Every finding on record at Flint Hills Care and Rehabilitation Center

The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to administer scheduled pain medication and take action to manage severe pain for Resident (R)32. Additionally, the facility failed to re-order the scheduled pain medication and notify the provider when the pain medication was not available. As a result of the deficient practice, R32 experienced severe pain with ineffective pain relief for two days and had physical symptoms of abrupt withdrawal, including nausea and vomiting, related to the facility not administering the scheduled, physician ordered pain medication. This also placed R32 at risk for discomfort and further decline in her overall well-being.Findings included: - A review of the Electronic Health Record (EHR), documented R32 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right hip, chronic pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R32's 02/01/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R32 required supervision for bathing and was independent in all activities of daily living (ADL). The MDS documented R32 received no routine pain medications; R32 did not receive as-needed pain medications or non-medicated pain intervention during the observation period. The MDS noted R1 had reported occasional pain with a pain score of three (pain scale with zero indicating no pain and 10 the worst pain imaginable) during the interview. R32's Pain Care Area Assessment (CAA) dated 02/18/25, documented R32 was at risk for alterations in comfort related to cervical (neck/spine) disc disorder. R32 would maintain current level of function and have minimal risks. R32's 05/05/25 Quarterly MDS documented a BIMS score of 13, which indicated intact cognition. The MDS documented R32 required moderate assistance for bathing and was independent for all other ADLs. The MDS documented R32 received routine pain medications, received non-medicated pain intervention, and did not receive as-needed pain medications during the observation period. The MDS noted R32 reported almost constant pain with a pain score of nine out of 10 during the interview. R32's Care Plan dated 04/19/24 directed staff to notify the physician if interventions were unsuccessful or if the current complaint of pain was a significant change from past experiences. The plan instructed staff to monitor and record pain characteristics every shift and as needed for quality and severity using a pain scale of one to ten, location, onset, duration, aggravating factors, and relieving factors. The plan instructed staff to administer analgesics per orders. The plan, dated 03/28/25, instructed staff R32's acceptable pain level was seven. The plan instructed staff to provide non-pharmacological pain interventions such as heat, ice, coloring, watching television, and plants. The plan, dated 05/08/25, instructed staff to identify, record, and treat existing conditions that may increase pain and or discomfort. R32's Physician Orders documented the following orders:Pain monitoring; (able to communicate) Are you free of pain or hurting? If no, indicate response through chart code Y for yes and N for no. Address new or changes in pain, complete pain evaluation in user define assessment every shift for pain, dated 02/11/25.Pregabalin capsule (medication used to treat nerve pain) 150 milligrams (mg), give one capsule by mouth, three times a day for right hip pain, dated 04/26/25. Acetaminophen (over-the-counter pain medication) oral tablet 325 mg, give two tablets by mouth, every four hours as needed for general discomfort, dated 06/28/25. R32's June 2025 Medication Administration Record (MAR) documented the pregabalin 150 mg capsule was not administered on the following dates:06/28/25 07:00 PM through 10:00 PM.06/29/25 07:00 AM through 10:00 AM, 11:00 AM through 02:00 PM, and 07:00 PM through 10:00 PM.06/30/25 between 07:00AM thru 10:00AM. R32's June 2025 MAR documented R32 received as needed acetaminophen 325 mg tablet two by mouth on 06/28/25 at 05:51 PM for a pain score of seven that was effective. R32's MAR lacked any documentation that R32 received any as-needed acetaminophen for pain on 06/29/25 and 06/30/25.R32's June MAR from 06/28/25 through 06/30/25 documented Y indicating the resident was free from pain each shift. R32's X-ray Report dated 02/22/25 documented severe osteoarthritis of the right hip marked by severe narrowing of the weight-bearing aspect of the hip joint, subarticular sclerosis (a hardening or increased density of the bone located just below the cartilage in the hip joint) and marginal osteophytosis (also known as bone spurs or osteophytes, refers to the formation of abnormal bony growths around the hip joint).R32's Progress Note dated 02/28/2025 at 12:08 PM documented the resident had an orthopedic appointment that day for right hip pain. The note documented the following physician communication: The X-rays of the right hip showed advanced arthritis and R32 would need a revision specialist to discuss removal of the hardware and a hip replacement. The Orders Administration Note dated 06/28/25 at 09:40 PM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff contacted the pharmacy about the medication. The Orders Administration Note dated 06/29/25 at 07:53 AM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff were waiting on the pharmacy. The Orders Administration Note dated 06/29/25 at 11:16 AM, documented the pregabalin capsule 150 mg was unavailable. The note indicated staff were waiting on the pharmacy. The Orders Administration Note dated 06/29/25 at 09:01 PM, documented the resident refused to take the pregabalin capsules that were in the E-kit (an emergency medication box). The Orders Administration Note dated 06/30/25 at 06:51 AM, documented the pregabalin capsule 150 mg was not administered, but lacked why the medication was not administered. R32's Progress Note dated 06/30/25 at 10:54 AM documented staff called the pharmacy, and they had a prescription for the pregabalin capsule but did not have it ready to go. The note recorded the facility would pick up the medication in 30 minutes. The note said staff offered R32 six capsules of 25 mg pregabalin the previous night and the night before that but R32 declined and said she wanted acetaminophen. R32's Progress Note dated 6/30/25 at 12:09 PM documented R32 did not receive proper medications due to the medication not being available from the pharmacy; the pharmacy stated that they did not have a prescription. The note documented R32 refused to take the medication from the E-kit because she would have had to take six pills instead of one pill of pregabalin. Staff notified the pharmacy, and the medication was picked up. The note documented R32 had been experiencing some nausea and vomiting.R32's EMR lacked evidence staff notified the physician regarding R32's pain medication and unmanaged pain. During an interview on 06/29/25 at 11:03 AM, R32 reported she was in constant pain with a pain scale score of 10 and reported the facility ran out of her pain medication yesterday and she was in severe pain and was not receiving any other medication for her pain. During an observation on 06/30/25 at 09:00 AM, R32 was in her bed with her eyes closed.During an observation on 06/30/25 at 10:48 AM, R32 sat up in bed with her garbage can in front of her and she was vomiting. R32 reported a wave of nausea came over her and not sure why. R32 reported she could not recall if she had been offered the pregabalin from the nurse on 06/29/25 and reported she was still in severe pain at a level of 10. During an observation on 06/30/25 at 11:23 AM, the pharmacy delivered R32's pregabalin. During an observation on 06/30/25 at 03:45 PM R32 remained in bed and reported she felt a little better and was glad she received her pain medication. On 07/01/25 at 08:30 AM R32 sat up on the edge of the bed and reported her pain was now tolerable and was glad she would be able to get out of bed today. On 06/30/25 at 10:01 AM, Certified Medication Aide (CMA) R reported pregabalin was not in the E-kit. CMA R said R32 used her own pharmacy that did not provide an E-kit, so the facility was not allowed to take any medication from the facility's pharmacy E-kit for residents that used their own pharmacy. CMA R reported that she called R32's pharmacy that morning at 09:07 AM to have R32's pain medication delivered. CMA R reported she was not sure if R32's medication had been ordered over the weekend as she did not work and was not certain if R32's pharmacy was open on Sundays. On 06/30/25 at 10:30 AM, Licensed Nurse (LN) H reported if a resident did not have a medication available, the nurse would pull the medication from the E-kit if it was in the E-kit. If the medication was not in the E-kit the pharmacy would be called for an immediate delivery. LN H reported that R32's pharmacy was slower than the facility pharmacy. LN H reported that R32 was offered the pregabalin from the E-kit last night and she declined per the report she received today as the resident did not want to take that many pills. LN H said the E-kit was reviewed and had a stock of eight 25 mg pregabalin capsules available. LN H reported she was not certain if the pharmacy had been called to re-order the medication. LN H reported that the physician should be called when a medication is not available. During an interview on 06/30/25 at 10:52 AM with R32's pharmacy, Pharmacy Staff HH reported that they received no calls over the weekend for a pregabalin refill for R32. Pharmacy Staff HH said the pharmacy has an on-call number when it is closed and reported the facility called this morning for a refill, and they would be delivering the medication soon to the facility. During an interview on 06/30/25 at 11:11 AM with the facility's pharmacy, Pharmacy Staff II reported when a resident at the facility chose to use their own pharmacy at the facility, those residents would still be able to have staff use the E-kit for medications when their medications were not available. During an interview on 06/30/25 at 11:18 AM, Administrative Nurse D reported she expected the residents to have all their medications available and to be always administered. She expected the nurse to contact the pharmacy to order that medication. Administrative Nurse D reported that the staff is not allowed to use the medications from the E-kit if the residents use their own pharmacy and not the facility pharmacy. Administrative Nurse D also reported that she expected the staff to notify the physician when the medication was unavailable to be administered and that she considered the above concern a medication error. The facility's policy Pain Management dated 02/21/25 documented the facility must ensure pain management is provided to residents who requires such services, consistent with professional standards of practice, comprehensive person-centered care plan, and the resident's goals and preferences. The facility's policy Unavailable Medications dated 11/8/24 documented the facility shall use uniform guidelines for unavailable medications. The facility would maintain a contract with a pharmacy to supply the facility with routine, as-needed, and emergency medications. The facility shall follow established procedures to ensure residents have sufficient medications. Notify the physician of the inability to obtain medications to obtain alternative treatment orders.

The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care for Resident (R) 7. Additionally, the facility failed to provide adequate incontinence care (the management and support provided to individuals who experience involuntary loss of urine) for R40 and R34 when staff failed to complete proper hand hygiene and cleansing of the peri-area. The facility failed to store respiratory equipment in a sanitary manner for R32 and R20. The facility failed to provide personal protective equipment (PPE- gowns, face shields,/eyeglasses/goggles, and gloves) for the laundry staff to utilize when sorting soiled linens. These deficient practices had the potential to spread infections to the residents in the facility.Findings included:- Observation on 06/29/25 at 10:55 AM, R32's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) was intact, with clear liquid noted in the medication chamber, and the intact nebulizer system was in a plastic bag. R32 reported she received her breathing treatment last night and had not seen the staff rinse the nebulizer equipment.Observation on 06/29/25 at 11:00 AM, Certified Nurse Aide (CNA) P and CNA Q provided peri-care to R40. Neither CNA changed their gloves in between the dirty and the clean during peri-care provided. CNA P reported she did not know to change gloves and perform hand hygiene between the clean and the dirty actions of the task.Observation on 06/29/25 at 12:11 PM CNA P moved back and forth between residents, standing while assisting the three residents to eat lunch. CNA P wiped off the residents' faces with their neck napkin and picked up another resident's fork without any hand hygiene being completed during the entire time CNA P assisted the residents. CNA P handled her cell phone several times when assisting the three residents to eat.During an observation on 06/30/25 at 08:30 AM, R20's nebulizer was attached to the machine, and the medication chamber had a clear liquid in the chamber. Licensed Nurse (LN) H prepared to administer R20's nebulizer medication. LN H dumped the clear liquid out of the chamber and added the new medication to the chamber to administer the treatment. LN H reported nurses would rinse the nebulizer out after each use, place the equipment on a paper towel to air dry, and then place the equipment into the storage bag.During an observation on 06/30/25 at 08:37 AM, CNA KK and CNA O provided peri-care to R34. CNA O applied double gloves and removed the first pair after she cleansed the peri-area and then applied the barrier cream. CNA O commented as she removed her gloves that her gloves were now clean to the other aide.During an observation on 06/30/25 at 03:51 PM, CNA JJ applied gloves without performing hand hygiene. CNA JJ did not don a gown. CNA JJ placed two unopened alcohol prep packets on the floor, grabbed an alcohol prep packet off the bathroom floor, opened it up, and placed the alcohol prep pad on her pant leg. CNA JJ emptied the leg bag, and the drain release hit the inside of the graduate several times. CNA JJ used the alcohol pad that was on her pant leg and wiped the drain release. CNA JJ used the dirty gloved hand on the handle of the faucet to turn it on and off, then took off her gloves, picked up the other prep pad off the floor, and propelled the resident back to the lounge in his wheelchair. CNA JJ then performed hand hygiene.During an observation on 07/01/25 at 12:40 PM, no PPE was noted in the soiled part of the laundry room. Laundry Staff W reported that she never wore a gown or goggles in the soiled laundry area when she sorted laundry; she reported she wore just disposable gloves.On 06/29/25 at 12:52 PM, CNA P reported that normally there were more staff to assist residents with meals, and she had to assist all the residents.On 06/29/25 at 01:25 PM, LN G reported that the staff who assisted the residents in the dining room should sanitize their hands between residents. LN G said staff were not to handle their personal cell phones during care.During an interview with CNA O and CNA KK on 06/30/25 at 08:50 AM, CNA O reported that she wore double gloves as it was easier to do that since it was a messy job to complete. CNA KK reported that she would normally change her gloves when providing care, but she would not always wash her hands in between glove changes.During an interview on 06/30/25 at 04:00 PM, CNA JJ reported she should have washed her hands prior to the procedure, and she should have worn a gown. She reported she should have placed the prep pads on a barrier, and she should not have touched the leg bag drain to the inside of the graduate, and she should have washed her hands before she moved the resident back to the lounge.During an interview on 06/30/25 at 04:04 PM, LN H reported the staff should wear PPE, including a gown, when performing care when emptying the catheter bag. LN H reported that handwashing prior to providing care and after is important and that no items should be placed directly on the floor without a barrier. She reported that the drainage bag drain should not touch the inside of the graduate.During an interview on 07/01/25 at 12:42 PM, Laundry Supervisor V reported that the goggles and gown were usually hung in the soiled room by the sink and reported she did not know where the PPE was.During an interview on 07/01/25 at 12:53 PM, Administrative Nurse E reported no staff should double glove at any time when providing care and said the facility expected the staff to perform hand hygiene after gloves were removed. Administrative Nurse E said she expected staff to wear the required PPE for residents who require EBP. Additionally, she expected staff to sit when assisting residents to eat and expected staff to sanitize their hands in between residents, especially after wiping a resident's mouth, and no staff should be handling their cell phones when providing any care to residents. Administrative Nurse E stated she expected the laundry staff to have and use PPE in the soiled laundry room and expected the nebulizers to be rinsed out and air dried after each use before placing the equipment in the storage bag.During an interview on 07/01/25 at 01:19 PM, Consultant Staff GG reported that the laundry aide had been educated to use the impervious (provides protection against splashing and spraying of body fluids) barrier gown and goggles as her PPE and reported the PPE had not been replaced after the area was painted.The facility's policy Nebulizer Therapy dated 11/08/24 documented clean equipment after each use, disassembling parts after each treatment, rinsing the nebulizer cup and mouthpiece with sterile or distilled water, shaking off excess water, air drying on an absorbent towel, and once completely dry, storing nebulizer equipment in a zip lock bag.The facility's policy Perineal Care dated 11/08/24 lacked the documentation regarding washing hands in between glove changes. The policy documented change gloves if soiled and continuing with perineal care.The facility did not provide a policy on emptying a catheter drainage bag.The facility's policy Sorting Soiled Linen dated 01/2016 documented that soiled linens are sorted into proper wash classifications, employees must wear the proper PPE, which includes gloves and a protective apron.The facility's policy Meal Supervision and Assistance dated 08/2024 lacked direction for staff to be seated during meal assistance and lacked hand hygiene.

The facility reported a census of 44 residents; the sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) during transportation provided by the facility for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures.Findings included:- Review of Certified Nurse Aide (CNA) /Transportation Aide's O's health care credentials revealed she lacked CPR certification. Review of the facility's Code Status Listing dated [DATE], revealed 24 of the 44 residents identified as Full Code (requesting to receive CPR in the event their heart stopped and/or breathing stopped). Review of the Transportation Schedule/Log, dated [DATE] through [DATE], revealed that CNA O transported 17 Full Code residents for 52 separate appointments during that time frame. The resident transported by the facility for offsite appointments without available CPR-certified staff included Resident (R)12, R18, R29, R32, and R36. On [DATE] at 12:38 PM, Administrative Nurse D confirmed the above findings. She reported that the facility should ensure a CPR-certified staff member is available when transporting residents to appointments. She agreed that the lack of CPR-certified staff when providing transportation placed the residents at risk for decreased quality of care and inadequate resuscitative measures. The 06/2017 facility policy Medical Emergency Response documentation included that current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider whose training includes hands-on skills practice and in-person assessment and demonstration of skills. CPR-certified staff are available at all times.

The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to identify an elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) as a potential neglect and report to the State Agency (SA) as required. This placed the resident at risk for neglect and impaired safety.Findings included:- Review of the Electronic Health Record (EHR) documented Resident (R)30 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and mood disorder. R30 admitted to the facility on [DATE].R30's 09/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of eight, which indicated moderately impaired cognition. The MDS documented R30 required maximal assistance for bathing, transfers, dressing, and toileting. The MDS documented R30 required moderate assistance with oral care, personal hygiene, and bed mobility. The MDS documented R30 was independent with eating and wheelchair mobility. The MDS documented R30 had wandering behaviors daily and placed the resident at significant risk of getting to a potentially dangerous place, like outside the facility.R30's 09/18/24 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R30 had impaired cognitive function/dementia or impaired thought processes related to his dementia. R30 would get agitated when he could not remember what to do or how to do it. R30 would wander looking for different places.R30's 09/18/24 Behavioral Symptoms CAA documented R30 was an elopement risk and wandered aimlessly. R30's information and photo were placed in the elopement book. Staff are aware R30 was a risk for elopement, and his anxiety could cause him to wander.R30's 04/30/25 Quarterly MDS documented a BIMS score of eight, which indicated moderately impaired cognition; no behaviors were noted. The MDS documented R30 was dependent on staff assistance for toileting and required maximal assistance with showers and moderate assistance with lower dressing. The MDS documented R30 was independent with eating and wheelchair mobility.R30's Care Plan dated 09/17/24, documented R30 was at risk for elopement related to cognitive status, mobility status, and assessment indicating a high risk potential for wandering/elopement. The plan directed staff to provide the following interventions:Encourage independence while in the building but ensure supervision while outside.Encourage participation in positive, meaningful activity programs of choice.Engage R30 in active conversation as a form of redirection.In the event of an elopement, follow search and reporting protocols.Keep routine consistent to alleviate confusion.Observe for signs/symptoms of acute illness, which may enhance confusion.Provide picture/identification and description of R30 in the elopement book.Redirect when wandering around doors/exits.Visualize the resident's whereabouts frequently.R30's Wandering/Elopement Risk Scale, dated 09/10/24 and 12/20/24, documented a score of 10.0 which indicated the resident was at risk to wander.R30's Progress Note on 12/22/24 at 01:00 PM, documented upon coming out of the third dining room bathroom, an unknown Licensed Nurse (LN) was notified by an unknown Certified Nurse Aide (CNA) that a family member alerted staff that R30 exited the building through the north side Emporia Lane hallway exit. The note recorded both the LN and CNA ran to the door. The LN entered the door code and ran outside to find R30 in his wheelchair on a street near the facility. The note recorded the LN asked R30 what he was doing, to which he said he was leaving the [expletive] place. The note documented staff found and safely returned R30 into the facility, and elopement procedure was initiated. Staff assessed R30 for pain; he denied any injuries, and none were noted.R30's Risk Management Report dated 12/22/24 at 01:00 PM documented the above note and that R30 was oriented to person but confused with impaired memory; he was an active seeker and wanderer.During an observation on 06/30/25 at 09:40 AM, R30 was noted to be able to self-propel in his wheelchair in the hallway.On 06/29/25 at 01:09 PM, R30's representative reported that R30 was found outside the facility last year and reported she was told he did not leave the facility property. R30's representative reported that she was concerned now that she heard R30 had made it out to the street when he exited the building.During an interview on 06/30/25 at 12:56 PM Administrative Nurse D reported R30 exited the building on 12/22/24 and did not report to the State Agency as she did not feel like the incident was a true elopement. Administrative Nurse D said the resident was in view of a family member of another resident, so R30 really did not elope. Administrative Nurse D reported she did not receive a statement from the family/visitor who reported to the nursing staff that R30 had gone out the door.During an interview on 06/30/25 01:30 PM Administrative Staff A reported that she was told the day R30 exited the facility, the resident was observed by a housekeeper and the housekeeper kept the resident in their sight outside until the nursing staff went outside to assist the resident back into the facility. Administrative Staff A reviewed the investigation and said she would call the incident an elopement. Administrative Staff A reported that she could not recall any immediate interventions to prevent R30 from elopement except for the medication change that was requested.The facility's policy Residents Right to Freedom from Abuse, Neglect, and Exploitation. dated 2017 documented the facility have a duty to report all alleged violations of abuse, neglect, exploitation, mistreatment, including injuries of unknown origin as well as the results of all investigations of alleged violations pursuant to 42 CFR 483.12c.

The facility had a census of 44 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 32 This placed the resident at risk for impaired rights related to returning to the facility.Findings included:- Review of the Electronic Health Record (EHR), documented R32 had diagnoses of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right hip, chronic pain, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).R32's 02/01/25 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The MDS documented R32 required supervision for bathing and was independent for all activities of daily living (ADL).R32's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 02/18/25, documented R32 required assistance with ADLs related to weakness and shortness of breath. R32 had depression and may have lack of motivation to complete ADLs.R32's 01/12/25 at 12:18 AM Progress Note documented resident was transferred to the hospital due to a large amount of blood in stool.R32's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R32 and/or his representative.On 07/01/25 at 09:43 AM, Licensed Nurse (LN) G reported when a resident was transferred to the hospital, the nurse asked the resident and or representative if they wanted a bed hold. LN G reported there was no form that was completed by the nurse at the time of transfer and said she would notify Social Service Designee (SSD) X, Administrative Nurse D and Administrative Staff A of the transfer.On 07/01/25 at 09:55 AM, SSD X reported there was no bed hold completed when R32 transferred to the hospital on [DATE]. SSD X reported the nurse could complete a Bed-Hold Notification Agreement under the assessment tab in the EHR. Additionally, SSD X reported the bed hold could be completed on the next business day if the form had not been completed the day of transfer.During an interview on 07/01/25 at 10:00 AM, Administrative Staff A she expected the bed-hold to be completed the day of the transfer or the next business day.The facility's Transfer and/ or Discharge, Including Against Medical Advice, Discharge Notification dated 11/08/24 documented to provide a notice of transfer and the facility's bed hold notice to the resident and representative as indicated.

The facility reported a census of 44 residents; 12 residents were sampled for review. Based on observation, interview, and record review the facility failed to ensure accurate Minimum Data Set (MDS) assessments for Residents (R) 18, R42, and R7 related to urinary continence and/or indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) and R7 for communication/sensory status. The deficient practice placed the affected residents at risk for impaired care due to unidentified care needs.Findings included:- R18's Electronic Health Records (EHR) documented diagnoses, which included neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying).R18's admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. He had an indwelling catheter and was always continent (able to control bladder/urine flow).The 06/19/25 Urinary Continence Indwelling Catheter Care Area Assessment, (CAA) documented the resident had an indwelling catheter for neurogenic bladder.On 06/29/25 at 03:57 PM, the resident sat in his wheelchair. His catheter tubing was positioned below his bladder. He reported he had an indwelling catheter because he could not completely empty his bladder without it. R18 verified he has had a catheter throughout his stay at the facility.On 07/01/25 at 11:54 AM, Administrative Nurse F verified above findings and reported she always coded the MDS for residents with indwelling catheters as always continent. She stated that the facility used the Resident Assessment Instrument (RAI) manual for guidance to accurately code the MDS. She reviewed the RAI manual, and she confirmed she should code the MDS for residents with catheters as not rated. Administrative Nurse F stated the admission MDS, dated [DATE] was not accurate.The RAI manual, dated 10/2019, documentation included the MDS coding for the number of calendar days in the look-back period should be coded to reflect Code 9, not rated: if during the seven-day look-back period the resident had an indwelling bladder catheter. - R42's Electronic Health Records (EHR), dated 06/01/25, documented diagnoses which included neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying).R42's admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. He had an indwelling catheter and was always continent (able to control bladder/urine flow).The 05/28/25Urinary Continence Indwelling Catheter Care Area Assessment (CAA) documented the resident had an indwelling catheter for urinary retention.On 06/29/25 at 11:49 AM, R42 laid in bed with his catheter positioned through his right pant leg below his bladder.On 07/01/25 at 11:54 AM, Administrative Nurse F verified above findings and reported she always coded the MDS for residents with indwelling catheters as always continent. She stated that the facility used the Resident Assessment Instrument (RAI) manual for guidance to accurately code the MDS. She reviewed the RAI manual, and she confirmed she should code the MDS for residents with catheters as not rated. Administrative Nurse F stated the admission MDS, dated [DATE] was not accurate.The RAI manual, dated 10/2019, documentation included the MDS coding for the number of calendar days in the look-back period should be coded to reflect Code 9, not rated: if during the seven-day look-back period the resident had an indwelling bladder catheter. - R7's Electronic Health Records (EHR) dated 06/01/25, documented diagnoses which included bladder obstruction and hearing loss.The 08/30/24, Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The resident had an indwelling catheter and was always continent (able to control bladder/urine flow).The 09/06/24 Urinary Continence/Indwelling Catheter and Communication Care Area Assessment (CAA) documented he had an indwelling catheter due to urinary retention and a communication problem related to his hearing deficit.R7's 05/26/25 Quarterly MDS documentation included a BIMS score of six, indicating severe cognitive impairment. His hearing was adequate, and he did not wear hearing aids. R 7 had a catheter, and the MDS recorded he was always continent.R7's EHR Physician Orders (POS) documented the following orders:Enhanced Barrier Precautions due to his catheter placement, ordered 11/4/24.Place hearing aid on charger in med room at bedtime, ordered 04/23/25.On 06/30/25 at 03:40 PM, observation revealed R7 returned from his appointment. The resident's hearing aid was not in his ears. Certified Medication Aide (CMA) T found the hearing aids in his bag with his paperwork in the back of his wheelchair.On 07/01/25 at 11:54 AM, Administrative Nurse F verified above findings and reported she always coded the MDS for residents with indwelling catheters as always continent. She stated that the facility used the Resident Assessment Instrument (RAI) manual for guidance to accurately code the MDS. She reviewed the RAI manual, and she confirmed she should code the MDS for residents with catheters as not rated. Administrative Nurse F stated the Annual MDS, dated [DATE] was inaccurately coded as always continent and the Quarterly MDS, dated [DATE] was inaccurately coded as always continent and lacked indication of residents hearing deficit and use of hearing aids.

The facility reported a census of 44 residents. The sample included 12 residents, with one reviewed for hearing aid use. Based on the interview and record review, the facility failed to ensure that dependent Resident (R) 7 received staff assistance in placing his hearing aids. This placed the resident at risk for social isolation, mental decline, and loss of independence. Findings included:- R7's Electronic Health Record (EHR) revealed diagnoses of conductive hearing loss and a need for assistance with personal care. R7's 08/30/24 Annual Minimum Data Set (MDS) documented that the resident had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R7 was dependent on staff for toileting, bathing, dressing, footwear, and personal hygiene. The MDS noted R7 had minimal difficulty with hearing, and R7 used hearing aids. The 09/06/24 Communication Care Area Assessment (CAA) documented R7 had a communication problem related to having difficulty understanding or making his needs known. The CAA noted R7 had hearing deficits and staff would ensure R7 understood what requests were being made. R7's 05/26/25 Quarterly MDS documented a BIMS score of six, which indicated severely impaired cognition. The MDS documented R7's hearing was adequate, and he had no hearing aids. R7's Care Plan dated 06/07/23 documented R7 had a communication problem related to having difficulty understanding or making his needs known, related to a hearing deficit. The plan did not address R7's hearing aids.R7s Physician's Orders documented an order that directed the Certified Medication Aide (CMA) to ensure that the resident had a leg bag on, his hair was combed, his face washed, and shaved. The order directed to ensure R7 had clean clothes and a hearing aid when going to the Program of All-Inclusive Care for the Elderly (PACE) Monday through Friday by 08:30 AM, date ordered 04/10/25. R7s Physician's Orders documented an order to place the hearing aid on the charger in the medication room at bedtime, date ordered 04/23/25R7's Progress Note dated 01/23/25 at 09:07 AM documented that his right hearing aid was identified as missing when staff assisted R7 in getting ready for PACE services.R7's Progress Note dated 04/29/25 at 03:28 AM documented that the staff were unable to find the hearing aids to place on the charger in the medication room. R7's Progress Note dated 05/03/25 at 09:56 PM documented R7 did not have hearing aids on, and the hearing aids could not be located. R7's Progress Note dated 06/23/25 at 07:45 PM documented that hearing aids were not with R7 when he returned from PACE. During an observation on 06/29/25 at 01:55 PM, R7 had no hearing aids in his ears. R7 sat in the television lounge with the television on. R7 had difficulty hearing when he was asked questions. During an observation on 06/30/25 at 03:40 PM, R7 returned from the PACE program and was seated in his wheelchair at the church service activity. R7 had no hearing aids in his ears. Certified Nurse Aide (CNA) JJ found the hearing aids in a bag attached to the back of R7's wheelchair. During an observation on 07/01/25 at 08:25 AM, R7 sat in the television lounge in a recliner with no hearing aids noted in his ears. R7 reported he had no hearing aids when asked. On 06/30/25 at 11:21 AM, Activity Staff Z reported that R7 required bilateral hearing aids, and the nursing staff would apply the hearing aids. On 07/01/25 at 08:36 AM, CNA O reported she had to wait for the Certified Medication Aide to give her R7's hearing aids out of the locked medication cart. CNA O reported R7 had been up in his recliner for a couple of hours now and had his breakfast without his hearing aids applied. On 07/01/25 at 09:48 AM, CMA R reported she had not placed R7's hearing aids in his ears that morning and reported that the nurse had applied them as the hearing aids were no longer locked up in the medication room. On 07/01/25 at 09:55 AM, Licensed Nurse (LN) G reported she applied R7's hearing aids before he transferred to PACE that morning. LN G reported that R7's hearing aids could not be located at times, but eventually, staff would find them.On 07/01/25 at 11:52 AM, Administrative Nurse F expected staff to apply and remove the resident's hearing aids daily. The facility's policy Care and Use of Hearing Aids, dated 11/08/24, documented it is the practice of this facility to assist residents in using their hearing aids and to provide care to the hearing aids to ensure they are clean and protected from loss or breakage when not in use.

The facility reported a census of 44 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)30, identified as a high risk for elopement (when a cognitively impaired resident leaves the facility or safe area without staff knowledge or supervision). This placed the resident at risk for injuries, accidents, and further elopements. Findings included:- Review of the Electronic Health Record (EHR) documented R30 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and mood disorder. R30 was admitted to the facility on [DATE].R30's 09/15/24 Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of eight, which indicated moderately impaired cognition. The MDS documented R30 required maximal assistance for bathing, transfers, dressing, and toileting. The MDS documented R30 required moderate assistance with oral care, personal hygiene, and bed mobility. The MDS documented R30 was independent with eating and wheelchair mobility. The MDS documented R30 had wandering behaviors daily and placed the resident at significant risk of getting to a potentially dangerous place, like outside the facility. R30's 09/18/24 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R30 had impaired cognitive function/dementia or impaired thought processes related to his dementia. R30 would get agitated when he could not remember what to do or how to do it. R30 would wander looking for different places. R30's 09/18/24 Behavioral Symptoms CAA documented R30 was an elopement risk and wandered aimlessly. R30's information and photo were placed in the elopement book. Staff are aware R30 was a risk for elopement, and his anxiety could cause him to wander. R30's 04/30/25 Quarterly MDS documented a BIMS score of eight, which indicated moderately impaired cognition; no behaviors were noted. The MDS documented R30 was dependent on staff assistance for toileting and required maximal assistance with showers and moderate assistance with lower dressing. The MDS documented R30 was independent with eating and wheelchair mobility.R30's Care Plan dated 09/17/24, documented R30 was at risk for elopement related to cognitive status, mobility status, and assessment indicating a high risk potential for wandering/elopement. The plan directed staff to provide the following interventions:Encourage independence while in the building, but ensure supervision while outside.Encourage participation in positive, meaningful activity programs or choices.Engage R30 in active conversation as a form of redirection.In the event of an elopement, follow search and reporting protocols.Keep the routine consistent to alleviate confusion.Observe for signs/symptoms of acute illness, which may enhance confusion.Provide picture/identification and description of R30 in the elopement book.Redirect when wandering around doors/exits.Visualize the resident's whereabouts frequently.R30's Wandering/Elopement Risk Scale dated 09/10/24 and 12/20/24 documented a score of 10.0, which indicated the resident was at risk to wander. R30's Progress Note on 12/22/24 at 01:00 PM, documented upon coming out of the third dining room bathroom, an unknown Licensed Nurse (LN) was notified by an unknown Certified Nurse Aide (CNA) that a family member alerted staff that R30 exited the building through the north side Emporia Lane hallway exit. The note recorded both the LN and CNA ran to the door. The LN entered the door code and ran outside to find R30 in his wheelchair on a street near the facility. The note recorded the LN asked R30 what he was doing, to which he said he was leaving the [expletive] place. The note documented staff found and safely returned R30 into the facility, and the elopement procedure was initiated. Staff assessed R30 for pain, which he denied, and injuries; none were noted.R30's Risk Management Report dated 12/22/24 at 01:00 PM documented the above note and that R30 was oriented to person but confused with impaired memory; he was an active seeker and wanderer. Maintenance Supervisor U's Witness Statement dated 12/22/24 documented he showed up to the facility at 01:35 PM to check the function of the exit door on Emporia Hall. The door alarm worked with no concerns. The housekeeper's Witness Statement dated 12/22/24 documented that she was on Jayhawk hallway and a family member came to tell her a resident had left. The family member thought the housekeeper did not understand and went to get other staff members. The housekeeper entered the code in the door, and another lady went and got R30.The Logbook Report for Doors, Locks, and Alarms for exit doors documented the doors were checked weekly, and were last checked on 12/21/24, and were functioning. During an observation on 06/30/25 at 09:40 AM, R30 was noted to be able to self-propel in his wheelchair in the hallway.On 06/29/25 at 01:09 PM, R30's representative reported that R30 was found outside the facility last year and reported she was told he did not leave the facility property. R30's representative reported that she was concerned now that she heard R30 had made it out to the street when he exited the building. On 06/30/25 at 08:01 AM, Maintenance Supervisor U reported that the exit doors were checked weekly to verify that the door alarm would function properly. Maintenance Supervisor U reported he had to come to the facility on a Saturday in December to check an alarm on an exit door, as he had received a call from Administrative Staff A to make sure the door was functioning properly, as a resident had made it outside. Maintenance Supervisor U reported he did not complete a log for that day, and the door was checked.On 06/30/25 at 09:54 AM, Certified Medication Aide (CMA) R reported she was unsure if an elopement book was available. On 06/30/25 at 10:18 AM, CNA O reported that she could not think of any resident who was an elopement risk. CNA O reported she was not sure if there was an elopement book. On 06/30/25 at 10:27 AM, LN H provided the Elopement Book at the nurse's station that contained seven residents in the book, which included R30. LN H reported that the residents who had a history of elopement, were confused, and able to ambulate independently, and or exit seeking would be at high risk for elopement. LN H reported that the higher the number on the Wander/Elopement Risk Scale, indicated the resident was higher risk. LN H reported that a score of 10.0 was high risk for elopement and that R30 would wander around independently in his wheelchair.During an interview on 06/30/25 at 12:56 PM, Administrative Nurse D reported R30 exited the building on 12/22/24 and did not report to the State Agency as she did not feel like the incident was a true elopement. Administrative Nurse D said the resident was in view of a family member of another resident, so R30 really did not elope. Administrative Nurse D reported she did not receive a statement from the family/visitor who reported to the nursing staff that R30 had gone out the door. During an interview on 06/30/25 01:30 PM, Administrative Staff A reported that she was told that the day R30 exited the facility, the resident was observed by a housekeeper and the housekeeper kept the resident in their sight outside until the nursing staff went outside to assist the resident back into the facility. Administrative Staff reviewed the investigation and said in review, she would call the incident an elopement. Administrative Staff A reported that she could not recall any immediate interventions to prevent R30 from eloping, except for the medication change that was requested.The facility's Elopement/Wandering Residents dated 11/08/24, documented this facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with the person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Staff are to be vigilant in responding to alarms in a timely manner.

The facility reported a census of 44 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview, and record review, the facility failed to notify the physician for blood sugars outside of the physician-ordered parameters for Resident (R) R29. The deficient practice placed the affected resident at risk for complications related to hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar)Findings included:- R29's Physician Orders dated 06/01/25 revealed the following diagnosis: type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).R29's Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS noted R29 dependent upon staff for all activities of daily living (ADLs). The MDS did not indicate that injections or insulin were administered.R29's Quarterly MDS dated [DATE] indicated a BIMS score of zero, indicating severely impaired cognition. The MDS noted R29 received seven days of injections and seven days of insulin (a hormone that lowers the level of glucose in the blood) during the observation period.R29's Care Plan, revised on 02/22/25, indicated R29 received diabetes medication as ordered by the physician, and fasting blood sugars as ordered four times a day. The plan directed staff to report blood sugars if less than 60 milligrams per deciliter (mg/dl) and greater than 400 mg/dl. R29's Physician Orders documented a finger stick blood glucose four times a day; notify the physician if the blood sugar is less than 60 mg/dl or greater than 400 mg/dl R29's Electronic Medical Record (EMR) under the Vitals tab, reviewed from 04/18/25 to 06/30/25, documented two blood sugars over the 400 mg/dl parameter. On 05/11/25 at 05:02 PM, R29's blood sugar was 435 mg/dl. On 05/13/25 at 10:40 AM, R29's blood sugar was 499 mg/dl.R29's Progress Notes dated 05/11/25 at 05:02 PM lacked evidence of notification to the physician for blood sugars out of the parameters.R29's Progress Note dated 05/13/25 at 10:40 AM lacked evidence of notification to the physician for blood sugars outside the parameters.On 07/01/25 at 11:00 AM, Licensed Nurse (LN) G stated that the nurses should notify the physician of blood sugars when the level is above the ordered parameters to obtain an order for an additional dose of insulin.On 07/01/25 at 11:10 AM, Administrative Nurse D stated the nursing staff should reach out to the physician for additional insulin orders when blood sugars are above the parameters. The facility did not provide a policy for unnecessary medications.

The facility reported a census of 44 residents. Based on record review and interviews, the facility failed to submit accurate staffing information through Payroll Based Journaling (PBJ - Staffing Data Report), when the facility failed to submit accurate weekend staffing coverage hours.Findings included:- Review of the PBJ Quarterly Staffing Data Report documented that the facility had excessively low weekend staffing in Fiscal Year (FY) 2024 Quarter (Q) 3, FY 2024 Q4, FY 2025 Q1, and FY 2025 Q2.Review of the Nursing Schedule and nursing hours for weekend staffing during the above-noted quarters revealed staffing was adequate and consistent with the weekday (Monday through Friday) staffing patterns.On 07/01/25 at 12:38 PM, Administrative Staff A and Administrative Nurse D reviewed the PBJ reports, the nursing schedule, and daily staff postings for the weekends of the above-noted quarters and concurred that the PBJ Data Reports were inaccurate. They stated the facility's administrative nurses often filled in on the weekends to provide direct care. They confirmed those hours were not reflected in the PBJ data reports. Administrative Staff A stated that the facility's corporate office submitted the PBJ data and did not accurately reflect the direct care nursing time provided to the residents of the facility.The facility did not provide a policy to address reporting accurate PBJ Data.

The facility reported a census of 45 residents. Based on observation, interview, and record review, the facility failed to ensure staff-maintained food on the steam table at a temperature of at least 135 degrees. Findings included: - Observation, on 06/24/24 at 12:30 PM, revealed Dietary Staff CC, obtained temperature of the food on the steam table as follows: Chicken paprikash had a temperature of 110 degrees Fahrenheit. Buttered egg noodles had a temperature of 120 degrees Fahrenheit. Interview on 06/24/24 at 12:30 PM, Dietary Staff CC reported she kept the food uncovered while she served the food to the residents. Dietary Staff CC obtained a temperature of the food when she removed it from the oven/cook top which registered 170 degrees Fahrenheit and placed it in the steam table pans but did not obtain the temperature as it was held on the steam table prior to serving the residents. Interview on 06/25/24 at 12:05 PM with Dietary staff BB, reported dietary staff had the exhaust fans on and the air conditioner yesterday (06/24/24) and this may have caused the lower food temperatures. Dietary Staff BB confirmed she would expect staff to ensure the holding temperature of the food on the steam table at 135 degrees Fahrenheit. The facility policy Food Production and Food Safety, dated 2021, instructed staff the maintain a temperature at or above 135 degrees Fahrenheit during holding distribution and service. The facility failed to ensure staff maintained the holding temperature of the food at 135 degrees Fahrenheit on the steam table as required to prevent food borne illness.

The facility reported a census of 45 residents with nine residents selected for review, which included four residents reviewed for abuse, neglect, and exploitation. Based on observation, interview and record review, the facility failed to ensure staff were competent in interactions with aggressive behaviors for one Resident (R)9, with dementia. Findings included: - Review of Resident (R)9's medical record revealed diagnoses that included frontal temporal neurocognitive disorder( sometimes called frontotemporal dementia, which is damage to neurons in the frontal and temporal lobes of the brain which result in unusual behaviors, emotional problems, trouble communicating, difficulty with work, or difficulty with walking), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and moderate dementia (progressive mental disorder characterized by failing memory, confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired ability to make decisions. The resident received antipsychotic (a class of medications used to treat major mental conditions which cause a break from reality) medications. The resident was frequently incontinent of urine and had no impairment in upper or lower extremities. The Cognitive Loss Care Area Assessment (CAA), dated 03/24/24, assessed the resident required consistency in care, and staff advised to use cues and reorientation to assist with this. The resident received psychotropic medications (medications that alter mood or thought). The Care Plan dated 04/03/24, instructed staff the resident had behaviors of resistance to cares and aggression, and poor impulse control. The care plan instructed staff to calmly walk away from the resident and approach later . A Nurse's note, dated 06/22/24 at 02:25 AM, revealed Licensed Nurse I, assessed R9 for signs of abuse and found no redness or bruising or statements of pain. An Intake Detail for Complaint 188743, dated 06/24/24 at 08:50 AM, revealed the facility was investigating an alleged altercation between R9 and Certified Nurse Aide (CNA) M. Observation on 06/25/24 at 07:30 AM, revealed the resident seated in his wheelchair in the dining room with his eyes closed. Certified Medication Aide (CMA) R stated the resident was offered food and refused to eat but had taken his crushed medications earlier in the morning. CMA R stated the resident would spit out his medications at times and refused cares. Interview, on 06/25/24 at 07:44 AM, with Administrative Nurse D, revealed the resident had aggression, and medication the provider made medication changes. Administrative Nurse D stated staff received training in dementia through computerized and paper courses, but staff would probably benefit with a more interactive approach to training for aggression in residents. Observation, on 06/25/24 at 08:05 AM, revealed Certified Nurse Aide (CNA) O, CNA P and Administrative Nurse D, transferred the resident from his wheelchair to recliner in the common living area. The resident required constant cuing and had difficulty following directions for the transfer. Interview, on 06/25/24 at 08:30 AM, with CNA O revealed the resident could become aggressive with staff during cares, and the staff should remain calm and walk away from the resident and come back later. Interview, on 06/25/24 at 08:45 AM, with Licensed Nurse (LN) H, revealed the resident's dementia worsened and the resident becomes agitated when there is a lot of noise around him. LN H stated the resident did not comprehend what staff were doing when they provided cares and easily became agitated. Staff should wait for the resident to calm down and try again. Interview, on 06/25/24 at 08:44 AM, with CNA M, revealed on 06/22/24 at approximately 11:30 PM, she and CNA N (a new trainee) took the resident to his room for incontinence care and to prepare the resident for bed. CNA M stated the resident became uncooperative after transferring him into bed and CNA N left the room to find another staff member for assistance. CNA M stated with the resident positioned in bed, she attempted to remove his shorts and soiled brief. The resident struck his fists at her, yelled, and pulled her hair and caused her to lose her balance and she raised her arms in response to this. CNA M stated she yelled out in pain and the resident continued to yell. CNA N and LN G came into the room and deescalated the situation and completed the tasks. Interview, on 06/25/24 at 12:30 PM, LN G revealed on 06/22/24 at approximately 11:45 PM, CNA N requested her assistance with R9. LN G stated she entered R9's room shortly after CNA N and saw R9 hit CNA M with his right hand while CNA M held onto his left hand with both of her hands. The resident continued to attempt to strike at CNA M and kick her. LN G stated she, CNA M and CNA N were able to change the resident out of his wet brief and provide incontinence care with difficulty. LN G stated the resident frequently became aggressive and more training in dealing with this type of behavior would be beneficial for staff and the resident. The facility policy Comprehensive Care Plans, reviewed 11/12/23, instructed staff the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record including discussions with the resident/resident representative. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. The facility failed to ensure staff competency for interactions with aggressive residents and failed to provide person centered training for this resident's resistive behaviors to prevent potential detrimental physical and mental health consequences.

The facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for skin conditions. Based on record review and interview, the facility failed to provide appropriate treatment services for one Resident (R)7's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) at a Stage 3 (full thickness pressure injury extending through the skin into the tissue below), present on admission to her coccyx (area at the base of the spine) when they failed to obtain physician ordered treatment until seven days after admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a pressure reducing device to the seat of her wheelchair until three days after admission. R7's pressure area deteriorated to an unstageable wound, became infected, and she required hospitalization for wound management. Findings included: - The Medical Diagnosis tab for R7 included diagnoses of protein-calorie malnutrition, pressure ulcer of sacral region (large triangular bone/area between the two hip bones), muscle weakness, functional diarrhea, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and tremor. The Admission/Discharge report dated 11/21/23 through 02/20/24 revealed R7 admitted to the facility from the hospital on 01/26/24 and discharged back to the hospital on 02/13/24 (the 19th day of stay at the facility). The Admission Minimum Data Set (MDS) dated [DATE] assessed R7 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R7 did not reject care, was frequently incontinent of bowel, and used a walker and a wheelchair for mobility. R7 was dependent on staff for toileting and for rolling left to left and right side and returning to her back when in bed. She was at risk for pressure ulcers and had one stage 3 ulcer which was present on admission and skin tears. The MDS revealed she had a pressure reducing device for her chair but not the bed and was not on a turning/repositioning program. R7 received pressure ulcer/injury care and nutrition or hydration to manage skin problems, application of dressings and ointments/medications other than to feet. The Pressure Ulcer/Injury Care Area assessment dated [DATE] revealed R7 admitted from the hospital with a stage 3 pressure ulcer to her coccyx, malnourished, weakness, debility, and a Foley catheter (tube inserted into the bladder to drain urine into a collection bag) that was removed on 02/02/24. R7 preferred to lie on her back and staff encouraged and assist her to turn side to side. The Care Plan initiated on 01/29/24, revealed R7 required partial/moderate assistance for toileting hygiene, moving from sitting to standing, transfers, and toilet transfers. R7 had urine incontinence at times and utilized disposable briefs and staff were to change as needed. R7 was at risk for skin breakdown related to a pressure ulcer present upon admission, frequent loose stools with unawareness of occurring until felt afterwards, refuses to lay down, removes her own dressing, leaving it open to constant diarrhea, adult neglect, and protein-calorie malnutrition. The Nursing Admit/Readmit assessment dated [DATE], revealed a pressure area to R7's coccyx, however the assessment lacked stage of ulcer and measurements of the pressure area. The Skin and Wound Evaluation dated 01/29/24 (three days after admission) revealed R7 had a stage three pressure area (lacked location), present on admission, which was 100 percent (%) covered with slough (dead tissue, usually cream or yellow in color). The area measured 4.0 centimeters (cm) by 2.9 cm. The Treatment Administration Record (TAR) dated January 2024, lacked treatment orders for the pressure area to R7's coccyx from date of admission 01/26/24 through 01/31/24. The physician Office Visit note, dated 01/31/24, revealed R7 had sacral ulcers which were unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on exam and the areas measured 2.5 cm by 2.5 cm, 1.0 cm by 1.5 cm, and 1.5 cm by 1.5 cm. R7's chronic diarrhea and poor nutrition with hypoalbuminemia (abnormally low levels of albumin in the blood) contributed to the areas. The note revealed an old dressing removed, sterile dressings were applied, and would get R7 set up with wound care services for the unstageable pressure ulcer. R7 reported she had not been receiving her antidiarrheals despite having numerous episodes of diarrhea daily, so will change those medications to be scheduled. The Order Summary Report dated 02/01/24 lacked treatment orders for R7's pressure ulcer to her coccyx. The TAR dated February 2024 revealed a treatment for R7's pressure area to her coccyx as needed began on 02/02/24 (seven days after admission) however lacked documentation the staff completed the treatment order. A routine treatment order began on 02/03/24 (eight days after admission) to R7's coccyx. The staff were to perform the treatment daily. The TAR lacked documentation the staff completed the treatment on 02/09/24. On 02/10/24 a new treatment began which included the use of Santyl (a prescription enzyme used to help break up and remove dead skin and tissue of a wound) ointment was to be done daily and as needed after every incontinence episode. The TAR revealed the staff completed the as needed treatment order twice, on 02/11/24 and 02/12/24. The Medication Administration Record (MAR) dated February 2024, included instructions dated 01/30/24 to administer loperamide (antidiarrheal), two milligrams, by mouth, as needed, every six hours, for functional diarrhea. The MAR lacked documentation the staff administered the medication at any time from 02/01/24 through 02/13/24. The Progress Notes dated 02/02/24 at 10:50 AM revealed a communication was sent to the physician via a fax regarding a referral R7 had for the Wound Care Center [designated hospital]. The note revealed R7 was being seen by the facility wound care Advanced Practice Registered Nurse (APRN), who came weekly, and the facility had been providing daily treatment. R7 was receiving skilled Medicare A services, R7 did not need the referral to the wound care center, and the facility notified the wound care center of lack of need for an appointment at this time. The Skin and Wound Evaluation dated 02/06/24 revealed R7's stage three pressure area to her sacrum had 80 % coverage of slough and 20 % coverage of eschar (dead tissue). The area lacked evidence of infection, however the tissue surrounding the wound had erythema (redness or inflammation of the skin) that measured 5.0 cm and the temperature of the tissue around the area was warm (indicating possible infection). The area measured 2.8 cm by 1.6 cm. The physician Office Visit note dated 02/08/24, revealed R7 had a worsening sloughing sacral wound measuring 3.0 cm by 3.0 cm with 4.0 cm to 5.0 cm surrounding erythema and induration (hardening of the skin and subcutaneous tissues around a wound due to inflammation which could be secondary to infection). The note included R7's treatment orders would be updated to use of Santyl to the wound and change the dressing daily and as needed, and additionally, referral placed to wound care at [specified facility]. The note included R7 recently grew pseudomonas (type of bacteria) in her stool and would treat with Levaquin (antibiotic). The Grievance/Concern Log dated 01/29/24 through 02/09/24 revealed a concern (lacked who reported the concern) of R7 not being cared for properly, the resident and staff were talked to, and the concern resolved on 02/09/24. The Progress Note dated 02/12/24 revealed R7's family member spoke with social services about moving R7 to [specified facility] for one of two reasons being R7 did not feel like she was receiving adequate care. The Skin and Wound Evaluation dated 02/13/24 revealed R7's pressure area had 100 % coverage of eschar (indicating unstageable pressure area). The area had no evidence of infection, however had a moderate odor after cleansing, and the wound increased in size to 6.2 cm by 5.0 cm. The Progress Note dated 02/13/24 at 10:42 AM, revealed R7's wound deteriorated, she was to go out for wound care today (02/13/24), she was encouraged to lay down to offload pressure and refused, and treatment to the coccyx completed for the second time this shift. The Plan of Care Note dated 02/13/24 at 10:58 AM by Administrative Staff A revealed R7's care plan reviewed related to R7 refusing to lay down, taking off the wound dressing, and refusing supplements recommended by the Registered Dietician. R7 was aware of skin issues but continued to refuse to help herself by not laying down and taking pressure off, taking bandage off the wound and letting loose stools come in contact with the wound, the resident does very little for herself, and expected one on one care. The staff encouraged R7 to let them know as soon as she can that she needed a dressing changed and her changed (from incontinence). R7 was able to take herself to the bathroom but not always aware of the diarrhea until after it had happened, which according to nursing staff was almost constant. The Progress Note dated 02/13/24 at 03:50 PM revealed R7 went to [specified hospital] for wound care appointment and admitted to the hospital due to her wounds. The electronic medical record (EMR) lacked notes to indicate R7 was seen by wound care other than on 02/13/24. The Wound Clinic Consult Note dated 02/13/24 revealed R7 was there for consultation regarding multiple sacral ulcers that were necrotic (pertaining to the death of tissue in response to disease or injury) with a foul odor. The note revealed R7 reported the small wound she had at home increased in size since admitted to the facility and the nursing facility was not prompt about changing after bowel incontinence episodes and she had sat in a dirty brief for up to an hour and a half. R7 required two to three staff to transfer her at the appointment and stated, I need to be in the hospital, and I am not getting the proper care that I need. The assessment of the wound revealed multiple wounds measured together 9.5 cm by 7.0 cm by 0.1 cm, wound bed appearance was black, eschar, grey, and yellow, surrounding tissue was warm and appeared pink and erythematous, and the wound drainage had a foul odor. The note revealed R7's sacral ulcers would mostly likely need antibiotic, and debridement and they referred R7 to the emergency room for further evaluation. The Progress Note dated 02/14/24 at 11:32 AM, revealed R7 was in the intensive care unit due to having low blood pressure in the night and receiving intravenous (into the vein) medications for the low blood pressure and for her wounds. R7 was to have surgery in the afternoon (of 02/14/24) for coccyx wound debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). On 02/21/24 at 09:33 AM, R7's family member stated, the spot on her back went from half dollar size to size of a dinner plate. The family member stated he was in the facility with R7 at times when she needed a new dressing and the staff would not do it or do it later the next [explicit language] day. The family member stated on the day of the Superbowl (02/11/24), family stopped at the nurse's desk and told the nurse she was ready for her medications and she needed a new dressing. The nurse came with medications and when R7 asked about a dressing, the nurse responded nobody had told her, and the nurse did not return to apply a new dressing while there, which was sometime after 08:00 PM. On 02/21/24 at 10:58 AM, an additional family member stated him and R7 spoke with Administrative Nurse D about the lack of wound care, however, could not recall what day, and was told R7 would get better care. When R7 went to see the wound care doctor it was much worse, so they admitted her to the hospital. On 02/21/24 at 12:13 PM, Certified Nurse Aide (CNA) M stated R7 was not resistive to cares, she used her call light to get help, she was incontinent of bowel and bladder and wore a brief that the staff changed, and she needed help to get to the bathroom. CNA M stated when R7 first came to the facility, she required two people to assist her, then she started walking when getting her strength up. CNA M stated R7 had constant diarrhea of large amounts that would soil the dressing on her coccyx, he would not remove the dressing, the nurse would come and take care of it. On 02/21/24 at 12:36 PM, Licensed Nurse (LN) I stated she mostly did skin care; however, she did not do weekly wound measurements, other staff were to complete those. LN I stated she did not know R7 had a wound on her bottom for a few days and thought it was Thursday or Friday after she came (02/01/24 or 02/02/24) she had physician orders for a treatment. LN I stated she put a patch on R7 the first day she was on treatments. LN I stated she put a dressing on R7 every day, multiple times because she had a lot of diarrhea, we could not keep a dressing on her bottom, and R7 expected a dressing to be put on right away. LN I stated R7 needed to tell someone and not complain for two hours later and say she had not had a dressing on stating how long it had been. LN I stated she does not take residents to the bathroom so she would not know when another dressing needed to be placed, the CNA's were not letting her know, and R7 would take herself to the bathroom. LN I stated she did not think R7 would take the dressing off, it would fall off when she wiped. LN I stated she felt like R7 could have done more to get more attention, rather than be caddy about it three hours later and tell other people sitting at the table, turning it into gossip rather than an actual request, or would get on the phone and tell her husband. LN I stated she most often would know what she needed by overhearing what she was saying on the phone to her husband and her friend. LN I stated the dressing would not stay on due to the diarrhea and she tried three different kinds of dressings, but they would not stick. LN I stated every day she came in the wound would be worse. LN I stated she was not sure if the Nurse Practitioner came in weekly to see her as she was scheduled opposite of her and if a resident was going to wound care the APRN could not see her as it would be double billing. On 02/21/24 at 01:05 PM, R7's friend stated one day when she was at the facility R7 had diarrhea and when heading back to her room the nurse was told she needed a diaper change. R7's friend stated they waited an hour and a half before anyone came to change her, and another time when she was there R7 waited 45 minutes after turning on her call light before anyone came to change her. R7's friend could not recall dates of occurrences, as she did not write it down. R7's friend stated she went to the doctor with her four or five days before R7 went to the wound care specialist and R7 had soiled herself before they got ready to leave and the staff said they could take care of it when she got to the doctor's office. R7's friend stated when they arrived at the doctor's office, R7 had feces all the way up to her belly button and to her back and lacked a bandage on her sore. R7's friend stated she went to the wound care appointment with her and when they took the bandage off the smell was so bad I almost puked and the nurse could not believe how bad the wound smelled and R7 was put in the hospital for the infection. R7's friend stated when she was at the facility, the staff had to help her out of the wheelchair, she could not take herself to the bathroom or get out of bed without help. R7's friend stated the wound went from a size of a ping pong ball to the size of a softball in a short time and the wound was black. On 02/21/24 at 01:27 PM, Administrative Nurse D stated the in house wound care nurse was in the facility on 02/06/24, however she did not see R7. On 02/08/24, R7 went to the doctor due to swelling and warmth to her left breast and was started on an antibiotic, a new wound treatment, and staff was to schedule for an appointment for regular wound care, which she went on 02/13/24. Wound care did a direct admit for R7 to the hospital. Administrative Nurse D stated wound measurement for newly admitted residents should be done within 24 hours of admission, and as needed treatments completed should be documented on the TAR. On 02/21/24 at 02:04 PM, CNA N stated R7 required one person to assist her with toileting and would let the staff know when she needed to go the bathroom. CNA N stated R7 had to go to the bathroom quite a bit for her bowels and at times when getting her in the bathroom and getting her brief down she had already went and would get her up and change her and she went again. CNA N stated she reported to the nurse every time R7 had diarrhea. CNA N stated two or three times when she first arrived in the morning, R7 lacked a dressing in place to her wound when they went to get R7 up, and one of those times she had bowel incontinence when doing a check and change and dressing removed due to bowel under the dressing but not on top of it. CNA N stated R7' s dressing needed to be changed two to three times an eight-hour shift because of bowel incontinence. CNA N stated when R7 first got to the facility, she did not have a cushion in her wheelchair, but therapy placed one on the following Monday (three days later). CNA N stated R7 would only lay down if really tired, which was not often and mainly stayed in the wheelchair when she was not in bed. On 02/21/24 at 02:20 PM, Administrative Nurse D stated every morning when she came in if R7 was up and said she did not have a patch on, she would have R7 go with the nurse and aides to clean her up and do a treatment. Administrative Nurse D stated in the morning when she arrived, she would make sure R7 was the first wound care patient done. Administrative Nurse D stated one day, R7 went to the dining room and was sitting at the table with her husband on the phone getting ready to eat and was waiting on the wound care nurse to come in, R7 had told her the dressing was off as she was going to the table, but Administrative Nurse D was to pass medications that day. R7's dressing was not changed until after she ate breakfast. Administrative Nurse D stated R7 talked to her and Social Service Staff X on 02/12/24, and prior to that on 02/09/24, R7's family member talked to her about the same thing (fault of wound getting worse). Administrative Nurse D stated she watched several days and would get on the nurse if she did not have a bandage on and to get on her treatment. Administrative Nurse stated she talked to the night nurse about making sure if the dressing came off to replace it, and there were a couple of times R7 did not have a treatment in place when she came in, however she had chronic diarrhea and believed we were doing the best we could. and R7 had poor nutrition. Administrative Nurse D stated R7 had a cushion in her wheelchair the Monday after she came in (01/29/24), and R7 lacked documentation of wound measurements when admitted , and lacked a treatment order until 02/02/24 (seven days after admission). On 02/21/24 at 02:51 PM, CNA O stated she helped R7 everyday she worked and there were a couple of time R7 lacked coverage to her wound, she would tell the nurse and they usually drop what they were doing except for one, who would not acknowledge the need for a dressing when reported to her or would say she was in the middle of report or she was busy and R7 would have to wait. CNA O stated there was two or three times at the start of her shift, the wound would not have a dressing in place and R7 would have diarrhea four to six times a shift. On 02/21/24 at 03:09 PM, CNA P stated she provided care to R7 for a few days and one of those days she lacked a dressing in place to her wound and when reporting to the nurse, the nurse responded she had not had a chance to do that yet, she had constant diarrhea, and the dressing would not stay. On 02/21/24 at 04:30 PM, CNA Q stated she provided cares to R7 and a couple of times she did not have a dressing in place, one time she told the nurse and the other time I think I forgot, I was doing something else. CNA Q stated she did not think R7 removed her dressings herself. On 02/21/24 at 04:40 PM, LN J stated one time during her shift R7 did not have a dressing in place, but she had just been changed. LN J stated she was getting report at the time and that was first, so I did it after shift report. LN J stated R7 would have diarrhea constantly and would change the dressing four or five times during the night. LN J stated she worked the day R7 admitted , and she completed a skin assessment on her, and remembered sometime removing a dressing to take pictures, but could not recall if it was when R7 admitted . LN J stated she could not remember if R7 admitted with treatment orders. LN J stated for new resident admissions, therapy determines if the resident needs a cushion or not. On 2/21/24 at 04:57 PM, LN K stated one day Administrative Nurse D and said as soon as report was done, R7 needed a dressing put on. Administrative Nurse D thought it had already been asked at report but that was to LN I and not to her. LN K stated R7 had less episodes of diarrhea at night than during the day. LN K stated R7 did not toilet herself and was a check and change at night. LN K stated R7 would require assistance to reposition, R7 could help some, but not completely and she laid mostly on her right side. On 02/22/4 at 10:37 AM, attempted to reach Consultant Physician GG and was unsuccessful. The facility policy Wound Treatment Management dated 01/01/20, revealed the policy was to promote wound healing of various types of wounds and provide evidence-based treatments in accordance with current standards of practice and physician orders. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Dressing changes may be provided outside the frequency parameters in certain situations: feces seeped underneath the dressing, dressing dislodged, dressing soiled otherwise or wet. Treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modification include lack of progression towards healing and changes in characteristics of the wound. The facility policy Documentation of Wound Treatments dated 01/02/20, revealed wound assessments were to be documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The wound assessment documentation should include the type of wound, stage of the wound, measurements of the height, width, depth, undermining, tunneling, description of wound bed, tissue around wound bed, presence and amount of drainage, presence or absence of odor, and presence or absence of pain. Wound treatments documented at the time of each treatment. The facility failed to obtain physician ordered treatment until seven days after R7's admission to the facility, failed to assess the wound until three days after admission to the facility, failed to ensure R7 had a dressing replaced timely when soiled or absent, and failed to provide a pressure reducing device to the seat of her wheelchair until three days after admission. R7's pressure area deteriorated to an unstageable wound, became infected, and she required hospitalization for wound management.

The facility reported a census of 44 residents. Based on observation, record review, and interview, the facility failed to have sufficient nursing staff at all times to meet the residents bathing needs and adequate call light response time. Findings included: - The Facility assessment dated [DATE], revealed an average census of 41 to 43 residents with a staffing plan of two Licensed Nurses (LN) providing direct care and 12 nurse aides. An example documented revealed one LN for day shift from 05:00 AM to 05:00 PM and one LN for evening shift 05:00 PM to 05:00 AM, three CNA's on days and evenings, two CNA's on nights, two Certified Medication Aides (CMA) on days and one CMA on nights, a transportation CNA full time day shift and a restorative aide full time. The facility nursing schedule dated December 2023 revealed on day shift, 06:00 AM to 02:00 PM, the following days had two CNA's scheduled: 12/09/23, 12/11/23, 12/12/23, 12/13/23, 12/28/23, 12/29/23, and 12/31/23. On 12/16/23 there were 2.5 CNA's. Those dates lacked a restorative aide with exception on 12/29/23 from 09:00 AM to 02:00 PM, and on 12/31/23 from 06:00 AM to 02:00 PM. A transportation CNA scheduled on 12/11/23 through 12/13/23 and 12/28/23 through 12/29/23. The facility lacked sufficient staff on eight days shifts for December 2023. The facility nursing schedule dated January 20204 revealed on day shift, two CNAs scheduled on 01/01/24, 01/02/24, 01/08/24 through 01/11/24, 01/22/24, and 01/25/24. There were 2.5 CNAs scheduled for 01/16/24 and 01/19/24. On 01/04/24, there was one CNA scheduled, however an extra CMA was on the schedule for that day. On 01/20/24 there was one CNA scheduled. On those dates the restorative scheduled 06:00 AM to 02:00 PM on 01/01/24 and 09:00 AM to 02:00 PM on 01/02/24, 01/08/24, and 01/22/24. The transportation aide scheduled 01/02/24, 01/08/24, 01/10/24, 01/11/24, 01/22/24, and 01/25/24. The facility lacked sufficient staff for 12 day shifts in January 2024. The facility nursing schedule dated February 2024 from 02/01/24 through 02/22/24 revealed two CNA's scheduled on 02/02/24, 02/11/24, 02/14/24, and 02/16/24. On those dates, a restorative aide scheduled on 02/14/24 from 09:00 AM to 02:00 PM, and a transportation aide scheduled 02/02/24, 02/14/24, and 02/16/24. The facility lacked sufficient staff for four-day shifts from 02/01/24 through 02/22/24. The facility failed to provide bathing to Resident (R)2 for 12 of 21 opportunities between 12/23/23 through 02/20/24. Refer to F676. The facility failed to provide bathing to dependent resident R6 for 12 of 17 bathing opportunities from 12/25/24 through 02/21/24. Refer to F677. On 02/20/24 at 02:31 PM, R8 stated when using the call light, you can buzz your buzzer and may be quite a lengthy time before the staff assist you and has been as long as an hour and a half. R8 stated the staff try to keep the response time to 15 minutes. R8 was unable to recall the extended wait time for the call light response. On 02/20/24 at 03:12 PM, a confidential resident interview revealed the staff does not respond timely to the call light, the facility was short on staff, and sometimes it took half an hour before the staff would respond. On 02/21/24 at 12:24 PM, CNA M stated on a regular basis, they are responsible for 30 or more residents on the day shift, sometimes the entire building. CNA M stated the 06:00 AM to 02:00 PM shift was to have three CNA's, however, some days there are only one or two. CNA M stated there were a lot of call in's and three CNA's was not enough and ten or more residents in the north side of the building required mechanical lifts to be used. CNA M stated the transportation aide would help out if able to. CNA M stated with three CNA's, it was difficult to complete showers because two aides work the north side and one aide works on the south side. On 02/21/24 at 01:05 PM, R7's friend stated one day when she was at the facility R7 had diarrhea and when heading back to her room the nurse was told she needed a diaper change. R7's friend stated they waited an hour and a half before anyone came to change her, and another time when she was there R7 waited 45 minutes after turning on her call light before anyone came to change her. R7's friend could not recall dates of occurrences, as she did not write it down. On 02/21/24 at 01:48 PM, CNA N stated depending on the assignment, she was responsible for around 30 residents on the north side or 15 on the south side. CNA N stated the north side had ten residents transferred with a mechanical lift and one resident on the south side. CNA N stated there were three to four other residents that required two staff to assist. CNA N stated most of the time there was enough time to complete required assignments unless short staffed and sometimes cannot get the showers done, which happens once or twice a week. CNA N stated when that happens, she lets the next shift know and they to pick up what the previous shift could not get done. On 02/21/24 at 02:51 PM, CNA O stated she works the 06:00 AM to 02:00 PM and the 02:00 PM to 10:00 PM shift and was responsible for all residents on her shift on a regular basis. CNA O stated there are three CNAs on the evening shift if lucky and sometimes only one or two CNAs. CNA O stated sometimes showers get done and if not, they pass on to night shift then the morning shift would need to do those baths. On 02/21/24 at 03:09 PM, CNA P stated on a regular basis she was responsible for all residents on her shift. CNA P stated there was not enough time to complete showers and pass snacks. CNA P stated there was never a day they could complete all scheduled showers, with the exception of yesterday (02/20/24), there was five CNA's, and that had never happened for at least a year. On 02/21/24 at 03:32 PM, R2's family member stated on 02/10/24, the family took him home and gave him a shower at the house because he stunk. R2's family member stated he was to have a shower two to three times a week, but he was getting bathed maybe once a week and was told by staff there was not enough time or the day shift did not have it down for him to have a shower. The facility failed to provide bathing to R2 for 12 of 21 opportunities between 12/23/23 through 02/20/24. Refer to F676. On 02/21/24 at 04:21 PM, Administrative Nurse D stated there were not any call light response times over 45 minutes for R7. On 02/27/24 at 01:39 PM, Administrative Nurse D stated she staffed three CNA's on day and evening shift and two on night shift. Administrative D stated the transportation aide was full time and could help out in between appointments when she could and the restorative aide was the Certified Medication Aide (CMA) and would do direct care, not every day, but some days. The facility policy Call Lights: Accessibility and Timely Response dated 09/09/20, lacked the expected staff call light response time. The facility failed to provide a policy for sufficient staffing. The facility failed to provide adequate staff to meet bathing needs and timely call light response for these residents in the facility.

The facility reported a census of 44 residents with nine residents selected for review, including three residents reviewed for bathing. Based on observation, interview, and record review, the facility failed to provide two of two non-dependent residents, Resident (R)2 and R8 adequate bathing. Findings included: - The Medical Diagnosis tab for Resident (R)2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and need for assistance with personal care. The Admission Minimum Data Set (MDS) dated [DATE] assessed R2 with a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive impairment. R2 rejected care one to three days of the assessment period and required physical help of one staff for transfer only for bathing task. The Cognitive Loss/Dementia Care Area assessment dated [DATE], revealed R2 had dementia, required cues for cares, and resisted assistance or redirection at times. The Quarterly MDS dated [DATE] revealed R2 had a loss of short and long-term memory, impaired decision making, and rejected care four to six days. The Care Plan dated 09/29/23 revealed R2 required bathing assist of two or more staff, would refuse bathing, and the staff were to offer bathing/showers and remind of the importance of hygiene. If R2 refused, the staff were to offer washcloths and soapy water for sponge bathing. The Care Plan lacked the frequency when staff were to provide bathing. The Bathing Sheet schedule, located at the nurse's station, undated, revealed the staff was to bathe R2 on Monday, Thursday, and Saturday, during the day shift. The staff had handwritten R2's name on the days of the week for day shift to bathe. The task tab for bathing in the electronic record and the paper Comprehensive Shower Review from 12/23/23 through 02/20/24 revealed R2 lacked bathing from 12/26/23 through 01/01/24 (seven days), 01/09/24 through 01/24/24 (16 days), 01/30/24 through 02/03/24 (five days), and 02/05/24 through 02/11/24 (seven days). The facility failed to provide bathing according to the Bathing Sheet schedule for 12 of 21 opportunities from 12/23/23 through 02/20/24. On 02/20/24 at 03:31 PM, R2 sat in a reclining chair in the living room area by the nurse's station. R2 had a slight facial hair stubble. On 02/21/24 at 12:18 PM, Certified Nurse Aide (CMA) M stated it was hard to get bathing done on the day shift due to not enough staff. CNA M stated if staff were not able to get the shower done, then the nurse would be notified, and the second shift was to pick it up. CNA M stated the next shift would be notified the shower was not done, asked if they can take care of it, and they should have. CNA M stated if a resident refused a shower, then someone else should come back later and ask, and if the resident still refused, staff would have the resident sign a paper if they were able, and staff would let the nurse know. CNA M stated R2 was to have a shower every other day On 02/21/24 at 01:48 PM, CNA N stated the nurse assigns the showers. She gave R2's shower one or two times before. CNA N stated R2 did fine the second time by herself however the first time it took two staff. CNA N stated she thought R2 was to have a shower daily. On 02/21/24 at 03:09 PM, CNA P stated she usually worked 02:00 PM to 10:00 PM, and staff were to give R2 his shower first. CNA P stated R2 was to have a shower on Tuesday and was not sure of the other day, however, there was a schedule which showed what showers were due on each day. On 02/21/24 at 03:32 PM, R2's family member stated on 02/10/24, the family took him home and gave him a shower at the house because he stunk. R2's family member stated he was to have a shower two to three times a week, but he was getting bathed maybe once a week and was told by staff there was not enough time or the day shift did not have it down for him to have a shower. On 02/22/24 at 08:03 AM, Licensed Nurse (LN) H stated the night shift nurse should update the Bathing Sheets to show when the staff were to provide resident bathing. On 02/22/24 at 08:09 AM, Administrative Nurse D stated during morning meeting Monday through Friday she would make a list of what showers did not get done, and staff were to get them done. Administrative Nurse D stated if a resident refused a shower, the staff were to let the nurse know immediately, and the nurse was to go try and convince the resident to take one. If the resident was not able to be convinced to take a shower, then bathing supplies were to be offered such as a basin, soap, towels and to wash up in the room. If a resident allowed that, the staff were to document that. Administrative Nurse D stated she expected the staff to complete the showers as they were scheduled. The facility policy Bathing A Resident dated 09/09/20 revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The policy lacked expectations of bathing frequency. The facility failed to provide bathing to R2 for 12 of 21 opportunities between 12/23/23 through 02/20/24. - The Medical Diagnosis tab for Resident (R)8 included diagnoses for muscle weakness and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE] assessed R8 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. R8 required assistance of one person for transfer only for bathing and did not reject care. The Activities of Daily Living [ADL] Functional/Rehabilitation Care Area assessment dated [DATE] revealed R8 had made a lot of progress with ADL function since recovery from a fracture (broken bone). The Quarterly MDS dated [DATE] assessed R8 with a BIMS score of 15 and she did not reject care. The Care Plan dated 12/04/23 revealed R8 required partial assistance of one staff to provide a shower two times a week and as necessary. The Bathing Sheet schedule located at the nurse's station, undated, revealed R8 was to receive a shower on Tuesday, Thursday, and Sunday, indicating R8 should not have more than two days in a row without a shower. Review of the bathing task in the electronic record and the paper Comprehensive Shower Review sheets from 12/24/24 through 02/11/24 revealed R8 lacked bathing from 12/29/23 through 01/06/24 (nine days), 01/19/24 through 01/24/24 (six days), 01/31/24 through 02/03/24 (four days), and 02/05/24 through 02/10/24 (six days). R8 refused bathing on 01/16/24. The facility failed to provide bathing eight of 22 opportunities from 12/24/23 through 02/11/24. Additionally, R8 lacked bathing on 02/20/24, however received a shower on 02/18/24 and 02/22/24. On 02/20/24 at 02:31 PM, R8 stated she was not getting her showers as scheduled. R8 stated her schedule was Sunday, Tuesday, and Thursday, usually on the morning shift. R8 stated if the morning shift did not assist, then the shower usually did not get done. R8 stated she was getting a shower once a week and sometimes went a week and a half without bathing. R8 stated she would ask the staff why she could not take a shower, and staff would respond would be they were short of staff. R8 stated she had not received a shower yet today (scheduled day). On 02/21/24 at 12:18 PM, Certified Nurse Aide (CNA) M stated it was hard to get bathing done on the day shift due to not enough staff. CNA M stated if staff were not able to get the shower done, then the nurse would be notified, and the second shift was to pick it up. CNA M stated the next shift would be notified the shower was not done, asked if they can take care of it, and were to do it. CNA M stated if a resident refused a shower, then someone else should come back later and ask, and if the resident still refused, staff have the resident sign a paper if they were able, and staff would let the nurse know. CNA M stated R8 was to have a shower every other day, and if they were short on staff, there was a problem getting R8's shower done because she takes an hour-long shower. CNA M states if they do not get the shower done, then it gets passed on to second shift. On 02/21/24 at 01:48 PM, CNA N stated the nurse assigns the showers, and this week, confirmed there had been problems getting R8's shower done. CNA N stated sometimes they cannot get her shower done on the day shift, she does not refuse, and she enjoys her showers. CNA N stated she thought R8 was to receive a shower on Tuesday, Thursday, and Sunday. On 02/21/24 at 03:09 PM, CNA P stated R8 was to have a shower on the day shift, and there were times the day shift would not be able to get the shower done so her shift would need to complete it. On 02/22/24 at 08:03 AM, Licensed Nurse (LN) H stated the night shift nurse should update the Bathing Sheets for which shows when a resident was to be bathed. On 02/22/24 at 08:09 AM, Administrative Nurse D stated during morning meeting Monday through Friday, she would make a list of what showers did not get done and staff were to get them done. Administrative Nurse D stated if a resident refused a shower, the staff were to let the nurse know immediately, and the nurse was to go try and convince the resident to take one. If the resident was not able to be convinced to take a shower, then bathing supplies were to be offered such as a basin, soap, towels and to wash up in the room. If a resident allowed that, the staff were to document that. Administrative Nurse D stated she expected the staff to complete the showers as they were scheduled. The facility policy Bathing A Resident dated 09/09/20 revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The policy lacked expectations of bathing frequency. The facility failed to provide bathing for R8 on eight of 22 opportunities from 12/24/23 through 02/11/24 and on 02/20/24.

The facility reported a census of 44 residents with nine residents selected for review, including three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide adequate bathing for one dependent resident, Resident (R)6. Findings included: - The Medical Diagnosis tab for R6 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half 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, stiffness in other specified joint, and contracture (abnormal permanent fixation of a joint or muscle) of muscle of right shoulder and right hand. The Annual Minimum Data Set (MDS) dated [DATE], assessed R6 with a Brief Interview of Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, she did not reject care, and was totally dependent on two or more staff for bathing. The Activities of Daily Living [ADL]Functional/Rehabilitation Potential Care Area assessment dated [DATE], revealed R6 had hemiplegia to her right side, required assistance of two staff to transfer manually, or with the use of the Hoyer (total body mechanical lift) lift at times, and required partial to extensive assistance with ADL's. The Quarterly MDS dated [DATE] revealed no rejection of care and lacked a BIMS assessment of staff assessment of her mental status. The Care Plan dated 02/16/24, revealed R6 was totally dependent on two or more staff to provide a shower, two times a week, on Monday and Thursday, after lunch, and as necessary. R6 often refused showers and staff were to notify the charge nurse so an attempt could be made to check on her and talk her into a shower. The Bathing Sheet undated and located at the nurse's station, revealed R6 was to receive a shower on the day shift on Monday and Thursday. Review of the electronic documentation task bathing and the paper Comprehensive Shower Review sheets from 12/23/23 through 02/21/24 revealed R6 lacked 12 of 17 opportunities to be bathed. R6 lacked bathing 12/25/23 through 01/14/24 (21 days), 01/16/24 through 01/24/24 (nine days), 01/26/24 through 02/04/24 (10 days), 02/06/24 through 02/11/24 (six days), and lacked bathing from 02/15/24 through 02/21/24 (seven days). R6 refused a shower on 01/08/24 and 01/22/24. On 02/21/24 at 12:18 PM, Certified Nurse Aide (CNA) M stated it was hard to get bathing done on the day shift due to not enough staff. CNA M stated staff were not able to get the showers done, then the nurse would be notified, and the second shift was to pick it up. CNA M stated the next shift would be notified the shower was not done, asked if they can take care of it, and they were to complete the bathing. CNA M stated if a resident refuses a shower, then someone else should come back later and ask, and if the resident continued to refuse, staff should have them sign a paper if they were able, and staff would let the nurse know. CNA M stated R6 was to have a shower every other day and would refuse a lot as she only wanted certain girls to give her a shower. On 02/21/24 at 01:48 PM, CNA N stated the nurse assigns the showers. R6 was to have a shower on Monday and Thursday on the day shift, and she would refuse a shower at times. CNA N stated R6 required two staff to transfer her and to provide the shower, and that would pull everyone off of the floor. CNA N stated the nurse and the Certified Medication Aide (CMA) would help cover the floor when a shower required two staff to assist. On 02/22/24 at 07:58 AM, R6 sat in her wheelchair in the dining room. R6's hair appeared greasy with numerous white flakes noted on her scalp. On 02/22/24 at 08:03 AM, Licensed Nurse (LN) H stated the night shift nurse should update the Bathing Sheets that shows when a resident was to be bathed. On 02/22/24 at 08:09 AM, Administrative Nurse D stated during morning meeting Monday through Friday she would make a list of what showers did not get done and they were to get them done. Administrative Nurse D stated if a resident refused a shower, the staff were to let the nurse know immediately and the nurse was to go try and convince the resident to take one. If the resident was not able to be convinced to take a shower, then bathing supplies were to be offered such as a basin, soap, towels and to wash up in the room. If a resident allowed that, the staff were to document that. Administrative Nurse D stated she expected the staff to complete the showers as they were scheduled. The facility policy Bathing A Resident dated 09/09/20, revealed it was the practice of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. The policy lacked expectations of bathing frequency. The facility failed to provide bathing to dependent resident R6 for 12 of 17 bathing opportunities from 12/25/24 through 02/21/24.

The facility reported a census of 43 residents. Based on observation, interview and record review, the facility failed to provide infection surveillance tracking by organism to prevent the spread of infections. Findings included: - Review of the Infection Tracking logs from January 2023 through July 2023, revealed lack of microorganism identification from cultures (if obtained) on the logs to determine patterns for infections in the facility. Interview, on 08/17/23 at 3:00 PM, with Administrative Nurse D, confirmed the lack of identification of microorganisms for tracking. Administrative Nurse D stated the facility changed computerized programs, and failed to notice the organism identification did not transfer over to the Infection Tracking logs for determination of organism prevalence in the facility. The facility policy Infection Prevention and Control Program, revised 08/15/22, instructed staff to utilize a system of surveillance for prevention, identification, reporting, investigating, and controlling infections and communicable diseases for all residents. The facility failed to identify the causative organisms for infections from culture reports to determine prevalence of organisms in the facility as required.

The facility reported a census of 43 residents. Based on interview and record review, the facility failed to ensure four Residents (R) 25, 40, 36 and 146 acknowledged receipt of COVID-19 vaccination information to make informed declination decisions as required. Findings included: - Review of Resident (R)25, R40, R36 and R 146, medical records revealed lacked COVID-19 declinations/receipt of vaccine information to make informed decisions. Interview, on 08/17/23 at 03:30 PM, with Administrative Nurse D, confirmed lack of declinations for these four residents. Administrative Nurse D stated she would expect staff to provide vaccine information and resident/legal guardian signature on the declination. The facility policy Vaccine Information Statements, dated 11/01/19, instructed staff to provide the most current vaccine information statement to the legal representative prior to administration and document in the medical record. The facility did not provide a policy for declinations of vaccines. The facility failed to ensure residents/legal guardians acknowledge receipt of COVID-19 vaccine information for making informed declinations for the vaccine as required.

The facility reported a census of 43 residents with 15 selected for review. Based on observation, interview, and record review, the facility failed to ensure laboratory tests ordered by the physician were completed for two Residents (R)18 and R 34 and failed to ensure proper wheelchair positioning for one resident R2. Findings included: - Review of Resident (R)18's Physician Order Sheet, dated 07/27/23, revealed diagnoses included emphysema (long-term, progressive disease of the lungs characterized by shortness of breath, hypertension (elevated blood pressure), and alcohol dependence. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident received seven days of an antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) during the seven days look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/09/22, assessed the resident with a long history of chronic alcohol abuse and the resident was no longer able to care for himself. The Quarterly MDS, dated [DATE], assessed the resident with moderately impaired cognitive function, and received seven days of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications and seven days of antidepressants during the seven days look back period. The Care Plan, revised 07/30/23, instructed staff the resident was at risk for potential side effects due to medications. On 01/20/23, the physician instructed staff to obtain a current blood count (CBC), comprehensive metabolic profile (CMP), and thyroid stimulating hormone (TSH,) every six months. The facility obtained the above laboratory tests on 01/24/23 but failed to obtain the laboratory tests in June 2023 as ordered by the physician. Observation, on 08/15/23 at 08:30 AM, revealed the resident in his bed in his room, alert to name. Interview, on 08/17/23 at 02:30 PM, with Administrative Nurse D, confirmed the facility failed to obtain the CBC, CMP and TSH every six months as ordered by the physician. Administrative Nurse D stated she would expect staff to follow physician orders and would need to determine the cause of the system error. The facility did not provide a policy for following physician laboratory orders. The facility failed to obtain this resident's laboratory values for monitoring as ordered by the physician. - Review of Resident (R) 34's Physician Order Sheet, dated 08/03/23, revealed diagnoses included chronic respiratory failure (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing,) liver transplant status, immunodeficiency (weakened immune system to fight infections,) and chronic kidney disease. The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive status. The resident received seven days of antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression), antibiotic, and diuretic (medications that remove excess fluid from the body) medications within the seven days look back period. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA ), assessed the resident had weakness and was rejecting her liver transplant and received antirejection medications. The Care Plan, revised 07/11/23, assessed the resident was at risk for potential side effects related to medications. On 12/07/22, the physician instructed staff to obtain CMV (cytomegalovirus, a viral disease that causes severe health problems in organ transplant recipients) and PCR (polymerase Chain Reaction (a sensitive laboratory test for the detection of CMV) every month. Review of the medical record revealed the facility obtained the tests on 12/16/22 and 06/08/23 but lacked testing in January 2023, February 2023, March 2023, April 2023, May 2023, and July 2023. Observation, on 08/15/23 at 10:30 AM, revealed the resident in her bed in her room. The resident stated she felt weak and required staff assistance for ADLs. Interview, on 08/16/23 at 3:30 PM, with Administrative Nurse D, confirmed lack of monthly testing of the CMV and PCR testing as ordered by the physician and would investigate the error. The facility did not provide a policy for following physician laboratory orders. The facility failed to obtain this resident's monthly laboratory tests as ordered by the physician, for a total of six months. - Review of Resident (R) 2's Physician Order Sheet, dated 08/03/23, revealed diagnoses included hemiplegia (paralysis) right side, cerebral vascular accident (CVA stroke) right shoulder contracture (tightening of muscle, ligaments, and tendons) and fracture of fibula (bone in the between the knee and ankle) and femur (large bone in the thigh which moves at the hip and knee.) The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status and dependent on staff for bed mobility and transfers. The resident had impairment in functional range of motion on both sides of her upper and lower extremities. The Care Plan, revised 06/21/23, instructed staff to keep her feet up on foot pedals when up in wheelchair and provide a wheelchair cushion. Observation, on 08/15/23 at 01:54 PM, revealed the resident seated in her wheelchair leaning to the right with both feet dangling off the wheelchair pedals. Observation on 08/16/23 at 07:30 AM, revealed the resident seated in her wheelchair in the dining room. The resident's feet dangled off the wheelchair pedals in a hyperextended position. Observation on 08/17/23 at 10:19 AM, revealed the resident seated in her wheelchair in the common living area. The resident leaned to the right with her shoulder against the side of the wheelchair. The resident's feet dangled off the foot pedals in a hyperextended position. Interview, on 08/17/23 at 10:19 AM, with Certified Nurse Aide (CNA) O, confirmed the resident leaned to the right and her feet did not fit the wheelchair pedals. CNA O obtained a pillow and placed it on the resident's right side and the resident sat in an upright position. The resident responded that this felt better. Interview, on 08/17/23 at 10:36 AM, with Licensed Nurse G, revealed the wheelchair seating for this resident did not accommodate her needs as the footrests appeared too long for the resident's legs and she leaned to the right. Interview, on 08/17/23 at 10:46 AM, with Administrative Nurse D, confirmed the foot pedals did not accommodate the resident's feet appropriately and therapy could determine her positioning needs. Interview, on 08/17/23 at 10: 50 AM, with Consulting Therapy Staff GG, confirmed the need for wheelchair positioning devices and adjustments of foot pedals. The facility policy Turning and Repositioning, dated 01/01/20, instructed staff to ensure the resident's feet are properly supported on footrests and utilize positioning devices as needed to maintain posture. The facility failed to ensure this resident received positioning devices and proper foot pedals to maintain comfortable anatomical body alignment to enhance her sense of well-being.

The facility reported a census of 43 residents with 15 sampled for review. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)8, regarding an indwelling urinary catheter. Findings included: - The Physician Order Sheet (POS), dated 08/01/23, documented the resident had a diagnosis of urinary retention (inability to pass urine). The Admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderate impairment. He required extensive assistance of one staff for toileting and did not have an indwelling urinary catheter (a catheter (hollow tube) is inserted into the bladder to drain or collect urine). The resident was frequently incontinent of urine. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/12/23, inaccurately documented the resident had an indwelling urinary catheter. The indwelling catheter care plan, dated 06/06/23, instructed staff the resident admitted to the facility with an indwelling urinary catheter, which was discontinued (DC'd) then replaced due to a diagnosis of urinary retention. Staff were to ensure the catheter tubing was anchored to the resident's leg to prevent injury. Review of the resident's electronic medical record (EMR) revealed the following physician's order: Anchor catheter tubing to prevent injury, ordered 08/10/23. On 08/17/23 at 07:40 AM, Certified Nurse Aide (CNA) P and Certified Medication Aide (CMA) R entered the resident's room to empty his urinary catheter collection bag. Staff assisted the resident to stand up and his pants were lowered to perform peri-care (the cleansing of the genitals). When the resident's pants were lowered, the tubing hung loose, not anchored to the resident's leg, as ordered. On 08/17/23 at 11:05 AM, Administrative Nurse D stated the Urinary Incontinence and Indwelling CAA, dated 06/12/23, was inaccurate. The facility followed the Resident Instrument for Assessment (RAI) manual for the completion of MDSs. The facility failed to complete an accurate Minimum Data Set (MDS) for this resident with an indwelling urinary catheter.

The facility reported a census of 41 residents, that included three residents sampled for accidents. The facility identified 11 residents required a mechanical lift transfer. Based on record review and interview, the facility failed to ensure dependent Resident (R)1 remained free from neglect, when Certified Nurse Aide (CNA) M attempted an unsafe transfer of R1 from the bath chair to her wheelchair, without use of the care planned mechanical lift, on 12/20/22. R1's legs buckled during the transfer and CNA M called for assistance; however, when CNA N entered the room, the two staff continued to transfer R1 to her wheelchair, without use of the care planned mechanical lift. CNA N and CNA M did not report the unsafe transfer and Administrative Nurse D began an investigation on 12/26/22, after she was notified R1 had complained of pain, and had faint yellow bruising to her lateral side (outside) of her left leg, just below her knee, since 12/23/22. Six days after the incident, on 12/26/22, X-rays completed and R1 diagnosed with an oblique nondisplaced hairline fracture to her left fibular head (upper end of one of the two bones of the lower leg at the knee area). The staff failure of an unsafe transfer of R1 without the care planned mechanical lift and failure to report the fall, placed R1 in immediate jeopardy, and placed all 11 resident who used mechanical lifts at risk for unsafe transfers. Findings included: - The signed Physician Order Sheet (POS), dated 01/04/23, documented Resident (R)1's diagnoses included hemiplegia (paralysis of one side of the body), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), polyarthritis (inflammation of five or more simultaneous joints characterized by pain, swelling, heat, redness, and limitation of movement), and muscle weakness. The 10/06/22 Annual Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status score (BIMS) of two, indicating severely impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfer, and toileting, and required total assist with bathing. The resident had range of motion impairment of her upper and lower extremity. The resident used a wheelchair for mobility. The 10/17/22 Fall Care Area Assessment (CAA), documented the resident required a mechanical full body lift (Hoyer lift) for transfers as she could not bear weight. The 01/06/23 Significant Change of Condition Minimum Data Set (MDS), documented the resident had a BIMS score of 0, indicating severely impaired cognition. The resident required total dependence of staff for bed mobility and transfers and required extensive assistance of staff with toileting. She used a wheelchair for mobility. The 01/23/23 Fall Care Area Assessment (CAA), documented the resident required a mechanical lift for transfers as she could no longer bear weight related to a femur (thigh bone) and fibula (one of the two bones in the lower leg) fracture. The resident had an immobilizer to her left lower extremity. She did not use the call light, however, would call out Hey to get staff's attention. The resident's Fall Care Plan, dated 11/02/19, instructed the staff the resident required the use of the mechanical lift for transfer when the resident refused, or was unable to bear her weight. The resident's Activities of Daily Living (ADL) Care Plan, dated 05/20/22, documented the resident required total assistance to move between surfaces with use of the Hoyer lift. The resident's care plan revision on 12/26/22 instructed staff the resident required a mechanical lift for all transfers. On 11/02/22, the Morse Fall Scale (an assessment to predict a risk of falls), revealed a score of 75, that indicated the resident as at a high risk for falls (a score higher than 50 indicates a resident at risk for falls). Review of the Incident note dated 12/26/22, documented Administrative Nurse D began a facility investigation as the resident had pain in her left leg since 12/23/22, and had faint yellow bruising to her lateral side (outside) of her left leg, just below her knee. During the investigation, staff reported the resident was lowered to the ground onto her knees during a transfer out of a shower chair to the resident's wheelchair on 12/20/22. The two CNAs picked the resident up from the floor and placed her into her wheelchair. Administrative Nurse D notified the on-call physician due to the resident's pain in her left leg. The physician ordered an X-ray of the resident's left hip, pelvis, and knee. Orders also included to increase her Tylenol 650 milligrams from twice a day to three times a day, provide bedrest, and get an appointment for an orthopedic physician. Staff should splint the left leg until the orthopedic physician could see the resident. Review of the Fall Investigation Note, on 12/26/22, documented the X-ray of the resident's left knee had an oblique nondisplaced hairline fracture to her left fibular head with the diagnosis of osteopenia (low bone density). The facility provided the Abuse Prevention and Reporting Education for CNA N, dated 12/28/22. CNA N had Staff Transfer Audit on only one occasion, dated 01/04/23 to monitor for reoccurrence of failure to use the mechanical lift with transfers that required it. The facility failed to provide any additional audits/competency monitoring for CNA N. The facility provided Abuse Prevention and Reporting education for CNA M, dated 12/29/22, however, the facility failed to provide Transfer Audits or Competency Checklist for Total (Hoyer) Lift or Competency Checklist for Sit to Stand lift for CNA M from 12/29/22 (after her suspension when the facility allowed her to return to work) through 02/07/23 to monitor for any reoccurrence of failure to use the mechanical lift with transfers that required it. The facility provided a Staff Transfer Audit for CNA O, signed 01/17/23, however, the facility failed to provide any additional audit/competency monitoring for CNA O. In addition, the facility failed to provide Abuse Prevention and Reporting Education for CNA O. The facility provided a Competency Checklist for Total (Hoyer) lift with six staff competencies. Four staff members lacked a date of completion, one staff member with a completion date of 01/02/23, and one staff member with a completion date of 02/08/23. The facility further failed to provide a Competency Checklist for Total (Hoyer) Lift for CNA M, CNA N and CNA O from 12/26/22 through 02/14/23. The facility provided a Competency Checklist for Sit to Stand lift with six staff competencies. Five of the six staff competencies were the same staff as the Competency checklist for the total mechanical lift (Hoyer). Four of the six staff lacked a completion date, one staff member with a completion date of 01/02/23 (the same date of the mechanical lift competency, and one staff member with a completion date of 01/06/23 (the same date of the mechanical lift competency. Furthermore, the facility failed to provide a Competency Checklist for Sit to Stand lift for CNA M, CNA N, and CNA O, from 12/26/22 through 2/14/23. A Teachable Moment Form, dated 02/08/23, documented observation made (behavior to change); Improper usage of mechanical lifts; with education given that all CNA/CMA nurses need to see me for mechanical lift training competencies revealed seven staff signatures, all dated 02/08/23, and were the same staff as the Competency Checklist for the total (Hoyer) lift and the competency checklist for the sit to stand mechanical lifts. On 02/01/23 at 03:38 PM, Administrative Nurse D reported that she was advised by staff that R1 complained of pain in left leg/knee on Friday, 12/23/22. Administrative Nurse D reported she did not assess R1 at that time. On 12/26/22, she was advised the resident complained of a mild discomfort in her left leg/knee on Sunday, 12/25/22. The resident did not want to get out of bed. Administrative Nurse D notified the resident's physician for an x-ray of her left hip, leg and knee. The x-ray of her left knee revealed an oblique nondisplaced hairline fracture to her left fibular head. On 12/26/22 at approximately 3:00 PM, Administrative Nurse D started an investigation and interviewing staff members. CNA N reported that on 12/20/23 she and CNA M were transferring the resident in the shower room and the resident knees began to buckle and the staff members lowered the resident to the bathroom floor onto her knees. CNA M and CNA N transferred the resident from the bathroom room floor to the resident's wheelchair. CNA N reported she should not have listened to CNA M, who advised her not to report the to the charge nurse that the resident was lowered to the floor. Administrative Nurse D reported she then visited with CNA M who verified that the resident was lowered to the floor, and she told CNA N not to report the fall. At that time each of the staff members were suspended due to the investigation. CNA N was suspended for three hours. CNA N received Abuse, Neglect and Reporting of Incidents prior to her shift. CNA M was suspended for one week. CNA M received Abuse, Neglect and Reporting of Incident prior to her shift and placed on 90-day probation. On 02/02/23 at 05:11 PM, CNA PP reported during rounds on 12/25/22 at approximately 03:00 PM, CNA PP repositioned R1. R1 complained of left leg and knee pain. Staff member advised when he repositioned the resident to change her soiled brief, the resident complained of pain in her left leg and knee. Upon completion of cares, CNA PP, advised Certified Medication Aide (CMA) R that the resident complained of pain. On 02/07/23 at 10:02 AM, CNA P reported staff should transfer the resident with a mechanical lift and the resident's care plan instructed staff to use a mechanical lift for all transfers. On 02/07/23 at 10:02 AM, CNA Q reported staff should refer to the resident's care plans and tasks, and that should identify what cares the resident would require. On 02/07/23 at 02:18 PM, CNA N reported the investigation began on 12/26/22. On 12/20/22 (six days prior to the investigation), CNA N answered the call light to the shower room, after CNA M gave the resident a shower. CNA M placed her arms around the resident's waist and lifted her to a standing position. When CNA N entered the shower room, the resident's knees began to buckle and the resident was in a squatted position, but her knees did not touch the floor while CNA N was in the room. CNA N assisted CNA M with transferring the resident to her wheelchair. CNA N reported she was extremely intimidated by CNA M, however CNA N told CNA M the resident was to transfer with a mechanical lift per her care plan. CNA M advised when I work with her nothing is reported to the nurse's, she does not have time to wait for someone else. You are not to tell anyone that this incident happened. CNA M reported she received education on reporting falls, follow resident care plans, accident, abuse and neglect policies. On 02/07/23 at 02:41 PM, CNA M reported she transferred R1 in the shower without a gait belt, mechanical lift, and another staff member. She did activate the shower room call light for a staff member to assist her because she was no longer able to hold the resident during the transfer from the bath chair to the wheelchair, and the resident knees began to buckle. CNA M lifted the resident up as much as she could, but her knees still buckled. CNA N entered the shower room and assisted her with the transfer to the resident's wheelchair. Before CNA N entered the shower room, CNA M reported that she was no longer able to hold the resident and lowered the resident onto her shoes. Both staff members transferred the resident to her wheelchair. CNA M stated she advised CNA N the resident no longer required a mechanical lift and CNA N argued about it, but I told her that I knew the resident's better than her. CNA M stated, I told her not to report this incident to the charge nurse or anyone else in the facility. Furthermore, CNA M reported that the previous week, she and CNA O transferred the resident in the shower room without a gait belt or a mechanical lift. CNA M reported that she bear hugged R1 and the resident began to lose her balance. CNA O assisted her to transfer the resident to her wheelchair. CNA M reported she transferred R1 on several occasions without using the gait belt and the mechanical lift, because she had worked at the facility for two and half years. CNA M reported she did not know where to find the resident's care plans or tasks, to see what cares the residents required. She reported she only received the information from the previous shift or charge nurses. CNA M reported she continued to transfer other residents as well, on several occasions, without the gait belt or use of a mechanical lift. CNA M reported she received education on reporting falls, follow resident care plans, accident, abuse and neglect policies. CNA M reported she did know the policies of the facility; however, she could transfer the resident by herself without difficulty. She further stated would continue transferring residents without another staff member, because she did not want to wait for another staff member to help her. On 02/08/23 at 12:43 PM, CNA O reported that on 12/15/22, she and CNA M were in the shower room with the resident. CNA M gave the resident a bear hug under her arms, CNA O reported that they assisted the resident to the edge of the shower chair. We went under her arms to transfer her back into the chair. After her shower, staff placed their arms under the resident's arms and transferred the resident, without using the gait belt or the mechanical lift, from the shower chair to the resident's wheelchair. CNA M advised CNA O that the resident was not a mechanical lift, and she did not look at the resident's care plan, as she trusted her co-worker. Staff should use the mechanical lift with all transfers. On 02/15/22 at 10:07 AM, Administrative Staff A verified the facility provided all the documentation the facility had regarding the fall and staff education/audits related to R1's fall on 12/20/22. The facility's Resident Right to Freedom from Abuse and Neglect Policy and Procedure, revision 11/06/17, documented staff would ensure the residents were free from abuse and neglect. The facility's undated Accident and Supervision Policy documented the resident would remain free of accident hazards as is possible; and each resident would receive adequate supervision and assistive devices to prevent accidents. The facility's undated Comprehensive Care Plan Policy documented the facility would develop and implement a comprehensive person-centered care plan. Qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out interventions, initially and when changes were made. The facility failed to ensure this dependent resident remained free from neglect, when staff failed to transfer the resident as care planned, when staff attempted to transfer the resident from a shower chair to her wheelchair, that resulted in a fracture to her left fibular head. In addition, staff failed to report the incident. The staff failure of an unsafe transfer of this resident without the care planned mechanical lift and failure to report the fall, placed R1 in immediate jeopardy, and placed all 11 resident who used mechanical lifts at risk for unsafe transfers. The facility provided an acceptable plan of removal of the immediate jeopardy on 02/15/23 at 08:30 PM, after completion of the following: All staff educated on Abuse, Neglect, Exploitation training initiated on 12/26/22, and completed on 12/29/22 at approximately 01:00 PM. Competency training for safe transfers for mechanical lifts initiated on 02/08/23, and the majority of the staff completed the training by 02/15/23. On 02/07/23 at 03:30 PM, Administrative staff A terminated CNA N and escorted her out of the building. On 02/15/23 at 08:30 PM, staff were to complete a transfer competency evaluation/ demonstration before staff were allowed to work on the floor. The survey team validated the immediate jeopardy was removed on 02/15/23 at 08:30 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a scope and severity of J (isolated immediate jeopardy) and was lowered to a scope of severity of G (isolated with actual harm) following the removal of the immediate jeopardy.

The facility reported a census of 39 residents, which included three residents reviewed for neglect. Based on interview and record review, the facility failed to provide toileting assistance in a timely manner for Resident (R) 1, who was left on a bedpan for an extensive amount of time (approximately five hours), placing the resident in immediate jeopardy. This deficient practice resulted in a large deep tissue injury (DTI - a pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise and may subsequently progress to a stage 3-4 pressure ulcer even with optimal treatment) which measured 26.2 centimeters (cm) x 30.4 cm. Findings included: - R1's signed Physician Orders, dated 02/05/2021, documented the resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Admission MDS, dated [DATE], documented the resident with a BIMS score of 14, indicating intact cognition. The resident had occasional incontinence of bowel and required extensive assistance with toilet use and bed mobility. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 11/28/20, documented the resident required a mechanical lift for transfers and she requested the bedpan for toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment, dated 11/28/20, documented the resident requested the bedpan and or toileting assistance and the staff were to encourage the resident to use the call light when she needed to toilet. The Pressure Ulcer/Injury CAA, dated 11/28/20, revealed R1 required encouragement to get up from bed and to change position while in bed. The 5-day Minimum Data Set, (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of one, indicating severely impaired cognition. She required extensive assistance from staff with bed mobility and toileting. The resident also had a stage 1 pressure ulcer (pressure injury characterized by superficial reddening of the skin, that when pressed does not turn white). The resident had a pressure reducing device for her chair and the staff were providing applications of medication and dressings to the pressure ulcer. The Care Plan, dated 11/28/20, revealed R1 was at risk for skin breakdown based on the Braden Scale assessment (a validated assessment tool commonly used to measure a patient's degree of risk for developing a pressure ulcer). The resident's care plan listed the following interventions: 1. Do not massage reddened bony prominences (General prevention). 2. Do not use donut type devices (General prevention). 3. Elevate head of bed no more than 30 degrees (Friction and shear risk). 4. Ensure adequate protein intake (Nutrition risk). 5. Increase caloric intake when indicated (Nutrition risk). 6. Maintain good hydration (General provision). 7. Monitor closely for sensory impairment (Sensory, Activity, and Mobility risk). 8. Observe and assess weekly (Sensory, Activity, and Mobility risk). 9. Offer water in conjunction with turning/care schedules (Moisture risk). 10. Refer to dietician with skin concerns (Nutrition risk). 11. Supplement with vitamins when indicated (Nutrition risk). 12. Use absorbent incontinent briefs that hold moisture away from skin (Moisture risk). 13. Use commercial moisture barrier on skin as indicated (Moisture risk). 14. Use pressure redistribution surface to bed and wheelchair if indicated (Sensory, Activity, and Mobility risk). The care plan lacked any instruction to facility staff regarding the resident's use of a bed pan. The care plan, updated 02/10/21, revealed the following new interventions: 1. Reposition the resident side to side on rounds with 2 staff assistance as she allows in attempt to limit pressure to buttocks. May continue to get resident up for meals for short periods of time as resident allows. No bedpan use at this time. 2. Charge nurse to be notified when I am put on the bedpan and they are to check after 30 minutes to ensure resident is off the bedpan. Aide to check every 15 minutes to see if resident is finished with the bedpan and if resident cannot go then it must be removed. The resident has an actual impairment to skin integrity of the buttocks related to a suspected deep tissue injury. The following interventions were listed: 1. Reposition the resident side to side on rounds with 2 assist as she allows in attempt to limit pressure to buttocks. May continue to get resident up for meals for short periods of time as resident allows. No bedpan use at this time. 2. Identify/document potential causative factors and eliminate/resolve where possible. 3. Keep skin clean and dry. Use lotion on dry skin. Do not apply on open areas site of injury. 4. Monitor/document location, size and treatment of [REDACTED]. to the physician. 5. Use a draw sheet or lifting device to move me. 6. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The Incident Note, dated 02/06/21 at 10:32 AM, documented a new wound obtained on 02/06/21 and assessed by Licensed Nurse G. R1 had a dark purple non-blanchable outline of a bedpan on both of her buttocks and into her peri area. The resident reported pain when removed off the bedpan. The resident could not remember how long she had been on the bedpan or who placed her there. The injury was immediately cleansed, moisture barrier applied, and staff positioned the resident on her right side. The Wound Evaluation, dated 02/06/21 at 11:29 AM, documented the resident with a medical device related pressure injury/deep tissue injury. The area measured 27.13 centimeters (cm) x 29.29 cm, with100 percent [MEDICATION NAME] tissue, [DIAGNOSES REDACTED] (redness), and no swelling. The treatment included cleanse area with soap and water. The facility would provide additional care: Air flow pad, heel suspension/protection device, moisture control, moisture barrier, positioning wedge, and turning/repositioning program. Staff notified the resident's physician and guardian. On 02/11/21 at 09:50 AM, Certified Nurse Aide (CNA) N reported she went into the resident's room with CNA O around 10:00 AM and saw the resident lying on a bedpan. They immediately reported it to Administrative Nursing Staff D who stood in the hallway outside the resident's room at that time. Administrative Nursing Staff D immediately assessed the resident and CNA N and CNA O assisted with removing the bedpan from underneath the resident. The resident denied being in pain. The resident had a red injury on her buttocks from the bedpan. CNA N stated the staff did not receive report from the night shift about the resident being on a bedpan. On 02/15/21 at 09:10 AM, CNA M reported she came from the West Hall to help the staff on the East Hall with bed checks. The resident pushed her call light around 05:00 AM and requested use of the bed pan. CNA M assisted the resident onto the bedpan, gave her the call light, and reminded the resident to call when she was finished. She went back to the West Hall to help answer call lights and help with bed checks. She could not recall if she told CNA P the resident was on the bedpan before she left and went back to the West Hall. Per a Witness Statement, dated 02/06/21, CNA P documented at 01:15 AM she checked on the resident to make sure she did not have a bowel movement. The resident was dry. CNA P stated she did not put her on the bedpan at that time. Later, she was in another resident's room assisting with a brief change when CNA M came into the room and told her the resident's output from her catheter was 300 milliliters (ml). CNA P documented that CNA M did not tell her she assisted the resident onto a bedpan. On 02/15/21 at 09:35 AM, CNA Q reported she came to work at 06:00 AM and did not receive a report the resident was on the bedpan. She checked on the resident every two hours and the resident never reported to her she was on the bedpan. She stated the resident could use her call light and request use of the bedpan. She only checked her catheter during rounds before discovery of the bedpan. CNA Q stated she was on her break when the other aides found her on the bedpan. On 02/15/21 at 09:43 AM, Licensed Nurse G reported she went into the resident's room around 08:30 AM to check her blood sugar and give her insulin. The resident was alert and conversing appropriately with her. The resident sat up, ready to have breakfast and stated she needed to urinate. The resident had a catheter, so she removed the covers and checked her catheter tubing to make sure there were no kinks. The resident was a large woman and LN G did not notice a bedpan underneath her, nor did the resident say she was sitting on one. On 02/15/21 at 09:55 AM, CNA O reported she started work at 06:00 AM that morning and did not receive report from the night shift that the resident was on the bedpan. CNA O stated she checked on the resident once before discovering the bedpan and asked her if she needed anything and the resident replied no. CNA O went into the resident's room with CNA N at approximately 10:00 AM and they discovered the resident was on a bedpan. They notified Administrative Nursing Staff D immediately, assisted the resident off the bedpan, and discovered the resident had a large red injury on her buttocks. Per a Witness Statement, dated 02/06/21, Licensed Nursing Staff H documented she checked on the resident and her husband around 10:15 PM, helped them adjust the heat in the room, and checked positioning of the resident's nasal cannula. LN H spoke with CNA staff at approximately 10:30 PM regarding how the resident was doing and if she had been checked for incontinence. When the resident was placed on the bedpan at 05:00 that morning, staff did not report the resident was on a bedpan. On 02/15/21 at 09:00 AM, Administrative Nurse D reported her expectation of the staff was the CNAs should notify the charge nurse as soon as they left the room of the resident who was on a bed pan. Staff were to check on the resident in 15 minutes and if the resident needed more time, the CNA was to check back in another 15 minutes. If resident still had no results, they were to remove the bed pan and ask the resident to call them back if they need to try again later. The charge nurse was to check after 30 minutes to ensure that resident was off the bed pan. The facility policy, Helping a Resident with Toileting - Bed Pan, dated 09/09/20, documented .It is the practice of this facility to assist residents with toileting needs in order to maintain the resident's dignity as well as proper hygiene . Help the resident to the bedpan by rolling to side and then position on bedpan ensuring that perineal area and perirectal area is completely over the bedpan . Place the call bell within easy reach and provide privacy . Allow time for resident to complete toileting. The facility failed to provide toileting assistance in a timely manner for resident R1, who was left on a bedpan for an extensive amount of time (approximately five hours), placing the resident in immediate jeopardy. This deficient practice resulted in a large DTI, which measured 26.2 centimeters (cm) x 30.4 cm. This deficiency was cited as past non-compliance, as of 02/08/21 at 10:00 AM when the facility completed the following: 1. Low air loss mattress placed on the resident's bed on 02/06/21 at 10:45 AM. 2. Rojo cushion placed in resident's chair on 02/06/21 at 11:00 AM. 3. Wound photo in Point Click Care on 02/06/21. 4. Treatment to keep skin on the resident's buttocks pliable on 02/06/21. The on call physician was notified. Orders were given for zinc treatment to area TID. Reposition the resident side to side to keep pressure off buttocks every 2 hours. 5. Reposition side to side every hour initiated on 02/06/2021 at 10:15 AM by the DON. 6. Minimize out of bedtime to decrease pressure for the next 24 hours as resident allows except for meal times for 30 minutes initiated on 02/06/21 at 11:00 AM. 7. Suspend staff during investigation on 02/06/21 at approximately 12:30 PM. Suspended CNA M for placing resident on the bed pan and not taking her off the bed pan or notifying co-worker that the resident was on the bed pan. Disciplines were given related to the incident. 8. Education initiated on 02/06/21 at 11:15 AM for all nursing staff. PRN staff, staff on leave will be educated prior to next shift worked and new hires will be educated upon hire. 9. New process for use of bedpans - charge nurse must be notified whenever a bedpan is used at 02/06/21 at 11:15AM. 10. Reassess all others who use bedpans on 02/06/21 and completed by the DON at 03:00 PM. 11. Updated all care plans on residents who use bedpans on 02/07/21. 12. Notification of the resident's Durable Power of Attorney at 11:00 AM. 13. Report to the Kansas Department on Aging and Disability Services on 02/06/21 at 08:23 PM. 14. A Quality Assurance meeting was held at 09:00 AM on 02/08/21.

The facility reported a census of 41 residents with 15 selected for review including three reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to provide the necessary treatment for two of the threee residents reviewed, including Resident (R)22 to prevent the development of a deep tissue pressure injury to the left heel which became an unstageable ulcer with eschar and slough present and R39 when facility staff failed to provide timely treatment to a facility acquired pressure ulcer to the resident's right heel and failed to provide the treatment as ordered by the physician. Findings included: - The Electronic Medical Record (EMR) under the Census tab, revealed Resident (R)22 admitted to the facility on [DATE] and had a facility acquired pressure ulcer to the left heel which presented on 02/14/2020 per the Progress Note on 02/14/2020 at 11:39 AM. The Order Summary Report, dated 02/04/2020, included [DIAGNOSES REDACTED]. [MEDICATION NAME] blood to a body part) of small intestine, and an open wound of abdominal wall. The Admission Minimum Data Set (MDS), dated [DATE], assessed R22 required extensive assist of two or more staff for bed mobility and transfers with no limitation to upper or lower extremities. Her Brief Interview of Mental Status score (BIMS) was 9, indicating moderate cognitive impairment. Furthermore, she was at risk for developing pressure ulcers/injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and had no pressure ulcer/injuries present on admission. She was on a turning/repositioning program, there was a pressure reducing device on her chair, but not a pressure reducing device on the bed. The Pressure Ulcer/Injury Care Area Assessment, (CAA), dated 01/17/2020, indicated R22 as alert and oriented to person and place, was non-ambulatory, and required a mechanical lift for transfers due to non-weightbearing status. R22 had recent surgery to repair a small bowel perforation with ischemia. Her care plan was to include measures to protect her skin, change position, inspect for signs and symptoms of skin breakdown, promote nutrition, increase activity and strength, and encourage socialization and participation in activities of daily living (ADLs). In addition, the ADL Functional/Rehabilitation Potential CAA, dated 01/17/2020, indicated R22 spent the last few years sitting in a chair in her home and refused to get up for toileting or meals. She was reluctant to get up or be toileted. She had debility before her hospitalization and now had weakness and debility contributing to her inability to meet ADL needs independently. She preferred to lie in bed, required great encouragement to get up, and depended on the staff for total assistance. Her care plan will include to provide support in ADLs and encourage her to participate. The Cognitive Loss/Dementia CAA, dated 01/17/2020, indicated R22 had a history of [REDACTED]. She continued to neglect herself, refused to reposition or get up from bed, refused hygiene, and meals. R22's BIMS score was 9, indicating moderate cognitive impairment. R22 was unwilling or unable to participate in ADLs, did not care if hygiene was needed, and relied on staff for transfers, repositioning, and cares. Her care plan was to include encouragement for self-participation, offer choices, and involve her in activities and ADLs, provide simple instruction, offer assistance, and praise her efforts to participate. The Baseline Care Plan, dated 01/06/2020, included that R22 was at risk for skin breakdown based on the Braden scale assessment (an assessment used to determine pressure ulcer development risk) and at risk for alterations in skin integrity related to impaired mobility. The care plan instructed the staff to encourage repositioning and assist if unable to do herself, ensure proper nutritional intake, and use barrier creams as necessary. Furthermore, it included that she had weakness from recent hospitalization , needed ADL assistance of two staff with mechanical lift, and was totally dependent with bed mobility. The Comprehensive Care Plan, dated 01/24/2020, included a goal that R22 would have intact skin free of redness, blisters, or discoloration through next review. She was totally dependent on staff for bed mobility and was at risk for skin breakdown related to the Braden scale assessment. Staff were to encourage repositioning and assist if unable to do herself, keep the bed flat as possible to reduce shear, apply moisturizer daily to skin and not to massage over bony prominences. R22 needed assistance to turn/reposition at least every two hours and more often as needed or requested. The staff was to monitor/report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. The care plan instructed staff to educate the resident/family/caregivers as to causes of skin breakdown including transfer and repositioning requirements and frequent repositioning. On 02/07/2020 an intervention added on 01/27/2020 to apply moisturizer to R22's skin daily and not to massage over bony prominences. An intervention initiated on 2/14/20 directed staff to use a pressure redistribution surface to the bed and chair, the day staff noted the discolored area to left heel. The care plan lacked any interventions for R22 for prevention of skin breakdown of the heels such as offloading heels or heel protectors to heels, or any treatments that were in place to promote wound healing. The Nursing Admit Assessment, dated 01/04/2020, under the assessment tab in the EMR, revealed R22 needed extensive assistance with bed mobility and had very dry and flakey skin. The Braden Scale Assessment, dated 01/04/2020, assessed the resident with a score of 12, indicating high risk for pressure ulcer development. R22 did not make even slight changes in body or extremity position without assistance, her nutrition was very poor, she never ate a complete meal, required moderate to maximum assist in moving, and complete lifting without sliding against sheets was impossible. The Weekly Skin Check, under the assessment tab in the EMR, dated 02/07/2020, did not indicate any issues with R22's heels. The Incident Note, under the Progress Note tab in the EMR, dated 02/14/2020, revealed during the weekly skin assessment R22 had a dark area to her left heel and her skin was very dry. Staff applied Dermacerin (a topical moisturizing cream used to treat or prevent dry, rough skin) to the heel, and then wrapped with foam. A request was sent to the Primary Care physician (PCP) for treatment and staff requested a wound care center appointment. An order in the EMR was not found for the wound treatment. The Deep Tissue Injury Assessment, under the skin and wound tab, dated 02/14/2020, revealed the area to the left heel measured 2.14 centimeters (cm) by 2.78 cm. The Treatment Administration Record (TAR), had a start date of 02/16/2020 for Dermacerin (house stock lotion) cream, apply to bilateral lower extremities one time a day for dry skin. The Physician ordered the cream on 02/15/2020. On 02/17/2020 staff started a treatment to the left heel to wash with soap and water, rinse and pat dry, apply Dermacerin, apply foam, wrap with Kling (gauze roll), secure with tape, one time daily, until seen by the wound care center. This order was three days after staff identified the deep tissue injury to the left heel. A Fax note to the physician, dated 02/14/2020 included that during the weekly skin assessment, R22 had a dark dry area to left heel, the area measured 4.2 cm in diameter, and her skin was very dry. Staff applied Dermacerin. The faxed note included the question if they could continue the following treatment: apply foam wrap with Kling, change daily and PRN until seen by the wound care center. Apply Dermacerin to bilateral lower extremities daily. A response was on the fax that indicated the nurse called and would like to ask for a different treatment, if [MEDICATION NAME] would be better, and they are trying to get the resident into the wound care center. The response wrote on the fax was that the Dermacerin would be okay and refer to the wound care center. The facility staff noted the fax on 02/15/2020 and 02/17/2020. On 02/16/20 at 03:24 PM R22 reported that she had an area to her left heel, it looked like it had some seepage on the pad when the nurse took it off. They have now (after the deep tissue injury was found) placed mini boots (heel protectors) on both of her feet, and a pillow under her legs to keep her heels up. On 02/17/20 at 10:26 AM, Administrative Nurse F, reported R22 had orders for the left heel to be washed with soap and water, rinsed, and patted dry, Dermacerin to be applied, then place foam, wrap with Kling, and secure with tape. On 02/17/2020 at 10:32 AM, Administrative Nurse F performed the dressing change to the left heel and reported that the resident's left heel was soft and boggy (abnormal texture of tissue characterized by sponginess) and then a couple of weeks later the dark area showed up, however the area never presented as a blister. During the dressing change, the wound appeared irregular in shape, with eschar, slough and peeling skin. On 02/18/2020 at 2:17 PM, Administrative Nurse F reported the measurements of the wound as 3.3 cm by 1.9 cm that she measured today, yesterday's measurement was accidently deleted on the tablet used to take the picture of the wound. Review of the EMR lacked documentation of her left heel being soft and boggy or notification of the physician at that time for treatment instructions. The EMR further lacked any interventions implemented to prevent skin break down to the resident's heels prior to the discovery of the deep tissue injury. On 02/18/2020 at 10:35 AM, Certified Nurse Aide (CNA) M revealed that staff floated R22's heels with pillows before the wound opened up, that the resident rarely got out of bed, and after the wound was found they started using the heel protectors. Furthermore, she had not seen her heels since she admitted to the facility because R22 liked to wear socks when in bed. The resident argued if staff wanted to position her on her side and sometimes she can be talked in to it. Staff report new interventions regarding a resident's skin in report in the morning from the charge nurse or they show up when we log in to the electronic medical record. On 02/18/20 at 10:46 AM, R22 was in bed with the left leg on a pillow, the left heel was touching the bed, and the heel protector was sideways on her foot. On 02/18/20 at 11:42 AM, CNA M confirmed that staff checked the heel boots every two hours for proper placement. On 02/18/20 at 12:09 PM, CNA O pushed R22 in a wheelchair without boots in place, obtained her weight, then when returned to the room CNA O placed the heel boots on both of her feet. On 02/19/2020 at 10:08 AM, Licensed Nurse H revealed that the process when staff identified a new wound was to do a risk management form, an incident note, change of condition and the follow ups for the change of condition. LN H stated they had standing orders, mostly for skin tears and such. If we think there was a deep tissue injury or pressure, the wound care center was very fond of foam, so we ask for Dermacerin and foam until the resident could get to the wound care center. LN H also stated they try to start the treatment as soon as staff identify the wound. There was a place on the risk management form where staff can put an intervention on the care plan, and staff passed on new interventions to the nursing staff by a verbal report. On 02/19/2020 at 11:01 AM, Administrative Nurse D revealed that when a resident has been identified with a new wound, they take a picture of it, notify the doctor, put on a risk management form that there was a new skin issue, and initiate a standing order treatment if appropriate. A new treatment should be started the same day a pressure area or deep tissue injury was found. If they have measures in place a new intervention may not be required, unless it is not appropriate, then a new intervention needs added. A new intervention should be added the same day when the risk management form was done. Furthermore, Administrative Nurse D revealed the facility had standing orders for skin care, but they do not include any measures for boggy heels. If a resident had boggy heels a heel float or boots should be put in place. Documentation should be made in the EMR, and on the care plan as to what interventions were placed. Administrative Nurse D confirmed that interventions for the left heel were not placed on the care plan, just the problem that the area existed. The charge nurse should add the interventions then communicate them through report and Administrative Nurse [NAME] double checks to make sure the interventions were placed. The Prevention of Pressure Injuries Guidelines F686 policy, revised 11/2017, instructed that interventions for bed bound residents included to use a special mattress that contains foam, air, gel, or water as indicated, and for those with immobility risk factors to float heels when in bed, place a pillow from knee to ankle or with other devices as recommended. The Skin Integrity, Pressure Injuries Nursing Protocol F686, revised 11/2017, instructed staff to identify, implement, monitor, and modify interventions to attempt to stabilize, reduce, and remove underlying risk factors. Based on the results of the evaluations, the staff will implement interventions for the prevention and care of skin issues. The facility failed to prevent the development of an unstageable pressure ulcer on the resident's left heel after identification the resident was at high risk for pressure ulcer development. Staff failed to put interventions to prevent the development of pressure ulcers on the resident's heels, failed to notify the physician when the resident presented with boggy heels for direction and treatment, and failed to ensure timely treatment once the left heel presented as a dark purple area which opened and as of 02/18/2020 at 2:17 PM, measured 3.3 cm by 1.9 cm with eschar and slough present. - The Electronic Medical Record (EMR), under the census tab, revealed R 39 admitted to the facility on [DATE]. The Weekly Skin Check, dated 11/29/19 revealed a right heel discoloration measuring 2.0 centimeters (cm) by 2.0 cm and the stage of the area was written as not applicable. The Order Summary Report, dated 02/03/2020, included [DIAGNOSES REDACTED]. (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic [MEDICAL CONDITION] (a type of nerve damage that can occur with diabetes most often affecting the legs and feet). The Admission Minimum Data Set (MDS), dated [DATE], assessed R39 with a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. She was totally dependent of two or more staff for bed mobility and transfers and did not ambulate, with range of motion limitations to both upper and lower extremities. Furthermore, she was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers/injuries, and two stage two (partial thickness loss of the tissue, may present as an intact or open/ruptured blister) areas that were present on admission. Staff utilized a pressure reducing device for the chair and bed, she was on a turning/repositioning program, and she received pressure ulcer/injury care. The modification of the Quarterly MDS, dated [DATE], assessed the resident with a BIMS score of 9, indicating moderate cognitive impairment. The resident required extensive assist of two or more staff for bed mobility, was totally dependent on staff for transfers, and had range of motion limitations to both upper and lower extremities. She was at risk for developing pressure ulcers/injuries, had one or more unhealed pressure ulcer/injuries, and had one stage three pressure ulcer present that was not present on admission. She had a pressure relieving device to her bed, was on a turning/repositioning program, and received pressure ulcer/injury care. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 10/23/19 indicated R39 needed assistance with all activities of daily living (ADLs), admitted with two stage two ulcers to right buttocks, required staff assistance with repositioning, and very limited ability to move self. The care plan included daily wound care, moisture barriers, wound care center for wound care and evaluation, pressure relief measures, chair cushion, mattress, turning schedule while in bed, weekly skin assessment, and staff to report changes to the charge nurse. The CAA lacked identification of the need for interventions to prevent the development of pressure/vascular ulcers to the resident's feet/heels since the residento was at increased risk for ulcers related to a [DIAGNOSES REDACTED].>The ADL Functional/Rehabilitation Potential CAA, dated 10/23/19, indicated R39 exhibited some movement in hand, was unable to stand or ambulate, and needed assist with all ADLs. The care plan would include extensive assistance from staff with most ADLs, encourage resident participation as able, and provide assistive devices as needed. The Base Line Care Plan, dated 10/11/19, indicated R39 needed two or more staff assist with bed mobility and transfers. She was alert, cognitively intact, and had skin integrity issues-open areas. The Comprehensive Care Plan, dated 10/30/19, indicated R39 had actual impairment to skin integrity, an air overlay to her bed ( discontinued on 01/07/2020), heel floater at all times when in bed, was totally dependent of two staff for repositioning and turning in bed every two to three hours and as necessary. Staff were to use a draw sheet or lifting device to move her. On 11/02/19 staff added an intervention that R39 needed extensive assistance and cues to turn/reposition at least every two hours and more often as needed or required. On 01/17/2020 staff revised the care plan problem to include an open area to the right heel (49 days after the development of the pressure ulcer to the right heel). On 01/24/19 staff added an intervention to encourage R39 to roll side to side to back for pressure relief to skin and treatments as ordered. On 02/04/2020 staff added the intervention to return R39 to bed between meals, turn side to side, and no lying on her back until wounds healed. The Braden Assessment, dated 10/11/19, assessed R39 with a score of 13, indicating moderate risk of developing pressure ulcers. The EMR indicated R39 transferred to the hospital on [DATE] and returned to the facility on [DATE]. The hospital Discharge Orders, dated 11/27/19, did not indicate R39 had a pressure ulcer present to her right heel. The Nursing Admission note, dated 11/27/19 at 07:04 PM, indicated the skin color was normal for ethnicity and see full assessment for skin findings. However, the Nursing Admit/readmit Assessment, dated 11/27/19 lacked documentation of any skin areas present. The Weekly Skin Check, dated 11/29/19 indicated identification of a new skin concern. The right heel had discoloration measuring 2 centimeters (cm) by 2 cm. The stage was documented as not applicable and staff notified the physician and durable power of attorney. The Progress Note, dated 11/29/19 at 11:08 AM, indicated a light purplish colored area noted to the outer right heel measuring 2 cm by 2 cm and staff placed heel protectors on the resident. The Treatment Administration Record (TAR), dated 11/2019, did not include any treatments for the right heel ulcer. The Skin Wound Note, under the progress notes, dated 12/1/2019 at 11:33 (2 days after the discovery of the area), indicated staff sent a fax to the primary care physician (PCP) at that time related to the discolored area to her right heel with a slight blister like appearance. Both lower legs were pink in color, slightly warm, and small blisters were present to the right lower leg. Staff applied foam padding to the right heel wrapped loosely with Kling, secured with tape, and asked if they could continue the order to change daily and as needed. Furthermore, the fax included that staff encouraged the resident to float her heels and wore heel protectors when not floating heels. She refused to lie down between meals and sat up in the wheelchair for hours at a time with her legs dependent. Staff questioned the PCP if there were any other new orders. New orders received per fax from the PCP on 12/03/19 at 04:33 PM to pad the right heel with foam and wrap loosely with Kling, secure with tape, and change daily and as needed. The order was started on the TAR on 12/04/19. The facility failed to notify the physician the day staff identified the area and the resident did not have a treatment order for five days after staff first noted the area. The Weekly Skin Check, dated 12/06/19 described the right heel pressure ulcer as discolored and blister like and measured 3.3 cm by 2.5 cm. This was an increase in the size from the note on 11/29/19. The Wound-Weekly Observation Tool included measurements of the right heel pressure ulcer on the following dates: 1. 12/14/19: 4.0 cm by 4.0 cm 2. 12/20/19: 4.0 cm by 5.0 cm, the blister was no longer fluid filled, and staff received a new order on 12/19/19 for treatment with [MEDICATION NAME] (a dressing used for wounds) foam over the blister area. 3. 12/27/19: 4.0 cm by 4.0 cm, the blister was no longer fluid filled. 4. 01/03/2020: 3.5 cm by 3.5 cm by 0.1 cm deep, slough (dead tissue, usually cream or yellow in color) present. The Wound Clinic Progress Note, dated 01/10/2020, indicated there was worsening of colors to the right heel and it was aching, spasm present, and tender, with a pain level of 6. Noted [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues) to the right lower extremity and was hard and puffy. The right heel area was a Stage three and the wound bed appearance was black, white, pink, and yellow. The margins were well defined. The surrounding tissue was pink, and the temperature was cool. The wound drainage was brown, serous (clear), and tan, of a small amount and with no odor. The wound measured 3.3 cm by 2.7 cm by 0.1 cm. R39 was to return to the wound care clinic in 3 weeks. The Right Heel Assessments, under the skin and wound tab, included measurements for the following dates: 1. 01/17/2020: 2.28 cm by 1.12 cm by 0.1cm, the wound bed had eschar (dead tissue) present (percent of eschar not documented), light amount of serosanguinous (yellowish with small amounts of blood) exudate (fluid that leaks out of body vessels and tissues), wound edges attached, and the surrounding tissue was dry/flakey and normal in color. 2. 01/24/2020: 2.81 cm by 3.2 cm by 0.1cm, the wound bed was 90% eschar, there was a light amount of sanguineous/bloody drainage, wound edges attached. Surrounding tissue calloused, discolored, dry/flakey, [DIAGNOSES REDACTED] (red) and fragile. 3. 01/31/2020: 1.99 cm by 1.25 cm, no depth, the wound bed was 100% eschar, a light amount of exudate (type not documented), the wound edges were attached, the surrounding tissue was dry/flakey and fragile. 4. 02/07/2020: 2.73 cm by 1.51 cm, no depth, the wound bed was 100% eschar, a light amount of serous exudate, the wound edges were attached, and surrounding tissue was dry/flakey, [DIAGNOSES REDACTED], and fragile. Staff notified the physician per the 02/07/2020 Weekly Skin Check under the assessment tab. 5. 02/14/2020: 2.18 cm by 2.08 cm, depth not applicable, 100% eschar of wound bed, light serous exudate, no odor, edge attached, surrounding tissue dry and flakey, no [MEDICAL CONDITION], peri wound temperature normal. The physician was not notified per the 02/14/2020 Weekly Skin Check under the assessment tab. Observation, on 02/17/2020 at 01:12 PM through 02/17/2020 at 02:57 PM, revealed the resident laid in bed on her back side with the head of the bed elevated approximately 45 degrees. Her right leg was on top of a pillow and the pressure relief boot was in place to her right foot. The care plan indicated on 02/04/2020 that the resident was to lay side to side in bed between meals and no lying on her back until the wounds healed. On 02/18/20 at 08:12 AM, R39 was in bed with the head of the bed up between 45-90 degrees, the right heel dressing had a date on it of 02/16/2020. Her right leg was on top of a pillow and the pressure relief boot was in place to the right foot and the Velcro was not secured on the pressure relief boot. She said her right leg burned and staff released the Velcro strap to open the boot up to get more air. Redness was noted to her skin between the right lower leg dressing and the right heel dressing. R39 reported she took a pain pill last night and it helped some. The Treatment Administration Record (TAR) for 02/17/2020 revealed Administrative Nurse F signed the dressing change as completed on 02/17/2020. On 02/17/20 at 10:00 AM, Licensed Nurse (LN) I revealed that Administrative Nurse F was the wound nurse and completed R39's heel treatment today. On 02/17/20 at 02:58 PM, R39 reported the nurse was to come in here and rewrap her foot and the resident hadn't seen her. R39 reported that staff were to wrap it every day, but sometimes they forget. On 02/18/2020 at 10:15 AM, observation revealed R39 laid in bed on her back with the head of bed elevated between 45-90 degrees, the dressing to right heel continued to be dated for 02/16/2020. On 02/18/20 at 10:23 AM, Certified Nurse Aide (CNA) M revealed that when a skin issue was noticed she would notify the charge nurse immediately. R39 has a sore on her right foot/heel and believed it was a pressure ulcer. The area was tender to touch, if it was bothering her too much she wanted to stay in bed, and we would let the nurse know. R39 had a heel float device, which was a blue colored really firm pillow with a pillowcase over it and used to prop her legs on to keep her heels from touching the bed. She does not like the pillow and says it hurts. If she doesn't want that used, we use a pillow underneath. She had a small pillow that she likes. She had a pressure relief boot on her foot at all times. Staff roll her off her bottom every two hours when in bed and placed pillows/blankets between legs so no rubbing or touching occurred and we keep something under her heels. CNA M reported that R39 cannot move her right leg. Staff passed on new interventions regarding a resident's skin in report in the morning that we get from the charge nurse or they show up when we log in to the electronic medical record. On 02/18/20 at 02:13 PM, during interview Administrative Nurse F confirmed the wound to the resident's right heel had eschar present, the wound edges were pulled away from part of the wound, and the old dressing was dated on 02/17/2020 and had yellow and brown drainage on it. On 02/18/2020 at 02:45 PM, Administrative Nurse F revealed that the dressing had to secure it earlier today and she put the wrong date, yesterday's date instead of today's. Administrative Nurse F confirmed she did not change R39's dressing on 02/17/2020 and told the nurse on the next shift it needed done. Furthermore, she revealed that sometimes she does sign treatments that she has not done. On 02/18/20 at 04:50 PM, LN G revealed that she worked the second shift on 02/17/2020 and staff failed to pass on to her that R39's right heel dressing needed changed. The boot in place to her right foot was a new boot, believed that wound care center ordered it, that a pillow was used to float her heels before that, and the heel was tender since admission in October. She was on a repositioning schedule every couple of hours, she preferred to be on her back, so we do a half reposition as she allows us too. On 02/18/20 at 05:40 PM, CNA N revealed that before the pressure area appeared on R39's right heel she had a little pillow she liked to use, not necessarily for pressure relief because her heel would still touch. R39 had movement of her right leg, would slide down in the bed, and we added another pillow after the wound showed up. We tried the blue heel cushion, but she is not flexible and complained it hurt her hip when under her. She was not on a positioning program to my knowledge, but we try to position her off of her bottom by offloading a bit. CNA N does not recall her having an air mattress or air overlay on her bed and that she currently used a bariatric (a mattress designed for overweight people) mattress. The right heel boot was to be on at all times and if the dressing was ever loose or missing she would make the nurse aware. On 02/19/2020 at 10:08 AM, LN H revealed when staff identified a new wound they completed a risk management form, an incident note, change of condition and then follow up for the change of condition. LN H stated they had some standing orders, mostly for skin tears and such, if it is a deep tissue injury or pressure, the wound care center was very fond of foam, so we ask for Dermacerin (a topical moisturizing cream used to treat or prevent dry, rough skin) and foam until the resident can get to the wound care center. Staff try to start the treatment as soon as they identify the wound. There was a place on the risk management form where staff can put the intervention on the care plan, and they passed on new interventions to the nursing staff by a verbal report. The interventions for the right heel pressure ulcer included the boot to be in place and a heel pillow to raise her feet, but sometimes she would not use it. On 02/19/2020 at 11:01 AM, Administrative Nurse D revealed that when staff identified a resident with a new wound, they take a picture of it, notify the doctor, record on a risk management form that there is a new skin issue, and initiate a standing order treatment if appropriate. Staff should start a new treatment the same day a pressure area or deep tissue injury was found. A new intervention needs added if existing measures were inappropriate. A new intervention should be added the same day when the risk management was done. The charge nurse should add the interventions then communicate them through report and Administrative Nurse [NAME] double checks to make sure placement of the interventions. Furthermore, Administrative Nurse D revealed it is not appropriate for treatments to be signed for on the TAR when they have not been done. Interventions in place before development of the pressure ulcer to the heel was to try to reposition her, she refused a lot, and staff initiated a wedge in the bed for side to side positioning on 10/23/19. She had an air overlay on her old bed, but not since she had the bariatric bed. Staff changed out the beds in (MONTH) and the bariatric mattress was a pressure relieving mattress. The current care plan did not include the boots or heel floats and should be part of her care plan. The charge nurses and the MDS coordinator had the responsibility of adding intervent (TRUNCATED)

The facility identified a census of 36 residents. The sample included 3 residents reviewed for abuse. Based on observation, record review, and interview, the facility failed to protect residents and timely report an allegation of abuse, when direct care staff O witnessed verbal and threatening behavior of direct care staff P towards resident #1. Staff P continued to provide resident care for the remainder of his/her shift (approximately 6 ½ hours). This deficient practice placed all residents in the facility in immediate jeopardy. Findings included: - Resident #1's May 2017 electronic medical record (EMR) documented [DIAGNOSES REDACTED]. This change can cause dramatic, noticeable symptoms or it may not cause any symptoms). The quarterly Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with short and long term memory impairment and moderately impaired cognition. He/she required extensive assistance of 1to 2 staff members with most activities of daily living (ADLs) such as transfers (to wheelchair), toileting and personal hygiene. The Care Area Assessment (CAA) dated 8/22/16 for cognition documented the resident was nonverbal, had severe learning disabilities, and staff was unable to determine his/her capabilities. The care plan, updated on 12/22/16, directed staff to converse with the resident during cares, monitor and document for physical/nonverbal indicators of discomfort or distress, to follow-up as needed and to ensure/provide a safe environment. Review of the facility investigation dated 5/16/17 at 2:15 P.M. revealed on 5/16/17 at approximately noon, direct care staff O reported to administrative staff A an allegation of abuse toward resident #1 by direct care staff P, which occurred on 5/13/15 at 11:30 P.M. (72 .5 hours after the incident). According to direct care staff O's notarized witness statement, on 5/13/17 at 11:30 P.M. direct care staff O and P went to assist resident #1 to apply his/her soft, pressure reducing boots. The resident yelled and kicked off his/her boots. Direct care staff P told the resident to Shut Up. Resident #1 slapped and kicked at direct care staff P when staff P raised his/her hand toward the resident. On 5/17/17 at 9:30A.M.the resident laid in bed alert, but did not respond to questioning. On 5/17/17 at 1:55 P.M. direct care staff O stated he/she did not report the incident to the nurse on duty because the nurse was new (his/her first night as a new nurse) and he/she was passing medications and was busy. On 5/17/17 at 12:30 P.M direct care staff P denied mistreatment of [REDACTED]. He/she stated the two staff members (0 and P) attempted to place the resident's soft boots and the resident would not allow it. Staff P further stated he/she and staff O exited the room and reported the refusal to licensed nursing staff H. On 5/18/17 at 1:00 P.M. licensed nursing staff H denied he/she received any allegations of abuse on 5/13/17 or thereafter. On 5/17/17 at 4:35 P.M. administrative staff A stated he/she expected all staff to report all allegations of abuse directly to him/her verbally. He/she stated direct care staff member did not work after 5/13/16 and on 5/16/17 was suspended pending the outcome of the investigation. The facility's Abuse Neglect and Exploitation/Misappropriation protocol/ policy, revised [DATE], recorded the facility would protect individuals from abuse, neglect, and/or exploitation during an investigation of any allegations of abuse, neglect, and/or exploitation. The policy further documented any case of abuse, neglect, or exploitation would be immediately reported to the charge nurse/supervisor and the administrator. After business hours, the administrator would be contacted at home and advised of the situation. The facility failed to protect residents in the facility and timely report an allegation of abuse when direct care staff O observed direct care staff P display verbal and threatening behavior toward a resident. Staff P continued to provide care to the residents for the remainder of his/her shift (approximately 6 hours and 30 minutes). This deficient practice placed the residents in the facility in immediate jeopardy. The facility abated the immediate jeopardy on 5/18/17 at 5:00 P.M. when it implemented the following: Suspension of direct care staff P; interview of resident #1's roommate; the director of nursing performed a full body assessment on resident #1 and observed resident #1's behavior and demeanor; disciplinary action for direct care staff O; in-service to all staff with emphasis on the requirement to immediately notify the charge nurse or administrator and director of nursing to be completed by 5/18/17 at 5:00 P.M., and no staff would work without completion of this in-service; interviews of 5 residents weekly by the director of nursing or social services designee weekly for 3 months then monthly thereafter, and in-service all staff again on 5/22/17. The deficient practice remained at a scope and severity of an E.

The facility reported a census of 39 residents. The sample included 4 residents. Based on record review, observation, and interview, the facility failed to prevent a fall which resulted in a subdural hematoma (brain bleed) for 1 of 4 residents sampled for falls (#1). Findings included: - The electronic medical record (EMR) for resident #1 documented the following Diagnoses: [REDACTED]. The 9/16/16 quarterly Minimum Data Set (MDS) recorded a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The resident remained independent with locomotion on and off of the unit. He/she required limited assistance with transfers and extensive assistance with dressing, toileting and personal hygiene. He/she was not steady but able to stabilize without staff assistance. The assessment noted the resident had 2 non injury falls since the previous assessment. The significant change MDS dated [DATE] recorded the resident's cognition was the same; however, he/she required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He/she was not steady with transfers and only able to stabilize himself/herself with staff assistance. The assessment noted the resident had 2 non-injury falls since the previous assessment. The care area assessments (CAA) dated 12/16/16 recorded the resident required assistance with all Activities of Daily Living (ADLs), had an unsteady gait and balance, made poor decisions, forgot to notify staff for assistance, and experienced 4 falls within the last 90 days. The CAA for urinary incontinence indicated a care plan would be developed to address the resident's occasional bladder incontinence, history of bowel incontinence, dribbled urine, and use of diuretic (medications to alleviate the body of excess fluids). The fall risk assessments dated 9/6/16, 10/27/16, and 12/21/16 documented the resident was a high fall risk. The care plan for ADLs dated 12/30/16 recorded the resident had an ADL deficit related to chronic back pain, his/her knees gave out, he/she had an unsteady balance and gait. The care plan directed staff to assist with all ADLs and encourage the resident to use his/her call bell for assistance. The care plan however, did not address the resident's functional ability and/or care needs with toileting. The care plan documented the resident experienced falls on 3/1/16, 7/26/16, 9/5/16, 9/9/16, 9/21/16, 10/27/16, 12/7/16, and 12/21/16. The care plan updated on 9/21//16 for falls recorded the following interventions: monitor per fall protocol, remind resident to wear gripper socks when in bed instead of regular socks, remind to change gripper socks on a weekly basis, secure stool riser in place for more stability as resident tended to use to assist him/herself to stand, place grab bar on bathroom wall (east end) to allow resident to use, so he/she can leave the walker outside of the bathroom. On 9/26/16, staff added to ensure the call light was in reach and encourage resident to use, and staff were to be aware the resident needed prompt response to all requests for assistance. On 10/27/16, staff added the interventions: redirect resident not to turn off alarms and await staff assist, floor strips in front of recliner. On 12/7/16, the care plan was updated directing staff to check the resident's blood sugar following falls, and on 12/8/16, staff was instructed not to leave the wheelchair within reach of the resident while in the bed/recliner. The care plan lacked new interventions after falls on 6/25/16, 10/12/16, 12/7/16 and 12/21/16. The care plan further lacked documentation related to any specific interventions related to assisting the resident with toileting. Review of the nurse's note dated 12/21/16 at 2:22 A.M. documented staff heard the resident yell. Upon entering the resident's room, staff found the resident on the floor lying on his/her right side with blood around his/her head, and a laceration to the right side of his/her head near the temple. The resident reported he/she hit his/her head on the floor. He/she did not wear a brief and/or pants, and stated he/she tried to put on a clean brief, lost his/her balance and fell . Staff noted the resident had increased confusion, and the resident was transported to the emergency room for evaluation. Review of the nurse's note dated 12/21/16 at 5:03 A.M. documented the resident returned to the facility with staples to his/her right forehead. Review of the nurse's note dated 12/21/16 at 8:32 A.M. documented the facility received a phone call from the hospital which requested the resident's return to the hospital due to the computerized tomography (CT) (a diagnostic test) revealed a brain hemorrhage (bleed). The nurse's progress notes recorded the resident returned from the hospital on [DATE] at 3:59 P.M., was re-hosptalized on [DATE] at 1:00 A.M., and returned on 12/23/16 at 1:06 P.M. with orders for palliative care (comfort measures). On 1/4/17 at 2:20 P.M., the resident laid in bed on his/her back and was non-responsive to verbal stimuli. On 1/4/17 at 11:45 P.M., licensed nurse E stated the resident fell on [DATE]. He/she stated the resident quickly became impatient waiting for staff, and attempted to do things for himself/herself, no matter how many alarms were placed. Nurse E stated the resident had recliner, bed and wheelchair sensor alarms, but knew how to disconnect them. Nurse E further stated he/she came down the hall and heard the resident call for help. When he/she entered the resident's room, he/she observed the resident on the floor. On 1/5/17 at 12:30 P.M., direct care staff H stated the resident required staff assistance with toileting due to he/she was unsteady at times and was weaker. On 12/21/16, staff H assisted the resident to the bathroom when a personal alarm sounded across the hall. Staff H admitted he/she left the resident in the bathroom and tended to the alarm. On 1/5/17 at 3:00 P.M., administrative licensed nurse D acknowledged the potential hazard when residents' fall risk alarms and call lights signaled at the same time. Nurse D stated this was an unfortunate occurrence, but declined to comment about questions related to the facility's policy or practice of staff staying with resident(s) while toileting. On 1/8/16 at 1:30 P.M., physician KK was unavailable for interview. The facility's Resident Falls policy, revised 8/2016, lacked documentation related to the proper procedure to follow with witnessed or unwitnessed falls, specific fall interventions, and monitoring of confused residents during toileting. The facility also provided the undated Kansas Department on Aging Quality Practice Workgroup guidelines as a measure to prevent and investigate falls. These policies included strategies such as implement an individualized toileting schedule and review and revise the toileting schedule. The facility failed to implement interventions to prevent a fall which resulted in a serious injury for this cognitively impaired resident with impulsive behavior, an unsteady gait, a history of falls, poor safety awareness, and dressing and toileting difficulties. The resident sustained [REDACTED].

The facility identified a census of 46 residents. The sample included 3 residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement interventions to prevent the development of three facility acquired pressure ulcers, one stage 1 and two stage 2, for 1 resident (#1) when the resident ' s air mattress deflated, leaving the resident lying on a hard surface for an undetermined length of time. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 (indicated intact cognition). The assessment revealed the resident was totally dependent on staff for bed mobility and toileting. The resident was frequently incontinent of urine (inability to hold the urine or bowel), and occasionally incontinent of bowel. The assessment further indicated the resident was at risk for pressure ulcers, currently had a stage 3 pressure ulcer, and had a pressure reducing device for the bed and chair. He/she was on a turning and repositioning program. The Care Area Assessments (CAAs) dated 7/11/16 for pressure ulcers revealed the resident had a recurring stage 3 pressure ulcer on his/her coccyx (tailbone) that required treatment. The care plan dated 7/13/16 directed staff to keep the resident ' s skin clean and dry, and to use a lift sheet to move the resident. Staff applied lotion to the resident ' s skin. There was a low air loss mattress on the bed and a pressure reducing cushion in the wheelchair. He/she required extensive assist of 1 staff with turning every 2 hours and as needed. The skin observation tool dated 5/10/16 revealed the resident ' s skin was intact. On the Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE], the resident scored 15 (indicated a mild risk for pressure ulcer development). On 7/11/16, the resident scored 14 (indicated a moderate risk). The wound-weekly observation tool dated 5/17/16 documented the resident readmitted to the facility with a wound on his/her coccyx with 10 % slough (dead tissue) and measured 0.4 centimeters (cm) by 0.3 cm by 0.1 cm. (This was the recurring stage 3 pressure ulcer, which the facility had treatments in place and based on 9/9/16 observation was in the process of healing). The skin/wound progress note dated 8/19/16 at 5:20 AM documented the resident laid in bed on his/her back with the low air loss mattress deflated. The wound-weekly observation tool dated 8/26/16 identified an area of redness, which did not lighten in color when touched and indicated damage to the tissue underneath. The tool indicated this Stage 1 pressure ulcer was on the coccyx (which was inaccurate, based on observation on 9/6/16 at 1:55 PM, the wound was on the left buttock), and measured 2.6 cm by 3.1 cm with no depth. The skin/wound progress note dated 8/26/16 documented the wound and the red area on the resident ' s coccyx, and also documented two areas of dark purple discoloration under intact skin surrounding the coccyx (suspected deep tissue injury) that could be from exposure to the area from the deflated air mattress on 8/19/16. The superior area measured 0.5 cm by 0.6 cm with no depth, and the inferior site measured 0.7 cm by 0.4 cm with no depth. The skin/wound progress note dated 8/31/16 once again documented the wound and the red area on the resident ' s coccyx. The two dark purple areas previously surrounding the coccyx were now open Stage 2 pressure ulcers. The superior (upper) site measured 0.2 cm by 0.3 cm by 0.05 cm, and the inferior (lower) site measured 0.5 cm by 0.2 cm by 0.05 cm. On 09/06/16 at 9:38 AM, the resident laid in bed on his/her right side on a low air loss mattress. On 9/06/16 at 1:55 PM, licensed nursing staff H removed the dressing from resident ' s coccyx. He/she pointed to an area on the coccyx, and indicated the original coccyx wound (recurring stage 3 pressure ulcer). The skin was intact and pink. There was an area of dark pink intact skin on the left buttock (stage 1 pressure ulcer), near the coccyx, which measured approximately 5 cm by 3 cm. Staff H pressed on this skin, and it did not blanch (lighten in color when touched). There were two open areas (stage 2 pressure ulcers) between the sacrum and the red area on the left buttocks, each measured approximately less than 1 cm in diameter. On 9/07/16 at 9:30 AM, direct care staff O stated the resident had a pressure ulcer and a low air loss mattress on his/her bed. Staff checked the function of the air mattress when they entered the resident ' s room. On 9/06/16 at 1:39 PM licensed nursing staff H stated the resident had a pressure ulcer on his/her coccyx, an area of reddened skin to the right (should be left) of the pressure ulcer and 2 open areas near the coccyx wound. He/she said the resident was at risk for the development of another pressure ulcer, and there was a low air loss mattress on the resident ' s bed. Staff H further stated the low air loss mattress deflated on 8/19/16. On 9/07/16 at 9:46 AM, licensed nursing staff I stated the resident had a pressure ulcer, and was at risk for the development of another one. He/she said there was a low air loss mattress on the resident ' s bed. Staff I further stated nursing staff ensured the air mattress functioned properly by checking it once every shift, but this was not documented anywhere. On 9/07/16 at 12:30 PM, administrative nursing staff D stated he/she expected staff to implement interventions to prevent the resident from a new pressure ulcer development. This included for staff to ensure the resident ' s low air loss mattress functioned appropriately. Staff D further stated after the incident when the resident ' s air mattress deflated, he/she felt the 2 hour checks and repositioning of the resident were not getting done, so beginning 9/1/16, staff were expected to document the 2 hour check and repositioning, which included monitoring of the air mattress functioning. The facility ' s policy Wound Care , revised 7/2013, revealed staff prevented the occurrence of pressure ulcers through the reduction of pressure. The facility ' s policy Air Mattress , revised 8/2011, documented an air mattress relieved excess pressure to bony points on the body. The policy directed staff to check the mattress before the resident laid in the bed, and to report a faulty air mattress to maintenance and the licensed nursing staff. The facility failed to monitor appropriate function of the resident ' s air mattress, which deflated and the dependent resident developed three pressure ulcers, one stage 1 and two stage 2, after laying in a supine position on a hard surface for an undetermined length of time.The facility identified a census of 46 residents. The sample included 3 residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement interventions to prevent the development of three facility acquired pressure ulcers, one stage 1 and two stage 2, for 1 resident (#1) when the resident ' s air mattress deflated, leaving the resident lying on a hard surface for an undetermined length of time. Findings included: - The physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 (indicated intact cognition). The assessment revealed the resident was totally dependent on staff for bed mobility and toileting. The resident was frequently incontinent of urine (inability to hold the urine or bowel), and occasionally incontinent of bowel. The assessment further indicated the resident was at risk for pressure ulcers, currently had a stage 3 pressure ulcer, and had a pressure reducing device for the bed and chair. He/she was on a turning and repositioning program. The Care Area Assessments (CAAs) dated 7/11/16 for pressure ulcers revealed the resident had a recurring stage 3 pressure ulcer on his/her coccyx (tailbone) that required treatment. The care plan dated 7/13/16 directed staff to keep the resident ' s skin clean and dry, and to use a lift sheet to move the resident. Staff applied lotion to the resident ' s skin. There was a low air loss mattress on the bed and a pressure reducing cushion in the wheelchair. He/she required extensive assist of 1 staff with turning every 2 hours and as needed. The skin observation tool dated 5/10/16 revealed the resident ' s skin was intact. On the Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE], the resident scored 15 (indicated a mild risk for pressure ulcer development). On 7/11/16, the resident scored 14 (indicated a moderate risk). The wound-weekly observation tool dated 5/17/16 documented the resident readmitted to the facility with a wound on his/her coccyx with 10 % slough (dead tissue) and measured 0.4 centimeters (cm) by 0.3 cm by 0.1 cm. (This was the recurring stage 3 pressure ulcer, which the facility had treatments in place and based on 9/9/16 observation was in the process of healing). The skin/wound progress note dated 8/19/16 at 5:20 AM documented the resident laid in bed on his/her back with the low air loss mattress deflated. The wound-weekly observation tool dated 8/26/16 identified an area of redness, which did not lighten in color when touched and indicated damage to the tissue underneath. The tool indicated this Stage 1 pressure ulcer was on the coccyx (which was inaccurate, based on observation on 9/6/16 at 1:55 PM, the wound was on the left buttock), and measured 2.6 cm by 3.1 cm with no depth. The skin/wound progress note dated 8/26/16 documented the wound and the red area on the resident ' s coccyx, and also documented two areas of dark purple discoloration under intact skin surrounding the coccyx (suspected deep tissue injury) that could be from exposure to the area from the deflated air mattress on 8/19/16. The superior area measured 0.5 cm by 0.6 cm with no depth, and the inferior site measured 0.7 cm by 0.4 cm with no depth. The skin/wound progress note dated 8/31/16 once again documented the wound and the red area on the resident ' s coccyx. The two dark purple areas previously surrounding the coccyx were now open Stage 2 pressure ulcers. The superior (upper) site measured 0.2 cm by 0.3 cm by 0.05 cm, and the inferior (lower) site measured 0.5 cm by 0.2 cm by 0.05 cm. On 09/06/16 at 9:38 AM, the resident laid in bed on his/her right side on a low air loss mattress. On 9/06/16 at 1:55 PM, licensed nursing staff H removed the dressing from resident ' s coccyx. He/she pointed to an area on the coccyx, and indicated the original coccyx wound (recurring stage 3 pressure ulcer). The skin was intact and pink. There was an area of dark pink intact skin on the left buttock (stage 1 pressure ulcer), near the coccyx, which measured approximately 5 cm by 3 cm. Staff H pressed on this skin, and it did not blanch (lighten in color when touched). There were two open areas (stage 2 pressure ulcers) between the sacrum and the red area on the left buttocks, each measured approximately less than 1 cm in diameter. On 9/07/16 at 9:30 AM, direct care staff O stated the resident had a pressure ulcer and a low air loss mattress on his/her bed. Staff checked the function of the air mattress when they entered the resident ' s room. On 9/06/16 at 1:39 PM licensed nursing staff H stated the resident had a pressure ulcer on his/her coccyx, an area of reddened skin to the right (should be left) of the pressure ulcer and 2 open areas near the coccyx wound. He/she said the resident was at risk for the development of another pressure ulcer, and there was a low air loss mattress on the resident ' s bed. Staff H further stated the low air loss mattress deflated on 8/19/16. On 9/07/16 at 9:46 AM, licensed nursing staff I stated the resident had a pressure ulcer, and was at risk for the development of another one. He/she said there was a low air loss mattress on the resident ' s bed. Staff I further stated nursing staff ensured the air mattress functioned properly by checking it once every shift, but this was not documented anywhere. On 9/07/16 at 12:30 PM, administrative nursing staff D stated he/she expected staff to implement interventions to prevent the resident from a new pressure ulcer development. This included for staff to ensure the resident ' s low air loss mattress functioned appropriately. Staff D further stated after the incident when the resident ' s air mattress deflated, he/she felt the 2 hour checks and repositioning of the resident were not getting done, so beginning 9/1/16, staff were expected to document the 2 hour check and repositioning, which included monitoring of the air mattress functioning. The facility ' s policy Wound Care , revised 7/2013, revealed staff prevented the occurrence of pressure ulcers through the reduction of pressure. The facility ' s policy Air Mattress , revised 8/2011, documented an air mattress relieved excess pressure to bony points on the body. The policy directed staff to check the mattress before the resident laid in the bed, and to report a faulty air mattress to maintenance and the licensed nursing staff. The facility failed to monitor appropriate function of the resident ' s air mattress, which deflated and the dependent resident developed three pressure ulcers, one stage 1 and two stage 2, after laying in a supine position on a hard surface for an undetermined length of time.

The facility identified a census of 61 with 5 residents in the sample. Based on observation, interview, and record review the facility failed to monitor for adverse drug interactions for one of three residents sampled for anticoagulant (agent to prevent blood clots) medications (#3). Findings included: - The physician order [REDACTED].#3 recorded [DIAGNOSES REDACTED]. a blood vessel). Review of the annual Minimum Data Set assessment dated [DATE] recorded the resident with a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident required extensive assistance from one staff member for all activities of daily living except eating. Review of the Care Area Assessment for activities of daily living dated 4/28/14 recorded the resident received the [MEDICATION NAME]([MEDICATION NAME] sodium a non-steroidal (NSAID) anti-[MEDICAL CONDITION] pain medication) for leg pain and the blood thinner [MEDICATION NAME]. The revised plan of care for anticoagulant therapy dated 10/21/14 recorded the resident with a history of a [MEDICAL CONDITION] ([MEDICAL CONDITION]-potentially life threatening blood clot, usually in the legs). The staff would administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness of the medication each shift. Perform labs as ordered and report abnormal lab results to the physician. Monitor/document/report PRN (as needed) adverse reactions of anticoagulant therapy, blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Resident/family/care giver teaching included taking the medication at the same time each day, use of a soft toothbrush, electric razor, and to avoid activities that could result in injury. Take precautions to avoid falls, and signs or symptoms of bleeding. Avoid foods high in vitamin K (clotting vitamin). Review the medication list for adverse interactions and avoid use of aspirin or NSAIDS. The Medication Administration Record [REDACTED] [MEDICATION NAME] sodium (Aleve) 220 milligrams twice daily for pain, dated 5/29/14; [MEDICATION NAME] 9 mg daily Tuesday/Thursday and [MEDICATION NAME] 8 mg daily Sunday, Monday, Wednesday, Friday and Saturday for embolism and [MEDICAL CONDITION] dated 9/29/14 through 10/10/14; [MEDICATION NAME] 8 mg daily from 10/11/14 through 10/28/14; [MEDICATION NAME] 7.5 mg daily; [MEDICATION NAME] 150 mg for rash every on 10/13/14; [MEDICATION NAME] 150 mg for rash on 10/20/14; [MEDICATION NAME] 150 mg for rash every 72 hours for 5 days dated 10/27/14 (given on 10/27/14 and 10/30/14), and [MEDICATION NAME] 150 mg for rash each Tuesday until 12/9/14, dated 10/28/14 (given on 10/28/14). Bactrim ([MEDICATION NAME]-[MEDICATION NAME]) 400 - 80 milligrams antibiotic twice daily for rash dated 10/27/14. The Lexicomp ' s Drug Reference Handbook for Nursing, 13th Edition, pages 1245 - 1247 recorded bleed was the major adverse effect of [MEDICATION NAME]. The level/effects of [MEDICATION NAME] may be increased with interactions of [MEDICATION NAME] and the medications NSAIDS, Fluconazole ([MEDICATION NAME]), and sulfonamide derivatives (Bactrim). The physician's order [REDACTED]. laboratory results dated [DATE] recorded a PT level 26.9 seconds and INR level of 2.71 and recorded the physician note for no changes in the medication. The resident laboratory results were at the therapeutic goal. Laboratory result dated 9/11/14 recorded a PT/INR level 21.1 seconds and 1.96. Review of the facility fax to the physician recorded the physician note to continue the current dose, of [MEDICATION NAME], and recheck the INR in 2 weeks. Laboratory result dated 9/26/14 recorded a PT/INR level of 18.5 seconds and 1.64 Laboratory report dated 10/10/14 recorded a PT/INR of 29.4 seconds and 3.05. Review of the facility fax to the physician recorded the physician note to continue the current dose, of [MEDICATION NAME], and to recheck the PT/INR in 7 days (10/17/14). The clinical record lacked evidence of the physician ordered laboratory blood test on 10/17/14. A Physician order [REDACTED]. The clinical record lacked evidence of any PT/INR lab blood tests since 10/10/14. Nursing note dated 10/10/14 recorded laboratory results for the PT/INR and recorded the physician ordered change of [MEDICATION NAME] dose. Nursing note dated 10/29/14 at 2:15 A.M. documented the pharmacy recommendation for a PDI (potential drug interaction) with the [MEDICATION NAME] faxed to the physician and recorded the physician order [REDACTED]. Nursing note dated 10/31/14 at 5:11 A.M. recorded at 4:20 A.M. the resident was confused, had a moderate amount of bright red blood from vaginal/rectal area, had a pulse of 130, blood pressure 165/92, respirations 26, and temperature of 99.5 degrees Fahrenheit. The nursing staff obtained a physician's order [REDACTED]. The hospital emergency room note dated 10/31/14 at 5:03 A.M. recorded the resident was examined for rectal bleeding, pulse 118, respirations 22, and blood pressure 110/55. The laboratory report recorded a low hemoglobin (measure of blood that carried oxygen to the cells from the lungs and carbon [MEDICATION NAME] away from the cells in the longs) of 10.9 (normal 12.0 to 16.0 grams/deciliter), low hematocrit (measure of the packed cell volume of red blood cells, expressed a percentage of the total blood volume) of 34.0 (normal 36 to 48 percent), a high PT 81.1 (normal 11.5 -14) seconds, and a high critical INR 11.87 (normal of 0.87 to 1.13 and [MEDICATION NAME] for [MEDICAL CONDITION] 2.0 to 3.0), and occult (microscopic or invisible blood in the stool) blood test positive. The resident received Vitamin K 10 milligrams and two units of fresh frozen plasma (the liquid portion of human blood frozen and used for blood transfusion). A transfer form from the local hospital emergency room dated 10/31/14 documented at 9:31 A.M. the resident was transferred to a larger acute hospital with [DIAGNOSES REDACTED]. A nursing note dated 10/31/14 timed 9:17 A.M. recorded the local hospital notified the facility the resident was transferred to a large hospital for further treatment. Review of a hospital emergency room report dated 10/31/14 timed 11:10 A.M. recorded the resident with an admission of coagulopathy (clotting disorder/bleeding disorder in which the blood's ability to clot (coagulate) was impaired). Observation on 11/14/14 at 4:00 P.M. revealed the resident sat in an upright chair in an acute healthcare facility with an intravenous antibiotic infusing and reported he/she felt nauseous. On 11/13/14 at 3:50 P.M. licensed nurse H reported nursing staff obtain lab work as the physician ordered. The nursing staff recorded the orders for laboratory tests on the desk calendar and the computer desktop. The resident received the medication [MEDICATION NAME] daily at 6:00 P.M. On 11/14/14 at 12:10 P.M. licensed nursing staff J reported the facility obtained laboratory tests as the physician ordered and the laboratory faxed the report results to the physician. On 11/14/14 at 1:00 P.M. licensed nursing staff K revealed the facility received the laboratory results for PT/INR by fax and notified the physician. The nursing staff followed the physician orders [REDACTED]. On 11/14/14 at 1:05 P.M. administrative nursing staff D reported the resident received [MEDICATION NAME] daily and the medication [MEDICATION NAME]. The licensed nurses recorded the physician lab orders and faxed the physician the lab results. On 11/18/14 at 3:10 P.M. administrative staff A revealed the facility failed to obtain the physician ordered PT/INR on 10/17/14. The physician decreased the [MEDICATION NAME] dose due to a pharmacy recommendation of a potential interaction of other medications with [MEDICATION NAME]; however, the facility did not obtain a PT/INR after 10/10/14. On 11/18/14 at 4:40 P.M. consultant physician FF reported the resident received [MEDICATION NAME] therapy for recurrent [MEDICAL CONDITION] of his/her legs. The facility staff performed laboratory blood tests from physician orders [REDACTED]. The physician ' s office called the facility with changes in medications. The last PT/INR received from the facility was dated 10/10/14. Consultant physician FF reported he/she lowered the resident ' s [MEDICATION NAME] dose (on 10/27-28/14) due to a possible interaction of medications, and ordered the lab test PT/INR every 3 days, and to notify the physician with the result. Consultant physician FF reported the resident was in the hospital emergency roiagnom on [DATE] with an INR of 10. The facility provided a policy dated 7/2011 for Lab Monitoring and Collection recorded the nursing staff would document in the nurse ' s notes when lab collections were taken. Nursing staff would notify the physician if laboratory specimens were not collected on a scheduled day of collection for any reason. Nursing staff would document this notification in the nurses ' notes and record on the 24-hour report. The facility failed to provide necessary care and services to monitor for serious adverse medication interactions of [MEDICATION NAME] for this resident that resulted in bleeding, and required hospitalization and emergency treatment with a transfusion and medication to reverse bleeding.

The facility reported a census of 69 residents. The sample included 3 residents for advanced directives (a written document that indicated the medical decisions for health care professionals when the resident could not speak). Based on interview and record review the facility failed to assess the resident and initiate cardiopulmonary resuscitation (CPR) for 1 (#1) of 3 resident ' s reviewed who was a full code (staff to provide CPR) when staff found the resident was not breathing and died in the facility which placed the resident in immediate jeopardy. Findings included: - Resident #1 admitted to the facility on [DATE]. Review of the physician order [REDACTED]. If code status is unknown, patient is Full Code". Review of the nursing admission assessment dated [DATE] documented the resident was cognitively intact and required assistance from staff for all activities of daily living. The facility admission papers signed by the resident on [DATE] checked both yes and no for full code status. During an interview on [DATE] at 9:50 A.M., social services staff X reported the resident first checked no (the do not resuscitate box) after having said he/she wanted to be a full code. I brought it to his/her attention regarding the code status because the resident had said he/she wanted to be a full code and the resident then checked the yes (full code - initiate CPR box). Social service staff X revealed, he/she did not change the form. Review of the plan of care dated [DATE] lacked documentation regarding the resident's code status. Nursing note dated [DATE] timed 3:03 A.M. recorded (on [DATE]) at 11:00 P.M. a CNA stated to this nurse that the resident did not look well at all. Upon arrival to the resident's room, staff found the resident nonresponsive and vital signs absent. Staff contacted the emergency contact who provided the number for the resident's child. Staff notified the resident's responsible party and requested the mortuary preference. Staff received a physician telephone order to release the body. Review of the record of death and mortician's receipt completed by nursing staff recorded the resident's death on [DATE] at 11:00 P.M. On [DATE] at 9:05 A.M., direct care staff N revealed the call light for the resident's roommate sounded between 10:00 P.M. and 10:10 P.M. and he/she answered the light at that time and observed the resident lay quietly in bed without any movement and he/she knew the resident had died . Direct care staff N did not touch the resident and went to get the charge nurse H to come and assess the resident. On [DATE] at 10:55 A.M. licensed nursing staff H revealed on [DATE] around 11:00 P.M., direct care staff N reported the resident was in trouble. Upon assessment, the resident was very pale without vital signs. Licensed nursing staff H revealed he/she was not aware the resident was a full code until approximately 11:30 P.M. when looking through the chart for emergency contact information. Licensed nursing staff H reported he/she did not start CPR on the resident because at least 10 minutes had passed. Review of the witness statement given by licensed nursing staff I on [DATE] revealed, on [DATE] between 10:30 P.M. and 11:00 P.M. licensed nursing staff H paged him/her to come to the nursing station and said the resident had died . Licensed nursing staff I went into the resident's room and found him/her lying on his/her back, head turned slightly to the left shoulder with a washcloth folded upon his/her head. The resident was without respirations, pulse, or movement. Licensed nursing staff I repositioned the resident's head on the pillow in proper alignment and found the residents skin was very warm, moist, and pale yellow in color. Review of the resident's clinical record lacked evidence licensed nursing staff attempted to perform CPR for the resident at this time. On [DATE] at 10:11 A.M. licensed nursing staff J reported if he/she found a resident not breathing and no pulse, he/she would initiate CPR after checking the resident's code status. On [DATE] at 9:45 A.M. licensed nursing staff K revealed the resident's chart and order sheet identified the code status. If a resident was found not breathing or unresponsive, not cold to touch and within a reasonable time of last observation of the resident, the nursing staff initiated CPR for a full code status. On [DATE] at 10:30 A.M. licensed nursing staff L reported the resident's code status was in the chart and computer and when a resident was found unresponsive and not breathing staff checked for vital signs, touched the resident skin for warmth. When the resident was a full code staff obtained the crash cart and started CPR. On [DATE] at 2:00 P.M. administrative nursing staff D reported licensed nursing staff needed to know the code status of the resident that was in the chart and in the computer. When a resident was a full code status, he/she expected the nurse to start CPR for a resident who was a full code, while another staff member called for an ambulance. On [DATE] at 11:25 A.M. administrative nursing staff D reported licensed nursing staff H notified him/her on [DATE] at 10:46 P.M. the resident passed away. Review of the facility provided undated Nursing Policy and Procedure CPR Protocol directed the facility must provide, identify, and act according to the advance directives of its residents. Each resident had an advanced directive listed on their chart "CPR/FULL CODE or DNR (do not resuscitate)". When a resident was a full code/CPR, staff would administer CPR according to industry standards when required. The facility failed to provide CPR for this resident who was a full code and was not breathing. This placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on [DATE] at 7:00 A.M. when the facility: Developed a policy on CPR in accordance with the CMS memo dated [DATE]. Developed a procedure for identification of the code status of residents. Residents with a DNR would have a DNR spine label on the outside of their chart. Completed inservice of all staff with duties in the Health Care Unit regarding the CPR policy and their role. This inservice will be completed on [DATE] at 7:00 A.M. Only licensed nurses with a current CPR certification would be hired. All licensed staff and the transportation driver would be CPR certified. The director of nursing would monitor the current status of CPR certified staff. The Quality Assurance Performance Indicator (QAPI) Committee would review the plan of correction at the next scheduled QAPI meeting. This deficient practice remains at the scope and severity of a D.

- Review of the physician order [REDACTED]. The Admission MDS 3.0 (minimum data set), dated 5-10-12, revealed a BIMS (brief interview of mental status) score of 15/15, evidenced the resident as cognitively intact. The resident required extensive assistance with 2 staff for bed mobility, dependant for transfers and independent with eating skills. The resident's admission weight of 152 lbs (pounds) and resident's height of 69 inches. The CAA (care area assessment), dated 5-10-12, revealed ADL summary (activities of daily living), "Resident recent admit from hospital and requires extensive to total assistance with ADL's". Nutritional summary revealed, "Resident requires use of a therapeutic diet and admitted with numerous pressure ulcers." The care plan, dated 5-10-12, directed staff to give nutritional supplements as ordered and double portion of proteins at each meal and provide a minimum of 12-16 ozs (ounces) of fluid per dietary meal tray. Additions to the care plan, on 5-23-12, directed staff to provide nutritional supplements QID (four times a day) to the resident. The dietary card, (to inform dietary staff what to serve), revealed the resident received double portions of proteins, 8 ozs of whole milk, 4 ozs of juice and 2 (8 ozs) healthshakes for breakfast. The resident received double portion of proteins, 8 ozs of whole milk and 2 (8 ozs) healthshakes at lunch. The resident received 8 ozs of whole milk and 4 ozs of juice at supper. The June 2012 dietary meal percentage book, revealed percentages of meal intake as 75-100%, except for 2 days, on 6-25-12, the resident refused breakfast, and lunch and supper lacked documentation of meal intake. On 6-26-12, the resident ate 10% of breakfast, and lunch and supper lacked documentation. The July 2012 dietary meal percentage book, revealed percentages of meal intake, for the 45 possible meals, the resident consumed 50-100% of meals. The physician fax, dated 6-26-12, revealed the resident refused to eat and with behaviors of cursing at staff. The facility failed to inform the resident's physician of the resident's current weight at that time. The physician replied, "Likely patients personality and has a history of drug abuse". The initial nutritional assessment, dated 5-4-12, revealed an admission weight of 152 lbs. The assessment failed to list the likes and dislikes of the resident's food preferences. The dietary notes, dated 5-23-12, revealed, "[MEDICATION NAME] level of 1.6 and will serve double portions of protein. Received physicians order for healthshakes QID." The laboratory flowsheet, dated 6-26-12, revealed an [MEDICATION NAME] level of 2.2 (normal range 3.5-5.0). The [MEDICATION NAME] tests for proteins that are stored in the body. The dietary notes, dated 6-22-12, revealed, "Resident was discouraged today because the residents choices for the meals were not served correctly and that it made him/her feel like not eating". The dietary notes, dated 7-9-12, revealed, "Resident continues to stay in room and po (by mouth) intake is 80% with continuing to drink healthshakes QID". The dietary notes, dated 7-10-12, revealed,"Resident has had a 9.5% weight loss x 30 days as of 7-3-12. Weight today is 134 lbs. Po intake continues to be 80% and PO intake calorie x 2 days was 1800 calories per day (7-8-12 thru 7-9-12)". The resident's weight on June 1st, 2012, evidenced on the MAR (medication administration review), 6-1-12=143 lbs, 6-21-12=138 lbs. The resident lost 9 pounds from 5-4-12 to 6-1-12, of a percentage of 5.9% in 30 days and 18 pounds from 5-4-12 to 7-10-12. This represents a loss over 2 months, which equals 11.8% weight loss and this represents a significant weight loss. On 7-11-12, at 8:09 a.m., staff delivered the resident's hall tray with scrambled eggs, wheat toast, raisin bran cereal, 2 vanilla shakes (16 ozs), glass of milk, 12 ozs glass of water and 8 ozs glass of orange juice. The resident was served 1 portion of eggs. The resident consumed 100% of breakfast and refused the 2 vanilla shakes. On 7-11-12, at 12:30 p.m., staff delivered the resident's hall tray, with one turkey sandwich, mashed potatoes, green beans and cake, 12 ozs glass of milk, 8 ozs glass of water. The turkey sandwich was one portion of protein. The resident consumed 100% of lunch and refused the 2 vanilla shakes. On 7-16-12, at 12:15 p.m., staff delivered the hall tray, and staff L, observed the chicken noodle soup and fruit crisp was not what the resident ordered. Staff changed the tray to what the resident ordered, consisting of ham and beans with cornbread and a fruit crisp, 8 ozs glass of milk. On 7-16-12, at 11:07 a.m., the resident stated," I love to eat but I never eat 100% of my food. The most I ever eat is 75%. I like to eat fried potatoes but they are never cooked right. I never eat the fish or chicken because it is undercooked. I like tomato soup but the tomato soup here is cheesy and I don't like the flavor. I just started ordering grilled cheese because I know they can't mess that up. I started refusing the supplements about a week ago because I am tired of them. The staff forget to bring the supplements most of the time anyway. I never get my double portions of protein. In the morning I have to ask for two eggs otherwise they just send me one egg. I don't like bell peppers or white onions, but nobody has asked me what I don't like. No one has ever asked me my preferences." On 7-10-12, at 4:39 p.m., licensed staff C stated, "It seems when (the resident) gets up he/she will have trouble with their stomach. The resident states he/she likes to lay down alot." On 7-11-12, at 10:06 a.m., licensed staff O stated, "The supplements aren't a physicians order, the resident just request them." The physician fax, dated 5-23-12, revealed a physicians order for healthshakes. On 7-11-12, at 12:36 p.m. administrative staff H stated, "We go over the weights every morning and the dietary manager gets the weights too. The resident's daily weights were discontinued yesterday when he/she had an appointment with the physician. After the resident attended his/her appointment, he/she refuses to eat or come out of his/her room." On 7-16-12, at 10:45 a.m., licensed staff C, stated, " The resident refused to come out of their room, but will eat what he/she orders on the alternate meals. I think some of his/her eating is behavior and controling what he/she does everyday." On 7-11-12, at 12:30 p.m., dietary staff G, stated, "I don't know how we do the double portions for protein." On 7-11-12, at 12:51 p.m.,dietary staff E stated,"If I have more than one complaint I will investigate. I haven't had any complaints of food temperature or dislikes. I put the dislikes and likes on their card and I put the dislikes and likes on the original admission assessment." On 7-11-12, at 12:57 p.m., dietary staff E, stated, "The nurses notify the physician of any significiant weight loss. We go over the weights weekly with the nurses." On 7-16-12 at 10:41 a.m., licensed staff C, stated, "The nutritional supplements intake is charted under the meal intake percentage intake under fluids. There is no way to tell the difference between the regular fluids and the nutritional supplement". On 7-16-12, at 12:15 p.m., when asked what staff considered double proteins, dietary staff E stated, "He/she is refusing their supplements." On 7-16-12 at 12:30 p.m.,the resident stated, "I keep waiting for the dietary manager to come down to discuss my double portions of proteins because I would eat cheesy eggs at every meal." The facility's dietary policy and procedure on weights, dated January 2010, revealed, "...Nursing staff is responsible to obtain weights...Dietary manager is responsible for tracking and calculating weights for weight loss/gain. Significant weight changes are 5% in 1 month, 7.5% in 3 months and 10% in 6 months...Dietary manager will bring any significant weight changes to charge nurse's attention...Doctor to be notified of undesirable weight change and any measures taken by facility. Dietary manager will place any significant weight change on list for dietician monthly review..." The facility failed to maintain the resident's acceptable parameters of nutritional status. The facility failed to serve the resident double portions and failed to explore the resident's food preferences. The resident experienced a significant weight loss of 5.9% over 30 days and 11.89% (18 pounds) over 2 months. The facility identified a census of 51 residents. The 21 residents selected for review included 3 reviewed for nutrition. Based on observation, interviews, and record review, the facility failed to identify weight loss for 2 (#65 and #56) of the 3 sampled residents, and ensure these 2 residents maintained acceptable perimeters of nutrition. Findings included: - Resident # 56 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (minimum data set assessment) dated 5/10/2012, documented the resident with severely impaired cognitive status, the resident required extensive assistance of one staff with eating, no weight lost, and on an therapeutic (special physician ordered) diet. The CAA's (care area assessment) dated 5/16/2012, revealed the resident with impaired cognitive functioning, and required extensive assistance of 1-2 staff with ADL's (activity of daily living). The care plan dated 5/16/2012 revealed the resident with impaired cognition and the resident as rarely able to make self understood due to his/hers dementia. The nutritional care plan dated 7/12/2012 revealed the resident had the potential for impaired nutritional status, and weight loss due to the resident consuming less than 75% of foods offered at times, and the resident had shown an 12 pounds weight loss since admission on 5/10/2012. The staff should discuss food preference with the resident, and the family, to offer small appealing meals, provides nutritional supplements per physician orders, and health shakes three times daily. Staff recorded resident's weight as: 5/10/2012 - 154 (# ) 5/29/2012 - 149 (#) = weight loss of 5 # = % (percentage) of weight loss 3.24% 6/02/2012 - 148 (#) = weight loss of 6 # = % of weight loss 3.89% 7/01/2012 - 142 (#) = weight loss of 12 # = % of weight loss 7.79% over nearly two months Review of the dietary staff E note dated 7/11/2012, documented " Resident is showing insidious weight loss. Resident's weight has slowly declined, the resident has experienced weight loss in the last 7 days due to his/her oral intake has gone from 80% to 25%. The facility faxed the physician that the resident's weight is down, and requested to start a health shake three times daily since he/she is not eating well. " Review of the facility meal intake charting for the month of June 2012, revealed of the 87 possible meals reviewed, the resident ate 75% or less 44 of those 87 meals. Further review of the July 2012, meal charting revealed out of the 33 possible meals reviewed, the resident ate 75% or less 28 of those 33 meals. Review of the physician order [REDACTED]. Review of the residents laboratory values revealed: 5/10/2012 - Total protein as 5.5 low (6.4 - 8.2) [MEDICATION NAME] 2.9 low (3.3 - 4.5) 7/11/2012 - Total protein as 6.1 low (6.4 - 8.2) [MEDICATION NAME] 3.3 low (3.4 -5.0) Generally a low total protein and [MEDICATION NAME] level indicates that the resident has an low storage of protein in their body. A physician communication sheet dated 7/11/2012, revealed that the facility notified the physician by fax on that date of the resident's 12 pound weight loss since admission to facility. The faxed communication sheet requested to start the resident on health shakes to increase the resident's calorie intake, and also asked if the physician had any other recommendations for the resident's weight loss. The communication sheet returned by the physician ordered for the resident to start on health shakes three times daily, and to start [MEDICATION NAME] (medication used to treat loss of appetite) 400 mg (milligrams) per ml (milliliters), start 10 ml x 30 days for the resident. Observation at 12:30 PM on 7/16/2012, revealed the resident in the dining room with direct care staff member K attempting to get the resident to eat and drink their lunch meal. The direct care staff K asked the resident what type of salad dressing the resident wanted french or ranch? The resident responded, "which kids do we want to eat this?" Further observation of resident during the meal service revealed the resident falling asleep, had difficulty picking up the large glasses of fluids to drink, and also had difficulty with getting the spoon with beans into his/her mouth. Staff woke the resident up periodically, and encouraged and prompted the resident to eat and drink. The resident started cussing at the staff member stating they are "stupid", and requested the staff to leave them alone. Review of the facility meal intake sheets revealed the resident consumed "bites" of meal and drank 50 cc (cubic centimeters) of fluid. Observation at 3:00 PM on 7/16/2012, revealed the resident attempted to drink the physician ordered supplemental health shake for increased calorie intake through a straw. Further observation revealed the health shake frozen, and the resident was unable to drink the frozen shake. An interview at 10:00 AM on 7/16/2012, with administrative nursing staff D revealed, "I was unaware of the resident's weight loss until you (surveyor P) brought it to our attention last week. That is when I put a care for nutrition in place." For some reason the resident weights did not pull up on our weight sheets this month. The facility dietary manager is the one that notifies nursing of the weight changes and concerns. An interview at 10:15 AM on 7/16/2012, with dietary staff E stated, "For some reason the computer did not pull up the resident's weight on the weight review sheets this month. We were unaware of the residents weight loss until last week when you (surveyor P) brought it up, at that time we notified the physician of the weight loss and requested new weight loss interventions for the resident. The facility provided a, "Weight protocol policy and procedure, revised 1/2010, which revealed, "...All monthly weights are to be completed by the 7th of each month. The dietary manager is responsible for tracking and calculating weights for weight loss/gain. Significant weight changes are 5 % in a month, 7.5% in 3 months ....Doctor is to be notified of undesirable weight change and any measure taken by the facility... " The facility failed to assess the resident's nutritional status to develop and implement timely interventions to prevent weight loss for this resident. The facility failed to serve the physician ordered health shakes in a manner in which the resident can drink. The resident experienced a 7.79% (12 pound) weight loss since admission to the facility on [DATE].

The facility reported a census of 48 residents. Based on observation, interviews, and record review the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 ( #01) of the 4 sampled residents reviewed with accidents. Resident #01 experience harm from a head injury which resulted from the second fall in 1 night, from the resident's bed. The resident required medical treatment at a local hospital. Findings included: - Resident #01 admitted to the facility, on 12/31/2010, with [DIAGNOSES REDACTED]. The admitting preliminary nursing assessment, dated 12/31/2010, identified the resident as "Alert, anxious and confused. In addition, the assessment identified the resident required assistance with bed mobility, locomotion, grooming, and totally dependent on staff for transfers, dressing, toileting and bathing." Additionally, the assessment identified, "The resident does not use call light appropriately, 1/2 rail in place to prevent rolling out of bed, doesn't ask for help, and as a fall risk." The temporary care plan, dated 12/31/2010, documented the resident, "Required assist of two for all activities of daily living, transfer with a mechanical lift, at risk for falls, use diabetic precautions, bed alarm, and half side rails." Nurse's documented the following: 1.) 1/1/2011 at 3:30 p.m., "Upon entering room this nurse noted res (resident) was anxious, with noted confusion. A (alert) and O (Orientated) but disorientated to time et (and) place, not orientated to time et place." 2.) 1/2/2011 at 3:20 p.m., "Res (resident) pleasantly confused. Denies pain or discomfort at this time. 2 assist with adl's (activities of daily living) et mechanical lift for transfers. Geri chair for mobility, able to make needs know at times." 1/3/2011 at 1:15 a.m., "Res found on floor beside the bed, alarms sounding at approx. (approximately) 0000 (12:00 a.m.) Res stated that he/she just rolled over and fell on floor. No apparent injury. Res. was helped back to bed. ROM (Range of motion) ...(checked) Vitals and neuro's started per protocol. Res denies any pain or discomfort, all vitals and neuro's wnl (within normal limits). 1/3/2010 1:25 a.m., "Physician notified via (per) fax. ...(Director of nursing) also notified at approx 0030." 1/3/2011 at 02:30 a.m., "Res found on floor next to bed. Res has 5 cm (centimeter) laceration to upper lt (left) forehead. Laceration clean with soap and water steri strips and TAO (triple antibiotic ointment) applied. Res stated he/she had some pain @ (at) laceration. Res denies having pain anywhere else. Res cleaned up and lifted into geri chair. Res is by nurse station now. Vitals and neuro's to date are WNL (within normal limits). Physician and Director of Nursing notified of fall and injury. Will cont to monitor." 1/3/2011 04:30 a.m., "This nurse walked around nurse's station to do vital and neuro's on res.(resident) Res had blood on arm and on chair and dripping on floor. Blood was cleaned up and res had skin tear about 2.5 cm (centimeters) in diameter to left arm just below elbow. Steri strips applied after cleaning with soap and water, covered with 2 x (by) 2 and Kerlix. Dr. notified of above incident." 1/3/2011 at 6:45 a.m., "'Written per standing order. Tylenol 325 mg (milligrams) or 500 mg 1 or 2 tab @ 4 hours as needed for pain." 1/3/ at 7:00 a.m., "Res up in geri chair c/o (complaining) pain et discomfort prn (as needed) Tylenol given. Res crying et shaking arms. Res stated, my leg hurts. This nurse questioned as to what hurts. Res states my whole leg hurts. Res. FBS (fasting blood sugar) 137 and talking to person not there. This nurse call for ambulance to transfer res to ...(hospital) to evaluate et tx (treat). 1/3/2011 at 9:00 a.m., "Spoke with nurse in ER (emergency room ) at hospital res being transferred to hospital in Topeka." 1/13/2011 at 10:00 a.m., "Late entry for 07:10 a.m. res daughter called et notified of previous falls et being sent to ER (emergency room ) for eval (evaluation). Wound care notes, dated 1/3/2010 no time identified, "Present to Lt (left) forehead is a 5.0 cm (centimeter) by 5.0 cm purple hematoma with 2.5 cm laceration to its center. Laceration is with steri strips so I am unable to measure depth. Small amount serosanguineous drainage present. Patient is preparing for transfer to hospital ER (emergency room ) at this time." emergency room notes, dated 1/3/2011, documented, the following: 1.) At 8:27 a.m., "Pt arrived to ed (emergency department) with large hematoma to forehead and steri strips in place. Pt had dressing to lf (left) forearm and steri strips to small laceration." 2.) Patient transferred to another hospital on [DATE] at 11:02 a.m. due to an "Acute intracranial bleed." On 1/19/2011 at 9:20 a.m. licensed nursing staff A stated, "...(The resident) was admitted a couple of days before this incident. Prior to the incident he/she was kind of confused. I was in ..(the resident's) room doing a blood sugar around 5:00 p.m., and it was okay. When I went back, at bed time, he/she told me they had already done his/her blood sugar. Prior to the incident he/she was kind of confused. I did her 5:00 pm blood sugar and when I went back to do his/her blood sugars around 9:00 p.m., he/she told me they had already taken his/her blood sugar. ..(The resident) did not use the call light he/she would just holler out at you. Actually he/she was in bed all evening and ate supper in bed. Right around midnight, I found him/her on the floor. I heard him/her yelling help help and the alarm was sounding. I checked ...(the resident) vitals and neurological signs. We put ...(the resident) back to bed and made sure the bed alarm was turned on. ...(The resident) also had a fall mat on the floor and it was in place. I suppose ..(the resident) bed was about 3 feet off the floor. There was also a half rail on the bed and it was in the up position. The first time we thought maybe ...(the resident) rolled out of bed. We heard the alarm sounding again around 2:30 a.m.. When I got to the room I found him/her on the floor next to the bed. ...(The resident) had a laceration on the forehead it was about 5 cm (centimeter) in size. I cleaned the laceration, it wasn't very deep. We then placed him/her in the Geri-chair and took ...(the resident) up by the nurse's station so we could monitor him/her. Other than making sure ...(the resident) was up in the bed. I can't recall us doing anything else." On 1/19/2011 at 3:30 p.m., licensed nursing staff B stated, "Our staff placed the resident in a Geri-chair and placed him/her close to the nurse's station, so they could monitor him/her closer. However that may have been after the second fall." This resident fell out of the bed at approximately 12:00 a.m., and received no injuries. The facility failed to develop any new interventions or actions to prevent further incidents. At approximately 2:30 a.m., facility staff found the resident on the floor beside the bed. during this second fall the resident sustained [REDACTED]. At approximately 8:00 a.m., the facility staff noted blood at the resident's laceration site and transferred the resident to the emergency room at the local hospital. The local hospital then transferred the resident to another hospital, due to an intercranial bleed.