident's care plan, reviewed on 10/28/10, directed staff the resident required assistance of 1 to 2 staff with all activities of daily living tasks, assist with transfers and ambulation, low bed, and had an intervention to ensure a fall mat next to the resident's bed. Staff recorded, on the 11/30/10 change of condition report, at 11:10 AM, the resident found on floor, with a laceration to the resident's forehead and the resident's face bleeding. Staff applied pressure to the area and notified emergency medical services. Staff recorded the resident fell while trying to go to the bathroom. Review of the facility's investigation of the resident's fall with injuries revealed staff recorded the resident's bed slightly up from the low position. Staff recorded in the 12/1/10 nursing notes, at 3:52 AM, the resident found lying on the resident's side on the floor at 11:10 PM. Staff recorded the resident noted to have lacerations to the face and forehead, with large amounts of blood noted on the floor. Staff applied pressure to the lacerations and notified emergency medical services. At 11:20 PM, emergency medical services transported the resident to a local hospital for treatment. The 12/1/10 computerized tomography report of the resident's head revealed a 5 cm (centimeter) laceration to the resident's forehead and a 2.5 cm laceration to the resident's right cheek. At 2:00 AM, the resident returned to the facility with Dermabond in place to the lacerations to the right forehead and right cheek. . Staff recorded on the resident's care plan, on 11/30/10, the resident had a fall in the resident's room and rolled out of the resident's bed, hitting the resident's head on the bed frame. The intervention implemented after the 11/30/10 was to transfer the resident to the emergency room for repair of the laceration and conduct neurological checks. Staff recorded in the change in condition report and nursing notes, dated 12/1/10, at 2:45 PM, the social service designee found the resident sitting on the floor next to the resident's bed. Appeared the resident slid out of bed and found leaning with the resident's back against the side of the bed. Staff assessed the resident and found no evidence of the resident hitting the resident's head. Staff recorded the fall mat in place but appeared to have slid with the resident. Staff recorded the resident as unable to explain what the resident was attempting to do. Staff documented the resident's laceration to the forehead re-opened and gaping open approximately 0.5 cm (centimeters). Staff cleansed the area and applied steri-strips. Staff added an intervention, dated 12/1/10, to prevent additional falls for hospice to check the air mattress for proper functioning and requested an order for [REDACTED]. Staff recorded in the 12/2/10 nursing notes, at 4:22 PM, staff attempted to obtain the urine analysis without success. Review of the resident's clinical record lacked evidence staff attempted to obtain the urine analysis until staff recorded in the 12/7/10 nursing notes, at 6:07 PM, the resident's physician ordered Bactrim DS (Double Strength), twice a day, for 7 days, for the treatment of [REDACTED]. On 12/28/10, at 3:30 PM, CNA AA stated, "I was the only who found (the resident). I was doing my rounds. Got there about 11:15 PM. There was blood everywhere. (The resident) was face done by (the resident's) bed. (The resident) has a floor pad. (The resident) hit their head on the metal wheel cover of the bed. (The resident) said (the resident) had to go to the bathroom. Used to have bed alarm, but not anymore. Had cut in middle of fore head. Called nurse and she would not allow me to move (the resident). (The resident) layed with (the resident's) face like that for 20 min as nurse would not let me move (the resident). EMS arrived in about 20 minutes. (The resident) seemed to be fine as (the resident) kept talking. Was taken to hospital, had laceration glued, as skin too fragile for suturing. The floor mat was not up to the head of the bed as the night stand was in the way. As far as I know, there was nothing new done to prevent any more falls. The next day (the resident) had another fall out of (the resident's) bed. (The resident) was confused." On 12/28/10, at 3:32 PM, observation revealed the resident in a low bed, with a fall mat on the floor by the resident's bed. On 12/29/10, at 8:40 AM, CNA P stated the resident fell on the third shift. CNA P added, "Happened on 3rd shift. (The resident) has a mat down on the floor, low bed. We make sure (the resident) is centered in bed..." On 12/29/10, at 9:35 AM, observation revealed CNAs (Certified Nurse Aides) CC and P transferred the resident from the wheelchair to the resident's bed. Observation revealed the CNAs positioned the resident in the middle of the bed and placed the bed in the low position. Observation revealed the bed's metal wheel covers not covered and exposed when the bed in the low position. In addition, the fall mat, located next to the resident's bed, appeared very slippery when stepped on. Observation revealed the fall mat lacked any type of non-skid strips on the back side of the fall mat or on the floor to secure the fall mat. On 12/29/10, at 9:35 AM, CNA P stated, "We did have a problem keeping the air mattress inflated. Not sure when that was. (The resident) is on Hospice. We call them if any problems. I know there is a knob to the mattress against the wall and if you bump that, the mattress goes down immediately." On 12/29/10, at 10:07 AM, social service staff E stated, "I was the one who found (the resident) on the floor. It was in the afternoon, after lunch. I was walking down hall and saw (the resident). I waved at nursing desk for someone to come down and stayed with (the resident) till the nurse came down. (The resident) was sitting on floor by the bed. The fall mat was on the floor. The bed was down low. (The resident) is on an air mattress. The mattress was a little down. I think the nurse that was in there checked the mattress. Everything was checked. I think hospice checked the mattress as well. (The resident) said (the resident) needed to go to the bathroom. I don't know about the air mattress machine being turned off. We just routinely check the mattress to make sure it is up when we go by the room." On 12/29/10, at 2:41 PM, licensed staff B stated that hospice had a work order. This staff member added, "The mattress settings were not done correctly on the air mattress. The settings were for some one a lot heavier than (the resident). We are putting the non-skid strips under the floor mat now." On 12/29/10, at 3:15 PM, licensed staff C revealed a hospice work order, dated 12/2/10, which recorded the air mattress pressure readjusted. Documentation on the work order read, "Bed went flat and they are having increased difficulty with the bed. This licensed staff stated, "They had the bed adjusted for someone much heavier than (the resident)". The facility failed to provide adequate supervision and assistive devices to prevent accidents for this resident. The resident experienced harm, as the resident fell from the bed and sustained lacerations to the forehead and right cheek, which required emergency room treatment. Staff failed to ensure the resident's bed in the low position. In addition, staff failed to secure the fall mat next to the resident's bed and failed to obtain an urine analysis for 5 days after an additional fall, as care planned. - Resident #71 admitted to the facility, on 8/18/2010, with diagnoses, which included, closed right fracture hip, osteoarthrosis, atrial fibulation, senile dementia, anemia, and kidney disease The admission assessment and the assessment completed, on 12/10/2010, identified both long and short term memory loss, severely impaired with decision making, required assist of two for all activities of daily living, and non ambulatory. The initial plan of care developed, on 9/9/2010, documented, "I am at risk for falls related to use of narcotic pain medications, new environment, and history of fall with recent fractured right hip. I am able to apply toe touch weight bearing to right leg." Interventions included, "Call light or personal items available and in easy reach, non skid footwear to prevent slipping, assist times 1-2 with gait belt for transfers. Keep environment well lit and free of clutter with clear pathways, observe for side effects of pain medications, Pt/Ot (physical therapy/occupational therapy) to evaluate and treat, wheelchair for mobility, assist to propel, verbal reminders as needed to limit weight bearing on right leg." Nurse's notes identified the following: 1. On 9/09/10, "Fall in bathroom at 4:40 a.m. Res. (Resident) had taken ...(himself/herself) to the bathroom. Res ambulated self back to bed without assistance and fell on floor. Found skin tear left elbow and wrist The wrist was steri stripped." Care plan updated on 9/11/2010, "Bed alarm" 2.. On 9/20/2010, "Found on floor by bedside at 4:30 am Hand in diaper urinated on floor Care plan, updated on 9/20/10, "Check UA (urine alysis) dt (due to) increased confusion" Further review identified the urinalysis ordered, on 9/21/10. However, not obtained until 9/23/10 (48 hours after ordered) Bactrim Double strength ordered, on 9/25/10, for treatment of [REDACTED]. 3. On 12/12/2010 at 7:07 p.m., "Staff found resident in own room with another resident from another room and the resident was in a position to lift the patient from w/c (wheelchair). Resident questioned about actions and stated was just trying to help ...(resident #71) to toilet. According to a CNA (certified nurse aide) working that area, patient was last given care and was in the bed with call light in reach. Patient states severe pain to LUE (left upper extremity) on ROM (Range of motion). The other resident stated that ...(resident) moved ...(resident #71) from bed to w/c and that ...(Resident #1) did drop him, there was no witness to this. Being the resident was found in w/c. Resident normally calls out for help or uses call light. No one heard a call out nor was the call light on. Physician on call gave an order for [REDACTED]. Awaiting results. Family notified of incident reported to on coming staff for further evaluation." The report of the x-ray of left humerus and forearm on 12/12/2010, failed to identify any problems or fractures. No evidence the care plan updated at this time. 4. On 12/22/2010 at 6:56 a.m. Summoned staff via calling for help, upon arrival found res kneeling on floor with upper body on bed. Alarm did not sound r/t (related to) upper body being on bed. Denies hitting head. ROM (range of motion) to lower ext. (extremity) WNL (within normal limits) c/o (complaints) mild pain to shoulders, which has been an on going concern since the last fall. Care plan updated on 12/22/10, "Offer urinal at noc (night) when aware. 5. On 12/31/201 at 11:00 p.m. the following occurred: Falls: ambulating-without assistance in resident's room, alarm sounded upon response found res laying on rt (right) side on floor, in room. Stated attempted to transfer self from bed to w/c injuries skin tear to left arm and skin tear to head." Care plan updated, on 12/31/2010, fall mat next to bed and rearranged the room. 6. On 1/1/2011 at 8:18 a.m., "Staff summoned via alarm, found res laying on floor, on right side in room. Res has fallen several times, has been restless, hollering x 4 days. Two skin tears to right peripheral area and skin tear to right elbow Neuro (neurological) checks were initiated. Care plan reviewed failed to identify any updates 7. On 1/10/2011 at 6:20 a.m., "Found on floor beside ..(resident #71) bed, no apparent injuries, confusion increased, delusions, alarm was in place and sounding." . 1/10/11 care plan updated to "Frequent visual checks". Observation identified the following: On 1/10/2011 at 10:00 a.m., Resident #1 lay in bed with head elevated, the bed in a high position, personal alarm attached. On 1/10/2011 at 11:00 a.m., certified staff P repositioned the resident and provided incontinence care and positioned the resident so nurse could do dressing change to left upper leg. At this time, Licensed staff member D identified a 7 centimeter by 3 1/2 centimeter skin tear on right lower arm and hand." Licensed staff member D stated, on 1/11/2010 at 11:10 a.m., "I noticed the skin tear this morning when I was helping getting ..(the resident) up. I put an OpSite on it at that time. We are investigating to try and identify what occurred. ...(the resident) has had several falls and incidents. ...(The resident) is declining and we are consulting with Hospice." The bed remained in a high position, personal alarm attached. On 1/10/11 at 11;35 a.m., resident up in wheelchair in the dining room. On 1/11/11 at 7:30 a.m., resident up in wheelchair, in the dining room, at breakfast table. Personal alarm not attached. The resident incurred at least 6 falls/incidents within,the last 4 months, with minor injuries. the facility failed to assess for the cause and develop appropriate interventions after each incident. - The 11/23/10 quarterly MDS assessment documented resident #21 with poor memory skills, needed extensive assistance from one care staff for ADL ' s, unsteady moving from surface to surface, failed to ambulate during the assessment period, sustained falls with injury since admission. The resident's [DIAGNOSES REDACTED]. The 11/13/10 fall risk assessment documented the resident at high risk for falls. The 12/2/10 care plan instructed the staff provide the following: 1) Place the call light and personal items available and in easy reach. 2) Non-skid footwear to prevent slipping 3) Assist with one staff and a gait belt for transfers. 4) Observe for side effects of psychotropic medications. 5) Encourage rest periods. 6) Wheelchair for mobility. Assist to propel prn in halls (as needed). Can propel self in room. 7) Revision on 10/11/10, " Review toileting schedule." 8) Revision on 12/16/10, "Physician medication review, and dip UA (urinalysis)." The care plan failed to evidence revision after the resident experienced falls on 12/6 and 12/9. Nurses notes revealed the following information: On 10/11/10 at 3:05 AM, "I heard a thud and found resident on floor in doorway to bathroom. Resident to have laceration with hematoma to right forehead, 2 small lacerations to right forehead. Steri-stripped all 3 areas after bleeding stopped. Neuro-checks WNL (with-in normal limits), unable to check pupil response due to resident not allowing to open eyes. No other injuries noted, no complaints of pain. Resident confused to incident and not sure what happened." Intervention, "review toilet schedule." On 10/12/10 an addendum to toileting schedule, toilet the resident at 3:00 AM, and 05:00 AM. On 12/6/10 at 9:40 AM, " (Resident) hollered out, staff responded immediately and found resident on floor, just inside her door. Stated she was attempting to go to bathroom. Had last been toileted at 7:40 AM, was wearing slipper socks. Recent cataract surgery, recent BP (blood pressure) medication changes, history of UTI's (urinary tract infection). Assessment by nurse, no injury noted ...Intervention physician medication review, check dip-stick." On 1/6/10 at 3:30 PM, licensed staff C reported the clinical record failed to evidence the planned intervention of a physician medication review and a urine dip-stick check for UTI's, completed following this fall. On 12/9/10 at 8:50 AM, "Patient found on floor by housekeeping. Resident states that he/she was reaching for something on the floor, and fell out of the wheelchair. No injuries noted ... " A 12/13/10 right hand and wrist Xray, documented, "Osteoarthritis changes of the right wrist with degenerative changes. No fracture or dislocation." On 12/16/10 at 2:05 AM, "Resident found laying on right side on floor in resident's room. Resident stated (she/he) hit (her/his) head during incident. Redness and swelling noted to right forehead. Neuro assessment performed without deficit. ROM (range of motion) to upper and lower extremities WNL per resident's norm. Vital signs 98.9 (temperature), 244/81 (blood pressure), 20 (respirations), 83 (pulse). Resident assisted to wheelchair with assist times 2 without difficulty. Resident complained of right wrist pain. The right wrist red and edematous. Resident complained of nausea. No emesis noted. Ambulance called to facility... Resident transported to (Hospital), at 2:25 AM via ambulance. On 12/16/10 at 5:00 AM, "Resident continues of ATB (antibiotic) related to UTI and cellulitis right hand. No ADR's (adverse drug reaction) noted, denies pain at this time." On 12/16/10 at 11:21 AM, "(Hospital) called to report radiologist stated that there is a possible fracture of resident right wrist. Stated to leave splint in place and make follow up appointment with (physician). (Physician) office called and appointment made for tomorrow. Family member notified at 11:35 AM, of results. Family member expressing concern over resident holding neck back when sitting up in chair. States that they are trying to get in touch with (the physician) to get a high back wheelchair for the resident." On 12/28/10 at 10:20 AM, observation revealed the resident in a recliner chair, in the room, with the right hand and wrist wrapped in an ace wrap with a metal forearm splint, and propped up on a pillow. On 12/29/10 at 9:15 AM, observation revealed nurse aide P placed a gait belt on the resident, stood the resident from the high back wheel chair, the resident held onto the staff and stood with knees bent, and failed to take steps as directed. Staff P placed the resident back into the wheelchair, propelled to the bathroom, stood the resident, and pivoted around to the toilet. The resident failed to bear weight during the transfer. On 12/29/10 at 2:16 PM, nurse aide S made 2:00 AM, rounds, on 12/16/10, finished on hall 4 went on to hall 3, and heard someone yell out from hall 2. Staff S found the resident by the recliner and bedside table. The resident reported she/he reported reaching for something and fell out of the wheelchair. The resident went out to the hospital about 2:45 AM. Staff S stated the resident's returned with the splint and ace wrap, and the swelling in the fingers, of the right wrist. On 12/29/10 at 2;40 PM, licensed nursing staff B, the resident had an X-ray of the right wrist a few days prior to the fall due to some swelling, however, the wrist had increased swelling, and the resident complained of pain after the fall. The resident returned from the physician today, with written information of no fracture found. The facility failed to develop and implement interventions after the resident sustained [REDACTED]. - The 12/8/10 quarterly MDS assessment documented resident # 49 with poor memory skills, needed extensive assistance from one care staff for ADL's, with no recent falls, and no skin problems. The 12/7/10 fall risk assessment documented the resident at high risk for falls. The 12/16/10 care plan instructed the staff to transfer the resident with a mechanical lift and one to two assistance, provide a personal alarm in the wheelchair and in the bed, observe for proper positioning in the bed and the chair, and not to leave the resident unattended in the bathroom. Revision of the care plan on the following dates documented the following: 1) On 12/26/10, documented the staff needed to observe for proper positioning in bed, and not too close to the edge of the bed, on rounds. 2) On 1/1/11, reassess urinary frequency. 3) On 1/7/10 1/2 rail on exit side of the bed to assist with repositioning and as an aide to help define bed parameters due to blindness. Nurses notes revealed the following information: On 1/1/10 at 12:15 AM, "(Resident) stated had a dream, responding to bladder urgency. Rolled out of bed, landed on mat, face first. Abrasion to right forehead. Neuro checks initiated with normal limits. Bed in low position, mat in place, alarm in use. Urinal offered frequently. Episodes of increased confusion at night, history of rolling out of bed. per wife. Re-assess urinary frequency at night." On 1/7/10 at 5:00 AM, "rolled over from bed to mat, stated was turning to right side. Injuries: abrasion face and bridge of nose. (Vital signs with-in normal limits). Attempted to position self in bed, stated 'I was turning my self to right side.' Abrasion to right forehead, and bridge of nos. Neuro checks initiated WNL. Call light in reach bed in low position, alarm in place. Alarm was in place at time of fall..." Observations, on 1/6/10 at 3:35 PM, observations revealed the resident in low bed on back, with eyes closed, and a black mat on the floor next to the bed. The resident had a dried black bloody scab on the forehead measuring approximately 1.5 cm. (centimeters) x 1 cm., and a dried black bloody scab measuring approximately .5 cm. x .25 cm., on the bridge of nose. On 1/10/11 at 9:45 AM, observation revealed the resident in a low bed, with a mat next to the bed, and the bed lacked the 1/2 rail as planned to prevent the resident from rolling out of the bed. At 11:30 AM, resident in the dining room, in a wheelchair, without a personal body alarm attached to the resident and the wheelchair. On 1/10/10 at 1:45 PM, L and M placed a gait belt around the resident and transferred to the toilet in a main bathroom. Observation revealed the wheelchair lacked a personal alarm. The resident pivoted around with 2 the assistance of 2 care staff, however failed to bear weight well. The staff provided perineal care to front and back. Transferred back to the wheelchair. Noted no alarm on the wheelchair. At 3:45 PM, nurse aides K and L reported the resident use to stand and ambulate better, however had a recent decline, not able to stand as well. The nurse aides reported the resident never had a personal alarm on the wheelchair. On 1/11/10 at 11:02 AM, licensed staff C confirmed the staff needed to apply a personal alarm to the wheelchair as planned. Licensed staff C further confirmed the failure of the staff to apply the 1/2 rail to the side of the bed as planned. On 1/11/10 at 2:42 PM, licensed staff C reported the clinical record lacked any evidence of a reassessment of the resident's urinary voiding pattern. The facility failed to implement interventions as planned after the resident sustained [REDACTED]. - The 11/2/10 significant change MDS assessment, documented resident # 36 with poor long and short term memory problems, no recent falls, severely impaired with decision making, physical behavior symptoms directed toward others, behaviors significantly interfere with the resident's care, behavior of wandering, and needed extensive assistance from 2 care staff for ADL's. The 1/3/11 fall risk assessment documented the resident at high risk for falls. The 11/11/10 Care plan instructed the staff to observe for proper positioning in bed and wheelchair, bed in low position, bed alarm in place, Wheelchair alarm in place, fall mat next to the bed. 1 to 2 assist with transfers. The plan of care failed to include a plan to address the need to provide preventative devices to the resident's arms and hands to prevent repetitive bruising and skin tears. The facility skin log documented the following information: On 12/21/10, "overall skin warm, dry to touch, bruising noted to bilateral upper extremities, bilateral lower extremities, no signs or symptoms of new skin issues noted at this time." On 1/4/10, "no redness." On 1/8/10, "skin tear to right hand 3 cm. cleanse with sterile normal saline, OpSite (dressing)applied, skin monitored." The nurses notes documented the following: On 1/8/10 at 5:44 PM, "Patient was observed bumping into side rail repetitively, and after CNA (certified nurse aide) noticed bleeding, small amount of bleeding noted from area, 3 cm (centimeters) long. Applied sterile 2 x 2 to area to stop bleeding cleaned with sterile normal saline, OpSite applied to area. Observation, on 1/6/10 at 3:00 PM, revealed the resident in a wheelchair propelling self down the hall, near the hand railing on the wall. The entire top of the resident's hands discolored with purple/blue bruising. On 1/10/11 at 10:00 AM, observation revealed the resident in wheelchair in the hallway, sitting quietly, with Steri-strips and a clear dressing on the top of the resident's right hand and a dark red discoloration around the Steri-strips. On 1/11/10 at 9:20 AM, nurse aide Q reported the resident hits her/his hands on the door frames and hand rails when propelling about in the wheelchair, and hits at the staff during personal cares. Staff Q reported the nurse aides placed protective sleeve on the resident's forearms in the past, but the resident removed the sleeves, and staff failed to try the protectors again. On 1/11/10 at 11:00 AM, licensed nursing staff C confirmed the staff needed to provide protective covering on the resident's and hands to prevent skin tears and bruising. The facility failed to plan and implement interventions to prevent injury to this resident's arms and hands. - The facility admitted resident #34 on 9/28/06, with [DIAGNOSES REDACTED]. The 9/2/10 dated quarterly minimum data set indicated the resident as severely impaired cognition, requiring extensive assist of one or two staff for all activities of daily living including transfer and ambulation, and indicated one fall within the past 180 days. The 11/5/10 dated physician's orders [REDACTED]. Ambulate with hand held assist as tolerated, distance as tolerated daily to maintain current ability to ambulate two times a day everyday. The 12/9/10 dated care plan addressed the resident at risk for falls and identified interventions used including call light within reach, provide clear pathways and a clutter free environment, PT (physical therapy) and OT (occupational therapy), screen as indicated, provide rest periods prn (as needed), ...keep bed in low position with mattress at bedside, restorative program for range of motion and ambulation, ensure shoes or non-skid socks on when up. On 1/10/11, at 11:00 am, observation revealed the resident sat a table, in the wheelchair, with arms flexed at the elbow and hands fisted on each side of the head. No shoes or gripper socks on at this time. On 1/10/11, at 1:15 pm, resident observed moving self around in the wheelchair, in the dining room, with his/her feet. No shoes or gripper socks on feet. On 1/11/11, at 7:20 am, resident observed in bed sleeping on his/her back. No safety mat on floor, or in evidence in the room. On 1/11/11, at 7:25 am, the resident observed walking alone, in the hall to the dining room, with gown open , brief exposed. Staff B and F, immediately assisted the resident to return to the room, provided incontinence care, grooming of face and hands, dressed the resident, seated him/her in the wheelchair, and then returned him to the dining room, without shoes or gripper socks to the feet. On 1/11/11, at 8:55 am, the resident observed assisted to bed by staff T. No fall mat or other safety measures in place. On 1/11/11, at 9:30 am, and again at 11:30 am, resident observed in unchanged position. On 1/11/11, at 9:46 am, licensed staff D stated, "I am in charge of restorative. The aides do it and I keep the plan on my computer. He/she doesn't have a mat or alarm. I don't think he/she ever wears shoes." On 1/11/11, at 9:55 am, direct care staff T stated, "I never put shoes on him/her, only socks. I don't remember ever seeing a mat in his/her room." On 1/11/11. at 9:57 am, direct care staff V stated, "The restorative aide is supposed to be doing it. I help ambulate some people. He/she isn't one I do. I don't know about socks or shoes. I would imagine he/she would have shoes in his/her room." On 1/11/11, at 9:59 am, direct care staff Q stated, "I help ambulate people sometimes. I have been off for four days, so I don't know who did it. I don't know about shoes. I don't remember ever seeing them. He/She used to have a landing strip. I haven't seen it for a long time. I think it was in his/her other room." On 1/11/11, at 1:35 pm, direct care staff S stated, "He/She used to have a landing strip. It's been gone for a long time. He/She never wears shoes. I don't remember him/her ever having any. He/She is not a fall risk. He/She can walk ok." On 1/11/11, at 1:40 pm, direct care staff O stated, "He/She was in another room. When he/she moved, they didn't move the mat. I don't think I have ever seen him/her in shoes. I don't think he/she even has any. He/She isn't a fall risk. He/She is pretty steady most of the time." On 1/12/11, at 8:39 am, licensed staff J stated, "He/She used to wear footie socks with the grips on the bottom. He/She hasn't needed them, or I haven't seen them in quite a long time. He/She never had a mat by his/her bed, we just keep the bed in the low position, like we do for everybody. He/She is able to stand up out of his/her wheelchair at times. I think restorative works with him/her some. I am not sure exactly what they do with him. He/She hasn't had a fall recently, and since he/she is in the chair all the time, he's/she's not too likely to fall." On 1/12/11, at 8:40 am, licensed staff I stated, "I was here when he/she changed rooms. There was a mat on the floor in the old room, but not in the new one. The personal alarm was discontinued because he/she can't get himself/herself up. He/She is not able to ambulate anymore. So since he/she is not an elopement risk, he/she didn't need it. He/She never has had shoes that I know of. I think restorative works with him/her. We don't do it over here. He/She hasn't had a fall, since he/she doesn't get out of the chair." The facility failed to provide interventions, as planned, to ensure this confused, dependent resident remained free from further falls.