Every finding on record at F W Huston Medical Center

The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to store unexpired medication in the emergency kit as required, and staff failed to discard or destroy expired medications. This deficient practice placed residents of the facility at risk of receiving ineffective medications. Findings included:- On 08/11/25 at 07:45 AM, observation with License Nurse (LN) G revealed that the facility's medication room had an emergency kit. The emergency kit contained the following expired medications:One bottle of Coumadin (blood thinner medication) 1 milligram (mg), 10 tablets that expired 06/13/25.One bottle of Cefuroxime (antibiotic medication) 500 mg, 10 tablets, expired 06/13/25. One Albuterol sulfate inhaler (bronchodilator medication) 2.5 mg per three milliliters (ml) expired 05/06/25. One scopolamine (antinausea medication) patch, one mg per three-day patch, expired 06/13/25. LN G verified the expiration dates.On 08/12/25 at 11:00 AM, Administrative Nurse D verified that the pharmacy consultant was to inspect the medication room monthly, which included the emergency kit and replace expired medications. Administrative Nurse D stated the pharmacist had apparently not checked the emergency kit for expired medications. The facility's Medication Storage policy dated 06/02/25 stated any discontinued, unused (no use in 30 days), or outdated medication must be returned to the pharmacy.

The facility identified a census of 38 residents. The facility had one main dining room and kitchen. Based on observations, record review, and interview, the facility failed to properly label and store food and failed to perform hand hygiene during meal tray pass. This deficient practice had the risk of spreading foodborne illness to all affected residents.Findings included:- On 08/10/25 at 08:49 AM, during the initial tour of the kitchen, the deep freezer had an opened package of waffles, an opened package of hashbrowns, and an opened package of pancakes not labeled and dated or stored in a sealed container/bag. A refrigerator had an opened package of ham and an opened bag of grated Parmesan cheese, not labeled, dated, or in a sealed container/bag. A sealable bag of hot dogs that was unsealed and not labeled or dated.On 08/10/25 at 11:22 AM, Dietary CC wore gloves and passed a lunch plate to Resident (R) 22, then asked R14 what she wanted to drink. Dietary CC grabbed a roll of silverware but dropped a utensil on the ground. She picked the utensil up, then doffed (removed) her gloves; no hand hygiene was performed. Dietary CC went over to R14 and asked her what she wanted to eat for lunch. Dietary CC donned (put on) gloves and brought R22 his dessert. She grabbed a pen at the kitchen window and waited for another lunch plate. Dietary CC brought a lunch plate and dessert to R30. She brought R22 and R30's dessert back to the window for ice cream to be added. Dietary CC did not perform hand hygiene during this observation.On 08/10/25 at 11:26 AM, Dietary CC grabbed a lunch plate and dessert for R14, then asked R21 what she wanted for lunch. She rested her gloved hands on her hips while she waited. Dietary CC got three beverages for R21, then went over to R27 and placed her left hand on R27's chair. Dietary CC delivered R22 and R30's dessert bowls back to them. She pulled her gloves further up on her wrist, then opened a cabinet to grab a cup for ice water. Dietary CC delivered the water to R27, then moved R27 closer to the table by pushing her chair forward. Dietary CC went into the kitchen and grabbed a snack package. She then asked a male visitor what he wanted to drink. Dietary CC doffed gloves and talked to another staff member. She did not perform hand hygiene after doffing gloves and before grabbing beverages for the male visitor. Dietary CC did not perform hand hygiene during this observation.On 08/10/25 at 11:32 AM, Dietary CC delivered a plate and silverware to R5. She asked R2 what he wanted to drink, then delivered a dessert and lunch plate to the male visitor. Dietary CC delivered a lunch plate and silverware to a female resident. Dietary CC did not perform hand hygiene during this observation.On 08/12/25 at 01:43 PM, Dietary DD stated that if she opened a bag of food, she would put the food in a freezer bag, then dated and labeled it.On 08/12/25 at 01:44 PM, Dietary EE stated he prevented cross-contamination during meal pass by taking plates out one at a time and performing hand hygiene between each plate. He stated he washed his hands after taking off his gloves.On 08/12/25 at 01:46 PM, Dietary BB stated if dietary staff opened a food item, they placed the food in a sealable bag and then dated it. He stated that dietary staff performed hand hygiene throughout meal service and washed their hands after removing gloves.The facility's Dietary and Nutritional Services policy, not dated, directed staff to handle all food in a manner that ensured it was safe, wholesome, and free from contamination. The policy directed staff to follow hygiene practices, maintain food at safe temperatures, and comply with food safety regulations. The policy directed staff labeled and dated all foods upon receipt.The facility's Hand Hygiene and Glove Usage policy, last revised 12/10/24, directed the facility to train all staff members in hand hygiene and glove usage expectations.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to maintain a Quality Assessment and Assurance Committee (QA&A) that had the required membership in attendance. This placed the resident with a lack of quality care.Findings included:- Upon review of the facility's QA&A committee attendance signed roster for the monthly meetings held 07/16/24 to 07/15/25, the roster of attendance lacked the signature of the Medical Director.On 08/12/25 at 09:12 AM, Administrative Staff B reported the Medical Director had not signed the attendance roster but had joined the meeting via the Owl conferencing method (a camera device of a cascading camera and an extension microphone which provides audio-visual experience).The facility's Quality Assurance and Performance Improvement Plan policy, dated 01/2025, documented all department managers, the administrator, the director of nursing, the infection control and prevention officer, medical director, consultant pharmacist, resident/patient and/or family representatives (if appropriate), and additional staff who provided leadership by being on the Quality Committee. The Quality Committee will meet monthly.

The facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment free of chemical hazards for cognitively impaired, independently mobile residents. This placed residents at risk of possible injury.Findings included:- On 08/10/25 at 08:00 AM, upon initial tour of the facility, through the open door to the beauty shop sink, chair, and workstation, a black unlocked cabinet was found with three hair coloring kits, three cans of hair spray, and one box of hair curling permanent kit.On 08/11/25 at 08:04 AM, Administrative Nurse E stated the cabinet had a magnetic lock and should have been locked.The facility's Hazardous Materials and Waste Management Policy, dated 10/2020, documented that hazardous materials and waste shall be stored in a safe and secure manner to prevent injury to patients, visitors, and staff. Storage areas for hazardous chemicals shall be kept locked at all times.

The facility had a census of 38 residents. The sample included 12 residents, with five residents reviewed for immunizations: Resident (R) 4, R10, R14, R19, and R37, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, obtain an informed declination, or a physician documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.Findings included:- Review of R4, R10, R14, R19, and R37 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20.Review of R4's electronic health record revealed the resident was admitted to the facility on [DATE]. R4 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R10's electronic health record revealed the resident was admitted to the facility on [DATE]. R10 had not been offered or received a pneumococcal PCV20 vaccine since admission.Review of R14's electronic health record revealed the resident was admitted to the facility on [DATE]. R14 had not been offered or received a pneumococcal PVC20 vaccine since admission.Review of R19's electronic health record revealed the resident was admitted to the facility on [DATE]. R19 had not been offered or received a pneumococcal PCV20 vaccine since admission. Review of R37's electronic health record revealed the resident was admitted to the facility on [DATE]. R37 had not been offered or received a pneumococcal PCV20 vaccine since admission.On 08/11/25 at 01:15 PM, License Nurse (LN) H stated that when a resident was admitted to the facility, she would check the Web IZ (a web-based, immunization registry system used by many states and local government agencies designed to track and manage immunization records for public health purposes. status and determine what immunizations the resident had received and what vaccinations they needed to receive to be up to date. The website supports vaccine recommendations based on the CDC guidelines and can integrate with other health care systems for their vaccination status. LN H stated the facility would contact the physician for an order to administer the vaccinations the resident needed to receive, then administer the vaccine after providing the resident and/or the durable power of attorney (DPOA) the Vaccine Information Sheet (VIS) consent form. LN H stated the resident and/or the DPOA would sign a consent or denial form, and that would be kept in the resident's electronic health record. LN H verified that 12 of the residents in the facility were not asked or received the pneumococcal vaccine per protocol. On 8/12/25 at 01:30 PM, Administrative Nurse D verified the lack of a system to identify the residents in the building who were eligible to receive the pneumococcal vaccinations. And verified the lack of denial forms in the resident's medical records. The facility's Flu and Pneumococcal Vaccine policy dated 12/24/24, documented all residents at the facility would have the opportunity to receive the flu vaccine annually, and the pneumonia vaccine as recommended by the physician to assure as much protection from the diseases as possible. Upon admission to the facility, staff would obtain dates from the family or resident of any past flu or pneumonia vaccines received. Flu and Pneumonia VIS are provided to family and/or residents annually and at the time of admission or hire from October through the following March each year. The resident, resident durable power of attorney, resident guardian, or resident's responsible party would sign a consent or denial form for the vaccinations. If the flu or pneumonia vaccines are not available, the resident would be offered the vaccine or vaccines at the first availability from the pharmacy

The facility identified a census of 38 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notification of transfer to Resident (R) 1 or their representative for all applicable transfers/discharges. The facility failed to ensure the written notification of transfers given to R1 had the required information. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of transfers/discharges for R1. This deficient practice had the risk for miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R1 and placed R1 at risk for impaired rights.Findings included:- R1 admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE].R1's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), hyperlipidemia (condition of elevated blood lipid levels), presence of a cardiac pacemaker (implanted device to regulate the beating of the heart), and atherosclerotic heart disease of native coronary artery (abnormal condition that may affect the flow of oxygen to the heart).The Annual Minimum Data Set (MDS) dated 05/08/25, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.The Quarterly MDS dated 07/30/25, documented R1 had a BIMS score of 15, which indicated intact cognition.The Functional Abilities Care Area Assessment (CAA) dated 05/12/25, documented R1 needed assistance with his self-care and mobility.R1's Care Plan dated 05/02/24, documented R1 had diagnoses of hypertension, hyperlipidemia, and atherosclerotic heart disease. The plan directed R1 had a cardiac pacemaker in place.R1's EMR revealed the following:An eInteract Transfer Form on 04/18/25 at 01:30 PM, documented R1 transferred to the hospital for chest pain.An eInteract Transfer Form on 07/02/25 at 10:38 AM, documented R1 transferred to the hospital for aspiration (inhaling liquid or food into the lungs).Upon request, the facility was unable to provide a written notification of transfer and bed hold acknowledgement for R1's transfer to the hospital on [DATE].Upon request, the facility provided a written notification of transfer and bed hold acknowledgement for R1's transfer to the hospital on [DATE]. The Notice of Emergency Transfer/Discharge form, dated 07/02/25, documented the reason for the transfer to the emergency room (ER) as aspiration. The notice explained R1's right to an appeal but did not explain how to file an appeal, who would help R1 file an appeal, or the correct agency and contact information to file an appeal with.Upon request, the facility was unable to provide documentation of LTCO notification for R1's transfer to the hospital on [DATE] and 07/02/25.On 08/11/25 at 07:55 AM, R1 sat in his wheelchair at the dining room table and ate breakfast.On 08/11/25 at 03:17 PM, Administrative Nurse D stated the facility did not have a written notification of transfer for R1's 04/18/25 transfer.On 08/12/25 at 01:56 PM, Licensed Nurse (LN) G stated that when she transferred a resident to the hospital, she provided the bed hold acknowledgement and written notification of transfer to the resident. She stated she gave Administrative Nurse D a copy of the signed forms.On 08/12/25 at 02:16 PM, Administrative Nurse D stated she updated the previous notification of transfer form with her and Administrative Staff A's contact information, but she did not change any other information on the form. She stated for the first several months when she started at the facility, she sent the transfer notifications to the LTCO, but she did not think she had sent them since February 2025. Administrative Nurse D stated the LTCO notifications were transitioning to Social Services.The facility's Bed Hold and Return to Facility Policy and Procedure, revised 12/13/24, directed the facility provided written information about the state's bed hold duration and payment amount before the transfer. The policy directed the facility provided bed hold and return information at admission and before a hospital transfer or therapeutic leave. In the case of emergency transfers or discharges, the facility provided the bed hold policy to the resident, their responsible party, and the LTCO on the first business day following the transfer/discharge.The facility did not provide a policy on written notification of transfers.

The facility identified a census of 38 residents. The sample included 12 residents, with one resident reviewed for bathing. Based on observations, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 32. This deficient practice had the risk for poor hygiene and decreased self-esteem and dignity for R32.Findings included:- R32's Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following 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) affecting right dominant side, repeated falls, and difficulty in walking.The Significant Change Minimum Data Set (MDS) dated 02/15/25, documented R32 had a Brief Interview for Mental Status (BIMS) score of ten, which indicated moderate cognitive impairment. R32 had impairment on both sides, upper and lower extremities. R32 required partial/moderate assistance with bathing.The Quarterly MDS dated 07/23/25, documented R32 had a BIMS score of nine, which indicated moderate cognitive impairment. R32 had impairment on one side upper and lower extremities. R32 required partial/moderate assistance with bathing.The Functional Abilities Care Area Assessment (CAA) dated 02/19/25, documented R32 had a limited range of motion on his right side and required assistance with activities of daily living (ADL).R32's Care Plan dated 08/11/22, documented R32 required assistance with ADLs and preferred a shower three times a week after he got up.The Documentation Survey Report for 05/01/25 to 08/11/25 revealed the following documentation for the scheduled task Type of Bathing Provided this Shift: shower provided on 25 out of 44 scheduled days, none provided on 18 out of 44 scheduled days, and the resident refused one out of 44 scheduled days.R32's EMR revealed a Plan of Care note on 08/06/25 at 05:16 PM that documented R32's representative stated R32 was supposed to receive a shower the previous Sunday, and he waited but did not get a shower.On 08/10/25 at 01:57 PM, R32 sat in his recliner in his room with his representative visiting. R32's representative stated R32 was supposed to get a shower daily, but he was okay with every other day. She stated R32 had issues getting his showers on the weekends. R32 agreed with the weekend shower issue.On 08/11/25 at 08:06 PM, R32 self-propelled in his wheelchair from the dining room towards the day area.On 08/12/25 at 01:53 PM, Certified Nurse Aide (CNA) M stated that CNAs were responsible for bathing, and the showers were divided between the CNAs. She stated that bathing was documented in Point of Care (POC- CNA documentation system). CNA M stated staff documented none provided if the bathing did not get done. She stated if a resident refused bathing, the CNA got another CNA to encourage them to bathe.On 08/12/25 at 01:56 PM, Licensed Nurse (LN) G stated the CNAs were responsible for bathing, and they had a bathing list. She stated staff tried to offer R32 bathing every day per his wife's request because he did not like assistance with toileting and changing throughout the day. LN G stated bathing was documented in POC, and if staff documented none provided, then the shower did not get done.On 08/12/25 at 02:12 PM, CNA N stated R32 required full assistance with bathing, and he showered every other day. She stated that if staff documented none provided, then it meant the resident did not get a shower that day. She stated that bathing was documented in POC.On 08/12/25 at 02:16 PM, Administrative Nurse D stated CNAs and nurses were responsible for bathing, and she expected staff to complete bathing twice weekly or per resident preference. She stated staff documented bathing in POC, and the system alerted the nurse if a resident did not receive bathing for five days.The facility's Restorative ADL Services policy, dated October 2020, directed that residents received assistance with ADLs every shift as appropriate, which included bathing.

The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through 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) 2024 Quarter (Q) 4 indicated the facility failed to have licensed nursing coverage 24 hours a day, three days in July 2024, and three days in September 2024.The PBJ report provided by the CMS for the FY 2024 Quarter 1 indicated no Registered nurse (RN) hours for one day in October 2024, licensed nursing coverage for three days in December 2024, and the report indicated the facility failed to have four days in October 2024, five days in November 2024, and nine days in December 2024. The PBJ report documented that the facility was a one-star rating. The PBJ report provided by the CMS for FY 2025 Quarter 2 indicated the facility failed to have licensed nursing coverage 24 hours a day, one day in February 2025, and one day in March 2025.A review of the facility's staffing and RN hours of the days listed above revealed adequate licensed nursing staff and RN coverage.On 08/11/25 at 10:00 AM, Administrative Nurse D stated the facility had a CMS PBJ audit for the quarter ending June 30, 2024, and the CMS had cleared them and no further action was taken at that time. Administrative Nurse D stated she started in December 2024, and the Director of Nursing and the Assistant Director of Nursing would work the floor and not document the hours worked since they were salary. Another concern was noted the facility incorrectly calculated hours when staff worked half of their shift before midnight and the other half after midnight. Administrative Nurse D verified that they use three different agencies, and those times were not accounted for correctly at times. The facility's Payroll Based Journal policy, dated 08/12/25, documented the CMS Payroll-Based Journal (PBJ) requires long-term care facilities to submit staffing and census data on a quarterly basis. This data, which includes information on nursing and non-nursing staff, is used to assess staffing levels and inform quality ratings. The facility must submit the data by the end of the 45th calendar day after the end of the fiscal year. The facility must submit data, including hours worked and paid, for each staff member, on a quarterly basis. The PBJ allows CMS to collect staffing data regularly, improving transparency and informing quality initiatives.

The facility identified a census of 37 residents. Based on record and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care. Findings included: - RN coverage documentation for 04/08/23 to 06/18/23 was requested from the facility. The facility provided [NAME] Living Center Schedule documents with who provided RN coverage each day. The documents listed the following dates where RN coverage was recorded as provided by Administrative Nurse F: 04/08/23 - 04/09/23, 04/22/23 - 04/23/23, 05/06/23 - 05/07/23, 05/13/23 - 05/14/23, 06/03/23 - 06/04/23, and 06/17/23 - 06/18/23. Upon request, the facility was unable to provide verifiable clock-in times or timesheets for Administrative Nurse F on the above dates. On 10/18/23 at 11:52 AM Administrative Staff B stated the facility had no way to log hours for Administrative Nurse F, who was the facility's previous Director of Nursing (DON), due to the DON being a salaried employee. She stated that their salaried employees did not clock in and out for their scheduled shifts and therefore the facility had no real way to track those hours to ensure eight consecutive hours were acheived. The facility was unable to provide a policy related to nursing coverage. The facility failed to provide a RN service for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care.

The facility had a census of 37 residents. Five Certified Nurse Aide's (CNA) were reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's performance evaluation records revealed the following: CNA O, hired 07/10/20, no yearly performance evaluations were provided upon request. CNA P, hired 10/07/19, no yearly performance evaluations were provided upon request. CNA Q, hired 06/30/19, no yearly performance evaluations were provided upon request. On 10/18/23 at 11:52 AM Administrative Staff B stated she provided the information to the managers for the employees that were due for a yearly evaluation. She stated that managers had one month from the employee's annual hire date to complete the evaluations. She further stated the previous Director of Nursing (DON) had done the yearly performance evaluations and that she was unable to locate the evaluations for three of the five requested CNAs. The facility did not provide a policy related to the completion of yearly employee evaluations. The facility failed to ensure three of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change Minimum Data Set (MDS) for Resident (R) 20. This deficient practice placed R20 at risk of unidentified care needs. Findings included: - R20's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease (condition in which the kidneys are damaged and cannot filter blood as well as they should), and other symptoms and signs involving cognitive functions and awareness. The Quarterly MDS dated [DATE], lacked documentation that R20 was receiving hospice services at that time. The Annual MDS dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severe cognitive impairment. The MDS documented R20 required extensive assistance of one staff member for transfers, dressing and two staff for toileting. The MDS further documented R20 was receiving hospice services. The Cognitive Loss / Dementia Care Area Assessment (CAA) dated 09/08/23, documented R20 had a BIMS score of zero and had severe cognitive impairment and directed staff to cue/assist R20 with orientation and activities of daily living. R20's Care Plan with an initiated date of 06/30/23, documented R20 was receiving hospice services. R20's EMR revealed R20 was admitted to hospice on 06/30/23. R20's EMR lacked evidence that a comprehensive significant change MDS/assessment was completed for R20 after R20 went on hospice services and before the Annual MDS dated on 09/08/23. On 10/17/23 at 09:21 AM R20 slept in her bed in her room. On 10/18/23 at 02:03 PM Administrative Nurse D confirmed that she completed the MDS documentation for the residents. She stated that R20 should have had a comprehensive Significant Change MDS when R20 was admitted to hospice care. She further stated that it was very possible that she may have missed doing the MDS for R20 at that time. The facility was unable to provide a policy related to MDS assessments. The facility failed to identify a significant change in the physical condition and complete a comprehensive Significant Change MDS for Resident R20 when she was admitted to hospice care. This deficient practice placed R20 at risk of unidentified care needs.

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 4's comprehensive person-centered care plan to include her right-hand splint. This deficient practice placed R4 at risk of worsening contracture (abnormal permanent fixation of a joint or muscle), along with loss of independence. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of 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) affecting right dominant side, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R4 required extensive assistance of two staff member for ADLs. The MDS documented R4 had not received a nursing restorative program for the observation period. R4's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/01/23 documented R4 required assistance of staff with ADLs. R4's Care Plan dated 07/21/23 documented staff would encourage her to participate in her individualized restorative program. R4's Care Plan lacked direction for her right-hand splint. R4's EMR, under Reports tab for Tasks from 07/01/23 through 09/18/23 revealed: R4 had a brace that she was to wear on her right hand/wrist. Please assist her with applying this in the mornings and off at bedtime or per her request. Please keep in mind she may sometimes refuse to wear her brace. The Task lacked documentation R4's right hand splint was applied. Observation on 10/16/23 at 01:54 PM R4 sat in her wheelchair next to her bed. R4's right arm rested tight next to her right side with her finger curled inward sat on her lap. R4 did not wear a right-hand splint. On 10/17/23 at 09:44 AM R4 sat in her wheelchair in front of her TV. R4's right arm rested against her right side, with her hand resting on her right leg. R4 lacked a right-hand splint or a pillow for hand elevation. On10/18/23 at 09:50 AM R4 sat in her wheelchair in front of her TV. R4's arm was snug against her body and her right hand fingers curled inward; her hand rested on her right leg. R4 lacked a right-hand splint or a pillow for hand elevation. On 10/18/23 at 09:50 AM R4 stated she had not had a splint on her right hand in a long time. R4 stated she did not receive ROM to her right-hand to prevent contractures from worsening. On 10/18/23 at 09:58 AM Certified Nurse Aide (CNA) O stated R4 had a right-hand splint, but she had not worn the splint in a long time. CNA O stated staff would elevate R4's hand/arm on a red pillow and stretch out her fingers when R4 was in her wheelchair. CNA O stated she was not aware of any restorative program for R4 and was not aware if therapy was treating R4. On 10/18/23 at 10:20 AM Consultant HH stated R4 was discharged on [DATE] from therapy after education to nursing staff regarding R4's right hand splint application and removal. Consultant HH stated he was not aware that R4 was not wearing the right-hand splint and she was not on a ROM/restorative program at that time. Consultant HH stated the therapy department provided the restorative programs. On 10/18/23 at 01:14 PM CNA M stated everyone had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident) which contained the information and direction for each resident's care. On 10/18/23 at Licensed Nurse (LN) G stated she was not aware of a right-hand splint for R4. LN G stated everyone had access to the Kardex which should contain personalized care direction. LN G stated R4's care plan should have direction to the staff for her right-hand splint. On 10/18/23 at 02:03 PM Administrative Nurse D stated if R4 refused to wear her right-hand splint, therapy should have evaluated her. Administrative Nurse D stated everyone had access to the Kardex which has to care plan information on the care for each resident. Administrative Nurse D stated the care plan should have direction for R4's right-hand splint. The facility was unable to provide a policy related to comprehensive person centered care plan revision. The facility failed to revise R4's comprehensive care plan with direction for her right-hand splint. This deficient practice placed R4 at risk of worsening contractures and further loss of independence with ADLs.

The facility identified a census of 37 residents. The sample included 12 residents with two resident reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to provide care and services to prevent a decrease in range of motion (ROM)/mobility and/or development of contractures (abnormal fixation of a joint or muscle) for Resident (R) 4. The deficient practices placed R4 at risk of loss of ability to perform activities of daily living (ADLs) and development or worsening of contractures. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of 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) affecting right dominant side, hemiparesis (muscular weakness of one half of the body), hemiplegia (paralysis of one side of the body), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R4 required extensive assistance of two staff member for ADLs. The MDS documented R4 had not received a nursing restorative program for the observation period. R4's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/01/23 documented R4 required assistance of staff with ADLs. R4's Care Plan dated 07/21/23 documented staff would encourage her to participate in her individualized restorative program. R4's Care Plan lacked direction for her right-hand splint. R4's EMR, under Reports tab for Tasks from 07/01/23 through 09/18/23 revealed: R4 had a brace that she was to wear on her right hand/wrist. Please assist her with applying this in the mornings and off at bedtime or per her request. Please keep in mind she may sometimes refuse to wear her brace. The Task lacked documentation R4's right hand splint was applied. Observation on 10/16/23 at 01:54 PM R4 sat in her wheelchair next to her bed. R4's right arm rested tight next to her right side with her finger curled inward sat on her lap. R4 did not wear a right-hand splint. On 10/17/23 at 09:44 AM R4 sat in her wheelchair in front of her TV. R4's right arm rested against her right side, with her hand resting on her right leg. R4 lacked a right-hand splint or a pillow for hand elevation. On10/18/23 at 09:50 AM R4 sat in her wheelchair in front of her TV. R4's arm was snug against her body and her right hand fingers curled inward; her hand rested on her right leg. R4 lacked a right-hand splint or a pillow for hand elevation. On 10/18/23 at 09:50 AM R4 stated she had not had a splint on her right hand in a long time. R4 stated she did not receive ROM to her right-hand to prevent contractures from worsening. On 10/18/23 at 09:58 AM Certified Nurse Aide (CNA) O stated R4 had a right-hand splint, but she had not worn the splint in a long time. CNA O stated staff would elevate R4's hand/arm on a red pillow and stretch out her fingers when R4 was in her wheelchair. CNA O stated she was not aware of any restorative program for R4 and was not aware if therapy was treating R4. On 10/18/23 at 10:20 AM Consultant HH stated R4 was discharged on [DATE] from therapy after education to nursing staff regarding R4's right hand splint application and removal. Consultant HH stated he was not aware that R4 was not wearing the right-hand splint and she was not on a ROM/restorative program at that time. Consultant HH stated the therapy department provided the restorative programs. On 10/18/23 at 01:14 PM CNA M stated everyone had access to the Kardex (nursing tool that gives a brief overview of the care needs of each resident) which contained the information and direction for each resident's care. On 10/18/23 at Licensed Nurse (LN) G stated she was not aware of a right-hand splint for R4. On 10/18/23 at 02:03 PM Administrative Nurse D stated if R4 refused to wear her right-hand splint, therapy should have evaluated her. The facility was unable to provide a policy related prevention of contractures or related to ROM. The facility failed to ensure R4 received services and treatment for her right hand/arm contractures to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R4 at risk for further decline in independence and decreased ROM.

The facility identified a census of 37 residents. The sample included 12 with two reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to provide consist weekly weight monitoring as identified on Resident (R)14's nutritional plan of care and physician's orders. This deficient practice placed R14 at risk for complication related to weight loss and malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients). Findings included: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of 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), iron deficiency anemia, type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, and gastro-esophageal reflux disease (backflow of stomach contents to the esophagus). R14's Annual Minimum Data Set (MDS) completed 08/20/2023 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she weighed 156 pounds (lbs.) and noted no significant weight loss or prescribed weight loss regimen. The MDS indicated she ate independently with no staff assistance. R14's Nutrition Care Area Assessment (CAA) completed 09/01/23 indicated she had a body mass index (BMI- measure of body fat based on height and weight) of 28 indicating she was overweight. R14's Activities of Daily (ADL'S) CAA completed 09/01/23 indicated she required extensive assistance with cares. R14's Care Plan initiated 07/30/21 indicated she required assistance with her ADLs due to her medical diagnoses. The plan noted she was able to eat independently but occasionally needed set up assistance with her meals. The plan instructed staff to weigh her weekly for four weeks after admission and then as ordered. R14's Physician's Orders in the EMR indicated an order dated 02/13/23 for weekly weights to be obtained. A Weight Change note dated 05/12/23 was scanned into the EMR 's Miscellaneous section. The note indicated R14 struggled with dysphagia (swallowing difficulty) and had a gastrointestinal (GI) consult completed due to her weight loss pattern. A review of R14's EMR between 02/13/23 to 10/18/23 (35 weeks reviewed) revealed 16 missed weekly weight occurrences for the weeks of 2/13, 2/20, 2/27, 4/20, 4/27, 5/25, 6/8, 6/22, 7/13, 7/20, 7/27, 8/24, 8/31, 9/7, 9/22, and 9/29. On 10/17/23 at 09:30AM R14 sat in wheelchair in her room. She reported she was getting ready for doctor's appointment. She reported she recently had issues with meals and was seen by a GI doctor but seemed to be better. On 10/18/23 at 08:21AM R14 was assisted to the dining by staff in the dining room. She was served her meal with weighted silverware and Dycem (non-slip mat) under her plate. R14 consumed her meal without issue and returned to her room. On 10/18/23 at 09:12 AM Certified Nurses Aided (CNA) M stated most residents were either weighed every two weeks or monthly. He stated the weights obtained were entered into the EMR. He stated weight changes were reported to the nurse. He stated refusals were documented into the EMR. He stated the facility's weight scale was recently replaced due to inaccuracies, but weights should not have been missed. He stated R14 was weighed every two weeks. On 10/18/23 at 01:30PM Licensed Nurse (LN) G stated staff weighed the residents based on their physician orders and care planned needs. She stated the weights should be entered in the EMR system. She stated significant changes in weights were to be reported to the nursing team, dietary, and medical doctor. On 10/18/23 at 02:03PM Administrative Nurse D stated staff were expected to follow the care planned interventions related to weights. She stated staff were expected to monitor and report weight changes, refusals, and missed occurrences. She stated the facility recently switched out its weight scale due to inaccurate weight readings, but it should not have caused missing weights. The facility was unable to provide a policy related to weight monitring as requested on 10/18/23. The facility failed to provide consist weekly weight monitoring as identified on R14's nutritional care plan and physician orders. This deficient practice placed R14 at risk for complication related to weight loss and malnutrition.

The facility identified a census of 37 residents. The sample included 12 residents with five residents sampled for unnecessary medication review. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 35's diclofenac sodium gel (topical medication used to treat joint pain and inflammation) had a dosage for administration. This deficient practice had the risk for physical complications and unnecessary medication usage. Findings included: - R35's Electronic Medical Record (EMR) documented diagnoses of unilateral primary osteoarthritis of the left hip (inflammation of a joint characterized by pain, swelling, redness and limitation of movement). The Admission Minimum Data Set (MDS), dated [DATE], recorded R35 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that R35 was cognitively intact. The MDS recorded that R35 required supervision of one staff while walking, with transfers, and limited assistance of one staff for bed mobility. The Pain Care Area Assessment (CAA) dated 12/16/22, documented R35 had chronic pain. R35's Care Plan with an initiated date of 12/06/22, documented R35 was at risk of pain due to her diagnosis of osteoarthritis. An intervention initiated 12/06/22 documented R35's provider ordered medications for pain and directed staff to administer them as ordered. R35's EMR recorded the following medication order under the Orders tab with a start date of 02/13/23: Diclofenac sodium external gel 1%. Apply to left hip topically four times a day related to unilateral primary osteoarthritis left hip. The order lacked a measured dosage for staff to administer. An observation on 10/17/23 at 09:22 AM revealed R35 sat in a recliner in her room. On 10/18/23 at 12:55 PM Licensed Nurse (LN) G stated diclofenac sodium would normally have instructions in the box that would show the dosage; however, the box did not contain that information. She stated that she would normally use the plastic measuring tool to measure the ordered amount, but since there was no listed amount/dosage, she was unsure how much to administer to R35. On 10/18/23 at 02:03 PM Administrative Nurse D stated the order for diclofenac sodium should have had a dosage amount listed on the order so that staff would know how much of the medication to administer. The facility was unable to provide a policy for medication orders/administration. The facility failed to ensure the medication order for R35's diclofenac sodium gel had a dosage for administration. This deficient practice had the risk for physical complications and unnecessary medication usage.

The facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to document the non-pharmacological interventions used, and a rational for continued use of psychotropic (alters mood or thought) medication with no gradual reduction for Resident (R)6. The facility also failed to ensure an appropriate indication for use or documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for R25. This deficient practice placed these residents at risk for unnecessary psychotropic medication and related complications. Findings included: - R6's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), without behavioral disturbance, psychotic (episode of psychosis (any major mental disorder characterized by a gross impairment in reality perception) disturbance, mood disturbance or anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R6 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R6 received antidepressant (class of medications used to treat mood disorders) for seven days for the observation period. The MDS documented a gradual reduction was not done. R6's Psychotropic Drug Use Care Area Assessment (CAA) dated 09/11/23 documented R6 received medication to manage her depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R6's Care Plan dated 08/08/22 documented the physician ordered antidepressant medication to treat R6's anxiety and directed staff to administer the medication as ordered. The plan of care also directed staff to monitor for any changes in mood/behaviors as needed and to document any non-pharmacological interventions used or depression/anxiety. The plan of care directed staff to monitor for effectiveness. Review of R6's EMR under the Orders tab revealed the following physician orders: Citalopram hydrobromide (antidepressant) tablet 10 milligrams (mg) give 10 mg by mouth at bedtime for increase in anxiety dated 09/19/22. R6's clincial record alcked evidence of a gradual dose reduction attempt or physician docuemtnation of the rational for continued use of antidepressant medication with no gradual reduction. Observation on 10/17/23 at 09:10 AM R6 laid on her bed with her bilateral extremities supported with a pillow of the mattress. On 10/18/23 at 01:24 PM Licensed Nurse (LN) G stated she did not review the pharmacy monthly reviews. LN G stated she was not aware of who needed a gradual reduction of psychotropic medication. On 10/18/23 at 02:03 PM Administrative Nurse D stated she would continue to search for the physician documentation regarding not attempting a gradual reduction for R6's antidepressant medication. The facility was unable to provide a policy related to psychotropic medication use. The facility failed to provide a physician documented rationale stating why a gradual dose reduction was contraindicated for the continued use of psychotropic medication for R6. This deficient practice placed her at risk for unnecessary psychotropic medication and related complications. - R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and major depressive disorder (major mood disorder which causes persistent feelings pf sadness). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. No staff interview was completed. The MDS documented that R25 required extensive assistance of two staff members for activities of daily living (ADLs). The MDS documented R25 had received antidepressant medication for seven days for the observation period. The MDS documented no gradual reduction was completed during the observation period for R25. The Quarterly MDS dated [DATE] documented a BIMS score of zero which indicated severely impaired cognition. No staff interview was completed. The MDS documented that R25 required extensive assistance of two staff members for ADLs. The MDS documented R25 had received antidepressant medication for six days and antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) medication for five days during observation period. The MDS documented no physician documentation that a gradual dose reduction was clinically contraindicated. R25's Psychotropic Drug Use Care Area Assessment (CAA) dated 02/01/23 documented R25 received psychotropic medications to manage her behaviors. R25's Care Plan dated 06/25/20 documented staff would follow physician recommendations related to her mood and psychoactive medications. Review of the EMR under Orders tab revealed the following physician orders: Olanzapine (antipsychotic) oral tablet five milligrams (mg) give five mg by mouth daily related to Alzheimer's disease with late onset (needs given in the morning to assist with resident behaviors) dated 07/13/23. Haloperidol (antipsychotic) oral tablet two mg give one tablet by mouth every six hours as needed for agitation related to Alzheimer's disease with late onset for 14 days dated 10/11/23. The facility was unable to provide physician documentation for appropriate indication or documented rationale which included the multiple unsuccessful attempts for nonpharmacological symptoms management and the risk versus benefits for the continued use of olanzapine for R25. Observation on 10/18/23 at 10:15 AM R25 sat in her wheelchair next her in her room. On 10/18/23 at 01:24 PM Licensed Nurse (LN) G stated she did not review the pharmacy monthly reviews. LN G stated she was not aware of who needed a gradual reduction of psychotropic medication if a diagnosis needed to be clarified. LN G stated psychotropic medications should not be given to resident with diagnoses of dementia/Alzheimer's disease. On 10/18/23 at 02:03 PM Administrative Nurse D stated R25 was on hospice services for comfort measures. Administrative Nurse D stated she would continue to search for the physician documentation for the rationale for the use of antipsychotic medication for R25 who had a diagnosis of Alzheimer's disease. lack of a gradual reduction for R6's antidepressant medication. The facility was unable to provide a policy related to psychotropic medication use. The facility failed ensure an appropriate indication or or the required physician for the continued use of antipsychotic medications for R25. This deficient practice placed these residents at risk for unnecessary psychotropic medication and related complications.

The facility identified a census of 31 residents. The sample included 12 residents. One resident, (R) 24, was reviewed for transfer and discharge. Based on record review and interview, the facility failed to provide written notice of discharge to R24's representative and the Ombudsman when R24 was discharged to an acute care facility. Findings included: - The electronic medical record (EMR) for R24 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R24 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. He required limited to extensive assistance of one to two staff for his activities of daily living (ADLs). The ADLs Care Area Assessment (CAA) dated 01/27/22 documented R24 required caregiver assistance with ADLs due to his weakness, the loss of balance, a safety awareness deficit, and a history of falls. R24 required the use of a sit-to-stand lift (an assistive device that allows a patient to be transferred between to places, by using hydraulic power). R24 was able to self-propel his wheelchair with the use of his arms and legs while seated in the wheelchair. The [CONDITION(S)] and chronic [CONDITION(S)] care plan documented R24 required the use of a Foley catheter (a thin flexible tube that is placed in your bladder to drain your urine). The care plan directed staff that R24 had been prescribed multiple medications to treat his [CONDITION(S)] and chronic [CONDITION(S)], and to please administer medications as ordered and monitor for any signs and symptoms of any adverse drug reactions. A Health Status Note on 02/27/22 documented R24 was taken on a gurney via emergency medical services (EMS) to a hospital with transfer paperwork given to the paramedics. A Health Status Note dates 02/27/22 at 08:00PM documented that R24's family member returned a phone call and was notified at that time that R24 had been sent out to the hospital. A Psychosocial Note dated 03/01/22 at 03:01 PM documented R24 remained at the hospital. Updated medical records had been received and no discharge date was available at that time. The facility Nursing Home to Hospital Transfer Form dated 02/27/22 documented the reason for transfer was [CONDITION(S)] (a skin infection caused by bacteria characterized by heat, redness and swelling) and a urinary tract infection ([CONDITION(S)] an infection of any part of the urinary system). The facility Notice of Emergency Transfer/Discharge Form dated 02/27/22 documented that a copy of the facility bed hold policy was proved along with this form. Both forms were sent with the resident upon transfer and discharge. R24 was not available for interview due to hospitalization . On 03/03/22 at 11:55 AM Administrative Nurse E stated that she was not positive if the facility notified the family of a discharge by written notification, but they did notify family by a phone call. She further stated that Administrative Nurse D was responsible for the notification to the families and the ombudsman. On 03/03/22 at 01:33 PM Licensed Nurse (LN) G stated that when a resident was sent to the hospital or transferred to another facility the nurse would typically print out a transfer discharge assessment that was given to the resident on discharge. The nurse would then notify the family/representative that the resident was being transferred outside of the facility. LN G stated she was not aware of any written notification of transfer that was mailed to the resident's representative. On 03/03/22 at 01:51 PM Administrative Nurse D stated that when R24 was transferred to the hospital on 02/27/22 she called the hospital to give a resident report, and notified by phone R24's physician, and family. Administrative Nurse D further stated that no written notification was mailed to the family and she was currently trying to compose an email to notify the families that way. The facility ombudsman had not been notified of any discharges since November 2021. The facility policy Transfer and Discharge of a Resident revised September 2020 documented: 1) Following the transfer, the Director of Nursing (DON), Social Services Designee, Social Worker, or other designee, provide a copy of the completed Notice of Emergency Transfer/Discharge form and Bed Hold Policy and Procedure to the responsible party and Ombudsman. a) This task may be completed the business day following the emergent transfer or discharge. b) This may be done by the way of postal mail, electronic mail, or fax. c) Documentation of the completed Notice and Policy being provided to both the responsible party and the Ombudsman is documented in the medical record. The DON, or designee, will perform an audit of planned and emergent transfers and discharges. Education and re-evaluation of the process will occur as indicated. The facility failed to provide the resident representative and Ombudsman with written notice of discharge as soon as practical when R24 was sent to an emergency acute facility.

The facility identified a census of 31 residents. The sample included 12 residents, with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to implement appropriate interventions aimed at preventing falls for Resident (R) 22, who was identified as a high fall risk. R22 from 10/06/21 to 02/19/22 had seven fall occurrences, which resulted in minor injury five of seven occurrences. This deficient practice placed R22 at risk for injuries related to falls. Findings included: - R22's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), and repeated falls. The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R22 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R22 fell two to six months prior to admission. The MDS documented R22 was a high fall risk, he had two non-injury falls and one fall with injury since admission. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated impaired cognition. The MDS documented that R22 required limited assistance of one staff member for ADL's. The MDS documented two or more injury falls since admission to the facility. R22's Falls Care Area Assessment (CAA) dated 10/18/21 documented history of repeated falls, staff assisted with ADL's as needed and followed facility fall protocol. Physical Therapy (PT) and Occupational Therapy (OT) evaluated and treated and staff would follow interventions as determined by the Interdisciplinary Team (IDT). R22's Care Plan dated 10/07/21 directed staff to follow the facility fall protocol, was on PT/OT and staff was to follow therapy recommendations. The Care Plan dated 10/26/21 documented R22 would be assessed by therapy for toilet transfers. The Care Plan revised 10/28/21 documented cane was removed and replaced with walker to assist in mobility. The Care Plan dated 01/29/22 documented a reacher/grabber stick was provided to R22 to access items dropped on to the floor. The Care Plan revised 02/17/22 documented non-skid strips placed on bathroom floor in front of the toilet. The Care Plan dated 02/19/22 documented staff was to remind R22 to lock the wheelchair brakes when he used the wheelchair for mobility. Review of the EMR under Progress Notes documented: On 10/26/21 at 08:02 AM R22 was found on the floor in the bathroom at 06:10 AM. Staff reported he was on the toilet at rounds and was reminded to use the call light to call for assistance when finished. When staff returned R22 was found on the floor. R22 was wearing socks, a brief with both lower extremities in one opening of the brief. A 2 centimeter (cm) skin tear was noted on right forearm/elbow area. R22 reported to staff he had pulled the toilet handle and toilet riser tipped forward. On 01/29/22 at 05:01 PM R22 was found sitting on the floor. There was several incontinent briefs scattered on the floor. A skin tear was noted on his right arm. On 1/31/2022 at 04:00 AM R22 was found on the floor in the bathroom, 1 cm by 1.8 cm skin tear noted on his left elbow. R22 reported he slid to the floor as he had stood up from the toilet. R22 was not wearing shoes or nonskid socks. Review of the fall investigations documented IDT interventions: On 10/26/21 toilet riser was changed. On 1/29/22 R22 was supplied with a reacher/grab stick On 1/31/22 non-skid strips were applied to the bathroom floor in front of the toilet. On 03/01/22 at 04:18 PM R22 sat in recliner in room, eyes closed. No non-skid strips or stool riser noted in bathroom. 03/02/22 at 01:33 PM R22 laid on his bed. He was unable to locate his reacher/grab stick when asked. No non skid strips or stool riser noted in the bathroom. On 03/03/22 at 01:28 PM in an interview, Certified Nurses Aide (CNA) M stated she would notify the nurse of any falls, after making sure the resident was safe. CNA M stated they filled out a sheet of questions to assist in the investigation of the fall. CNA M stated that when a new intervention was added to the care plan, staff are notified by in-service sheets. CNA M stated R22's interventions were check on him frequently and encourage him to use the call light for assistance. On 03/03/22 at 01:38PM in an interview, Licensed Nurse (LN) G stated after fall assessment completed, interventions are determined, and care planned by the IDT. LN G stated the nurses can update the care plan, but the Director of Nursing (DON) preferred to care plan the interventions. LN G stated interventions for R22's falls consisted of a PT consult. On 03/03/22 at 01:55 PM in an interview, Administrative Nurse D stated all fall are reviewed by the IDT and she was responsible for care plan updates. Administrative Nurse D stated nursing staff were responsible to make sure care planned interventions were in place for the residents. The facility Fall Management policy dated 04/18 documented interventions are determined by the IDT throughout the investigation process and the resident's plan of care is revised. The facility failed to ensure the interventions determined by the IDT to be helpful in preventing future falls for R22 were implemented by the staff and added to the care plan to assist in preventing possible major injury from falls.

The facility identified a census of 31 residents. The sample included 12 residents with two residents reviewed for activities of daily living (ADLs) care. Based on observations, record reviews, and interviews, the facility failed to follow Resident (R) 28's toileting schedule resulting in increased episodes of overnight incontinence. This deficient practice placed the resident at risk for increased incontinence, impaired psychosocial well-being, and skin breakdown. Findings include- - The Electronic Medical Record (EMR) indicated the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R28's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R28's MDS indicated she requires extensive assist from one staff member. She also had episodes of occasional incontinence. R28's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 08/08/21 indicated she needed assistance with one staff member for her ADL's related to lack of coordination, muscle weakness, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R28's Care Plan revised 07/30/21 instructed staff to follow her individualized toileting program and wake her up each night between 01:00 AM and 01:30 AM to allow R28 to void to prevent overnight urinary incontinence. A review of R28's ADL Look Back reported between 10/01/2022 through 03/02/2022 indicated no documentation showing that R28 had been given a voiding opportunity around the designated time resulting in the resident having incontinent episodes on 56 occasions. (10/1, 10/2, 10/6, 10/7, 10/8, 10/10, 10/12, 10/14, 10/15, 10/17, 10/20. 10/23, 11/8, 11/11, 11/12, 11/14, 11/16, 11/17, 11/18, 11/25, 11/27, 11/28, 12/2, 12/3, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10, 12/12, 12/14, 12/16, 12/17, 12/18, 12,19, 12/31, 1/2, 1/4, 1/5 1/10, 1/19, 1/25, 2/1, 2/3, 2/5, 2/8, 2/9, 2/11, 2/12, 2/14, 2/15, 2/18, 2/23, 2/24, 2/25). A review of R28's Care Tasks under Barrier Cream Application instructed that staff are to apply barrier cream after each episode of incontinence or toileting episode. The reviewed report between 10/01/2022 through 03/02/2022 indicated that the barrier cream was not applied on 47 occasions during the reviewed timeframe. A review of R28's Medication Administration Review (MAR) noted she received [MEDICATION(S)] lotion (medication used to reduce itching) related to incontinence associate [CONDITION(S)] located on both inner thighs, buttocks, and groin area as need for rash and inching. A review of R28's Skin Assessment Progress Note dated 11/17/21 at 03:52 PM reported that R28 notified staff that incontinence care for the last few days had been deficient. The note stated that the facilitiy's leadership staff had been notified for correct follow-up care. An interview on 03/01/22 at 10:00 AM with R28 stated that she is happy with her care at the facility except for some on the night staff were not completing her toileting care as they should. She stated staff did not always wake here up for her restroom break and did not clean here up well afterwards when she was incontinent. An interview on 03/03/22 at 12:34 PM with Certified Nurse Aid (CNA) M stated each resident's care plan was reviewed and accessible for staff. The CNAs completed the toileting tasks with the residents and then reported to the nurses. CNA M stated residents that are incontinent may be on a voiding program and the CNAs should get specific instructions about the program in the resident's care plan. An interview on 03/03/2022 at 13:30 PM with Administrative Nurse D stated that the care plans were reviewed by staff upon completion or updated. She reported staff should be following the care plan and waking up R28 based upon her toileting plan. A review of the facility's Urinary Incontinence Program policy revised 04/2018 stated that when an individualized toileting program is established the program may include prompted voiding, scheduled toileting, and bladder re-training. The policy indicated that residents should be re-evaluated periodically for changes in voiding patterns and adjustments of interventions if needed. The facility failed to follow R28's scheduled toileting schedule resulting in increased episodes of overnight incontinence. This deficient practice placed the resident at risk for at risk for increased incontinence, impaired psychosocial well-being, and skin breakdown.

The facility identified a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program for the residents of the facility. Findings included: - Review of Resident (R) 4's Electronic Medical Record (EMR) documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R4's EMR documented under Progress Notes revealed a phone call on 09/22/21 from the physician's office reported R4 had a [CONDITION(S)], and gave a new order for [MEDICATION(S)] (antibiotic used to treat bacterial infections) 500 mg by mouth daily for three days. Review of the lab report dated 11/10/21 for urinalysis (UA-examination of urine) for R4 and culture and sensitivity (C&S) dated 11/12/21 revealed organism growth of E -Cloacae. C&S report documented [MEDICATION(S)] (antibiotic used to treat bacterial infections) 100 mg was ordered for five days for [CONDITION(S)] starting 11/10/21. C&S documented organism susceptible to [MEDICATION(S)]. Review of the lab report dated 12/06/21 for UA and C&S dated 12/08/21 for R4 revealed organism growth of E - Cloacae. [MEDICATION(S)] 100 mg give by mouth twice daily was ordered for [CONDITION(S)] for seven days started 12/07/21 and was discontinued 12/09/21. C&S revealed infection was resistant to [MEDICATION(S)] and susceptible to [MEDICATION(S)] (a combination of two antibiotics used to treat a wide variety of bacterial infections). [MEDICATION(S)] 800-160 mg, give twice a day for seven days for [CONDITION(S)], was started on 12/09/21. Review of the lab report dated 02/10/22 for UA and C&S report dated 02/12/22 revealed organism growth of E - Cloacae. [MEDICATION(S)] 800-160 mg give twice daily was ordered for seven days related to [CONDITION(S)] started on 02/10/22. R4's clincial record lacked evidence of signs and symptoms which met porfessionally accepted criteria for testing and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/03/22 Administrative Nurse E, identified as certified Infection Preventionist (IP) and Administrative Nurse F, identified as the backup certified IP, were both unavailable for interview. On 03/03/22 at 01:38 PM in an interview, Licensed Nurse (LN) G stated residents on antibiotic therapy were assessed and charted on daily and 72 hours post antibiotic therapy. LN G stated that residents who received prophylactic antibiotic therapy received no special monitoring. On 03/03/22 at 01:55 PM in an interview, Administrative Nurse D stated she monitored the infection control log monthly and submitted the information to the quality assurance committee. Administrative Nurse D stated the facility did not follow a professionally accepted set of criteria or protocol for identification of, obtaining and treating UA's and C&S results before starting antibiotic therapy for R4 due to her history of chronic infections. The facility Executive Administrative Statement of Support for the F.W. [NAME] Medical Center Antimicrobial Stewardship Program policy dated 05/29/18 documented the antimicrobial stewardship program will strive to improve patient outcomes and reduce rates of healthcare-acquired infections and antimicrobial overuse. The facility Antibiotic Stewardship Program policy dated 06/2018 documented the facility would promote appropriate use of antibiotics while optimizing the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility would review and monitor antibiotic usage patterns monthly. Utilize tools to improve the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection. Appropriate test such as a culture was obtained before ordering an antibiotic The facility failed to implement the core components of antibiotic stewardship program to promote correct use of antibiotics or prevent incorrect or unnecessary antibiotic use. This practice could potentially put the residents at risk for worsening infection and antibiotic resistance.

The facility identified a census of 26 residents with 7 residents sampled. Based on observation, interview, and record review the facility failed to provide adequate supervision to protect the (gender) residents from resident-to-resident sexual abuse from resident #11, which placed 19 (gender) residents in immediate jeopardy. Findings included: - The admission Minimum Data Set Assessment (MDS) for resident #11, dated 8/19/15 recorded the resident with a BIMS of 7, which indicated severe cognitive impairment. The resident required supervision and set up with all activities of daily living, exhibited steady balance, and used a walker for ambulation. The Care Area Assessment (CAA) dated 8/29/15 for cognition recorded the resident ' s BIMS score of 7 and [DIAGNOSES REDACTED]. The resident wandered daily and almost continually while awake. During the review period, staff documented daily wandering on the behavior flow sheets. The nurse ' s notes recorded the resident exhibited sexually inappropriate behaviors. The CAA for behaviors dated 8/29/15 documented the resident wandered throughout facility all day while awake, exit seeking. Staff documented sexually inappropriate behaviors in the nurses ' notes with a recent history of hypersexual phases. During this review period, nursing staff met with the resident ' s family and discussed transferring him/her to senior behavioral health for medication review due to increased behaviors. Review of the interim plan of care dated 8/10/15 recorded the resident was cognitively impaired, hearing impaired, wore hearing aids, and did not understand the staff. The resident transferred with an assistive device, and independent with ambulation and locomotion. The interim plan of care lacked any interventions to direct staff for resident behaviors. The physician admission history and physical dated 8/10/15 documented the physician changed the resident ' s Depo-[MEDICATION NAME] from 75 milligrams every 2 weeks to 150 milligrams intramuscularly every month, due for another injection tomorrow. The resident tends to take off all his/her clothing at times during the day. The resident was oriented to person only. The resident continued with rapidly progressive cognitive loss from dementia over the past 18 months and appears to have progressed possibly from his/her recent hypersexual phase. Review of the physician admission orders [REDACTED]. The clinical record lacked documentation of follow up with the physician regarding an order for [REDACTED].>Nursing note on 8/11/15 at 9:39 A.M. documented the resident was alert, confused, and wandered. Nursing note dated 8/11/15 timed 4:01 P.M. recorded staff administered the medication [MEDICATION NAME] 0.5 milligrams for the resident ' s anxiety. Nursing note dated 8/11/15 at 9:39 P.M. documented the resident alert, confused, and wandered most of the evening, often without his/her walker. Nursing note date 8/13/15 at 3:29 A.M. recorded the resident wandered from door to door, chair to chair, and hall to hall until approximately 9:30 P.M. The resident went to sleep for approximately 15 minutes. Staff had redirected the resident back to his/her room and helped to bed several times. Nursing note dated 8/14/15 at 8:07 P.M. recorded staff notified the physician of wandering behaviors and increased anxiety. The physician ordered the medication [MEDICATION NAME] (an antipsychotic medication) 25 milligrams orally to be administered once. Nursing note dated 8/16/15 at 10:33 P.M. documented a staff member found the resident in a (gender) resident ' s room touching the (gender) resident ' s breasts. Staff redirected the resident after some resistance, and then notified the director of nursing and physician. The clinical record lacked any interventions to protect the (gender) residents in the facility. The physician response to a facsimile dated 8/16/15 at 10:42 pm, ordered to restart Depo-[MEDICATION NAME] 150 milligrams intramuscularly every 2 weeks for sexual impulse disorder. Review of the facility provided investigation dated 8/20/15, (for the 8/16/15 10:30 P.M. incident) documented direct care staff P observed the resident in resident #13 ' s room touching the resident ' s breasts and redirected resident #11 from the room. The facility investigation documented the plan to continue hourly visual checks on resident #11, monitor effectiveness of medication changes, allow the resident to wander, and redirect as necessary. Nursing note dated 8/17/15 at 5:21 P.M. documented staff administered the physician ordered Depo-[MEDICATION NAME] injection. Nursing notes dated 8/18/15 at 12:41 A.M. staff found the resident up walking around in his/her room naked at 12:15 A.M. Nursing notes dated 8/20/15 at 8:29 A.M., recorded the resident experienced a very rough evening and night, confused and delusional, with nonstop pacing and exit seeking. The resident pushed his/her walker very fast with an urgent concern look on his/her face. The resident was unable to sit still, diaphoretic (excess sweating) and becoming tired and unsteady on feet. Unable to verbalize what he/she was trying to do. The resident ' s behavior had not slowed down or changed and night shift reported the resident did not sleep well and was up and down all night. Nursing staff notified the resident ' s physician about the resident ' s behaviors. Nursing notes dated 8/20/15 timed 2:00 P.M. documented a physician order [REDACTED]. Nursing staff would continue to monitor until the Psychiatrist saw the resident on Monday, 8/24/15. Nursing notes dated 8/20/15 at 3:03 P.M. documented throughout the afternoon, the resident continued to go to all doors. The staff continued to redirect the resident with minimal results. Social notes dated 8/20/15 at 4:31 P.M. documented calls to behavioral health units. Staff anticipated a transfer to a behavioral unit on 8/21/15. Nursing note dated 8/21/15 at 1:19 A.M. documented staff found the resident exiting out of a (gender) peers (resident #17) room and redirected the resident back to his/her room. When asked, resident #17, reported resident #11 walked in and touched his/her shoulder, and he/she yelled at him/her to leave, and he/she left the room. Staff reminded the resident that he/she cannot go into another resident ' s room. Nursing staff sent a facsimile to the physician and notified the director of nursing. The clinical record lacked any additional interventions to protect the (gender) residents in the facility. Review of the incomplete facility investigation dated 8/21/15 documented a licensed nursing staff witnessed the resident leaving resident #17 ' s room and shutting the door. Resident #17 reported resident #11 touched him/her on the shoulder and he/she was startled and yelled out in fright. Resident #17 stated, (He/she) scared me. Staff redirected the resident back to his/her room across the hallway from resident #17. Nursing note dated 8/21/15 at 1:21 A.M., documented staff would place the resident on 15-minute checks to make sure he/she did not enter another peers ' room. The clinical record lacked evidence of any 15-minute checks. Nursing note dated 8/21/15 timed 1:39 P.M. documented the facility transferred the resident to an acute hospital behavior unit. Observation on 9/17/15 at 1:40 P.M. revealed the cognitively impaired resident #13 seated in a reclined Broda chair. The resident was nonverbal, unable to converse, and totally dependent on staff for all activities of daily living. During an interview on 9/17/15 at 3:50 P.M. administrative nursing staff D reported the night of the incident between resident #11 and resident #13, nursing staff increased his/her hourly checks to 15-minute checks. The next morning, since his/her behaviors had dissipated, staff stopped the frequent checks, back to hourly as the resident continued wandering. The licensed charge nurse monitored the resident hourly. Administrative nursing staff D revealed staff did not place the resident on one to one observations after the resident-to-resident sexual advances. On 9/17/15 at 4:47 P.M. administrative nursing staff D reported, nursing staff did not increase monitoring the resident to 15-minute checks and there was no documentation of any 15-minute checks during the resident ' s admission. On 9/18/15 at 12:35 P.M. licensed nursing staff G revealed the resident walked independently with a walker, had a lot of anxiety, required cueing and staff monitored the resident ' s location hourly due to the fall and elopement risk. On 9/18/15 at 1:20 P.M. direct care staff Q reported the resident was confused, ambulated independently with a walker and went in and out of resident rooms. Direct care staff Q revealed when the facility readmitted the resident, he/she was placed on a different hall from the first admission, which seemed to confuse the resident. On 9/18/15 at 1:40 P.M. direct care staff N reported the resident was an elopement risk, wandered all the time, and would go in and out of other resident rooms. Direct care staff N revealed only one resident on C-hall (resident #13 ' s hall) was cognitively able to complain or report any abuse. During an interview on 9/18/15 at 3:05 pm, resident #17 reported he/she only had one problem at the facility. It was the night someone came into his/her room. It startled me and scared me. On 9/21/15 at 1:15 P.M. direct care staff O reported the resident wandered in the facility and forgot to use the assistive walker when he/she became anxious, about half the time. The resident wandered in and out of others rooms. The facility provided policy Abuse, Neglect, and Exploitation Policy and Procedure dated 8/2012 directed that all persons within the facility have the right to be free from abuse. Sexual abuse included sexual harassment, sexual coercion, or sexual assault. Protection was provided to the resident or patient during the investigation of the alleged abuse. The facility provided policy Resident-to-Resident Altercations dated December 2007 documented all altercations, including those that may represent resident-to-resident abuse were investigated and reported to the nursing supervisor, the director of nursing services, and the administrator. The facility staff monitored residents for aggressive/inappropriate behavior towards other residents. If two residents were involved in an altercation, staff would separate the residents and institute measures to calm the situation. The facility failed to protect the residents in the facility from resident #11 ' s sexual advances, identified with [MEDICAL CONDITION], when the staff failed to provide adequate supervision to protect the (gender) residents in the facility from unwelcomed sexual advances on 8/16/15, with resident #13, a cognitively impaired dependent resident, and on 8/21/15, resident #17, identified as alert and oriented, which placed the (gender) residents in the facility in immediate jeopardy. The facility corrected the deficiency on 8/21/15 when the resident transferred out of the facility to a behavior unit. The facility abated the immediate jeopardy on 9/24/15 when they did all staff training at 2:00 P.M. when: The facility would ensure the safety of all residents from the aggressor: 1. Consult the PCP (primary care physician), DON (director of nursing), and family regarding incident and behaviors. 2. Assess the aggressor ' s behavior for up to 72 hours along with any contributing factors for behavior. 3. Consult mental health regarding aggressor. 4. Monitor the aggressor by making them a one on one until transfer or behaviors subside. 5. Update the care plan per physician's order [REDACTED]. The facility would ensure the safety of the resident who was the recipient of inappropriate behaviors: 6. Full body assessment with vital signs and verbal interview of occurrence. 7. Offer emotional support to resident per their preference. 8. Contact family, PCP, DON, and update care plan per physician's order [REDACTED]. 9. Re-evaluate and monitor residents for emotional distress. 10. The policy will be in effect immediately and staff will be educated by read and sign through the weekend. 11. Staff would be educated daily in person on new policy up to 9/24/15, when All Staff meeting occurs. All staff will be trained in person that day. 12. Yearly education would be provided. 13. The policy would be provided in New Employee Orientation Packet and reviewed at annual ANE (abuse, neglect, and exploitation) training. This deficient practice remains at the scope and severity of a E.

The facility identified a census of 26 residents. Based on observation, interview, and record review the facility failed to provide necessary care and services during transfers to prevent an avoidable fractured leg for 1 (#10) of 6 cognitively impaired dependent residents reviewed for falls. Findings included: - The facility electronic health records documented resident #10 with [DIAGNOSES REDACTED]. The significant change Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) of 00, which indicated severe cognitive impairment. The resident exhibited verbal and physical behaviors that significantly interfered with participation in activities or socialization. The resident required extensive assistance of two or more staff for bed mobility, transfers, dressing, and toileting, exhibited unsteady balance and only able to stabilize with assistance from staff, and used a wheelchair for mobility. The Care Area Assessment (CAAs) dated 5/9/15 documented the resident experienced a fall on 4/8/15 that resulted in a cervical spine (neck) fracture. The completed mobility assessments dated 4/15/15 and 7/18/15, recorded the resident required staff assistance with a sit to stand lift for transfers. The quarterly MDS dated [DATE] documented the resident with a BIMS score of 2, which indicaed severe cognitive impairment. He/she required extensive assistance of two staff for transfers, and experienced a non-injury fall since the previous assessment. The fall assessment dated [DATE] documented the resident with a score of (55), which recorded the resident was a high risk for falls. Review of the plan of care dated 1/5/15 recorded the resident with limited physical mobility related to the disease process and dementia with behavioral disturbance. The care plan directed the resident was totally dependent on two staff members for transfers. Staff used the sit-to-stand (Sera Life) for transfers, during toileting, and periods of agitation. The resident required two staff and a gait belt (belt used to help transfer a person from one place to another) to walk a few steps or pivot transfer dependent upon the resident ' s physical ability. Staff used the sit-to-stand lift when the resident was unable to pivot with staff for safety. Intervention added on 8/28/15 directed staff to ensure the ankle brace was in place except when the resident was sleeping. Nursing note dated 8/16/15 timed 9:28 P.M. documented one staff transferred the resident from the recliner to a wheelchair when the resident said Ouch, my ankle. The resident favored his/her right ankle, and would not place the foot on the floor or use it. Nursing staff assessed the resident ' s ankle symmetrical with the left ankle, no bruising, swelling or abnormality was noted. The resident complained of pain and staff administered a physician prescribed pain medication to the resident for pain. Nursing note dated 8/17/15 timed 11:36 A.M., recorded a facsimile sent to the resident ' s physician documenting right ankle pain. The resident reported, it feels like it ' s broken . The results of the physician ordered right ankle x-ray on 8/18/15 at 10:34 A.M. documented findings of an oblique (slanting) fracture (broken bone) to the right distal fibula (one of the two bones of the lower leg) with moderate amount of lateral ankle soft tissue [MEDICAL CONDITION] (swelling). On 8/18/15 at 10:24 P.M. physician orders [REDACTED]. Review of the August 2015 Medication Administration Record [REDACTED].M., 8/20/15 at 4:51 P.M. and 8/21 at 1:50 P.M. The medication record documented the resident received scheduled Tylenol extra strength 500 milligrams three times daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M. The facility provided investigation dated 8/24/15 documented direct care staff P failed to use a gait belt when he/she transferred the resident from a wheelchair to a stationary chair, and used a one to one pivot transfer. The facility staff member failed to transfer the resident with two staff members as care planned. A statement 8/20/15, recorded direct care staff transferred the resident from a wheelchair to a stationary chair, when the resident yelped out in pain. A statement on 8/21/15, documented licensed nursing staff J heard the resident say ouch, my ankle when transferred by direct care staff P. The resident began favoring the right ankle and not placing it on floor or using it. Licensed nursing staff J assessed the resident, found the right ankle to be symmetrical with left ankle, no bruising or swelling. The resident complained of pain and staff administered physician ordered pain medication, notified the responsible party and the director of nursing. Observation on 9/17/15 at 1:30 P.M. revealed the resident moved about in the facility in a lightweight wheelchair and immobilizer on the right ankle. On 9/21/15 at 3:00 P.M. observation revealed direct care staff L and M pushed the resident in the wheelchair to the hall bathroom and then transferred the resident to toilet, using the sit-to-stand lift mechanical lift. During an interview on 9/18/15 at 10:40 A.M. administrative nursing staff D reported staff administered physician ordered pain medication to the resident initially after the incident for his/her complaint of pain. The next morning after the incident, staff notified the resident ' s physician when the resident ' s ankle revealed bruising, swelling, and he/she complained of pain. On 9/18/15 at 12:25 P.M., licensed nursing staff G reported the resident required two staff for transfers with the sit-to-stand mechanical lift. On 9/18/15 at 1:40 P.M. direct care staff N reported two staff transferred the resident with the sit-to-stand mechanical lift both before after his/her ankle fracture. On 9/21/15 at 10:10 A.M. administrative nursing staff D revealed direct care staff P was suspended for not using a gait belt and unsafe transfer of the resident and remained on suspension. On 9/21/15 at 1:15 P.M. direct care staff O reported two staff always transfer the resident with a gait belt and pivot and watch the direction of his/her feet. Two staff also transferred the resident with the mechanical sit-to-stand lift when feeling weaker. The facility policy Abuse, Neglect, and Exploitation dated 8/2012, recorded the definition of Neglect, as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness and to ensure safety and well-being, or the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder. The Gait Belts Policy dated 6/2009 recorded gait belts were used to aid in transferring and ambulating all patients on fall precautions. All personnel were issued a gait belt for use in assisting appropriate residents and should have the gait belt with them at all times when on duty. The undated policy Minimal lift/safe patient handling and transfers policy recorded all patients were assessed upon admission and as needed for the appropriate and approved method of transfer based on the safe patient handling and transfers algorithm. Residents were transferred per the recommendation of this algorithm. The facility failed to provide safe transfers for this cognitively impaired dependent resident as care planned and resulted in an avoidable injury of a fractured right leg.

2 The facility identified a census of 26 residents with 7 residents sampled. Based on observation, interview, and record review the facility failed to provide adequate supervision to protect the (gender) residents from resident-to-resident sexual abuse from resident #11, which placed 19 (gender) residents in immediate jeopardy. Findings included: - The admission Minimum Data Set Assessment (MDS) for resident #11, dated 8/19/15 recorded the resident with a BIMS of 7, which indicated severe cognitive impairment. The resident required supervision and set up with all activities of daily living, exhibited steady balance, and used a walker for ambulation. The Care Area Assessment (CAA) dated 8/29/15 for cognition recorded the resident ' s BIMS score of 7 and [DIAGNOSES REDACTED]. The resident wandered daily and almost continually while awake. During the review period, staff documented daily wandering on the behavior flow sheets. The nurse ' s notes recorded the resident exhibited sexually inappropriate behaviors. The CAA for behaviors dated 8/29/15 documented the resident wandered throughout facility all day while awake, exit seeking. Staff documented sexually inappropriate behaviors in the nurses ' notes with a recent history of hypersexual phases. During this review period, nursing staff met with the resident ' s family and discussed transferring him/her to senior behavioral health for medication review due to increased behaviors. Review of the interim plan of care dated 8/10/15 recorded the resident was cognitively impaired, hearing impaired, wore hearing aids, and did not understand the staff. The resident transferred with an assistive device, and independent with ambulation and locomotion. The interim plan of care lacked any interventions to direct staff for resident behaviors. The physician admission history and physical dated 8/10/15 documented the physician changed the resident ' s Depo-[MEDICATION NAME] from 75 milligrams every 2 weeks to 150 milligrams intramuscularly every month, due for another injection tomorrow. The resident tends to take off all his/her clothing at times during the day. The resident was oriented to person only. The resident continued with rapidly progressive cognitive loss from dementia over the past 18 months and appears to have progressed possibly from his/her recent hypersexual phase. Review of the physician admission orders [REDACTED]. The clinical record lacked documentation of follow up with the physician regarding an order for [REDACTED].>Nursing note on 8/11/15 at 9:39 A.M. documented the resident was alert, confused, and wandered. Nursing note dated 8/11/15 timed 4:01 P.M. recorded staff administered the medication [MEDICATION NAME] 0.5 milligrams for the resident ' s anxiety. Nursing note dated 8/11/15 at 9:39 P.M. documented the resident alert, confused, and wandered most of the evening, often without his/her walker. Nursing note date 8/13/15 at 3:29 A.M. recorded the resident wandered from door to door, chair to chair, and hall to hall until approximately 9:30 P.M. The resident went to sleep for approximately 15 minutes. Staff had redirected the resident back to his/her room and helped to bed several times. Nursing note dated 8/14/15 at 8:07 P.M. recorded staff notified the physician of wandering behaviors and increased anxiety. The physician ordered the medication [MEDICATION NAME] (an antipsychotic medication) 25 milligrams orally to be administered once. Nursing note dated 8/16/15 at 10:33 P.M. documented a staff member found the resident in a (gender) resident ' s room touching the (gender) resident ' s breasts. Staff redirected the resident after some resistance, and then notified the director of nursing and physician. The clinical record lacked any interventions to protect the (gender) residents in the facility. The physician response to a facsimile dated 8/16/15 at 10:42 pm, ordered to restart Depo-[MEDICATION NAME] 150 milligrams intramuscularly every 2 weeks for sexual impulse disorder. Review of the facility provided investigation dated 8/20/15, (for the 8/16/15 10:30 P.M. incident) documented direct care staff P observed the resident in resident #13 ' s room touching the resident ' s breasts and redirected resident #11 from the room. The facility investigation documented the plan to continue hourly visual checks on resident #11, monitor effectiveness of medication changes, allow the resident to wander, and redirect as necessary. Nursing note dated 8/17/15 at 5:21 P.M. documented staff administered the physician ordered Depo-[MEDICATION NAME] injection. Nursing notes dated 8/18/15 at 12:41 A.M. staff found the resident up walking around in his/her room naked at 12:15 A.M. Nursing notes dated 8/20/15 at 8:29 A.M., recorded the resident experienced a very rough evening and night, confused and delusional, with nonstop pacing and exit seeking. The resident pushed his/her walker very fast with an urgent concern look on his/her face. The resident was unable to sit still, diaphoretic (excess sweating) and becoming tired and unsteady on feet. Unable to verbalize what he/she was trying to do. The resident ' s behavior had not slowed down or changed and night shift reported the resident did not sleep well and was up and down all night. Nursing staff notified the resident ' s physician about the resident ' s behaviors. Nursing notes dated 8/20/15 timed 2:00 P.M. documented a physician order [REDACTED]. Nursing staff would continue to monitor until the Psychiatrist saw the resident on Monday, 8/24/15. Nursing notes dated 8/20/15 at 3:03 P.M. documented throughout the afternoon, the resident continued to go to all doors. The staff continued to redirect the resident with minimal results. Social notes dated 8/20/15 at 4:31 P.M. documented calls to behavioral health units. Staff anticipated a transfer to a behavioral unit on 8/21/15. Nursing note dated 8/21/15 at 1:19 A.M. documented staff found the resident exiting out of a (gender) peers (resident #17) room and redirected the resident back to his/her room. When asked, resident #17, reported resident #11 walked in and touched his/her shoulder, and he/she yelled at him/her to leave, and he/she left the room. Staff reminded the resident that he/she cannot go into another resident ' s room. Nursing staff sent a facsimile to the physician and notified the director of nursing. The clinical record lacked any additional interventions to protect the (gender) residents in the facility. Review of the incomplete facility investigation dated 8/21/15 documented a licensed nursing staff witnessed the resident leaving resident #17 ' s room and shutting the door. Resident #17 reported resident #11 touched him/her on the shoulder and he/she was startled and yelled out in fright. Resident #17 stated, (He/she) scared me. Staff redirected the resident back to his/her room across the hallway from resident #17. Nursing note dated 8/21/15 at 1:21 A.M., documented staff would place the resident on 15-minute checks to make sure he/she did not enter another peers ' room. The clinical record lacked evidence of any 15-minute checks. Nursing note dated 8/21/15 timed 1:39 P.M. documented the facility transferred the resident to an acute hospital behavior unit. Observation on 9/17/15 at 1:40 P.M. revealed the cognitively impaired resident #13 seated in a reclined Broda chair. The resident was nonverbal, unable to converse, and totally dependent on staff for all activities of daily living. During an interview on 9/17/15 at 3:50 P.M. administrative nursing staff D reported the night of the incident between resident #11 and resident #13, nursing staff increased his/her hourly checks to 15-minute checks. The next morning, since his/her behaviors had dissipated, staff stopped the frequent checks, back to hourly as the resident continued wandering. The licensed charge nurse monitored the resident hourly. Administrative nursing staff D revealed staff did not place the resident on one to one observations after the resident-to-resident sexual advances. On 9/17/15 at 4:47 P.M. administrative nursing staff D reported, nursing staff did not increase monitoring the resident to 15-minute checks and there was no documentation of any 15-minute checks during the resident ' s admission. On 9/18/15 at 12:35 P.M. licensed nursing staff G revealed the resident walked independently with a walker, had a lot of anxiety, required cueing and staff monitored the resident ' s location hourly due to the fall and elopement risk. On 9/18/15 at 1:20 P.M. direct care staff Q reported the resident was confused, ambulated independently with a walker and went in and out of resident rooms. Direct care staff Q revealed when the facility readmitted the resident, he/she was placed on a different hall from the first admission, which seemed to confuse the resident. On 9/18/15 at 1:40 P.M. direct care staff N reported the resident was an elopement risk, wandered all the time, and would go in and out of other resident rooms. Direct care staff N revealed only one resident on C-hall (resident #13 ' s hall) was cognitively able to complain or report any abuse. During an interview on 9/18/15 at 3:05 pm, resident #17 reported he/she only had one problem at the facility. It was the night someone came into his/her room. It startled me and scared me. On 9/21/15 at 1:15 P.M. direct care staff O reported the resident wandered in the facility and forgot to use the assistive walker when he/she became anxious, about half the time. The resident wandered in and out of others rooms. The facility provided policy Abuse, Neglect, and Exploitation Policy and Procedure dated 8/2012 directed that all persons within the facility have the right to be free from abuse. Sexual abuse included sexual harassment, sexual coercion, or sexual assault. Protection was provided to the resident or patient during the investigation of the alleged abuse. The facility provided policy Resident-to-Resident Altercations dated December 2007 documented all altercations, including those that may represent resident-to-resident abuse were investigated and reported to the nursing supervisor, the director of nursing services, and the administrator. The facility staff monitored residents for aggressive/inappropriate behavior towards other residents. If two residents were involved in an altercation, staff would separate the residents and institute measures to calm the situation. The facility failed to protect the residents in the facility from resident #11 ' s sexual advances, identified with [MEDICAL CONDITION], when the staff failed to provide adequate supervision to protect the (gender) residents in the facility from unwelcomed sexual advances on 8/16/15, with resident #13, a cognitively impaired dependent resident, and on 8/21/15, resident #17, identified as alert and oriented, which placed the (gender) residents in the facility in immediate jeopardy. On 8/21/15 the resident transferred out of the facility to a behavior unit. The facility abated the immediate jeopardy on 9/24/15 when they did all staff training at 2:00 P.M. when: The facility would ensure the safety of all residents from the aggressor: 1. Consult the PCP (primary care physician), DON (director of nursing), and family regarding incident and behaviors. 2. Assess the aggressor ' s behavior for up to 72 hours along with any contributing factors for behavior. 3. Consult mental health regarding aggressor. 4. Monitor the aggressor by making them a one on one until transfer or behaviors subside. 5. Update the care plan per physician's order [REDACTED]. The facility would ensure the safety of the resident who was the recipient of inappropriate behaviors: 6. Full body assessment with vital signs and verbal interview of occurrence. 7. Offer emotional support to resident per their preference. 8. Contact family, PCP, DON, and update care plan per physician's order [REDACTED]. 9. Re-evaluate and monitor residents for emotional distress. 10. The policy will be in effect immediately and staff will be educated by read and sign through the weekend. 11. Staff would be educated daily in person on new policy up to 9/24/15, when All Staff meeting occurs. All staff will be trained in person that day. 12. Yearly education would be provided. 13. The policy would be provided in New Employee Orientation Packet and reviewed at annual ANE (abuse, neglect, and exploitation) training. This deficient practice remains at the scope and severity of a E.

The facility identified a census of 30 residents. Based on observation, interview, and record review the facility failed to provide supervision for 1 of 3 residents sampled for accidents (#2, a cognitively impaired independently mobile resident) failed to provide supervision to prevent resident #2 from exiting the facility without staff knowledge. This placed the Resident #2 in immediate jeopardy. Findings included: - The facility admitted resident #2 on 9/26/13 with [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 00, which identified the resident with severe cognitive impairment. The resident wandered daily, experienced delusions, and required supervision of one staff for locomotion. The resident exhibited unsteady balance, only able to stabilize with staff assistance and experienced two or more non-injury and one minor injury fall since the previous assessment. The Care Area Assessment (CAA) dated 1/31/15 for cognition documented the resident had poor short and long-term memory recall, poor safety awareness and a decreased ability to care for him/herself. The CAA for falls dated 1/31/15 documented the resident with five falls since the previous assessment period. The resident wandered throughout facility in a wheelchair. A physical therapy referral December 2014 recorded the resident was unable to follow commands to participate in therapy at that time. The CAA for behaviors dated 1/31/15 documented the resident wandered daily throughout the facility in a wheelchair and had a personal body alarm on at all times. The facility doors had alarms on at all times. The quarterly Minimum Data Set assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) 2, which indicated severe cognitive impairment, exhibited physical behaviors towards others as well as other behaviors not directed at others and wandering behavior daily. The resident required extensive assist with activities of daily living, unsteady balance, only able to stabilize with staff assistance, used a wheelchair for locomotion, and experienced two or more non-injury falls since the previous assessment. Review of the Elopement Risk Assessments dated 4/17/15 and 7/18/15, documented a score of (11) which indicated a total score of 11 or greater placed the resident at high risk to wander. Review of the comprehensive care plan initiated 9/12/14 and reviewed 5/27/15 identified the resident was an elopement risk and wanderer related to a [DIAGNOSES REDACTED]. The resident was disoriented to place and had a history of [REDACTED]. The care plan directed staff to: *Redirect the resident when seeking to go through exit doors. *Monitor the resident ' s location every 60 minutes. Document wandering behaviors in the wander log. *Identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. An additional intervention added 6/13/15 documented staff replaced all pagers batteries with new ones and tested each one. Staff checked all doors for the sounding alarm. A nursing note dated 4/9/15 timed 4:56 A.M. documented the resident had increased anger/agitation, tried to leave the facility but did not know where he/she was going. The resident was running over other residents and staff with his/her wheelchair. Nursing notes dated 5/3/15 at 1:21 P.M., documented the resident wandered in the halls in his/her wheelchair. Nursing note dated 5/4/15 at 3:44 A.M. recorded the resident was up in the evening exit seeking. Nursing note dated 6/4/15 at 4:04 P.M. documented the resident was very anxious and staff administered a PRN (as needed) medication at 3:30 P.M. The resident continued to roll his/her wheelchair up to different doors trying to open doors. One door had a key left in the lock and the resident received a triangle skin tear to the right inner skin fold between first and second finger. Nursing note dated 6/13/2015 at 1:57 P.M. documented at 7:30 A.M. night staff reported the resident was outside on the patio behind the assisted living. Nursing staff went out and brought the resident back inside. Only one pager responded and the staff did not hear the door alarm. The facility investigation documented the pagers were not sounding due to low batteries. Staff checked the door alarm sound and replaced batteries in all pagers. Nursing note dated 6/17/15 at 11:57 A.M. the resident continued to frequent the assisted living unit in search of a way to leave. Nursing note dated 6/25/15 at 5:48 P.M. documented the resident had been exit seeking all morning. Staff administered PRN antianxiety medication for anxious behavior. The resident exited the door on D-hall without staff assistance. Nursing staff brought the resident back inside. The resident continued wandering nonstop into different rooms and unable to slow down and nursing would continue to monitor the resident closely. Review of the facility investigation dated 6/25/15 documented staff observed the resident exit seeking on D-hall five minutes prior his/her elopement. Review of the door monitoring log documented the D-hall door activated at 7:42 A.M. and was reset at 7:49 A.M. The facility investigations included witness statements as follows: A witness statement from direct care staff M reported he/she attempted to redirect the resident from the exit, then left the resident and went to inform the charge nurses. A witness statement from direct care staff N reported possibly hearing a door alarm; however, no page came through to alert staff of an open exterior door. Direct care staff N continued with another resident and when finished went to the nursing station, still hearing an alarm. Direct care staff N identified the D-hall door alarming, opened the door, and found the resident in his/her wheelchair outside in the staff parking lot unattended. A witness statement from licensed nursing staff H recorded the resident left the building without a staff escort and staff observed the resident approximately 5 minutes prior to the elopement. A witness statement from direct care staff T reported he/she did not hear to the alarm sounding until he/she got down the D-hall. The investigation lacked evidence staff checked and ensured the pager system alerted all staff with the door alarm system. Nursing note dated 6/25/15 at 10:50 P.M. (not sure AM or PM) documented staff placed the resident on 15-minute checks. During an interview on 7/24/15 at 2:45 P.M. administrative nursing staff D reported the resident had not been on 15-minute checks. The facility provided hourly elopement location sheets for the resident. The facility lacked documentation of any 15-minute checks. Nursing note dated 6/26/15 at 8:04 P.M. documented the resident wandering continuously and attempted to go out the assisted living door, but was noticed by staff before he/she could set off alarm. Nursing notes on 6/27/15 at 3:24 P.M. recorded the resident continuously traveled up and down hallways pushing at door exits with nonstop exit seeking. The resident always closed the door after getting past the doorway so others cannot see him/her. A social service note dated 7/22/2015 at 10:32 A.M. the resident wheeled his/her wheelchair all through the home on a daily basis and all throughout the day continuously going to the exit doors. The staff helped him and attempt to turn him around and stay inside the building. Observation on 7/16/15 at 10:57 A.M. the resident propelled him/herself towards the assisting living, knocked on the door and attempted to push it open. At 10:59 A.M. the resident propelled in the wheelchair away from the assisted living door. At 11:00 A.M. the resident propelled up to the surveyor and asked, How do you get out of this place? I want to get out of here and get out there on the floor. He then propelled self towards the windows. At 11:05 A.M. the resident propelled towards the assisted living doors and staff redirected the resident to the lobby area. Observation tour of the building exit door alarms on 7/24/15 at 9:30 A.M. to 9:45 A.M. revealed the following doors with alarms not working properly: 9:35 A.M., D-wing door activates when pushed, after approximately. 15 seconds door opens and the test report ?alerts the D-wing door activated. Staff had to reset the alarm with code to silence the alarm. The door alarm continues to sound after closed. 9:43 A.M., C-wing door stuck and required staff to pound on the door several times before it would alarm. 9:45 A.M., B-wing door with double lock and key to exit because of stairs, alarmed okay. During the observation of the door alarms, administrative nursing staff D reported all doors that exit outside the building alarm to all the pagers at the same time. The pagers designate which door alarms by a universal transmit. From 6/11/15 through 7/24/15 staff failed to check all door alarms per the facility door alarm log. Additionally on the logs, the staff made the following notations: On 7/15/15 C-hall door not working properly On 7/17/15 at 9 A.M., C-hall door did not alarm door or pager, maintenance and information technology notified. On 7/18/15 C-hall door did not alarm, or pager, maintenance and information technology aware. On 7/19/15 at 11:55 A.M. C-hall door will not open in 15 seconds. Will not open unless code put in. Alarm goes off if left open extended period and resets without entering code. Called information technology and left message to notify them the dining room door had to be reset to alarm. Observation on 11:05 A.M. administrative nursing staff D activated the second assisted living door with the main assisted living door closed. The overhead sounding door alarm was not heard in the long-term care unit. Observation on 7/24/15 at 11:18 A.M. revealed the resident propelled in the wheelchair toward the assisted living door, opened the door, and entered into the assisted living. At 11:20 A.M. direct care staff S stopped the resident as he/she was shutting the assisted living door, took the resident to the dining room table. Observation on 7/24/15 at 4:00 P.M., the distance from the Assisted living 2 door patio to the highway, was 51 surveyor steps, an approximate 26-inch stride equaled approximately 110 feet. The speed limit on the highway coming into town is 55 miles per hour and goes to 35 miles per hour by the assisted living facility. On 7/24/15 at 4:20 P.M., observation revealed staff redirected the resident from the assisted living hallway door. On 7/24/15 at 5:15 P.M., the resident actively propelled in his/her wheelchair around the dining room and the lobby. During an interview on 7/16/15 at 11:05 A.M. administrative nursing staff D revealed the resident ' s elopement on 6/13/15 happened at a busy time of the morning and the staff did not hear the alarm go off. He/she revealed the alarm board documented that it sounded and that it rang to the pagers but the pagers did not have an audible sound. On 7/24/15 at 11:05 A.M. licensed nursing staff J reported opening any exit door alerts all staff pagers. On 7/24/15 at 11:57 A.M. information technology staff Y reported the computer system at the nursing station can check the status of the door alarms and if a door alarm battery or call light battery was low, can be replaced. Information technology staff Y reported he/she checked the computer every week on Monday morning. On 7/24/15 at 12:00 P.M. direct care staff R reported the resident wandered frequently in the assisted living and did not know the door reset code. Direct care staff R reported any exit door that opened set off all pagers and staff reset the door at the keypad. On 7/24/15 at 12:07 P.M. Housekeeping/maintenance staff X reported the facility lacked a policy for replacement of pager batteries. On 7/24/15 at 12:15 P.M. direct care staff Q revealed the resident was an exit seeker. Direct care staff Q reported there was no way to check the batteries in the pager. If staff was not continuously getting pages, we know the battery needs changed. On 7/24/15 at 12:42 P.M. licensed nursing staff I reported the nurses do elopement checks on the hour for all residents assessed at risk for elopement. Licensed nursing staff I revealed the morning of 6/13/15 another resident was at the door in the dining room wanting out when a staff member came in and said the resident was outside. The resident was in his/her wheelchair right off the patio. The pager did not alarm for the open door or when the code was entered, the pager did not show the reset. After staff brought the resident into the building, batteries in the pagers were changed. Licensed nursing staff I revealed he/she did not know how often to change the pager batteries. The resident traveled around and sometimes will turn around and come back. Nursing staff chased the resident around from door to door that day and kept a good eye on him/her all day. On 7/24/15 at 12:55 P.M. direct care staff P reported on 6/13/15 at approximately 7:15 he/she left his/her home for the 5-minute drive to the facility. Direct care staff P reported when he/she came out of the building, he/she observed the resident in his/her wheelchair off the assisted living patio concrete, stuck in the mud. Direct care staff P reported he/she could not hear the alarm until getting close to the door. Staff carried pagers that alarm all the time. Direct care staff P revealed the resident was very active and exits seeks daily. At night, the resident goes door-to-door exit seeking. Staff checked for the resident about every 15-minute and had found him in at times the evening on the couch in the assisted living. The nurses do the hourly check of the resident ' s location. On 7/24/15 at 2:00 P.M. direct care staff S reported staff monitored the resident and he/she tried to open the doors and heads toward the assisted living. Direct care staff S reported all the pagers sound at the same time with the door alarm. Direct care staff S revealed the charge nurse records the hourly monitoring of the resident and when the batteries get low, nursing staff change them. On 7/24/15 at 2:35 P.M. direct care staff O reported the resident was a fall risk, an exit seeker, however the direct care staff frequently check the resident and the nurse documents the hourly checks. The staff did not perform 15-minute checks on the resident. Direct care staff O reported when working the morning of 6/13/15, the door alarm did not come to the pagers. On 7/24/15 at 3:15 P.M. licensed nursing staff H reported seeing the resident around 6:45 A.M. on 6/13/15. The resident moves around in his/her wheelchair from door to door and in the dining room. The resident did so much exit seeking, staff constantly monitored the resident. The nurses document hourly checks of the resident. When an exit door opens all pagers alert at the same time. Staff recently found the resident out of his/her wheelchair on the floor crawling. The resident had personal alarms and when staff heard the alarm, they run to assist. Review of the facility safety policy lacked evidence to direct staff of routine maintenance of the pagers for the call system. The facility lacked a policy to direct staff in the testing of staff call pagers. The facility provided a policy Elopement Risk Assessment and Safety dated 9/11/14, directed all staff were responsible for monitoring residents, including those at risk for elopement. On 7/24/15 at 3:44 P.M. the facility was notified of immediate jeopardy. The facility failed to provide supervision to prevent the resident from leaving the facility unattended without staff knowledge. This deficient practice placed this cognitively impaired resident at risk for elopement risk, in immediate jeopardy. The facility abated the immediate jeopardy on 7/31/15 when all staff were inserviced when the facility: 1. Appropriately staffed the assisted living with staff assignment sheet to reflect caregiver assigned to the area. The caregiver would carry an appropriate pager to this area, answer all call lights, monitor resident safety, and respond to all door alarms. This was completed by 7/24/15. 2. All pagers will be checked at beginning of each shift by the Charge Nurse. This will be completed by sending a test page from the Home Free System. Charge Nurse will ensure each pager that is assigned received a page. Charge Nurse will document on the new form created for testing pagers. This document will be titled Pager Assignment/Test Sheet form. This will be completed by 7/24/15. 3. Door to enter Assisted Living will be removed to lessen the sound barrier of external door alarms. Motion sensor will be placed temporarily on entry to Assisted Living. This will notify staff of any person entering or exiting the Assisted Living hallway. This will be completed by 7/24/15. 4. 4. On 7/27/15 the Administrator, director of nursing and information technology personnel will research an updated wander guard system or other type of system that is compatible with current alarm/call light system for a more permanent solution. 5. 5. Train current staff on duty of updated changes. Create and read a sign for staff working throughout the weekend. On 7/27/15 director of nursing and quality assurance nurse will hold training huddles each shift for remaining staff. Training to be completed by 7/31/15. The deficient practice remains at the scope and severity of a D

2 The facility identified a census of 26 residents. Based on observation, interview, and record review the facility failed to provide necessary care and services during transfers to prevent an avoidable fractured leg for 1 (#10) of 6 cognitively impaired dependent residents reviewed for falls. Findings included: - The facility electronic health records documented resident #10 with [DIAGNOSES REDACTED]. The significant change Minimum Data Set Assessment ((MDS) dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) of 00, which indicated severe cognitive impairment. The resident exhibited verbal and physical behaviors that significantly interfered with participation in activities or socialization. The resident required extensive assistance of two or more staff for bed mobility, transfers, dressing, and toileting, exhibited unsteady balance and only able to stabilize with assistance from staff, and used a wheelchair for mobility. The Care Area Assessment (CAAs) dated 5/9/15 documented the resident experienced a fall on 4/8/15 that resulted in a cervical spine (neck) fracture. The completed mobility assessments dated 4/15/15 and 7/18/15, recorded the resident required staff assistance with a sit to stand lift for transfers. The quarterly MDS dated [DATE] documented the resident with a BIMS score of 2, which indicaed severe cognitive impairment. He/she required extensive assistance of two staff for transfers, and experienced a non-injury fall since the previous assessment. The fall assessment dated [DATE] documented the resident with a score of (55), which recorded the resident was a high risk for falls. Review of the plan of care dated 1/5/15 recorded the resident with limited physical mobility related to the disease process and dementia with behavioral disturbance. The care plan directed the resident was totally dependent on two staff members for transfers. Staff used the sit-to-stand (Sera Life) for transfers, during toileting, and periods of agitation. The resident required two staff and a gait belt (belt used to help transfer a person from one place to another) to walk a few steps or pivot transfer dependent upon the resident ' s physical ability. Staff used the sit-to-stand lift when the resident was unable to pivot with staff for safety. Intervention added on 8/28/15 directed staff to ensure the ankle brace was in place except when the resident was sleeping. Nursing note dated 8/16/15 timed 9:28 P.M. documented one staff transferred the resident from the recliner to a wheelchair when the resident said Ouch, my ankle. The resident favored his/her right ankle, and would not place the foot on the floor or use it. Nursing staff assessed the resident ' s ankle symmetrical with the left ankle, no bruising, swelling or abnormality was noted. The resident complained of pain and staff administered a physician prescribed pain medication to the resident for pain. Nursing note dated 8/17/15 timed 11:36 A.M., recorded a facsimile sent to the resident ' s physician documenting right ankle pain. The resident reported, it feels like it ' s broken . The results of the physician ordered right ankle x-ray on 8/18/15 at 10:34 A.M. documented findings of an oblique (slanting) fracture (broken bone) to the right distal fibula (one of the two bones of the lower leg) with moderate amount of lateral ankle soft tissue [MEDICAL CONDITION] (swelling). On 8/18/15 at 10:24 P.M. physician orders [REDACTED]. Review of the August 2015 Medication Administration Record [REDACTED].M., 8/20/15 at 4:51 P.M. and 8/21 at 1:50 P.M. The medication record documented the resident received scheduled Tylenol extra strength 500 milligrams three times daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M. The facility provided investigation dated 8/24/15 documented direct care staff P failed to use a gait belt when he/she transferred the resident from a wheelchair to a stationary chair, and used a one to one pivot transfer. The facility staff member failed to transfer the resident with two staff members as care planned. A statement 8/20/15, recorded direct care staff transferred the resident from a wheelchair to a stationary chair, when the resident yelped out in pain. A statement on 8/21/15, documented licensed nursing staff J heard the resident say ouch, my ankle when transferred by direct care staff P. The resident began favoring the right ankle and not placing it on floor or using it. Licensed nursing staff J assessed the resident, found the right ankle to be symmetrical with left ankle, no bruising or swelling. The resident complained of pain and staff administered physician ordered pain medication, notified the responsible party and the director of nursing. Observation on 9/17/15 at 1:30 P.M. revealed the resident moved about in the facility in a lightweight wheelchair and immobilizer on the right ankle. On 9/21/15 at 3:00 P.M. observation revealed direct care staff L and M pushed the resident in the wheelchair to the hall bathroom and then transferred the resident to toilet, using the sit-to-stand lift mechanical lift. During an interview on 9/18/15 at 10:40 A.M. administrative nursing staff D reported staff administered physician ordered pain medication to the resident initially after the incident for his/her complaint of pain. The next morning after the incident, staff notified the resident ' s physician when the resident ' s ankle revealed bruising, swelling, and he/she complained of pain. On 9/18/15 at 12:25 P.M., licensed nursing staff G reported the resident required two staff for transfers with the sit-to-stand mechanical lift. On 9/18/15 at 1:40 P.M. direct care staff N reported two staff transferred the resident with the sit-to-stand mechanical lift both before after his/her ankle fracture. On 9/21/15 at 10:10 A.M. administrative nursing staff D revealed direct care staff P was suspended for not using a gait belt and unsafe transfer of the resident and remained on suspension. On 9/21/15 at 1:15 P.M. direct care staff O reported two staff always transfer the resident with a gait belt and pivot and watch the direction of his/her feet. Two staff also transferred the resident with the mechanical sit-to-stand lift when feeling weaker. The facility policy Abuse, Neglect, and Exploitation dated 8/2012, recorded the definition of Neglect, as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness and to ensure safety and well-being, or the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder. The Gait Belts Policy dated 6/2009 recorded gait belts were used to aid in transferring and ambulating all patients on fall precautions. All personnel were issued a gait belt for use in assisting appropriate residents and should have the gait belt with them at all times when on duty. The undated policy Minimal lift/safe patient handling and transfers policy recorded all patients were assessed upon admission and as needed for the appropriate and approved method of transfer based on the safe patient handling and transfers algorithm. Residents were transferred per the recommendation of this algorithm. The facility failed to provide safe transfers for this cognitively impaired dependent resident as care planned and resulted in an avoidable injury of a fractured right leg.

The facility identified a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to develop and implement tinely and appropriate interventions to promote healing and prevent new or worsening of pressure sores for 1 (#7) of 1 resident sampled with pressure ulcers. the facility also failed to have a skin care plan in place for 17 days when he/she admitted to the facility with multiple wounds. The resident developed additional unstageable wounds after admission. Findings included: - The admission Minimum Data Set ((MDS) dated [DATE] for resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. He/she required extensive assistance from 2 or more staff for bed mobility, dressing, toilet use, and personal hygiene. The resident was dependent on staff for transferring and bathing. He/she had a prognosis of 6 months or less and had 5 stage 1 pressure ulcers, 1 stage 2 pressure ulcer, 1 stage 3 pressure ulcer, 1 stage 4 pressure ulcer, and 4 unstageable pressure ulcers. The 1/9/15 Care Area Assessment (CAA) regarding cognitive loss and dementia (progressive mental disorder characterized by failing memory, confusion) revealed the resident had a [DIAGNOSES REDACTED]. The 1/9/15 CAA regarding nutrition revealed the resident had extensive skin issues and staff were going to refer him/her to the dietitian to determine if hydration and/or supplements could improve his/her skin condition. The 1/9/15 CAA regarding pressure ulcers revealed assessment of the resident's skin reflected 12 skin issues ranging from stage 1 to unstageable. Staff provided a pressure relieving mattress. Due to the resident being on hospice, staff predicted a gradual decline in condition but planned to minimize risks and not increase the severity of his/her wounds. The interim care plan dated 12/29/14 revealed the resident had impaired skin integrity but lacked interventions. The comprehensive care plan with a revision date of 1/15/15 revealed the resident had actual impairment to skin integrity related to inadequate dietary intake and limited physical mobility. Staff provided the resident with repositioning every 2 hours. The care plan lacked evidence of treatments for and description of his/her wounds or location. The admitting nursing assessment and history dated 12/29/14 revealed the resident weighed 147.7 pounds (#) upon admission and had the following wounds, descriptions, and measurements: - Left buttock, pressure, 2.5 centimeters (cm) by (x) 2.5 cm - Right antecubital, bruising, 3.0 cm x 7.5 cm - Right lower arm, bruising, 4.5 cm x 4.0 cm - Right lower arm, 2 pinpoint sores - R trochanter (hip), 10 staples from surgery - Groin, red - Right foot outside, pressure, 2.0 cm x 1.2 cm - Right foot bunion area, pressure, 2.4 cm x 1.9 cm - Right heel, boggy - Left heel, boggy "Continued on skin assessment" The skin observations tool dated 12/30/14 revealed the following wounds, descriptions, and measurements: - Left foot bunion area, pressure, 0.5 cm x 0.5 cm - Left inner ankle, pressure, 3.0 cm x 2.5 cm - Left heel, red and boggy - Left great toe, several fluid filled - Left foot outside, pressure, 2.5 cm x 2.5 cm - Left inner ankle, pressure necrotic (pertaining to the death of tissue in response to disease or injury), 1.4 cm x 1.4 cm - Right inside knee, pressure, 2.5 cm x 2.5 cm The skin observation tool dated 1/1/15 revealed the resident had no skin issues noted at that time. The weekly pressure ulcer healing assessment sheets dated 1/5/15 had a place to number each wound but the form lacked documentation of a number associated with each wound. The forms revealed the following wounds, descriptions, and measurements: - Left upper buttock/sacrum, Stage 2, wound bed epithelium, no drainage, no undermining, wound edges intact, surrounding skin intact, 7.0 cm x 6.0 cm, Notes: Allevyn (type of wound dressing) to area, date of onset: admission (increased in size from 2.5 cm x 2.5 cm) - Right outer foot, Unstageable, Eschar (dead tissue) in wound bed, no drainage, no undermining, wound edges intact, surrounding skin intact, 1 cm x 1 cm, date of onset: admission - Left heel, Unstageable, Eschar in wound bed, wound edges intact, surrounding skin intact, 6 cm x 5 cm, Notes: necrotic tissue, date of onset: admission (increased in size from admission) - Right heel, Unstageable, no undermining, no drainage, rolled wound edges, surrounding skin dark red and intact, 8 cm x 6 cm, Notes: fluid filled with necrotic tissue, date of onset: admission (increased in size from admission) - Left great toe - bunion, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and pink/red, 3 cm x 3 cm, Notes: redness to bony area, date of onset: admission (increased in size from admission) - Right great toe, Stage 4, Slough (dead tissue, usually cream or yellow in color) in the wound bed, no undermining, no drainage, wound edges were red and hard or had induration, surrounding skin intact and dark red, 2 cm x 2 cm, Notes: Slough - tissue exposure, date of onset: admission (not documented previously) - Right inner knee, Stage 3, slough in wound bed, no undermining, no drainage, wound edges hard or had induration, surrounding skin intact, 2.5 cm x 1.2 cm, Notes: slough center, date of onset: admission - Left outer ankle, Unstageable, eschar in wound bed, no undermining, no drainage, wound edges intact, surrounding skin red, 4 cm x 6 cm, Notes: necrotic tissue, date of onset: admission (not documented previously) - Left little toe outer, Stage 1, [MEDICATION NAME] tissue in wound bed, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 0.3 cm x 0.6 cm, date of onset: admission (not previously documented) - Right upper inner ankle, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 0.5 cm, Notes: Reddened area, date of onset: admission (not previously documented) - Right inner ankle, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 2 cm x 2 cm, Notes: Pink tissue with no opening, date of onset: admission (not previously documented) - Right inner mid-foot, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact, 1.2 cm x 1 cm, Notes: Reddened and no opening, date of onset: admission (not previously documented) The Skin observation tool dated 1/8/15 revealed the following wounds, descriptions, and measurements: - Right toes, 2 cm x 2 cm, Stage 4 - Left toes, 0.3 cm x 0.6 cm, Stage 1 - Right ankle outer, 1 cm x 1 cm, Unstageable - Left heel, 6 cm x 5 cm, Unstageable - Right inner upper ankle, 0.5 cm x 0.5 cm, Stage 1 - Right heel, 8 cm x 6 cm, Unstageable - Right inner mid foot, 1.2 cm x 1 cm, Stage 1 - Right ankle inner, 2 cm x 2 cm, Stage 1 - Sacrum, 7 cm x 6 cm, Stage 2 - Left ankle outer, 4 cm x 6 cm, Unstageable - Left toes, 3 cm x 3 cm, Stage 1 - Right inner knee, 2.5 cm x 1.2 cm, Stage 3 The weekly pressure ulcer healing assessment sheets dated 1/15/15 had a place to number each wound but the form lacked documentation of a number associated with each wound. The forms revealed the following wounds, descriptions, and measurements: - Left upper buttock/sacrum, Stage 2, wound bed epithelium, no drainage, no undermining, wound edges intact, surrounding skin intact, 6 cm x 4 cm, date of onset: admission - Right outer foot, Unstageable, Eschar in wound bed, no drainage, no undermining, wound edges intact, surrounding skin intact, 1 cm x 1 cm, date of onset: admission - Left heel, Unstageable, Eschar in wound bed, wound edges intact, surrounding skin intact, 5.9 cm x 4.7 cm, date of onset: admission - Right heel, Unstageable, no undermining, no drainage, rolled wound edges, surrounding skin dark red and intact, 8 cm x 5 cm, date of onset: admission - Left great toe - bunion, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and pink/red, 3 cm x 3 cm, Notes: redness, date of onset: admission - Right great toe, Stage 4, Slough in the wound bed, no undermining, no drainage, wound edges were red and hard or had induration, surrounding skin intact and dark red, 2 cm x 2 cm, Notes: no change, date of onset: admission - Right inner knee, Stage 3, slough in wound bed, no undermining, no drainage, wound edges hard or had induration, surrounding skin intact, 2.4 cm x 1.2 cm, Notes: no change, date of onset: admission - Left outer ankle, Unstageable, eschar in wound bed, no undermining, no drainage, wound edges intact, surrounding skin red, 3.8 cm x 5.8 cm, date of onset: admission - Left little toe outer, Stage 1, [MEDICATION NAME] tissue in wound bed, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 0.4 cm x 0.7 cm, date of onset: admission - Right upper inner ankle, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 0.6 cm, date of onset: admission - Right inner ankle, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact and dark red, 2 cm x 2 cm, date of onset: admission - Right inner mid-foot, Stage 1, no undermining, no drainage, wound edges intact, surrounding skin intact, 1.3 cm x 1 cm, Notes: Reddened and no opening, date of onset: admission The above skin assessments were not thorough and lacked consistent assessment with measurements making it difficult to determine what was actually present on admission and if the wounds worsened or improved. The 12/31/14 laboratory results revealed an [MEDICATION NAME] level (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) was low at 3.2 and the desirable range was 3.5 to (-) 5.2. His/her total protein level was low at 6.2 and the desirable range was 6.6 - 8.7. Review of the clinical record revealed only one note from the dietitian: The 1/21/15 at 5:43 P.M. nutrition note revealed the resident weighed 122.2# and his/her previous weight was 140#, noting a 17# weight loss recently. The note showed he/she had decreased intake and appetite with weakness and a recent fall. The resident's diet was regular with mechanical soft texture and staff encouraged fluids. The note also revealed the resident's skin was intact, told the reader to refer to nursing, and showed the resident had a [MEDICAL CONDITION] previously noted in the medical record. Medications were reviewed and he/she may benefit from supplement for increased nutrition needs. The dietitian recommended Ensure Plus twice a day at med pass. Staff were to continue with the plan of care, check weights weekly, and monitor as needed. Review of the clinical record revealed the following weights: 12/29/14 equaled (=) 147.7# 1/8/15 = 140.0# 1/20/15 = 122.2# (a 17.3% loss since admission) 1/25/15 = 116.8# Review of the January 2015 Medication and Treatment Administration Record (MAR/TAR) on 1/26/15 at 7:17 A.M. lacked documentation showing staff provided the resident with Ensure Plus twice a day since the dietitian recommended per the 1/21/14 at 5:43 P.M. note. Observation on 1/22/15 at 8:25 A.M. revealed the resident sat in a broda chair at a table in the dining room and received eggs, biscuits and gravy, oatmeal, grape juice, milk, and water. The resident was able to eat and drink with intermittent cueing from staff. At 8:45 A.M. the staff left the table and the resident sat quietly. He/she consumed approximately 5-10% of the meal. At 9:10 A.M. 3 staff members returned to table but did not engage in conversation with the resident. The resident sat in his/her broda chair quietly with his/her eyes closed until 9:26 A.M. when direct care staff Q propelled the resident from the dining room to his/her room, locked the brakes, placed the call light in reach, and exited the room. Staff failed to give verbal encouragement or offer alternative foods. Observation on 1/22/15 at 2:07 P.M. revealed licensed nurse I and licensed nurse K performed wound care for the resident. Staff washed their hands, applied gloves, then used normal saline and a 4 by 4 guaze to clean with right inner foot wound, then applied Santyl ([MEDICATION NAME] ointment) to the wound bed, wrapped the foot with guaze, and secured it paper tape. The wound was covered with slough and surrounding skin appeasred pink/red. Staff changed gloves then cleansed the inner right knee wound with normal saline then covered it with an Allyven dressing. The surrounding skin appeared pink. Staff checked the placement of the dressing on the resident's sacrum and it was dry and intact. Throughout the procedure the resident scratched at his/her legs and attempted to kick off heel protectors. Staff replaced bilateral heel protectors prior to leaving the room. Interview on 1/21/15 at 1:54 P.M. with administrative nursing staff D revealed the dietitian only reviewed residents that the facility identified as at risk. Interview on 1/22/15 at 10:05 A.M. with administrative nursing staff D revealed he/she expected the admitting nurse to document measurements of all wounds. Staff D was unsure why the admitting nursing assessment failed to have documentation of measurements for all the resident's wounds. Staff D acknowledged he/she was unable to know for sure that the resident's heels were boggy and fluid filled upon admission of if the wounds worsened or developed since then. Interview on 1/22/15 at 10:33 A.M. with direct care staff Q revealed staff usually offered residents other food items if they did not consume much at a meal. Staff Q reported he/she did not offer any substitutions to this resident due him/her forgetting. Staff Q also reported some days this resident ate well and other days did not. Interview on 1/22/15 at 2:05 P.M. with licensed nursing staff I revealed the resident often removed his/her wound dressing due to scratching. Interview on 1/22/15 at 2:55 P.M. with administrative nursing staff D revealed the resident had not been referred to the dietitian until 1/21/15. Interview on 1/26/15 at 10:16 A.M. with direct care staff R revealed he/she was aware the resident had skin issues. Staff R reported the resident did receive Ensure but he/she was unsure how often. Staff R stated the staff were to document the percentage of the supplement the resident received in the as needed (prn) charting but that did not always get completed due to it being time consuming. Interview on 1/26/15 at 11:05 A.M. with licensed nursing staff J revealed he/she expected the admitting nurse to include a skin assessment and measurements of all wounds upon admission. Staff J reported due to this resident's extensive skin impairment the dietitian should have been involved since admission. Staff J did not think staff documented supplement percentage intake. He/she reported the resident rarely finished an entire can of Ensure and usually only consumed about 50 percent. Staff J acknowledged it would be difficult to determine the resident's actual protein intake without documentation of the actual amount of the supplement that was consumed. Interview on 1/26/15 at 11:45 A.M. with administrative nursing staff D revealed he/she was the wound nurse for the facility and knew all the resident's wounds were present at admit because the admitting nurse was present when Staff D performed the wound assessment on 1/5/15. Staff D reviewed the admitting nursing assessment with his/her first wound assessment and acknowledged the documentation did not match. Staff D reported he/she did not review the admitting nurse's skin assessment prior to completing the assessment on 1/5/15. He/she reported that he/she was attempting to educate the nursing staff regarding wound care, measuring, and assessment. Staff D stated the resident was on hospice so the family and physician decided when to refer to the dietitian. Staff D knew the dietitian saw the resident the previous week and recommended Ensure for him/her. Staff D reported the dietitian did not meet with the director of nursing or wound nurse when he/she visited. The dietitian met with the dietary manager who reported back and forth between nursing and the dietitian. The dietary manager always asked the nursing staff if any residents needed to be reviewed by the dietitian before he/she met with him/her. Staff D was unsure when the dietitian visited the facility or how often. The interview on 1/26/15 at 12:09 P.M. with administrative nursing staff E revealed he/she acknowledged the resident's care plan lacked interventions regarding skin care for staff reference. Staff E reported the nurse that admitted this resident was new and had only a done a couple of admission prior to the resident. Staff E stated the administrative staff had noticed some of their nurses needed more guidance and leadership. He/she also acknowledged it was difficult to compare the admission nursing assessment with the subsequent assessments. Staff E reported the dietitian was involved with every admission to the facility and he/she believed the 1/21/15 visit was this resident's admission dietitian assessment. He/she said the delay between this resident's admit and the dietitian reviewing him/her was not the typical timeframe and acknowledged it was an extended amount of time. Staff E reviewed the record and reported he/she did not see any evidence the facility had attempted to contact the dietitian for a referral for this resident. The policy provided by the facility with a revision date of October 2010 regarding prevention or pressure ulcers revealed documentation should include the type of skin care given, date and time the care was given, the position the resident was placed, the name and title of the individual who gave care, any changes in the resident's condition, the condition of the resident's skin (i.e., the size and lcoation of any red or tender areas), how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the care and reasons why, observations of anything unusual exhibited by the resident, the signature and title of the person recording the data, and documentation of advanced directives. The facility failed to provide a policy regarding pressure ulcer care, assessment, and documentation. The facility failed to provide thorough and consistent assessment with measurements for this severely cognitively impaired resident and failed to prevent increases in size of his/her wounds and development of additional wounds.

The facility identified a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide timely nutritional interventions for 1 (#7) for 4 residents reviewed for nutrition, who experienced significant weight loss of 16.6 percent and had multiple wounds. Findings included: - The admission Minimum Data Set ((MDS) dated [DATE] for resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. He/she required extensive assistance from 2 or more staff for bed mobility, dressing, toilet use, and personal hygiene. The resident was dependent on staff for transferring and bathing. His/her weight was 140 pounds (#), he/she received a mechanically altered diet, and required supervision with 1 staff physical assist for eating. He/she had a prognosis of 6 months or less and had 5 stage 1 pressure ulcers, 1 stage 2 pressure ulcer, 1 stage 3 pressure ulcer, 1 stage 4 pressure ulcer, and 4 unstageable pressure ulcers. The 1/9/15 Care Area Assessment (CAA) regarding nutrition revealed the resident had extensive skin issues and staff were going to refer him/her to the dietitian to determine if hydration and/or supplements could improve his/her skin condition. The interim care plan dated 12/29/14 failed to address nutritional needs. The comprehensive care plan with a revision date of 1/15/15 revealed the resident had actual impairment to skin integrity related to inadequate dietary intake and limited physical mobility. The care plan also revealed he/she was at risk for a nutritional problem due to a terminal diagnosis. The resident required assistance from staff to eat, requiring verbal cueing throughout meals. Staff invited the resident to activities that promoted additional intake, monitored and reported signs and symptoms of trouble swallowing, served his/her diet as ordered, and weighed the resident weekly at the same time. The care plan showed staff provided and served supplements as ordered and the form indicated for the person completing it to specify what type of supplement, but the care plan lacked that information. Review of the clinical record revealed the following weights: - 12/29/14 equaled (=) 147.7# - 1/8/15 = 140.0#, The clinical record lacked evidence the facility contacted the dietitian or physician or implemented any interventions to prevent further weight loss. - 1/20/15 = 122.2# (a 12.7 percent (%) loss since 1/8/15) - 1/25/15 = 116.8# (a 16.6% loss since 1/8/15), The facility received a dietitian recommendation on 1/21/15 to start Ensure twice daily but the clinical record lacked evidence staff initiated the Ensure. The 12/31/14 laboratory results revealed an [MEDICATION NAME] level (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) was low at 3.2 and the desirable range was 3.5 to (-) 5.2. His/her total protein level was low at 6.2 and the desirable range was 6.6 - 8.7. Review of the clinical record on 1/21/15 at 1:59 P.M. lacked evidence the dietitian assessed the resident as indicated by the nutrition CAA. The 1/21/15 at 4:04 P.M. faxed physician notification provided by the facility revealed the staff notified the physician the resident was being weighed by the hoyer lift (mechanical lift). When the resident was first weighed with the hoyer he/she weighed 140# and more current weight of 122.2#. Staff did not believe the scale had been zeroed out prior to weighing the resident for the 122.2# result. Staff asked the physician if they could monitor for the next weeks weight to compare. The physician replied 1/21/15 at 4:10 PM and approved the request to monitor and reweigh the following week. The 1/21/15 at 5:43 P.M. nutrition progress note revealed the dietitian reviewed the resident (23 days after admission). The note showed the resident weighed 122.2# and his/her previous weight was 140#, noting a 17# weight loss recently. The note showed he/she had decreased intake and appetite with weakness and a recent fall. The resident's diet was regular with mechanical soft texture and staff encouraged fluids. The note also revealed the resident's skin was intact, told the reader to refer to nursing, and showed the resident had a [MEDICAL CONDITION] previously noted in the medical record. Medications were reviewed and he/she may benefit from supplement for increased nutrition needs. The dietitian recommended Ensure Plus twice a day at med pass. Staff were to continue with the plan of care, check weights weekly, and monitor as needed. Review of the January 2015 Medication and Treatment Administration Record (MAR/TAR) on 1/26/15 at 7:17 A.M. lacked documentation showing staff provided the resident with Ensure Plus twice a day since the dietitian recommended per the 1/21/14 at 5:43 P.M. note. Observation on 1/22/15 at 8:25 A.M. revealed the resident sat in a broda chair at a table in the dining room and received eggs, biscuits and gravy, oatmeal, grape juice, milk, and water. The resident was able to eat and drink with intermittent cueing from staff. At 8:45 A.M. the staff left the table and the resident sat quietly. He/she consumed approximately 5-10% of the meal. At 9:10 A.M. 3 staff members returned to table but did not engage in conversation with the resident. The resident sat in his/her broda chair quietly with his/her eyes closed until 9:26 A.M. when direct care staff Q propelled the resident from the dining room to his/her room, locked the brakes, placed the call light in reach, and exited the room. Staff failed to encourage the resident during the meal and failed to offer him/her an alternate. Interview on 1/21/15 at 1:54 P.M. with administrative nursing staff D revealed the dietitian only reviewed residents that the facility identified as at risk. Interview on 1/22/15 at 10:33 A.M. with direct care staff Q revealed staff usually offered residents other food items if they did not consume much at a meal. Staff Q reported he/she did not offer any substitutions to this resident due him/her forgetting. Staff Q also reported some days this resident ate well and other days did not. Interview on 1/22/15 at 2:55 P.M. with administrative nursing staff D revealed the resident was not referred to the dietitian until 1/21/15. Interview on 1/22/15 at 3:53 P.M. with direct care staff P revealed the resident had multiple pressure wounds. Staff P also reported the resident's need for assistance with eating fluctuated and that staff offered him/her snacks when he/she did not eat well at a meal. Interview on 1/26/15 at 10:16 A.M. with direct care staff R revealed he/she was aware the resident had skin issues. Staff R reported the resident did receive Ensure but he/she was unsure how often. Staff R stated the staff were to document the percentage of the supplement the resident received in the as needed (prn) charting but that did not always get completed due to it being time consuming. Interview on 1/26/15 at 11:05 A.M. with licensed nursing staff J revealed due to this resident's extensive skin impairment the dietitian should have been involved since admission. Staff J did not think staff documented supplement percentage intake. He/she reported the resident rarely finished an entire can of Ensure and usually only consumed about 50 percent. Staff J acknowledged it would be difficult to determine the resident's actual protein intake without documentation of the actual amount of the supplement that the resident consumed. Interview on 1/26/15 at 11:45 A.M. with administrative nursing staff D revealed the resident was on hospice so the family and physician decided when to refer to the dietitian. Staff D knew the dietitian saw the resident the previous week and recommended Ensure for him/her. Staff D reported the dietitian did not meet with the director of nursing or wound nurse when he/she visited. The dietitian met with the dietary manager who reported back and forth between nursing and the dietitian. The dietary manager always asked the nursing staff if any residents needed to be reviewed by the dietitian before he/she met with him/her. Staff D was unsure when the dietitian visited the facility or how often. The interview on 1/26/15 at 12:09 P.M. with administrative nursing staff E revealed the dietitian was involved with every admission to the facility and he/she believed the 1/21/15 visit was this resident's admission dietitian assessment. He/she said the delay between this resident's admit and the dietitian reviewing him/her was not the typical timeframe and acknowledged it was an extended amount of time. Staff E reviewed the record and reported he/she did not see any evidence the facility attempted to contact the dietitian for a referral for this resident. The facility failed to provide a policy regarding monitoring nutritional status. The facility failed to develop and implement timely interventions to prevent significant weight loss for this severely cognitively impaired resident with 12 known pressure ulcers.

The facility reported a census of 31 residents. The sample included 3 residents. Based on observation, record review, and interview, the facility failed to provide interventions as planned for 2 (#1 and #3) residents who fell and one resident sustained [REDACTED]. Findings included: - The Significant Change in Status Minimum (MDS) data set [DATE] for resident #1 revealed a Brief Interview for Mental Status score of 0 (severe impaired cognition). The resident required extensive assistance of two plus (2+) persons with bed mobility, transfers, walking in her/his room, and toilet use. The resident also required extensive assistance of one person for locomotion on the unit, dressing, personal hygiene and total dependence of one person physical assist with bathing. The resident was not steady and was only able to stabilize with nursing staff assistance with moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfer. The resident had no functional limitations in her/his range of motion and used a walker and wheelchair (w/c) for mobility. The resident had two or more non-injury falls since admission/entry or re-entry or prior assessment. The fall Care Area assessment dated [DATE] revealed the resident required nursing staff assistance with transfers, toileting, walking, and was not safety conscious due to her/his altered thought processes. The resident was at risk for falls and had two falls. The resident had difficulty with sitting balance and would bend forward at the waist. Most of the falls happened when she/he attempted to transfer self, or to walk alone. The resident had a pommel cushion (a cushion with a upward-projecting protuberance at the front part to prevent a resident from slipping down on the seat)in the w/c which kept her/him from sliding or falling forward but became strong enough to stand up beyond the cushion. Her/his ambulatory abilities varied throughout the day. She/he did not always use her/his walker, and had a cushioned landing pad for falls from or by the bedside. The revised care plan dated 4/10/14 for potential for social isolation, elopement at risk related to cognition and communication deficits, macular degeneration (progressive deterioration of the retina) and difficulty processing surrounding activities listed the interventions nursing staff would maintain the resident's eye glasses in clean working order and provide the eye glasses to her/him daily during waking hours, family provided a bed/chair alarm and nursing staff would respond immediately to the resident's alarm when sounded, would consistently note resident's whereabouts for safety reasons, assist the resident outside when weather permitted, and provided non-slip shoes or grippers socks. The nursing notes and care plan revealed on 1/16/14 at 3:45 A.M. staff found the resident sitting on the floor of her/his room on her/his buttock covered in urine/BM and the floor was wet with urine. The resident's range of motion (ROM) was normal. The bed alarm did not sound. The intervention was for staff to replace the alarm system with the facility's personal alarm (PA) until the bed alarm was fixed. The nursing notes and care plan revealed on 3/12/14 at 11:15 A.M. the activity director informed nursing staff the resident sat on the floor between a recliner and the wall. The resident had good ROM, alignment and was able to move all extremities without difficulties. The alarm was off. The intervention was for nursing staff to frequently check the monitor to ensure the alarm was on. The nursing notes and care plan revealed on 5/2/14 at 8:20 A.M. nursing staff found the resident on the floor laying on her/his right side between a w/c and a recliner. The resident complained of right arm/shoulder pain scoring a 10 (being the worst pain). The physician was notified and an order for [REDACTED]. The nursing intervention was for nursing staff to ensure the alarm was present and on. The hospital radiological report dated 5/2/14 revealed an impacted fracture at the surgical neck of the humerus (right shoulder fracture). The Progress Note dated 5/2/14 at 12:45 P.M. revealed the resident fell while trying to transfer her/himself from a w/c to a chair. The resident received a fracture of the right humeral neck and was resting comfortably in bed. The physician ordered a shoulder immobilizer and staff notified the family of the treatment and offered to send the resident to see an orthopedic. Family indicated the resident was on hospice and wanted her/him comfortable. Record review on 5/28/14 at 3:17 P.M. revealed the February 2014, March 2014, and April 2014 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation nursing staff checked the resident's bed/chair alarm for function. The May 2014 TAR revealed nursing staff would check the resident's personal alarm on each shift and to start on the night shift on 5/28/14. Observation on 5/28/14 at 1:05 P.M. revealed the resident laid in bed with the bed in low position, a border air mattress was in place, and the call light was within reach. Direct care staff G revealed the resident laid on a white plastic alarm pad. Observation on 5/29/14 at 8:15 A.M. revealed the resident's alarm monitor was located at the nurse's station desk, switched in the off position and was verified by surveyor staff Z. At that time the resident sat in a w/c by the fireplace near the nursing station. No nursing staff were at the nursing station. At 8:20 A.M. licensed nursing staff E and administrative nursing staff B confirmed the resident's alarm monitor was switched off. Interview on 5/28/14 at 1:10 P.M. with direct care staff G stated the resident's family provided the alarm system, nursing staff checked the alarm daily and the alarm should never be turned off. If the alarm did not sound, with an alarm check, she/he would notify the charge nurse and a PA would be used until the family provided a new alarm Interview on 5/28/14 at 4:35 P.M. with licensed nursing staff D and confirmed by administrative staff A stated the resident's alarm was checked daily and nursing staff documented the results on the TAR. Interview on 5/29/14 at 8:40 A.M. with administrative nursing staff B stated staff documented on the TAR the resident's alarm check after her/his fall on May 2nd but nursing staff was not documenting the alarm checks before that. Interview on 5/29/14 at 10:12 A.M. with licensed nursing staff E revealed the resident's alarm monitor should be on at all times and never off. The charge nurse assigned to the resident's hallway would check the alarm and documented in the computer system's TAR. Interview on 5/29/14 at 12:30 P.M. with administrative nursing staff B stated the facility did not have a policy and procedure for PA alarm monitoring. The facility failed to provide interventions as planned for this cognitively impaired dependent resident with a history of falls which resulted in a fracture. - Review of the significant change Minimum Data Set (MDS) 3.0 for resident #3 dated 7/23/13 revealed a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. Review of the Care Area Assessment (CAA) dated 7/23/13 for cognitive loss revealed the resident had aphasia and responded with few words. Review of the communication CAA dated 7/23/13 revealed the resident had aphasia, dementia with short and long term memory deficits. Review of the CAA dated 7/23/13 for falls revealed the resident was a high risk for falls due to partial foot amputation in the 1960's, a history of depression, an orthotic shoe for the right foot, used pummel cushion (a chair cushion with a raised area between the thighs) in the chair to discourage standing without assistance, a floor mat was next to the bed, and quarter side rail to assist with repositioning. Review of the quarterly MDS 3.0 dated 4/16/14 revealed a BIMS score of 3 which indicated severe cognitive impairment. The resident had unclear speech, usually understood, and sometimes could be understood by others, The resident required extensive assist of one staff for bed mobility, transfers, dressing, dressing, toileting, personal hygiene, was not steady and able to stabilize with staff for moving from seated to stand, walking, moving off and on toilet, surface to surface transfer, impairment on one side, and used the walker and wheelchair for mobility. Review of the revised care plan for falls dated 5/8/14 revealed the resident was encouraged to spend time by the fireplace in recliner between meals for increased monitoring to prevent falls, staff were to continue to reposition and offer toilet every 2 hours, and appropriate footwear when up and with ambulation, bed controls were moved to the bottom outside of bed and staff were to check position of the bed, and fall mats in front of toilet. Review of the care plan update of falls dated 5/10/14 revealed staff were to attach the personal alarm so the resident could not reach and remove it, accompany the resident for toileting, decrease the time the resident stayed in bed, a bed alarm, encourage this cognitively impaired resident to use the call light, wear non-skid socks at all times, and to toilet the resident more often. Review of the revised care plan and the care plan update for falls lacked direction for staff on the use of a personal alarm. Review of the medical record and the electronic medical record lacked documentation of the use or functioning of the personal alarm. Review of the nurses' note dated 3/24/14 at 1050 A.M. staff found the resident on the floor in the bathroom sitting upright with back against wall. Review of the fall investigations on 5/29/14 at 11:28 A.M. administrative staff B acknowledged there was lack of evidence of investigation for the fall on 3/24/14. Observation on 5/28/14 at 11:05 A.M. revealed the resident was in bed, the bed was in the low position, a fall mat was next to the bed, and a personal alarm was at the head of the bed. Observation on 5/28/14 at 11:39 A.M. revealed the resident sat in the wheelchair in the dining room and a personal alarm was attached to the resident's shirt and the wheelchair. Observation on 5/29/14 at 7:30 A.M. revealed the resident sat in the wheelchair in the dining room. A personal alarm was attached to the resident's shirt on the right shoulder and the wheelchair. Observation on 5/29/14 at 11:09 A.M. revealed the resident was in bed and a personal alarm was located above the pillow at the head of the bed. Interview on 5/28/14 at 11:55 A.M. direct care staff G stated he/she checked the personal alarm functioning every morning but did not chart it. Interview on 5/28/14 at 4:38 P.M. direct care staff F stated the personal alarm checks use to be on the paper activities of daily living sheet but there was not a place to document it in the electronic record. Interview on 5/28/14 at 4:35 P.M. licensed staff P stated the staff were to check the alarm function every time a resident was transferred but not documented. Interview on 5/29/14 at 8:35 A.M. administrative nursing staff B stated there was not a place on the direct care staff paper flow sheet or the electronic medical record to monitor the personal alarm. The facility failed to provide a policy on the used and documentation of a personal alarm. The facility failed to document the use and functionality of a personal alarm for this cognitively impaired, aphasic resident to prevent future falls.

The facility had a census of 37 residents. The sample included 22 residents. Based upon observation, record review and interviews the facility failed to promote the prevention of pressure ulcers for 1 of 3 sampled residents (#19). Findings included: - Review of resident's #19's Significant Change Minimum Data Set (MDS) 3.0 dated 9/16/13 identified the resident scored 0 (severely impaired cognition) on the Brief Interview for Mental Status, and had behaviors 4 to 6 days of the 7 day look back period. The MDS identified the resident required extensive staff assistance with bed mobility, locomotion on/off unit, was totally dependent upon staff for transfers, walking in the room, dressing, eating, toilet use, and personal hygiene. The MDS coded the resident was frequently incontinent of urine, weighed 166 pounds, had not experienced a weight loss, and was at risk for pressure ulcer development. The MDS recorded the resident had (1) Stage I pressure ulcer, a pressure relieving device for his/her chair and on his/her bed, was on a turning/repositioning program, and received pressure ulcer care. The resident's clinical record did not support the facility completed the Care Area Assessments as required after completing the significant change assessment (a comprehensive assessment). The resident's care plan with a review date of 9/17/13 addressed the resident was at risk for skin breakdown due to being incontinent and the resident moved around a lot. Staff monitored the resident's bony areas and pressure points during dressing, bathing and toileting, the resident had a pressure relieving device in his/her chair and on his/her bed. The above interventions were in place since 5/21/11. The care plan included the resident had a Stage I pressure ulcer on his/her left hip, and staff repositioned the resident off his/her left hip as much as possible. A hand written entry dated 8/30/13 included the resident received Ensure pudding for lunch and dinner, and super cereal at breakfast. An undated entry documented heel protectors on heels when in bed. Review of the resident's care plan on 10/15/13 at approximately 2:30 P.M. did not address the resident's turning/repositioning program or the heel protectors. A wound report dated 8/19/13 documented the Stage I pressure ulcer on the resident's left hip measured 4 centimeters (cm) by 3 cm and on 9/15/13 it measured 1 1/2 cm by 1 1/2 cm. According to the resident' September 2013 Treatment Administration Record the pressure ulcer on the resident's left hip was healed as of 9/23/13. A nurse's note dated 8/1/13 and timed 4:50 A.M. included the resident had 2 small abrasions; 1 on his/her right hip that measured 1.2 centimeters (cm) by 3 cm and (1) on his/her right inner thigh that measured 6 cm by .1 cm, and staff applied barrier cream. A nurse's note dated 8/19/13 and not timed documented the resident had an area of redness on his/her left hip that measured 4 cm by 3 cm and staff encouraged this resident with severely impaired cognition to lie on his/her right side or back. A nurse's note dated 10/1/13 and timed 4:30 A.M. documented the resident's buttocks was red and staff applied barrier cream. The note included both of the resident's heels were mushy and staff applied heel protectors. A nurse's note dated 10/15/13 and timed 2:00 P.M. included the resident's right hip had a water filled blister that measured 2 cm by 2 cm, A nurse's note dated 10/16/13 and not timed documented the resident's left hip had a red blanchable area that was 4 cm in diameter. A nurse's note dated 10/17/13 and timed 4:00 A.M. documented the resident continued with the blister on his/her right hip, and staff observed the resident's left hip was red after the resident laid on his/her left hip for 1 to 1 1/2 hours. Staff repositioned the resident every 1 1/2 hours throughout the night, and the redness went away after staff repositioned the resident. The resident's clinical record did not support the facility had performed a tissue tolerance testing (ability of the skin to withstand the effects of unrelieved pressure) in order to individualize the resident's repositioning schedules when in bed and in the chair. A registered dietician's note dated 8/28/13 documented the resident weighed 163 pounds, and the resident had a gradual weight loss. The note included the resident's weight decreased 4.5 percent (%) in 1 month, 3% in 3 months, 7.8% in 6 months, and the RD recommended 2 cal (nutritional supplement to increase the resident's protein and calorie intake) 60 cubic centimeters twice a day to try and stabilize the resident's weight. The resident's laboratory report dated 10/9/13 recorded the resident's low serum [MEDICATION NAME] (indicator of protein storage) level at 2.6 grams/dl (g/dl), normal reference level at 3.5-5.2 g/dl. The report recorded the resident's low total protein as 5.3 g/dl, normal reference range of 6.6-8.7 g/dl. On 10/15/13 at 1:45 P.M. the resident laid in bed on his/her right side. Observation revealed the resident had a pressure relieving device on his/her bed and in his/her recliner. On 10/15/13 at 3:11 P.M. the resident laid in bed on his/her right side. Observation revealed the resident had a pillow between his/her legs, heel protectors bilaterally and the resident's heels/feet were not floated. Observation revealed the resident had a pressure relieving device on his/her bed, in his/her recliner but the resident's wheelchair did not have a pressure relieving device. On 10/16/13 at 7:05 A.M. the resident sat in his/her room in his/her wheelchair. Observation revealed the resident's wheelchair was without a pressure relieving device. On 10/6/13 at 7:30 A.M. direct care staff wheeled the resident to a dining room table. Observation revealed the resident's wheelchair did not have a pressure relieving device. Observation revealed the resident continued to sit at a dining room table in his/her wheelchair without a pressure relieving device at 7:45 A.M., 7:53 A.M., 7:57 A.M., 8:03 A.M., 8:08 A.M. 8:20 A.M. 8:25 A.M. 8:35 A.M., 8:40 A.M., 8:55 A.M. On 10/16/13 at 8:55 A.M. staff wheeled the resident to the lobby area of the facility. On 10/16/13 at 9:05 A.M. observation revealed the resident sat in his/her wheelchair in his/her room, and no pressure relieving device in his/her wheelchair. The resident sat in his/her wheelchair for 2 hours without a pressure relieving device. On 10/16/13 at 9:15 A.M. the resident sat in the recliner in his/her room. Observation revealed a pressure relieving device in the resident's recliner. Further observation revealed the resident had heel protectors on but the resident's heels were not floated. On 10/16/13 observation revealed the resident continued to sit in the recliner at 9:30 A.M., 9:45 A.M., 10:00 A.M., 10:15 A.M., 10:30 A.M., 10:45 A.M., 11:00 A.M., 11:15 A.M., 11:30 A.M., 11:45 A.M., 12:04 P.M., 12:10 P.M., 12:20 P.M., and 12:30 P.M. (duration of 3 hours and 15 minutes). On 10/16/13 at 12:30 P.M. the resident sat in the recliner in his/her room. Direct care staff P and R entered the resident's room. Staff removed the resident's blanket and observation revealed the resident had a pillow under his/her legs but the pillow was not positioned to float the resident's heels. Direct care staff P and R transferred the resident from the recliner to the resident's wheelchair. Observation revealed the resident's wheelchair without a pressure relieving device and staff did not check the resident for incontinence. On 10/16/13 at 1:30 P.M. direct care staff P and R transferred the resident from the wheelchair to the resident's bed. Observation revealed the resident was incontinent of urine. Further observation revealed a red area on the resident's right thigh (where the blister was) that measured approximately 2 cm by .5 cm. Observation also revealed the resident's buttock red. Staff performed incontinent care, placed the heel protectors on the resident, placed a pillow between the resident's legs, and positioned the resident on his/her right side. Observation revealed staff did not float the resident's heels. During interview with direct care staff R at that time he/she stated staff repositioned the resident at least every 2 hours. On 10/16/13 at 2:50 P.M. licensed nurse I entered the resident's room to perform a skin assessment. Observation revealed the resident had a red area on his/her right hip (where the blister was). During interview with licensed nurse I at that time, he/she stated the tape on the resident's brief caused the blister. Observation also revealed the resident's left hip red and the red area measured 4 centimeters in diameter (measurement provided by licensed nurse I). Observation revealed the resident's heels intact. Direct care staff P entered the resident's room and stated staff turned the resident less than a 1-1/2 hours ago and questioned why the resident's left hip was red. On 10/17/13 at 9:20 A.M. the resident sat in his/her wheelchair at a dining room table. Observation revealed the resident's wheelchair was without a pressure relieving device. On 10/17/13 at 9:29 A.M. licensed nurse H stated he/she did not know if the resident should have a pressure relieving device in his/her wheelchair. Licensed nurse H read the resident's care plan and stated he/she was not sure if the resident should have a pressure relieving device in both the recliner and the wheelchair or just in the recliner. On 10/17/13 at 3:00 P.M. licensed nurse H stated the resident should have a pressure relieving device in the recliner and the wheelchair. Licensed nurse H stated staff repositioned the resident every 2 hours when in bed and in the chair/recliner. Licensed nurse H stated the resident had a Stage 1 pressure ulcer that healed on 9/23/13. The facility did not provide a pressure ulcer policy and procedure. The facility failed to assess the resident to develop an individualize turning/repositioning program, failed to float the resident's heels, failed to place a pressure relieving device in the resident's wheelchair, and failed to reposition this resident with a history of pressure ulcers timely.

The facility had a census of 37 residents. The sample included 22 residents. Based upon record review, observation, and interviews the facility failed to maintain an environment free of accident hazards and failed to implement timely and effective interventions to prevent falls for 3 (#5, #29, #21) of 3 residents sampled for falls. Resident #29's falls resulted in fractures and a laceration. Findings included: - Review of resident #29's significant change Minimum Data Set (MDS) 3.0 dated 9/7/13 identified the resident scored 1 (severely impaired cognition) on the Brief Interview for Mental Status, displayed physical behaviors and wandered on a daily basis during the 7 day look back period. He/she had verbal behaviors 1 to 3 days of the 7 day look back and other behaviors not directed toward others 4 to 6 days of the 7 day look back. The MDS recorded the resident required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion off the unit, dressing, eating, toilet use, and personal hygiene, and limited staff assistance with locomotion on the unit. The MDS coded the resident was not steady and only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around while walking, on/off the toilet, and surface-to surface transfer. The MDS identified the resident was always incontinent of urine and had 1 non injury fall, 2 or more non- major injury fall and 1 fall with major injury since the prior assessment. The resident's care plan initiated on 1/6/12 documented the resident at a high risk for injury falls and had a history of [REDACTED]. staff toileted the resident every 2 hours and as needed. The facility did not consistently date when they initiated new interventions. A nurse's note (NN) dated 4/15/13 and timed 9:40 A.M. documented staff found the resident on the floor sitting on the scales. The care plan lacked evidence of additional fall interventions. A NN dated 6/9/13 and timed 10:20 A.M. documented the resident stood up from the couch, fell on his/her right side, and hit his/her hip, shoulder, wrist and head on the floor. The note documented the resident complained of wrist pain, the resident's right wrist was swollen, and the facility received a physician's orders [REDACTED]. The care plan lacked evidence of additional fall interventions. A radiology report dated dated 6/9/13 included the resident's right wrist was painful after the trauma and the impression was the resident had a comminuted distal radial ulnar fracture with apex ventral angulation of the radius (broken wrist). A NN dated 6/10/13 and timed 10:45 A.M. documented the resident tried to sit on the end of the extended footrest of the recliner and fell on to his/her bottom. The care plan lacked evidence of additional fall interventions. A NN dated 6/13/13 and timed 1:10 A.M. documented the resident had a bruise on the right side of his/her forehead that measured 5 centimeters (cm) by 6 cm. A NN dated 6/13/13 and timed 6 A.M. to 6 P.M. documented the resident returned from a physician's appointment with a forearm/wrist cast on his/her right arm. The note included at approximately 5:00 P.M. the resident leaned up against the fireplace and slid to the floor. The care plan lacked evidence of additional fall interventions. A NN dated 6/30/13 and timed 2:00 P.M. documented staff found the resident on the floor behind the recliner in the sitting area. The care plan lacked evidence of additional fall interventions. A NN dated 7/4/13 and timed 3:32 P.M. documented staff observed the resident seated on the floor by the fireplace. The care plan lacked evidence of additional fall interventions. A NN dated 7/5/13 and timed 2:15 P.M. documented staff found the resident on the floor at 11:30 A.M. and 12:30 P.M. with no injuries noted. The care plan lacked evidence of additional fall interventions. A NN dated 7/12/13 and timed 9:13 A.M. documented the resident fell at 8:50 A.M. The NN included the resident stumbled and grabbed the chair to catch his/her fall but instead the resident hit his/her head on the wall and slid on his/her buttock to the floor. The care plan lacked evidence of additional fall interventions. A NN dated 7/13/13 timed 10:30 A.M. documented the resident ambulated in the hall, when staff called to him/her, the resident lost his/her balance and staff assisted the resident to the floor. The care plan lacked evidence of additional fall interventions. A NN dated 7/27/13 and timed 2:45 P.M. documented staff found the resident on the floor in the theater room, the resident apparently fell , and had a 2 cm by 1 cm open area on his/her left brow bone with a moderate amount of bleeding. The note included staff transferred the resident to urgent care and the urgent care center glued the resident's left brow. The care plan lacked evidence of additional fall interventions. A NN dated 7/30/13 and timed 11:55 A.M. documented the resident sat on the floor next to the recliner. The care plan lacked evidence of additional fall interventions. A NN dated 8/3/13 and timed 5:15 P.M. documented the resident lost his/her balance and sat on the carpeted floor. The care plan lacked evidence of additional fall interventions. A NN dated 8/8/13 and timed 6:45 A.M. documented staff found the resident on the floor in a sitting position. The care plan lacked evidence of additional fall interventions. A NN dated 8/10/13 and timed 12:00 P.M. documented staff observed the resident's lower back with a bruise that measured 8 cm by 2 cm, a purple colored bruise on the resident's right ischium that measured 3 cm in diameter, and the resident complained of back pain. A NN dated 8/14/13 and timed 2:55 P.M. documented staff observed the resident on the floor beside the love seat. The care plan lacked evidence of additional fall interventions. A NN dated 8/15/13 and timed 4:15 P.M. documented staff found the resident on the floor lying on his/her right side with a peer's walker on top of him/her. The note included the resident had a scratch to his/her forehead with a brown spot. A NN dated 8/17/13 and timed 3:10 A.M. documented the resident with 1 on 1 attention related to his/her unsteady gait. A NN dated 8/18/13 and timed 10:10 A.M. documented staff placed the resident in the recliner, about 20 minutes later the resident got up from the recliner and attempted to walk to another resident, the resident was unsteady on his/her feet, started to loose his/her balance and resulted in the resident sitting down on the floor. The care plan lacked evidence of additional fall interventions. A NN dated 8/18/13 and timed 4:00 P.M. documented the resident had multiple non injury falls. The note included at 11:45 A.M. while in the dining room at the table the resident got himself/herself out of the wheelchair, attempted to grab another nearby resident's walker and fell on to the floor. At 2:15 P.M. the resident sat in the wheelchair in front of the nurse's station, again stood up and proceeded to roll off the seat to the carpet just as staff reached him/her. The note included the facility placed a personal alarm on the resident and kept the resident close to the staff. A Radiology Report dated 8/21/13 documented the resident had a history of [REDACTED]. The report included the impression was a nondisplaced inferior lateral left eighth rib fracture (broken rib bone). The care plan listed an intervention with no date, that stated prior to the left rib fracture identified on 8/26/13 (but completed on 8/21/13) documented the resident was in a wheel chair with a personal alarm on and a pommel cushion (designed to stabilize seating position and support hip abduction). The care plan documented on 9/12/13 the staff placed the resident on Vitamin D (supplement) daily and discontinued the Melatonin (used for difficulty sleeping) due to falls and sleepiness A NN dated 9/13/13 and timed 4:45 P.M. documented the resident was having difficulty sitting up, staff placed the resident in a recliner in a reclined position with a personal body alarm, and then staff found the resident on the floor in front of the recliner in a fetal position. A NN dated 9/13/13 Intervention for the above fall and timed 5:05 P.M. documented the facility placed the resident's mattress on the floor with fall mats beside it. The care plan documented on 9/25/13 the facility discontinued the resident's Zyprexa (an antipsychotic). On 10/15/13 at 1:46 P.M. the resident laid in bed on his/her left side. Observation revealed the resident in a low bed, a fall mat on the right side of the resident's bed and a personal alarm in place. The care plan documented on 10/16/13 staff placed the resident in a low bed in the lowest position and no side rails used. On 10/16/13 at 8:00 A.M. 8:55 A.M., 9:05 A.M., and 9:15 A.M. the resident sat in the recliner in the lobby area of the facility, the foot of the recliner elevated and the resident appeared asleep. On 10/16/13 at 12:15 P.M. and 12:30 P.M. the resident sat in his/her wheelchair in the television area of the facility. Observation revealed the resident leaned to the right and a personal alarm in place. On 10/16/13 at approximately 12:55 P.M. direct care staff P and V transferred the resident from the wheelchair to the bed via a gait belt. Observation revealed the resident was totally dependent upon staff for the transfer. Observation revealed staff lowered the resident's bed to the floor. During interview with direct care staff P at that time the staff stated the resident had a history of [REDACTED]. On 10/17/13 at 7:00 A.M. the resident was in a low bed, and a mat was beside the right side of the resident's bed. On 10/17/13 at 1:50 P.M. administrative nursing staff D stated the resident fell more this summer than in the past. Administrative nursing staff D stated fall interventions included staff ensured the resident wore non-skid socks and shoes, staff engaged the resident in conversation/activities, monitored the resident frequently, and 75 percent of the time the resident was in direct observation of the staff. Administrative nursing staff D stated staff provided the resident with finger foods, encouraged this severely cognitively impaired resident to use his/her walker, the facility discontinued the resident's Zyprexa on 3/25/13, and started the resident on Vitamin D. Administrative nursing staff D stated the resident had impaired vision and the facility had not pursued the sunglasses included in the resident's care plan. Administrative nursing staff D stated the facility placed the resident's mattress on the floor and placed mats on both sides of the resident's bed in September of 2013 and later that month the facility placed the resident in a low bed that lowered to the floor. Administrative nursing staff D stated the facility placed the resident in a wheelchair with a pommel cushion during August of 2013. Administrative nursing staff D stated it was his/her understanding the resident's personal alarm did not activate when the resident fell on [DATE]. Administrative nursing staff D stated the resident should have fall mats on both sides of his/her bed. On 10/17/13 at 3:00 P.M. licensed nurse H stated the resident had a history of [REDACTED]. He/she stated prior to the low bed the facility placed the resident's mattress on the floor. Licensed nurse H stated the facility kept the resident in line sight of staff. The facility did not provide a fall policy and procedure. The facility failed to implement timely and effective interventions for this dependent resident with severely impaired cognition with a history of falls. This resident had 22 falls in less than 6 months and sustained a rib and wrist fracture and a laceration that required a transfer to urgent care. - Review of resident #5's significant change Minimum Data Set ((MDS) dated [DATE] identified the resident scored 0 (severely impaired cognition) on the Brief Interview for Mental Status, had other behavioral symptoms not directed toward others occurred 4 to 6 days during the 7 day look back period. The MDS coded the resident required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, eating, toilet use, and personal hygiene and was frequently incontinent of urine. The MDS recorded the resident was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around with walking, moving on/off toilet, and surface to surface transfer. The MDS coded the resident had 1 non-injury fall since the prior assessment. The resident's Fall Risk assessment dated [DATE] identified the resident scored 19 and on 5/10/13 the resident scored 20. According to the legend a score of 10 or higher represented the resident at high risk for falls. The resident's care plan last reviewed 8/13/13 addressed the resident was at risk for falls. The care plan included the resident needed a wheelchair for mobility, the resident's personal bed was replaced with a hi-low bed with brakes on it as the resident's bed was too high, had no brakes which created a danger. The care plan included staff ensured the resident wore well fitting non-skid soled shoes, and or gripper socks when out of bed. The care plan included 2 staff transferred the resident via a gait belt or the sit/stand lift. A nurse's note dated 4/15/13 and timed 9:00 A.M. documented staff found the resident on the floor on his/her back beside the bed. A nurses' note dated 5/22/13 (time unknown) documented at 5:00 A.M. staff found the resident sitting on the floor beside bed leaning on the bed and the resident's right arm was in the 1/4 rail. A nurses's note dated 7/16/13 and timed 11:10 A.M. included a volunteer pushed the resident in his/her wheelchair, the wheelchair accidentally went off the sidewalk, there was a big dip down and the resident tipped out of the wheelchair onto the ground. A nurse's note dated 10/3/13 and timed 3:35 P.M. documented staff found the resident lying on the floor beside his/her bed. On 10/15/13 at 1:46 P.M. observation revealed the resident in bed on his/her back, the resident's bed was in the lowest position, and a mat beside the resident's bed. On 10/16/13 at 7:00 A.M. the resident sat in his/her wheelchair in the television area of the facility. On 10/16/13 at 12:45 P.M. direct care staff P and V transferred the resident from the wheelchair to the bed via a transfer belt. Observation revealed the resident totally dependent upon staff during the transfer. After staff finished performing care for the resident at approximately 12:48 P.M., staff placed the mat beside the resident's bed and observation revealed the resident's bed was not in the lowest position. During interview with direct care staff P at approximately 1:00 P.M., staff stated the resident's bed was not in the lowest position. Direct care staff P lowered the resident's bed to the lowest position and observation revealed the resident's bed was approximately 5 inches from the ground. On 10/17/13 at approximately 7:05 A.M. the resident laid in bed. Observation revealed the resident's bed was not in the lowest position and the fall mat approximately 6 inches from the resident's bed and positioned horizontally. On 10/17/13 at approximately 2:15 P.M. administrative nursing staff D stated the resident had a history of [REDACTED]. using a pain scale for dementia (loss of brain function), adjusted the resident's Neurontin (medication that can be used to treat seizures and pain), and checked the resident for toileting. On 10/17/13 at 2:45 P.M. licensed nurse H stated staff placed a fall mat beside the resident's bed, the resident utilized a high-low bed and the resident's bed should be in the lowest position at all times. The facility did not provide a fall policy and procedure. The facility failed to ensure the resident's fall mat was properly placed and the resident's bed in lowest position as planned for this resident with severely impaired cognition and a history of falls. - The significant change Minimum Data Set 3.0 dated 7/23/13 for resident #21 revealed a Brief Interview for Mental Status score of 2 (severe cognitive impairment). The resident required extensive assistance of two plus (2+) persons for bed mobility, transfer, and toilet use, and required extensive assistance of one person for locomotion on/off the unit, dressing, personal hygiene, and bathing. The resident was not steady and stabilized with staff assistance with moving from a seated to standing position, walking, turning around while walking, moving on/off the toilet, and surface to surface transfers. She/he had range of motion limitations to the upper/lower extremities on one side, and used a walker and wheelchair (w/c) for mobility. The resident was frequently incontinent of urine and was always continent of bowel. She/he had two or more non-injury falls since admission/reentry/prior assessment. The Care Area Assessment (CAA) dated 7/25/13 for falls revealed the resident had all her/his toes and part of her/his right foot removed as a result of a job accident in the 1960's. Her/his right foot, left hemiparesis (muscular weakness of one half of the body), and aphasia (condition in which language function is disordered or absent) placed the resident at risk for falls. The resident wore a special orthotic shoe on her/his right foot and an athletic shoe on the left foot. A pommel cushion (designed to stabilize seating position and support hip abduction) was used to discourage standing without assistance, and as a reminder to wait for assistance for transfer. The resident had a floor mat beside the left side of the bed, and quarter rails in an up position on either side of the bed to assist with repositioning in bed. The updated care plan dated 8/30/13 for at risk for falls revealed the resident required assistance of 2 to (:) 1 with a gait belt for transfers and toileting, required a gait belt with all ambulation, nursing staff would monitor for changes in the resident's condition which warranted increased supervision/assistance and would notify the physician of significant concerns, the resident used a w/c for long distance mobility, side rails in the up position for bed mobility while in bed, nursing staff would remind the resident to ask and wait for assist with transfers and ambulation, toilet upon rising and before/after meals, and provided perineal care when incontinent. Record review on 10/16/13 at 4:00 P.M. of handwritten fall events and interventions provided by administrative nursing staff A revealed: The Nursing Notes (NN) dated 5/10/13 at 8:00 A.M. revealed at 7:50 A.M. the resident tried to transfer self to the toilet in her/his room without help, lost her/his balance and fell to the floor. The handwritten record lacked addition fall interventions and a fall investigation. The NN dated 5/12/13 at 6:50 P.M. revealed the resident was assisted to the toilet by nursing staff after the evening meal and after checking on the resident left the resident on the toilet and when nursing staff returned they found the resident on the floor. The handwritten record revealed the resident had a fall while self-transferring to the toilet, and lacked additional fall interventions. The NN dated 5/15/13 at 4:30 P.M. revealed staff found the resident on the floor in doorway of her/his bathroom. The handwritten record revealed the resident had a non-injury fall while self-transferring and lacked additional fall interventions. The NN dated 5/25/13 at 11:30 A.M. revealed staff found the resident on the bathroom floor. The handwritten record revealed the resident had a non-injury fall while transferring self from the toilet and lacked additional fall interventions. The NN dated 7/6/13 at 4:00 P.M. revealed staff found the resident in front of the nurses' station after staff placed the resident in a recliner chair. The handwritten record revealed the resident had a non-injury fall while transferring self from a recliner chair to a w/c and lacked additional fall intervention. The NN dated 7/9/13 at 3:30 P.M. revealed staff found the resident on the floor in her/his room. The handwritten record revealed the resident had a non-injury fall and lacked additional fall intervention The NN dated 7/29/13 at 6:10 A.M. revealed staff found the resident on the floor in the bathroom. The handwritten record revealed the resident sustained [REDACTED]. The NN dated 8/28/13 at 3:50 P.M. revealed staff found the resident on the floor in the bathroom. The handwritten record revealed the resident had a non-injury fall and lacked additional fall intervention. The NN dated 9/11/13 at 3:07 P.M. revealed staff found the resident on the floor. The handwritten record revealed the resident had a non-injury fall and lacked additional fall interventions. Record review on 10/16/13 at 4:00 P.M. of handwritten fall events and interventions provided by administrative nursing staff A revealed the resident had a non-injury fall on 9/16/13 and staff encouraged the resident to wear appropriate footwear when ambulating. The NN dated 9/29/13 at 10:25 P.M. revealed staff found the resident sitting on the floor in front of her/his w/c. The handwritten record revealed the resident had a non-injury fall and had removed the PBA and the intervention included moving the PBA out of the resident's reach and applied side rails for bed mobility. The Fall Risk assessment dated [DATE] revealed a total score of 15; on 4/15/13 a total score of 14; and on 7/15/13 a total score of 6 where a total score above 10 represented a high risk for falls. Observation on 10/16/13 at 7:34 A.M. revealed the resident sat in a w/c, self-propelled in the hallway, and wore a PBA. Observation on 10/16/13 at 9:44 A.M. revealed the resident laid in bed sleeping, wore a PBA, the side rails were in up position with the bed in low position. Interview on 10/17/13 at 10:53 A.M. with direct care staff Q stated nursing staff educated (this severely cognitively impaired) resident regarding the consequences of transferring her/himself without assistance. The resident required visual monitoring, sat in a recliner chair in the common area, wore a PBA while in bed/wheelchair, the bed was placed in the low position, and the resident could not be left alone in the bathroom during toileting. Interview on 10/17/13 at 11:23 A.M. with licensed nursing staff H stated the resident wore a PBA while in the bed and wheelchair. The resident's family did not want a bed alarm used. The resident was not steady enough to ambulate by her/himself due to having only one entire foot. Nursing staff should initiate an incident report with a fall. Interview on 10/17/13 at 2:37 P.M. with administrative nursing staff D stated nursing staff initiated incident reports. The facility failed to provide a policy and procedure for falls. The facility failed to have effective interventions in place for the prevention of falls for this cognitively impaired resident with a history of numerous falls. - Observations during the initial tour on 10/14/13 from 9:30 A.M. to 10:30 A.M., revealed the facility lacked non-skid strips in 2 of 2 common bathing rooms. Interview on 10/17/13 at 9:30 A.M. direct care staff P stated staff should put towels down on the floor when showering a resident to prevent slipping. Interview on 10/17/13 at 10:00 A.M. licensed nursing staff H stated staff should put towels down on the floor when showering a resident to prevent slipping. Interview on 10/17/13 at 1:30 P.M. administrative staff D stated staff should put towels down on the floor when showering a resident to prevent slipping. The facility failed to provide a policy on preventing accidents. The facility failed to provide an environment free of accident hazards. - Observations during the initial tour on 10/14/13 from 9:30 A.M. to 10:30 A.M., Hall B's unlocked bathroom had a bottle of disinfectant spray in an unlocked cabinet. This bottle noted a caution to keep out of the reach of children and harmful if swallowed. Interview on 10/17/13 at 9:30 A.M. direct care staff P stated staff should keep the cabinet locked at all times, and the key should not be in the lock. Interview on 10/17/13 at 10:00 A.M. licensed nursing staff H stated staff were to keep the cabinet locked at all times, and the key should not be in the lock. Interview on 10/17/13 at 1:30 P.M. administrative staff D stated staff were to keep the cabinet locked at all times, and the key should not be in the lock. The facility failed to provide a policy on the storage of chemicals. The facility failed to provide an environment free of accident hazards.

The facility identified a census of 34 residents. The sample included 10 residents. Based on observation, interview, and record review the facility failed to prevent resident #46 from leaving the facility without staffs knowledge. Findings included: - Resident #46's admission Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status score (BIMS) was 0, which indicated the resident had severe cognitive impairment. The resident had physical behaviors toward staff and others that put him/her at risk for injury. The resident wandered daily and was at risk for getting into dangerous places, intruded on the privacy of others, and was independent with ambulation. The Cognition Care Area Assessment (CAA) dated 12-10-13 documented the resident had poor short-term memory, unable to remember location of his/her room, and wandered in and out of peers rooms. The Falls CAA dated 12-10-13 documented the resident urinated in inappropriate places and wet on the floor which endangered him/herself and peers. The admission Care Plan dated 11-26-13 documented the resident as an elopement risk and directed staff to monitor the exit alarms, provide every 15 minute safety checks, document behaviors in the behavior monitoring log, place stop signs at all the exit doors, place the resident's photograph on the elopement risk board, and made staff aware the resident was at risk for elopement. On 11-26-13 the care plan documented the resident eloped out of the facility alone, returned uninjured and staff provided one on one observation and documented the resident's where about's every 15 minutes. On 11-27-13 staff changed the resident's room so it was closer to the nurses station. On 12-8-13 the care plan documented the resident toileted in inappropriate places such as the floor in other residents' rooms and in trash cans. The care plan directed staff to toilet the resident every one and a half to two hours. On 12-9-13 the care plan documented the resident hollered at another resident twice, so staff moved the other resident to a different hall. The 12-10-13 Behavior Risk Assessment documented the resident paced and had aimless wandering constantly back and forth with no purposeful walking, had verbal aggression and eloped the first day of admission to the facility. On 11-26-13 at 1:00 P.M. the nurse's note (NN) documented the resident arrived at the facility with family. The resident was alert and oriented to self. On 11-26-13 at 2:45 P.M. the NN documented the resident eloped from the facility through the Assisted Living door. Staff found the resident across the street. The resident had shoes, socks, slacks, and a long sleeve shirt on. Staff assessed the resident's vital signs. The resident's ears, cheeks, and hands were cool to touch. Staff notified the physician. Observation on 12-9-13 at 3:31 P.M. revealed the resident ambulated in the hall independently. The resident stated he was hungry and staff provided a snack for the resident. On 12-10-13 at 8:04 A.M. observation revealed the resident wandered up and down the halls and wandered in and out of other residents rooms. On 12-11-13 at 9:31 A.M. observation revealed the resident wandered up and down the halls in and out of residents' rooms. On 12-11-13 at 10:08 A.M. direct care staff R stated he/she worked in the facility the day the resident eloped. He/she stated he/she normally carried a pager, but the facility was short several pagers so he/she did not have a pager that day. On 12-11-13 at 3:59 P.M. direct care staff P stated he/she worked in the facility the day the resident eloped from the facility and carried a pager, but it did not alarm or display letting him/her know the Assisted Living door alarmed. On 12-10-13 at 4:50 P.M. administrative nurse D stated the door alarm sounded on Assisted Living and staff responded, looked for a resident and did not see any residents in the vicinity. In the mean time, other staff started accounting for the residents' to determine who may have exited through the door. A person from across the street came to the facility and said a person was by a truck across the street and staff found the resident behind a building across the street from the facility. Administrative nurse D stated the charge nurse's pager did not alarm him/her the Assisted Living door opened and Information Technology (IT) staff checked the system and was not able to find a malfunction in the system. He/she stated the charge nurse and certified nursing assistants (CNAs) carried pagers. On 12-11-13 at 9:46 A.M. IT staff FF checked each exit door with the pager and each door alarmed and displayed which exit door was activated. He/she stated nursing monitored the pager system weekly. On 12-11-13 at approximately 2:30 P.M. licensed staff I stated the facility had 7 pagers but 2 pagers were not functioning that day, so 5 staff carried a pager. He/she stated staff checked the doors weekly; before the elopement staff checked the doors randomly. He/she stated the facility did not document when the doors were checked. On 12-11-13 at 4:55 P.M. licensed nurse J stated he/she was the charge nurse the day the resident eloped and his/her pager did not display or sound that the Assisted Living door was activated. The 12-11-13 Elopement Risk Assessment and Safety Policy documented staff ensured the safety of each resident admitted to the facility to avoid elopement. The policy documented staff checked the doors weekly and documented it. The facility failed to ensure this severely cognitively impaired resident's safety when he/she eloped from the facility and failed to monitor the exit doors and pager system weekly to ensure they functioned properly.

The facility census was 25 residents. The sample included 12 residents with 3 residents reviewed for weight loss. Based on observation, record review, and staff interview, the facility failed to prevent weight loss for 2 of 3 residents (#15 and #28). Findings included: - Resident #28's 9/19/11 admission Minimum Data Set 3.0 recorded the resident weighed 127 pounds. The quarterly Minimum Data Set 3.0 dated 6/22/12 recorded the resident was mildly cognitively impaired, had no signs/symptoms of a mood disorder, had no behaviors, was independent with bed mobility, transfer and eating, walked in room with supervision, had no pain, received a diuretic and an anti-depressant, weighed 109 pounds and was 67 inches tall. The Care Area Assessment (CAA) worksheet for cognitive impairment dated 10/5/11 recorded the resident had progressive dementia, was having difficulty dealing with the issues that his/her dementia created, was an avid reader, was well educated and widely traveled, was recently hospitalized with an acute gastrointestinal (GI) bleed which caused him/her to be more weak/unstable, had no falls, took various medications for hypertension, constipation, hypokalemia, [MEDICAL CONDITION] and recent GI bleed, took fluids well, sipped on tap water at bedside, as well as hot tea, juices and milk. The CAA for nutrition did not trigger. The record revealed the resident weighed 110 pounds on 7/01/2012,109 pounds on 6/01/2012 , 118 pounds on 3/06/2012, and 132 pounds on 1/01/2012. The resident lost 6.78% from the first weight to the third weight (4 months), and the resident lost 16.67% from the first weight to the fourth weight.(6 months) The care plan dated 2/10/12 recorded a list of his/her daily afternoon snack schedule: Monday-pink grapefruit,Tuesday-cucumber, Wednesday-green grapes, Thursday-yogurt, Friday-fresh fruit, Saturday-fresh orange, and Sunday-banana. Bed time snacks: Tuesday-yogurt, Wednesday-fresh fruit,Thursday-pink grapefruit, Saturday-cucumber, and Sunday-fresh orange. Also listed was low salt soup, and chicken broth in carton. The care plan listed the following approaches: 1/3/12 [MEDICATION NAME] (an anti-depressant) 25 milligram (mg) daily, 1/4/12 increase [MEDICATION NAME] (a diuretic) to 40 mg daily, and complete blood count, comprehensive metabolic panel, 1/9/12 appointment with the physician, and daily weights for 7 days, 2/8/12 [MEDICATION NAME] (an antibiotic) 750 mg for 7 days for pneumonia, 2/14/12 appointment with the physician for severe headache, 2/15/12 increase [MEDICATION NAME] to 50 mg for depression, 2/20/12 change diet to regular with super cereal daily at breakfast, 3/13/12 a 2 cal supplement at medication pass three times daily, 3/19/12 discontinue 2 cal as resident refused the supplement, and 7/11/12 [MEDICATION NAME] (an appetite stimulant) 80 mg twice daily. The care plan did not address weight loss as a problem and did not state any goals. The admission nutritional assessment dated [DATE] by the registered dietician, recorded the resident's height was 67 inches, weight 127.3 pounds, Carnation Instant Breakfast discontinued as the resident preferred fruit as snacks, will watch weight, and maintain intake over 50-75% at meals. The resident food preferences dated 9/10/11 recorded the resident received a regular diet, loved baked potatoes, liked scrambled eggs, toast, oatmeal, sausage, bacon for breakfast, entrees such as chicken, macaroni/cheese, rice casserole, liked fruit, bananas/berries/peach, preferred fruit over sweets, and did not like tomatoes. Nutrition note dated 1/25/12 recorded the resident's weight was 125.5 pounds on 1/15/12, food intake was 53% for December 2011, and received 75% of meals in his/her room. Nutrition note dated 2/18/12 by registered dietitian recorded resident weighed on 2/12, 127 pounds, 1/12, 131.5 pounds, 12/11, 132.6 pounds, weight down 4.2 pounds in 1 month, 5.6 pounds in 2 months, received a low salt diet, the resident had difficulty with headaches, had recent pneumonia, exacerbation of lung disease, resident was slightly under weight, recommend diet change to regular diet with super cereal at breakfast to get weight back near normal range. Nutrition notes 3/13/12 by registered dietician recorded the resident's March 2012 weight was 117.6 pounds, 2/12 was 127 pounds, 12/11 was 132.6 pounds, weight down 9.4 pounds in 1 month, weight down 15 pounds in 3 months, had regular diet with super cereal, daily 39% intake, had mastoiditis (an infection of the mastoid bone of the skull. The mastoid bone was located just behind the outside ear), no new laboratory results, resident with increased weight loss, recommend to start 30 milliliter (ml) 2 cal three times daily to slow weight loss. Nutrition note dated 7/26/12, the resident's weight on 7/12 was 110 pounds, on 6/12, 109 pounds, food intake was 61 % in 30 days, weight increase 0.9 pounds in 30 days, resident requested his/her food and drink choices for most meals, will continue to monitor. The list of residents who received supplements and super cereal provided by the kitchen revealed the resident did not receive any supplements and did not receive super cereal at breakfast. An observation on 7/30/12 at 8:15 A.M. the resident sat in his/her wheel chair at the breakfast table eating a bowl of oatmeal independently. The resident ate approximately 50-60%. An interview on 7/31/12 at 7:30 A.M. with administrative nursing staff B stated the resident had a lot of [MEDICAL CONDITION], and the physician increased the [MEDICATION NAME] dose on 1/4/12 from 20 milligram (mg) to 40 mg, and it remained at 40 mg. The staff said the resident was on weekly weights, and the facility notified the physician after each weight loss. The staff said the resident refused often to be weighed. The staff said they gave the resident snacks in the middle of the night as he/she often asked for it. The staff said the resident had weight loss, the care plan listed the approaches, but that there were no problem statement or goals listed. An interview on 7/31/12 at 7:44 A.M. with dietary staff F said he/she had a list of residents who received super cereal at breakfast, revealed the resident's name was not on the list, but should be, and wrote the resident's name on the list and informed the cook. An interview 7/31/12 at 9:00 A.M. with dietary staff F said the registered dietician on 2/18/12 recommended super cereal for breakfast, changed the diet to regular, but super cereal just was not on our list. The staff said the registered dietician came in once a month, but if he/she needed him/her more frequently, he/she communicated with him/her via phone or fax. The staff said he/she gave the registered dietician all his/her weight concerns weekly and monthly, and compiled meal percentages monthly. The staff said the dietician on 3/13/12 recommended the supplement, 2 cal. An interview with the resident on 7/31/12 at 11:20 A.M. the resident was alert and oriented said he/she lost weight, did not know why, and said he/she was probably a bit underweight for his/her height. An interview 8/1/12 with consultant K at 1:25 P.M. said he/she came to the facility on a monthly basis and he/she sat down with dietary staff F and talked over all the residents who the facility brought to his/her attention with a nutrition concern. He/she then filled out a Request for Diet Changes form with all his/her recommendations and left that with administrative nursing staff B or with the charge nurse, and wrote a separate form for the physician's signature, if his/her recommendation needed a physician's orders [REDACTED]. The staff said they did not go back to each chart to check if staff followed his/her recommendation, or if staff discontinued a recommendation because of resident refusal. The staff said he/she had verbal discussions with the facility staff on how residents were doing. When asked how communication could be more effective between facility staff and consultant, the consultant said they felt the Request for Diet Change form that he/she utilized to make recommendations had 2 additional columns on it titled Comments and Date Completed was underutilized. The facility failed to provide recommended nutritional interventions as planned, and failed to reassess after the resident refused a nutritional supplement for this resident with significant weight loss. The admission Minimum Data Set ((MDS) dated [DATE] for resident #15 indicated a weight of 146. The quarterly MDS dated [DATE] reported a weight of 134, and a Brief Interview for Mental Status (BIMS) of 3 indicating severely impaired cognition. The resident required extensive assistance with bed mobility, transfer, walking, dressing, and toileting. The resident was independent with eating. The 4/13/12 care plan did not address nutritional status or weight loss. Review of the weights reported: 4/6/12 -146 pounds, 5/1 -143 pounds, 6/1- 142 pounds, 6/3/12- 148 pounds, 6/10/12 -139.7 pounds, 6/17/12 -136.5 pounds, 6/24/12 -136.4 pounds, 7/1/12-134 pounds, 7/8/12- 131.8 pounds, 7/15-- 128.8 pounds, 7/22/12 134.8 pounds, and 7/29/12- 134.2 pounds indicating an overall weight loss of 8%. A 4/6/12 (admitted ) nutrition assessment by the registered dietician indicated a weight of 146.9 pounds. Lab values on 4/10/12 listed [MEDICATION NAME] level at 3.3 (low), and hemoglobin/hematocrit 9.3/27 (low). He/she had poor feeding skills, and requested smaller servings. The resident's average oral intake was 60 percent. The facility was to provide well balanced meals and the resident to maintain an oral intake greater than 50 percent and maintain weight within 5 percent. A nutrition progress note by the registered dietician on 4/8/12 indicated the resident's food intake was 60 percent at this time and he/she would continue to monitor. A nutrition progress note by registered dietician on 6/22/12 indicated the June weight was 141.8 pounds, May weight was 143.2 pounds. The resident's weight was down 1.4 pounds in 1 month, down 5.3 pounds in 2 months. The resident received a low sodium (diet) and had 62-86 percent intake. laboratory results dated [DATE] revealed the [MEDICATION NAME] level was 3, normal was 3.5-5.2. [MEDICAL CONDITION], malaise, fatigue, altered mental status, dementia, intake fair but was decreased. Weight was 141.8 pounds. Recommend the facility try 30 milliliters 2 cal (nutritional supplement) twice a day at medication pass to slow the resident's weight loss. A nutrition recommendation sheet dated 7/3/12 indicated staff notified the physician of an 8.5 percent (12.3 pounds) weight loss in the past 90 days, 6 percent (8.1 pounds) weight loss in past month, and physician order [REDACTED]. A nutrition progress note by registered dietician on 7/27 indicated the July weight 133.7 pounds, June 141.8 pounds, May 143 pounds, down 8 pounds in 1 month, and weight down 9.5 pounds in 2 months. The resident received a low sodium diet. [MEDICATION NAME] 3 (normal 3.5-5.2). The physician requested diet consult. The dietician did not recommend a supplement due to increased Blood Urea Nitrogen level (BUN) and creatinine, but did recommend as stated on 6/22/12 (2 cal 30 ml twice a day). Recommend facility staff to start med pass 60 ml (up from 30 ml due to weight decrease). Review of meal the consumption records indicated an average intake in July of 49% and the dietician progress notes indicated 60% intake in April, and 62-86 % intake in May/June. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of the July 2012 MAR indicated [REDACTED]. A review of [MEDICATION NAME] levels (a measure of the protein level in the blood) indicated the following, 4/10/12 3.3 (normal range of 3.5-5.2), 4/25/12 3.5 (normal range), 5/2/12, 3.4 (low), 5/9/12 3.3 (low), 6/12/12 3.2 (low), and 6/19/12 3.1(low). Observation on 7/30/12 at 7:40 A.M. the resident fed him/herself in the dining room, toast, bacon sausage, and coffee. On 7/30/12 at 11:45 A.M. the resident sat in the dining area, staff served him/her fried chicken, green beans, cake and coffee. At 12:05 P.M. the resident ate only cake. An interview with direct care staff G on 7/31/12 at 9:30 A.M. reported the resident became upset if the staff tried to help feed resident. He/she further stated staff attempted to give 2 cal with medication pass, but that sometimes the resident refused. An interview with administrative nursing staff B on 7/31/12 at 1:45 P.M. indicated dietary staff recorded the resident's meal consumption and reported values at care plan meetings. He/she further stated that he/she expected staff to notify the charge nurse if a resident had numerous refusals of 2 cal. He/she stated the registered dietician provided him/her with a copy of his/her recommendations and they were then faxed by the charge nurse to the physician. He/she acknowledged that interventions recommended on 6/22/12 were not initiated until 7/5/12. An interview on 8/1/12 at 1:25 P.M. with consultant staff J indicated that during his/her monthly visit the facility provided him/her with a list of concerns including weight loss, which administrative nursing staff B and/or dietary staff F completed. He/she stated that he/she completed a Request for Diet Changes when he/she had recommendations to communicate to facility staff and the physician. He/she stated that he/she gave the completed form to administrative nurse staff B or the charge nurse, for a physician's orders [REDACTED]. The facility Weight Loss Identification and Monitoring policy dated 7/5/12 indicated staff weighed each resident monthly, at a minimum, and compared with the prior month's weight. The dietary manager contacted the consulting dietician for a full review of resident's needs, and for recommendations for nutritional interventions. The nurse notified the provider of any recommendations the dietician wrote which required a physician order. Recommended dietary interventions which did not require a physician's orders [REDACTED]. The nurse and/or dietary manager added new nutritional interventions to the care plan. The nurse and dietary manager monitor that interventions occurred as care planned. The clinical record lacked evidence weight loss was unavoidable. The facility failed to assess and implement interventions, in a timely manner, for this dependent resident with declining intake and weight to prevent weight loss.

The facility identified a census of 30 residents. The sample included 16 residents. Based on observation, interview and record review the facility failed to provide nutrition as ordered by the physician and provide registered dietician follow up for a resident with weight loss for 1 of 3 residents (# 1) sampled for nutrition. Findings included: - Resident #1's physician's orders [REDACTED]. The POS ordered staff to provide a diet as tolerated, offer supplement as needed, give [MEDICATION NAME] every morning with breakfast and to give a house shake with meals which was ordered on [DATE]. The Annual Minimum Data Set (MDS) 3.0 dated 6/28/11 recorded the resident with unclear speech and was rarely understood. The resident had continuous inattention. The Brief Interview for Mental Status score was 0 which indicated the resident had severely impaired mental status. The resident required staff supervision and set up for eating. The resident had a swallowing disorder, a therapeutic diet, and no weight loss. The resident's height was 59 inches and weighed 83 pounds. The resident required extensive assistance of 1 staff for bed mobility and extensive assistance of 2 staff for transfers. The Care Area Assessment for nutrition dated 6/28/11 recorded the resident's weight continued to be in the 80's. The resident was a diabetic and taking [MEDICATION NAME] and tolerated the prescribed diet. They received Super Cereal for breakfast and would often eat more than one bowl. The resident fed themselves and could become angry if staff attempted to help with meals. The resident enjoyed chocolate. The resident ate slow and could take an hour or more to eat. The quarterly MDS dated [DATE] recorded the resident required supervision and set-up with meals. The resident ' s weight was 83 pounds, demonstrated no weight loss and received nutritional approaches. The Registered Dietician notes dated 9/2/10 revealed the dietician recommended house shakes with meals. Review of the clinical record revealed the most recent nutritional assessment completed by a Registered Dietician and the most recent calculation for calorie and fluid requirements was dated 2/9/11. This assessment recorded the resident required 25-30 kilocalories for each kilogram of weight, 39 grams of protein daily and 1160 cubic centimeters of fluids. The resident ' s Basic Metabolic Index was 16 which indicated the resident was under weight. The resident received house shakes three times daily with meals, snacks three times daily and super cereal at breakfast. The average dietary intake was poor. The resident's weight was up to 85.2 pounds. Review of the Comprehensive Care Plan last updated on 10/10/11 directed staff to provide a diet as tolerated with ground meat, snacks twice daily, especially chocolate in the afternoon. Staff were to give the resident seconds of the food they liked well. The resident usually did not accept help with eating. The resident had significant weight loss and refused meals related to cognition or agitation. The resident sometimes would take a nap in the chair mid-meal. This care plan directed staff to provide Carnation Instant Breakfast shakes twice daily, (which was not consistent with the physician orders [REDACTED]. Review of the weight log revealed the following weights: 2/1/11 Weight = 86.7 pounds 3/6/11 Weight = 82.9 pounds 4/3/11 Weight =81.6 pounds 5/2/11 Weight = 80.6 pounds - consisting of a 6.1 pound or 7.0 percent weight loss in 3 months. 6/1/11 Weight = 83.0 pounds 8/4/11 Weight = 80.8 pounds 9/1/11 Weight = 82.5 pounds 10/6/11 Weight = 81.3 pounds Review of the July 2011 - September 2011 Medication Administration Records and Treatment Administration Records in the chart failed to document the resident received a supplement. Review of the clinical record revealed staff failed to notify the physician of the resident's weight loss from 2/1/11 to 10/6/11. Observation on 10/20/11 at 8:04 A.M. revealed staff served the resident hot cereal, sausage, French toast, juice, water and chocolate milk. The resident consumed approximately 50% of the meal. The resident fed himself/herself with some difficulty while leaning to the right side of the wheelchair. Staff did not offer any house shakes with the meal. During observation on 10/20/11 at 11:22 A.M. staff served the resident Salisbury Steak, mashed potatoes, brown gravy, vegetable, chocolate milk and water. The resident fed himself/herself the majority of the mashed potatoes and very little of the rest of the meal. Staff did not offer any house shakes, but did bring the resident an additional bowl of mashed potatoes and gravy. At 12:16 P.M. staff served the resident a desert cake. The resident consumed approximately 60% of the meal. Observation on 10/20/11 at 2:45 P.M. revealed the resident laid awake in bed with a pressure sensor alarm positioned on his/her back. Direct care staff brought a mighty shake in a glass covered by plastic wrap and placed it on the night stand next to the resident's bed then left the room. Continued observation on 10/20/11 at 3:15 P.M. revealed the resident remained awake in the same position on the bed and the nutritional supplement remained on the table by the bed untouched. Staff failed to offer to assist the resident to drink the supplement. Further observation on 10/20/11 at 3:32 P.M. revealed staff did not encourage the resident to consume or offer to assist the resident to consume the supplement until 3:42 P.M. nearly an hour after the staff served the supplement to the resident. Observation on 10/20/11 at 3:42 P.M. revealed direct care staff E and F provided extensive assistance for the resident to sit up in the bed and transfer to the wheelchair. Staff removed the plastic wrap from the supplement and handed it to the resident who then handed the supplement back to staff E. The resident refused the supplement. During interview on 10/20/11 at 3:43 P.M. direct care staff F reported staff gave the resident a nutritional shake on his/her shift, but the resident often refused to drink the supplement. During interview on 10/24/11 at 1:03 P.M. administrative staff B reported the resident ate when he/she wanted to and if he/she ate a particular food well, then staff gave the resident more of that food. The resident did not like staff to feed him/her. At times the resident would eat 2 bowls of cereal, other times like that morning for breakfast the resident would not eat. During interview on 10/24/11 at 4:41 P.M. administrative staff B acknowledged staff failed to notify the physician of the resident ' s weight loss and the clinical record lacked evidence the Registered Dietician reassessed the resident ' s weight loss since 2/9/11, approximately 8 months ago. The facility provided a policy entitled Weight Loss Identification and Monitoring without a date which directed staff to weigh each resident monthly and would compare to the prior month's weight, the weight of 3 months prior and 6 months prior. The resident's physician would be notified of any resident weight loss which fell into the significant weight loss as defined as a loss of 5% in one month, 7% in 3 months and 10% in 6 months. The nurse would document notification of the provider. The nurse would notify the Dietary Manager and they would then notify the Consulting Dietician for a full review of the resident ' s needs, and for recommendations for nutritional interventions. The nurse or Dietary Manager would add new nutritional interventions to the care plan and they would monitor that interventions occurred as care planned. The facility failed to provide the physician ordered supplements and update the care plan with the ordered intervention and failed to notify the physician of the resident's weight loss. The facility failed to reassess and provide timely interventions for the prevention of further weight loss.